Some Basics In X-ray

(Some Basics in X. Ray) Miscellaneous ‫" ← ممكن حاجة من‬Heart ‫ أو‬chest" ‫أغلب الحالت‬ 30 ‫من الدرجة‬% → comment " Items" 70 ‫من الدرجة‬% → Diagnosis, III, ‫شغل نظرى‬ Com ment:1. Type of X. Ray:-

a) Plain b) e contrast → Barium swallow ( LT atrial enlargement) 2. Type of the patient: a) female " Breast shadow" lung ‫الـ درجة بياض تزيد كل ما تنزل تحت‬

b) male c) child 3. view:-

a) post Anterior view b) ant posterior view ( exception ‫) فى حالة طوارىء‬

False cardiomegally False congestion c) lat. View → ً‫غالبا‬

→ R.t ventric. enlargement → L.t atrial enlargement

4. centralization:-

From clavicles, dorsal spine which appears as tear drops We consider centralization if the space from dorsal spine to the medical end of the clavicles is equal on both sides ‫ → خطأ شائع‬Don’t use trachea in diagnosis of centralization

Centralization ‫ ← من‬centralized or not ← trachea ‫نحكم على ← بمعنى‬ ‫وليس العكس‬ 5.

Ribs :Ant half of the Rib differs from the post half of the Rib a) post half →

Horizontal, reach midline , more dense

b) N.B

ant half → oblique, doesn’t Reach midline , less dense

Ant half of ribs don’t reach midline as it continues with costal

cartilage → radiolucent. ‫فىركز‬ ‫ ← من المام وليس الخلف‬Horizontal Ribs ←COPD ‫حالت‬

Horizontal ← ‫ كده كده‬post Ribs ‫لن‬ ‫عشان محدش يضحك عليك‬ Ribs‫ازاى‬ ‫نعد إلى‬ Post Half " ← 1st Rib " ‫ تمثل الـ‬Bony thorax ‫•منأعلى نقطة فى‬ ‫الخلف‬

Horizontal Ribs ← ‫•نعد من الخلف‬ Post Half " ← 1st Rib " ‫ تمثل ال الـ‬Bony thorax ‫أعلى نقطة فى‬ ‫•من‬

‫المام‬ oblique Ribs ← ‫تيجى معاه على أدام وتعد من المام‬ •

•

concavity of theAppear 1st Rib

•

Appear Medical edge of scapula

As

As

Cavity

‫خطأ‬

shadow

6. Diaphragm : - " items"

1. Borders 2. contour 3. level 4. costophrenic Angle 5. cardiophrenic Angle 1. Borders:

Normally :Smooth sharply well defined



Abnormally: ill defined e.g lower labor pneumonic opacity

2. contour:- *Normally: convex upward



Abnormally: flat or depressed → emphysema. pneumothorax



‫ * مشدود علية من فوق‬Tinting : fibrosis

3. level:-

Normally: at the 6th Rib "Anteriorly" at the 10th Rib "posteriorly" N.B

L.t copula < R.T copula with 2.3 cm Abnormally: depressed or elevated 4. Costophrenic Angle:

Normally: Black Acute Angles Abnormally: White Obliterated e.g. pleural effusion 5. cardiophrenic Angles:

Normally 90 "Right Angle" 6. Hilum:

* Structures of Hilum: a) L.N ‫ل يرى‬ b) Main Bronchi ‫ل ترى‬ c) B.vs" Plum arteries and veins" →‫ترى‬ * CCC of normal Hilum:* Smooth and concave * Branching * appears as dots if end on view * Diameter of R.t pulm 16m.m L.T Plum 18mm * Symmetrical density * Causes of Hilar enlargement:L.V enlargement → festooned "lobulated" Bronchogenic → unilat, ill defined Pulm Hypertension → bilateral oligaemic lung"

7. Mediastinum:-

1) Position: - Tracheal shift Cardiac shift Upper mediastinum = tracheal position = if centralized

