Petri Sipola

1
Systematic evaluation of Chest X-ray

• Petri Sipola
• Radiologist
• Kuopio University Hospital

2
Start evaluation from heart

• From the center to the periphery
• CT-ratio (lt0.5), calcifications, bulging, back
  border in lateral view

3
Go to vessels

• General amount of vascularity and 1. irregularity
  of vessel borders and 2. detection of Kerley
  B-lines (LV compensation)
• Hilum size (formed of pulmonary arteries and in
  pathological state of lymph nodes)

4
Continue to mediasinum

• The upper mediastinum is normally quite minor,
  this have to be evaluated in context of patient
  age, obesity, imaging position etc. Check the
  blackness in lateral view as well. Check tracheal
  straightness (Cervicomediastinal expansions).
• Detect the arch of aorta and normality of notch
  between aorta and pulmonary vessels (no notch
  expansion, incresed notch coarctation?). Check
  lat. view to exclude thoracic aorta aneurysm
• Dilatation of ascending aorta can be seen in the
  right mid mediastinum

5
Next lung parenchyma

• Go PA-image systematically from left to right and
  from up to down with your eyes
• Is there symmetrical blackness (attenuation)
• Regional asymmetricity should be try to find of
  lateral view
• Check the visualization of borders of diaphragms
• Check the density behind heart, vessels and
  vertebral columns should be possible to visualize
• Check the lateral borders of the heart, they
  should be visualized (no border silhuette sign
  anterior impairment of air content in lung (dx.
  mid lobe / sin lingula)

6
Basal pneumonia on right
7
Lateral view lung parenchyma

• Check systematic increase in blackness in
  postero-inferior direction every vertebral
  column should be darker than upper side
• Check specifically the most apical parts of lobes

Posterobasal pneumonia, difficult to detect of PA
image
8
Pleural spaces

• In PA-image the lateral tips of pleural spaces
  are sharp as tooth-sticks the lowest part of
  chest, however, is posteroinerior pleural tip
• Detect the apical area, there can be pleural
  thickening that is easy to overlook
• All regional thickenings have to be detected.
  Most are benign (symmetric fat, pleural
  fibrotic bands, pleural plaques (calcified or
  not, healing rib fractures. Also malign pleural
  metastasis, mesothelioma). Check the old images,
  no differece in 1 year old benign.

Pleural fluid in supine postion
Pleural fluid in standing position
9
Thoracic spine and ribs

• Compression fractures (wedge shaped)
• Regional increase (decrese) in bone density
  (metastasis)
• Check the visualization of ribs (metastasis,
  fractures)

10
Soft tissue and hand bones

• Subcutaneous emphysema, marker of pneumothorax
• Soft tissue calcifications (malginant tumors)
• Bone tumors in hands, fractures, luxations in
  AC-joints