Post on 30-May-2017
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Imaging the Mediastinum
MediastinumMediastinum Bounded laterally by parietal pleura of each lung Superior margin is thoracic inlet
Defined by plane of 1st ribs Inferior margin is diaphragm Tissue planes extend superiorly into neck
around great vessels, trachea and esophagus Connects to abdominal cavity via esophageal,
caval and aortic hiatuses Connects to lungs along hilar vessels and
bronchi
MediastinumMediastinum Radiologic anatomy
CXR CT
Normal or not? Compartments and their pathologies:
Anterior Middle Posterior
Radiologic AnatomyRadiologic Anatomy
Landmarks to look for on the chest radiograph: Trachea Paratracheal stripe Descending aortic contour Azygo-esophageal contour
Pneumomediastinum with Pneumomediastinum with cervical emphysemacervical emphysema
Tracheal air columnTracheal air column
Should be straight
Slight bend to right due to aortic arch on its left.
Trachea deviates to the left
Right Aortic ArchRight Aortic Arch
Right paratracheal stripeRight paratracheal stripe
Extends from thoracic inlet to azygos vein
Widens out at azygos vein
No more than 3-4 mm thick
Aortic contourAortic contour
Azygo-esophageal recessAzygo-esophageal recess
Aortic contour and azygo-esophageal Aortic contour and azygo-esophageal recess abnormalrecess abnormal
Normal anatomy:Normal anatomy:CT/CXR correlationCT/CXR correlation
Normal anatomy:Normal anatomy:CT/CXR correlationCT/CXR correlation
Normal anatomy:Normal anatomy:CT/CXR correlationCT/CXR correlation
Normal anatomy:Normal anatomy:CT/CXR correlationCT/CXR correlation
Is the mediastinum wide?Is the mediastinum wide? First ask… is it technical?
Positioning: rotated:? AP? Lordotic? Supine?
Inspiration If so, repeat the film before proceeding to CT.
Then ask…Is it new? GET OLD FILMS before getting a CT unless
time is critical.
Think about normal variants!Think about normal variants!
Vascular structures Aortic anomalies Tortuous vessels Azygos vein
Lipomatosis Fat pads
Severe asthma on long term steroids
Mediastinal lipomatosisMediastinal lipomatosis
Pericardial Fat PadPericardial Fat Pad
Tortuous brachiocephalic Tortuous brachiocephalic vesselsvessels
70 year old with dysphagia70 year old with dysphagia
Tracheal air
column
Esophageal cancer
Abnormal right paratracheal stripe
Hodgkins Hodgkins diseasedisease
Abnormal right paratracheal stripe
Check the old film!Check the old film!
2 days earlier
Hematoma from line insertion
Air fluid levelsAir fluid levels Think bowel or abscess:
Hiatal hernia Zenker diverticulum Epiphrenic diverticulum Achalasia Mediastinal abscess
AchalasiaAchalasia
Zenker diverticulumZenker diverticulum
Hiatal herniaHiatal hernia
Mediastinal abscess after Mediastinal abscess after CABGCABG
Differential diagnosis of Differential diagnosis of mediastinal massesmediastinal masses
Traditionally, we divide the mediastinum into compartments.
Likely diagnosis of mass depends on what is contained in each compartment
These are not anatomic boundaries, and masses commonly cross over into compartments where they don’t “belong”.
Posterior mediastinumPosterior mediastinum Paraspinal area Masses usually visible
on lateral film overlying spine
May obscure descending aorta contour
Posterior mediastinumPosterior mediastinum Neurogenic tumors
Schwannoma Sympathetic nerve tumors
e.g. ganglioneuroma Neurenteric cyst, lateral
meningocele Lymph nodes (unusual
as only area involved) Extramedullary
hematopoesis Vertebral tumors, spurs
SchwannomaSchwannoma
Extramedullary hematopoesisExtramedullary hematopoesis
Chronic anemias, myelodysplasias
Lateral meningocele in NF-1Lateral meningocele in NF-1
Anterior mediastinumAnterior mediastinum Space anterior to
great vessels and heart, behind the sternum
Anterior mediastinumAnterior mediastinum Most common:
Lymphoma Thymic lesions Germ cell origin tumors Thyroid masses
Also: Foregut cysts, nerve tumors, aortic aneurysm,
etc.
Anterior mediastinal massesAnterior mediastinal masses
thymic hyperplasia teratocarcinoma
teratoma lymphoma
thymoma
hemorrhage
Middle mediastinumMiddle mediastinum Contains heart, great
vessels, esophagus, trachea, lymph nodes, nerves.
CXR abnormality in paratracheal area, azygo-esophageal recess, retrocardiac area
May be difficult to see on lateral view
Middle MediastinumMiddle Mediastinum
Lymph nodes Foregut cysts Vascular lesions e.g. aneurysm Bronchogenic carcinoma Hiatal hernia, other esophageal or GI
lesions
Lymphoma Lymphoma
Cardiac evaluationCardiac evaluation Remember: cardiothoracic ratio of about
0.5 applies only to good PA chest x-rays. Knowing which chambers form which
cardiac contours can help identify what is enlarged.
Look for accompanying signs: Pulmonary venous engorgement and isolated
LA enlargement suggests mitral stenosis. Dilated aorta and LV enlargement suggests
aortic valve insufficiency.
Normal heart contoursNormal heart contours
Left atrium
Left ventricle
Right atrium
Left atrial enlargement-mitral Left atrial enlargement-mitral stenosisstenosis
Mitral valve
Left atrial enlargementLeft atrial enlargement
“Double density”
Straightened left heart border LA enlarged
LV normal
Enlarged ascending aorta in ASEnlarged ascending aorta in AS
Calcific Aortic StenosisCalcific Aortic Stenosis Enlarged ascending aorta, normal arch,
normal overall heart size
LVH
LV enlargementLV enlargement
Dilated cardiomyopathy Dilated cardiomyopathy multichanber enlargementmultichanber enlargement
The EndThe End