N.B

At center

slightly to Right

Lower mediastinum = cardiac position = if centralized

Provided normal sized Heart ←

1/3 Heart

2/3Heat

At the R.t of Midline

at the left

2) Borders of Mediastinum:Normally:-sharply well defined ‫لنه أبيض مع أسود‬ Abnormally: - ill defined → upper or Middle lobar opacity N.B

Right Border: upper half → S.V.C and ascending Aorta lower half Rt Border of R.T atrium. L.T Border: - 1st space → Aortic Nukle 2nd space → main plum segment "pulm cone" 3rd space → cardiac waste L.T atrial appendage 5th space → Apex

Heat 1) Cardiothoracic ratio

Maxim Transverse cardiac diameter = 1/2 Maxim Transverse Thoracic diameter 2) Individual chamber enlargement :-

a) L.T ventricle - ↑ cardiothoracic Ratio - Apex shifted out and downward - Obtuse L.t cardiophrenic angle

- dipping in the diaphragm b) Right ventricle:- ↑ cardiothoracic Ratio - Apex shifted out wand, Rounded and uplifted - Acute left cardiophrenic Angle - dipping in the diaphragm

‫الهم‬

On lat view - obliterated Retrosternal space ‫ ← أكيد‬space ‫ لكثر من‬1/2 ‫الجزء السفل من ذلك‬ ‫ ← ممكن‬space ‫ لكثر من‬1/3 ‫الجزء السفل من ذلك‬ c) Left Atrial enlargement:- Normally: most posterior structure ‫عامل زى الكورة‬ -

obliteration of cardiac waste " Mitralization " Straight ‫أو‬ Convex

- Double contour: In cases of huge lt atrium appears behind R.T Atrium

‫الهم‬

On lat View with Barium Swallow: Back words Indentation of barium swallow d) Right Atrium: - Increase cardiothoracic ratio - Cardiac shadow takes more then 1/3of right hemi thorax

Aorta

Aortic dilatation: - Increase convexity of upper half of R.T Border - Prominent Aortic nukle

Plum Artery

* Plum dilatation : - Main Plum cone → at 2nd space ‫أكبر‬

- Hilar pulm vessals ‫كبيرة‬ - Lung field → Lung oligeaemia * Plum congestion : pulm vascular markings more in lower half than upper Half‫المفروض‬ ‫ المرحلة الولى‬a) early upper half = lowerhalf ‫ المرحلة الثانية‬b) Hypoxia at lower half→ V.C : upper half > lower half ( Redistribution , cephelization , Moustach sign) ‫ المرحلة الثالثة‬c) Transudation around B.Vs → interstitial pulm edema ( ground glass appearance ) ‫ المرحلة الخيرة‬d) intra – alveolar edema ( Bat wings appearance) Valves

Prosthetic valve: - ‫تعرف أزاى‬ * On the vertebral column → Aorta * On the left side of the vertebral column → Mitral * Mitral ← ‫ تحت الخط‬Aorta ← ‫فوق الخط‬ Pace maker SVC ‫ خلل‬Heart ← wire ‫بطارية‬, Cardiac aneurysm

Shouldering in the left Border of the Heart

Pericardial effusion -

Increase of the cardiothoracic Ratio

-

Borders are smooth and Regular

-

Lung oligaemia "Hilar B.vs Faint , small, plum Vasc marking attenuated

‫؟‬pericardial effuse ‫ بدلً من‬H.F

‫طيب ليه ميكنش‬

As both are similar at X-ray picture But

H.F almost has "Plum congestion" 8) Lung Field: * Normally it is black except intra plum vascular markings which is Branching and fainting on going laterally and (White) in X-Ray * Abnormalities: a) Too Black

b) Too White

"Hyper Translucency" Unilateral - Pneumothorax -Compensatory Emphysema

"Radiopacity"

