X-Rays
Kunal D Patel
Research Fellow
IMM
The 12-Steps
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1: Name
Pre-read
2: Date
3: Old films
4: What type of view(s)
5: Penetration
6: Inspiration
Quality Control
7: Rotation
8: Angulation
9: Soft tissues / bony structures
10: Mediastinum
Findings
11: Diaphragms
12: Lung Fields
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Reviewing these areas
Heart
• 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!
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A = Airway: are the trachea and mainstem bronchi
patent; is the trachea midline?
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B = Bones: are the clavicles, ribs, and sternum present
and are there fractures, lytic lesions?
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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?
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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 suspension
 Complex 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