IMAGE CRITIQUE & PATTERN
RECOGNITION ON
CHEST IMAGING
DR YAHUZA MANSUR ADAMU
BAYERO UNIVERSITY KANO.
2024.
Content
• Review of normal Anatomy on Chest
radiograph
• Image critique
• Pattern recognition
ANATOMY OF THE NORMAL CHEST RADIOGRAPH
• Understanding the normal anatomy on chest
radiograph is critical towards successful
interpretation of abnormal chest radiograph.
• Systematic approach to reading normal and
abnormal chest radiographs is also critical.
• Thus, the suggested approach is to read
centripetally (ie from outside to inside).
– Centripetal: Soft tissue, bony skeleton, pleura,
lungs, mediastinum).
– NB: alternative approach is centrifugal approach
(eg, practiced in AKTH).
ANATOMY OF THE NORMAL CHEST RADIOGRAPH
(i). Soft Tissue
• The soft tissue on the lateral chest wall consist
of the
• Skin
• Subcutaneous fat
• Muscles, and
• Facial planes
• The overlying breast shadow
• Especially in females, should be symmetrical
ANATOMY OF THE NORMAL CHEST RADIOGRAPH
(i). Soft Tissue
LATERAL SOFT
TISSUE OF THE
CHEST WALL
THE NORMAL ADULT MALE CHEST RADIOGRAPH
ANATOMY OF THE NORMAL CHEST RADIOGRAPH
(i). Soft Tissue
THE NORMAL ADULT FEMALE CHEST RADIOGRAPH
LATERAL SOFT
TISSUE OF THE
CHEST WALL
BREAST SHADOWS
ANATOMY OF THE NORMAL CHEST RADIOGRAPH
(ii). Bony Skeleton of the Chest Wall
• Components:
– 12 pair of ribs
• Attachment: each rib is attached anteriorly to the costochondral junction and
posteriorly to the spine.
• The 11th and 12th ribs are short ribs and do not articulate anteriorly, hence
called FLOATING RIBS
– Sternum
• Components: manubrium & body of sternum, joined @ manubriosternal
junction
• Best imaged on Oblique or Lateral view.
– Clavicles
• Articulations:
– medially @ the sterno-clavicular junction: difficult to see on frontal radiograph!
– and laterally @ the acromio-clavicular junction: visible on frontal radiograph!
– Vertebral column (spine)
• Lower cervical spine
• Thoracic spine
(ii). Bony Skeleton of the Chest Wall :
The sternum
(Oblique view)
MANUBRIUM
MANUBRIO-STERNAL
JUNCTION
BODY OF
STERNUM
ANATOMY OF THE NORMAL CHEST RADIOGRAPH
(iii). PLEURA
• A thick fibrous layer covering the inner lining of the
bony chest wall and the lung substance.
• Parietal pleura: the pleural covering of the inner bony
chest wall
• Visceral pleura: the pleural covering of the lungs
• Pleural space: a potential space between parietal and
visceral pleurae.
• The normal parietal and visceral pleura are not visible
on chest radiograph, except when thickened with
disease.
• The normal pleural space is also not visible on chest
radiograph, except in pathologic states when it
contains air (in a condition called PNEUMOTHORAX) or
fluid (HYDROTHORAX).
RT PNEUMOTHORAX
ANATOMY OF THE NORMAL CHEST RADIOGRAPH
(iv). LUNGS
• The lung is divided into lobes
– Right lung has 3 lobes, the upper, middle and lower
lobes.
– Left lung has 2 lobes, the upper lobe (comprising of
the upper lobe and the lingula) and the lower lobe.
• The lobes are separated from each other by
means of fissures. Thus,
– Greater or Oblique fissure: separates the upper and
lower lobe on the right and upper and lower lobes on
the left.
– Transverse fissure: separates the middle and upper
lobes on the right
– The fissures are best seen on the lateral chest
radiograph as thin white lines.
RIGHT LUNG
LEFT LUNG
Fissures on Lateral chest radiograph
ANATOMY OF THE NORMAL CHEST RADIOGRAPH
(iv). LUNGS
CHEST X-RAY
• The pulmonary arteries and
veins:
– Extends from the hilar outwards
to the lateral chest wall
– Often the arteries and veins
cannot be differentiated on
plain chest film;
– Whearas, on catheter DSA they
appear prominent!
