Thoracic

Radiographic
Anatomy
Einav Shochat MS4
Visiting Medical Student
PA and Lateral Chest Radiograph
Lobar Anatomy
 There are three lobes in the right lung and two
in the left
 Lobes are divided into anatomic segments; each
is supplied by its own bronchus and blood
vessels
Lobar Anatomy:
Right upper & right middle lobes

RUL RUL

RML borders the right

atrium and much of the RML
dome of the diaphragm.
RML Indistinct borders of
these areas suggest
RML pathology.
Lobar Anatomy: Right lower lobe

Consolidations of the
RLL lower lobes are largely
behind the diaphragm
dome, hence the RLL
diaphragm border will
still appear sharp on
the PA film.
Lobar Anatomy: Left upper lobe

LUL
LUL

LUL borders the left

atrium, left ventricle and
much of the dome of the
diaphragm. Indistinct
borders of these areas
suggest LUL pathology.
Lobar Anatomy: Left lower lobe

Most of the LLL is posterior

to the left border of the
heart and the dome of the LLL LLL
diaphragm. Distinct borders
of these areas with
surrounding opacity is seen
with LUL consolidations.
Can you find the source of this patient’s fever and cough?
Can you find the source of this patient’s fever and cough?

Left Lower
Lobe
pneumonia

Distinct
borders

Note the abnormal opacification of the lower vertebrae in the lateral view. Normally
there is less soft tissue around the inferior thoracic vertebrae making them appear
darker than the more superior vertebrae. See next slide for comparison.
On the right is the same radiograph from the previous slide with a normal
one for comparison.

Normally,
inferior
vertebrae
appear
darker

Note the general opacification of the lower lobe in the image on the right. Look
particularly at the vertebral bodies and posterior border of the heart.
Lobar Anatomy
 The lobes of the lungs are lined by visceral
pleura, which normally is not visualized
except along the interlobar fissures
 Fissure anatomy may have many anatomic
variations and may not be complete
On the right there are two fissures, the oblique (major)
fissure and the horizontal (minor) fissure. The left lung
contains an oblique fissure only.

minor minor

jor
ma
It is uncommon to see distinct fissures. If opacified
there may be thickening of or fluid between the pleura.

This patient has

congestive heart failure
and subsequent
subpleural thickening.
Can you identify the
oblique fissures?
It is uncommon to see distinct fissures. If opacified
there may be thickening of or fluid between the pleura.

This patient has

congestive heart failure
and subsequent
subpleural thickening.
Can you identify the
oblique fissures?
Here there is fluid trapped between the pleura within
the fissures.
Occasionally accessory fissures can be found. For example,
the azygos fissure, a normal variant, can form during the
embryonic migration of the azygos vein through the apical
pleura.
Knowing the normal position of the interlobar fissures helps us
diagnose pulmonary volume changes. For example when a lobe
collapses the fissure is displaced and seen as a sharp interface
between opacified (collapsed) and aerated lung.
Can you identify the pleural lining of the collapse lung?
Knowing the normal position of the interlobar fissures helps us
diagnose pulmonary volume changes. For example when a lobe
collapses the fissure is displaced and seen as an interface
between two densities (e.g., opacified/collapsed and aerated lung)
Can you identify the pleural lining of the collapse lung?

scapulae

Left pulmonary
artery:
vasculature are Inferior
pulled inferiorly by vertebrae
the collapsed LLL opacified by
LLL atelectasis

Left hemidiaphragm
Major fissure not becomes indistinct
normally seen on the PA when adjacent to
film because it runs parallel collapsed LLL
to the radiation beams
What’s happened here?
 What’s happened here?

Right upper
lobe collapse
We can use the pleura to identify whether a mass is within
the lung parenchyma or in the extrapleural space.
Is this mass intrapleural or extrapleural? How can you tell?
 We can use the pleura to identify whether a mass is within
the lung parenchyma or in the extrapleural space.
Is this mass intrapleural or extrapleural? How can you tell?

Extrapleural

The medial border of the mass is draped by pleura and is distinct where it is adjacent to
aerated lung. The lateral border is next to bone and soft tissue of more similar density.
The pleura is often involved in inflammatory and traumatic
insults to the chest. These may result in areas of thickening or
distortion of the pleural lining, which may be appreciated in
the normally sharp costophrenic & cardiophrenic angles/sulci.