Bilateral - emphysema

Homogenous

Heterogeneous

* Homogenous opacity 1) Total lung opacity 2) Lobar opacity 3) Opacity obliterating costophrenic Angle 4) Opacity with fluid level 5) coin shape opacity 6) Wedge shaped opacity "plum infarction" * Heterogeneous opacity - Linear

- Reticulo nodular

- Flossy cotton

- Miliary shadow

- Ring shadow

(Homogenous opacity) 1) Total lung opacity

lung ‫الـ يعنى تلقى‬ Heart ‫كلها بيضاء لدرجة مش باين منها‬

Causes -

massive pleural effusion →Trachea pushed to opposite side

-

total lung collapse → trachea pushed to the same side

-

total lung consolidation → normal trachea Air Bronchogram

‫تبان سوداء على خلفية بيضاء‬

Bronchi ‫تفريعة الـ‬

2) Opacity obliterating costophrenic Angle: - Pleural effusion: Surface and Rising laterally toward axilla and well defined But may be with Horizontal level if the condition is Hydropneumothorax 3) Opacity with fluid level: a) Hydropneumothorax Upper 1/2 → as pneumothorax Lower 1/2 → as pleural effusion b) Lung Abcess: cavity with fluid level N.B

Pneumothorax → Jet Black → it means absence of plum vascular making ‫معناه أسود أوى لنه من الممكن أن يكون لونه رمادى مش أسود‬ ‫مش‬ ‫بمعنى‬ 4) Coin shadow "Cannon ball shadow" Not necessary to be perfectly Rounded But well defined Causes: - Single - Multiple * Single

- Bronchogenic carcinoma - Single metastatic deposit - Benign tumor - Pneumonic stage of lung Abcess - Fungal genuloma -Rheumatoid Nodule - Tuberculoma - Plum infection "end on view"

* Multiple → Metastasis 5) Wedge shaped opacity → Plum infection "lat view" (Heterogeneous opacity)

1) Flossy cotton Multiple ill-defined patches of opacity → Perihilar → alveolar plum edema "Bat wings" → Bilat, Basal and asymmetrical → Bronchopneumonia. → Apical → T.B, fried Lander Bronchopneumonia 2) Reticulonodular: nodules ‫خطوط و‬ Coarse ( Honey comb) Bronchiectasis → Coarse lung fibrosis Fine (Ground glass appearance) → Fine lung fibrosis → Interstitial plum edema But

Lung fibrosis

- It is Retractile Tissue - Diagnosed in X. Ray By 1) Reticulonodular shadow

2) Signs of volume loss as - Pulled Trachea - Elevated or tinted diaphragm - Overcrowding of Ribs 3) Miliary shadow Multiple dot like opacities which are Rounded small uniform in size and Density. Cause 1) Miliary T.B. 2) Sarcoidosis 4) Ring Shadow:- Large with Fluid level → lung Abcess - Multiple, small→ Bronchiectasis (Hyper Translucency) Pneumothorax:-

- Jet Black translucency - Underlying lung collapse - Mediastinum pushed to the opposite side - Flat or depressed diaphragm Emphysema:-

Hyper Translucent lung field

- Ribbon shaped Heat - Wide, Horizontal Ribs - Wide costophrenic Angle -

Flat or depressed diaphragm (Most common x. Ray for exam)

Chest:-

Emphysema "COPD" + + + + + +

- Pneumothorax

+++

- Total lung opacity

+++++

- Total lung collapse

++

- Total lung pneumonia + + + + - Coin shadow

+++++

-

Pleural effusion

++++++

-

Hydropneumothorax + + + +

- Lung Abcess

++++

- Lung Fibrosis

++++

- Bronchiectasis

+++

-

Bronchopneumonia

++++++

- Miliary T.B Heart:

- Pericardial effusion

++++++

- Pulm Hypertension

+++++

- Artificial valve

++

- Chamber enlargement + + + + + + + + + N.B

X. ray (H.F) → (Cardiomegally + plum congestion + R.t side pleural

effusion).

With my best wishes, DR.M.BASIONEY