CATHETER PULMONARY DSA
ANATOMY OF THE NORMAL CHEST RADIOGRAPH
(v). The Mediastinum
• This is the central radiopaque shadow on frontal chest
radiograph
• It is divided into superior, anterior, middle and posterior
mediastinum; best appreciated on the Lateral view!
MEDIASTINUM
ANATOMY OF THE NORMAL CHEST RADIOGRAPH
(v). The Mediastinum
ANTERIOR
MEDIASTINUM
SUPERIOR POSTERIOR
MEDIASTINUM MEDIASTINUM
MIDDLE
MEDIASTINUM
ANATOMY OF THE NORMAL CHEST RADIOGRAPH
(v). The Mediastinum
• BOUNDRIES OF THE MEDIASTINUM
– Superior mediastinum
• Inferiorly: horizantal plane passing just above th aortic arch
• The compartment above this imaginary line constitute the sup. Med.
– Anterior mediastinum
• Anteriorly: manubrium sternum
• posteriorly: middle mediastinum
– Middle mediastinum
• Anteriorly: anterior mediastinum
• Posteriorly: posterior mediastinum
– Posterior mediastinum
• Anteriorly: middle mediastinum
• Posteriorly: thoracic vertebral column
ANATOMY OF THE NORMAL CHEST RADIOGRAPH
(v). The Mediastinum
• CONTENT OF THE MEDIASTINUM
– Anterior mediastinum
• Thymus, lymph nodes, mediastinal fat
– Middle mediastinum
• Heart, pericardium, Lymph nodes, tracheobronchial
tree/carina, hilar
– Posterior mediastinum
– Superior mediastinum
• The great vessels: superior vena cava & brachiocephalic
artery on the right, left common carotid artery, left
subclavian artery on the left
• Non vascular structures: trachea, oesophagus, phrenic
nerve, lymph nodes, recurrent laryngeal nerve, vagal nerve.
IMAGE CRITIQUE
ON
CHEST RADIOGRAPH
IMAGE CRITIQUE ON CHEST RADIOGRAPH
• Check for:
– Correct filling of Radiographers Column(s) on request
card.
– Correct matching of examination requested on the
request card and what was performed.
– Correct choice of film size relevant to the patient size/age
and the examination performed (NB: this may not be
applicable on digitally processed images)
– Correct patient identification on the radiograph,
comprising of Name, Identification number, Date of
examination, Name of institution, Age.
– Correct placement of Anatomical marker!
– Good inspiration radiograph: aim at visualising the 9 th –
11th posterior ribs above the diaphragms.
IMAGE CRITIQUE ON CHEST RADIOGRAPH
(Cont’d)
TYPICAL REQUEST FORM.
Note the content of the Radiographer’s column (highlighted in red box)
IMAGE CRITIQUE ON CHEST RADIOGRAPH
(Cont’d)
TYPICAL REQUEST FORM.
Note the content of the Radiographer’s column (highlighted in red box)
IMAGE CRITIQUE ON CHEST RADIOGRAPH
(Cont’d)
– Correct collimation: showing the lower cervical spine and
the acromio-clavicular joints superiorly, below-both
costophrenic angles inferiorly and showing the soft tissue
of lateral chest wall (including the breasts shadow) on
both sides symmetrically.
– Correct positioning/centering: the image must be at the
centre of the film or screen and the patient is not rotated
by checking that the medial ends of the clavicles and the
vertebra are equidistant.
– Correct exposure factor was used during exposure by
observing that vertebral shadows are just visible behind
the heart shadow and the pulmonary vasculature are well
displayed up to the lateral 1/3rd of the lung fields bilatrally.
– Film free of artefacts arising from the examination table,
bucky, patient dress/body, during processing, etc………
IMAGE CRITIQUE ON CHEST RADIOGRAPH
(Cont’d)
TYPICAL CHEST X-RAY
• IMAGE EVALUATION
OF
CHEST LESIONS
IMAGE EVALUATION OF CHEST LESIONS
• Content:
– Pneumonia
– Tuberculosis
• Primary Tuberculosis
• Post primary Tuberculosis
– Pulmonary carcinoma (Lung cancer)
– Hypertransradiant and Cystic Lung lesions
IMAGE EVALUATION OF CHEST LESIONS
PNEUMONIA
• Definition:
– Radiographic: air space opacification of a segment or lobe of a lung
– Pathologic: the alveolar air spaces are filled with inflammatory exudate, while the
bronchi and bronchioles remain patent.