Lateral Cardiophrenic Posterior

costophrenic angle costophrenic
Lateral angle
angle
costophrenic
angle
 Pleural effusions can be identified by: blunting of the lateral and
posterior costophrenic sulci, a meniscus sign, opacification of a
hemithorax, and/or fluid in the fissures.

Small free-flowing pleural effusions are best identified on the lateral radiograph
as this view captures the most dependent region of the thoracic cavity, the
posterior costophrenic angles.
Mediastinum
 Many structures can be identified within
the mediastium; we will start with the heart
and blood vessels…
How many structures can you identify?
 Aortic pulmonary
Vascular SVC
Aortic recess
pedicle
arch nary
o
Right pulm

Aorta
pulmonary Left
artery artery

LA
Right
pulmonary RA
artery
(lower lobe)
LV

RV
How many structures
can you identify?
 Brachiocephalic
vessels

Scap
Trachea

m
ri u

ula
ub
Aorta

n
Ma

ce
Right upper

pa
LPA lobe bronchus

ls
RPA
um

rna
ern Left upper
te
Pulmonary
os
f st
tr
outflow lobe
yo
Re

tract bronchus
Bod

LA Confluence
RV
of pulmonary
IVC veins
LV
Right
hemidiaphragm
Gastric air
bubble Left
hemidiaphragm
Which valve has been replaced?
 Which valve has been replaced?

Aortic valve
Note the orientation of the
valve perpendicular to the
plane of the PA film.
Which valve has been replaced?
Which valve has been replaced?

Pulmonic
The pulmonary outflow
tract is more superior
and lateral than many
people think.
Last one, name the valves…
 Last one, name the valves…

Aortic

Aortic
Tricuspid
Mitral
Tricuspid

Mitral
The Vascular Pedicle
 Found in the superior mediastinum.
 Right and left margins are normally formed by the
superior vena cava and the descending portion of
the aortic arch, respectively.
 A widened vascular pedicle can have several
etiologies including elevated intravascular
volume, aortic trauma, or pericardial effusion.
 Aortic
arch
Vascular
pedicle

Superior
vena
cava
Intravascular volume vs. Intravascular volume
depletion elevation
 Intravascular volume vs. Intravascular volume
depletion elevation

Vascular
Vascular
pedicle
pedicle
Superior Superior Aorta
Aorta
vena cava vena cava

Intravascular volume elevation resulting in an expanded SVC should not be

mistaken for hematoma, which would have a less distinct border and more
opacified appearance.
 Trauma patient with an aortic transection

Note the vascular pedicle’s “fuzzy”, opacified right border.

What is happening here?
 What is happening here?

Looks pretty
wide eh?

Can you follow the heart borders?

 What is happening here?

If you look closely you can

make out the superior
The wide vascular pericardial border
pedicle here
results from a
pericardial
effusion

The pacemaker
wires roughly
outline the right
atrium border
The left heart border effusion
effusion
can be seen within
the effusion

Comparing this with older films can also help make the diagnosis.
Pulmonary Airways & Vasculature
 The lungs on the normal chest radiograph
are made by pulmonary vessels, the
bronchi are normally not seen.
 This is because:
 Pulmonary vessels are blood-filled with density
similar to water.
 Bronchi are filled with air and normally have thin
walls that do not provide contrast to aerated
lungs.
Pulmonary Airways & Vasculature
 When lung parenchyma fill with water or
inflammatory material:
 Water-density vessels become less distinct.
 Air-filled bronchi can be seen as “air
bronchograms”.
 If airways are obstructed (e.g., tumor) they may fill
with fluid and no “air bronchograms” will be
appreciated.
How do these two radiographs differ?
 How do these two radiographs differ?

Normal Abnormal
well-defined indistinct
vessels vasculature
 In the normal chest radiograph only airways
within the mediastinum are apparent.

Trachea

Left Trachea
Right
mainstem
mainstem
bronchus
bronchus
Left
mainstem
bronchus
What is the source of this man’s chronic cough?
What is the source of this man’s chronic cough?