• Aetiology:
– usually streptococcus pneumoniae especially in adults. Others are Staphylococcus,
Haemophylus Influenzae, Klebsiella, Tuberculous, etc……..
• Types of pneumonia
– Lobar pneumonia: opacification of pulmonary lobes with the presence of air
bronchogram (a leafless tree-like branching pattern within the opacification)
– Atelectatic pneumonia: Lobar opacification without air-bronchogram due to
obstructive collapse of the distal bronchial airways.
– Bronchopneumonia: multifocal peribronchial opacification, usually in children
– Cavitating or necrotising pneumonia: occurs when there is extensive necrosis of the
lung tissue, commonly due to Klebsiella, Pseudomonas or Tuberculous pneumoniae.
• The cavitation may be associated with air-fluid level.
IMAGE EVALUATION OF CHEST LESIONS
LOBAR PNEUMONIA (Rt Upper Lobe)
IMAGE EVALUATION OF
LOBAR PNEUMONIA
WITH AIR-BRONCHOGRAM SIGN
IMAGE EVALUATION OF
LOBAR PNEUMONIA ON CT
WITH AIR-BRONCHOGRAM SIGN
IMAGE EVALUATION ON CHEST RADIOGRAPH
LOBAR PNEUMONIA
BRONCHOPNEUMONIA
IMAGE EVALUATION ON CHEST RADIOGRAPH
TUBERCULOSIS
• PRIMARY PULMONARY TB
– Small focus of lung opacification + hilar and/or mediastinal
adenopathy on the same side.
– Radiographically, presents as parenchymal disease,
lymphadenopathy, pleural effusion, miliary disease, or
atelectasis
– Usually a disease of infants and children.
• POST-PRIMARY PULMONARY TB
– Results from reactivation of previous and dormant prim.
PTB or very rarely as a continuation of primary disease.
– Almost exclusively a disease of adolescent and adulthood
– Radiographically, manifest as parenchymal disease with
cavitation, airway involvement, pleural extension and lung
complications in chronic cases.
Primary pulmonary tuberculosis
with typical radiographic findings.
Chest CT scan-pulmonary window-
shows a focal area of consolidation
Miliary pulmonary tuberculosis
POST PRIMARY PULMONARY TB
PULMONARY CARCINOMA
• Pulmonary Ca. presents in one of the following
patterns:
• a. solitary pulmonary nodule
• b. hilar mass pattern
– Presents as radiopaque masses distorting the normal
contour of the hilum
• c. lung collapse
• d. multiple masses pattern
– Usually due to metastatic carcinoma to the lung from a
primary site outside the lung, such as the breast, thyroid,
kidney, choriocarcinoma, etc….
• e. miliary pattern
PULMONARY CARCINOMA
PULMONARY CARCINOMA
Pulmonary carcinoma
MULTIPLE LUNG MASSES PATTERN
HYPERINFLATED & CYSTIC LUNG
• Hyperinflation is found in
airway obstruction from
asthma and chronic
obstructive airway disease.
• Hyperinflation is said to be
present on chest radiograph
when the 11th posterior rib
is shown above the
diaphragmatic outline. The
diaphragm most often is
flattened and the chest
assumed a “barrel shaped”
• e.g COUNT THE 11TH
POSTERIOR RIB ON THIS
Hyperinflated lung
HYPERINFLATED & CYSTIC LUNG
• Emphysema
– The presence of Hyperinflation + focal thin walled
cysts (bulla).
• Cystic bronchiectasis
– Cystic dilatation of the bronchi
– Appear as multiple basal ring shadows
– Best seen on high resolution CT scan
• Lung cysts must be differentiated from cavities,
the later has thicker wall than the former.
However, all could present with air-fluid level
when infected.
Hyperinflated lung
and
the Barrel-shaped chest
Bullae on Chest x-ray
Bronchiectasis.
HYPERTRANSRADIANT LUNG
• Definition: Complete
focal or generalised
radiolucency in the lung
field devoid of lung
markings.
• Causes: Pneumothorax,
large bulla.
THE END