Unilateral lung
opacification
Obstruction with ipsilateral
tracheal shift
from the RUL

Horizontal pressure
fissure differential
helps identify Tented right
RUL collapse hemidiaphragm

Inferior pulmonary
ligament tethering the
lobe and tenting the
diaphragm

Right upper lobe collapse secondary to obstruction of

the bronchus by squamous cell carcinoma.
What is the source of this patient’s dyspnea?
What is the source of this patient’s dyspnea?

Atelectasis
Seen commonly as crowded
parallel air-bronchograms
(if airways are not obstructed)
What is abnormal here?
What is abnormal here? The patient has Sarcoidosis.

Lateral border of
the SVC is
obscured by
lymphadenopathy
Bronchus
lumen is
obscured

Think about lymphadenopathy when opacities obscure the aortic

pulmonary recess (PA) or surrounding the left distal main
bronchus (on the lateral)
Other Mediastinal Structures
 Esophagus
 Thyroid
 Thymus
 Lymph nodes

 These are generally not seen unless there

is pathology
What could be the source of this anterior mediastinal mass?
What could be the source of this anterior mediastinal mass?

Ddx: Lymphoma/leukemia, germ cell tumors (e.g., teratoma),

thymic mass (e.g., thymoma, cyst), enlarged thyroid, vascular
(e.g., hematoma, aortic aneurysm).
This patient has a thymoma.
How about this one?
How about this one?

This patient has a an enlarged thyroid gland.

Extrapulmonary Structures
 Diaphragm
 Stomach/gastric bubble
 Liver, spleen
 Bones: clavicles, ribs, scapulae, spine
 Other soft tissues
In the normal radiograph, the diaphragm is domed with the right
side higher than the left (i.e., the heart lying on the left side of
the diaphragm may contribute to the lower level).

Left
diaphragm

Right
diaphragm
Elevated intrathoracic pressures (e.g., hyperinflation
from obstructive lung disease, tension pneumothorax)
will flatten the diaphragm.

Flat

Flattened
Not many structures left, so let’s just quiz…
What’s abnormal in these films?
 What’s abnormal in these films?

Notice the air

around the left and
right pulmonary
arteries.

LLL
atelectasis

The lucent stripe along the inferior heart border, crossing midline is called
a “continuous diaphragm” sign and is indicative of pneumomediastinum.
What’s abnormal in
this film?
What’s abnormal in
this film?

Free air

Normally the only air

we see under the
diaphragm is in the
gastric bubble and
bowels.
Subdiaphragmatic
free air is indicative of
perforated viscus.
What’s abnormal in this film?
What’s abnormal in this film?

Hiatal
hernia
This hiatal hernia is easier to see with the gastric
air bubble behind the heart.
What’s abnormal in this film?
What’s abnormal in this film?

Tracheal deviation

Gastric
bubble,
bad sign

Ruptured
diaphragm
What’s abnormal in this film?
What’s abnormal in this film?

Splenomegaly

Gastric air bubble

What’s abnormal in this film?

Gastric air bubble

 What’s abnormal in this film?

Ouch

Gastric air bubble

Which patient needs a chest tube?

Gastric air bubble

 Which patient needs a chest tube?

Pneumothorax
Skin fold
Scapula lateral border
medial
border

To decide whether a line in the lung

represents the scapula, a skin fold
or a pneumothorax consider the
density difference between the two
sides of the line. A pneumothorax
will have a sharp line with air density
(equal density) on both sides. Skin
or scapula will have a line with air on
one side and more opaque tissue on
Gastric air bubble
the other.
What’s abnormal in this film?
 What’s abnormal in this film?
Nothing

The left lung

appears more
opacified but it
is the result of
uneven
radiation.

The patient is rotated slightly causing the “heel effect”, the relative over exposure of
one hemithorax compared to the other caused by uneven radiation. Looking at the
relative exposure of the extrathoracic soft tissues can help identify the “heel effect”.
References:
 Collins J, Stern EJ. Chest Radiology, the
Essentials. Lippincott, Williams & Wilkins. 1999.
 Dafner RH. Clinical Radiology, the Essentials. 2nd
Ed. Lippincott, Williams & Wilkins. 1999.
 Freindlich IM, Bragg DG. A Radiologic Approach
to Diseases of the Chest. 2nd Ed. Williams &
Wilkins. 1997.