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Cardiac Radiology​

Causes of inferior rib notching:
a. Aortic coarctation                                                              b. Aortic thrombus                         
c. Aortitis (Takayasu's arteritis)                                              d. Arteritis                                          
e. Blalock Taussig operation                                                   f. Atherosclerotic occlusion
g. Pulmonary atresia                                                              h. Fallot's tetralogy                         
i. Multiple pulmonary arterial stenoses                                    j. Pulmonary/chest wall AV malformation   
k. Chronic SVC obstruction                                                     l. Neurofibromatosis                                     
m. Poliomyelitis/quadriplegia/paraplegia                                n. Hyperparathyroidism                                
o. Thalassemia                                                                    p. Melnick-Needles syndrome
Causes of superior margin rib notching:
a. Normal variant (isolated defects, projectional)        b. Paralytic polio                              
c. Quadriparesis                                                      d. Rheumatoid arthritis, SLE, scleroderma
e. Coarctation of aorta                                             f. OGI (Osteogenesis imperfecta)       
g. Marfan syndrome                                                 h. Hyperparathyroidism
i. Restrictive lung diseases                                        j. Chest drainage tube  
k. Osteochondroma                                                  l. Neural tumor
  1. Signs of Left atrial enlargement on CXR
    QElevation of left main bronchus (earliest sign), which, if gross, may lead to splaying of carina.
    1. Left atrium on enlargement bulges to right, produces a double shadow seen through the right side of heart (buttressing), until it eventually forms part of right heart border. The distinguishing point is that the right atrial border is limited below by the IVC while the left atrial border passes medially towards the spine before fading.
    2. A distance between the middle of the double density of heart and the left main stem bronchus of more than 7 cm has been shown to indicate left atrial enlargement in over 90% of cases.
    3. Particularly in rheumatic mitral valve disease, there may be left atrial with specific enlargement of the left atrial appendage, first seen as a straightening of left border below the left main bronchus, then as a discrete bulge on the left, immediately below the pulmonary bay and left main bronchus.
    4. Rarely, the enlarged left atrium may displace the esophagus to the side of spine, usually to right.
    5. Rarely, descending aorta may also be displaced to the left. (Bedford sign) Q i.e. the descending aorta is displaced to left by the enlarged left atrium and gives a smooth curve on the descending aorta.
Extra Edge

Elevation of left main bronchus is the earliest X-ray sign of LA enlargement.

  1. CXR features of CCF
    Features of CCF are basically due to following phases: Q
    1. Interstitial pulmonary edema                                       
    2. Air space edema
    3. Flow inversion                                                                 
    4. Generalized oligemia
    5. Cardiac enlargement                                                     
    6. Pleural effusion
Extra Edge

Upper lobar diversion of vessels is earliest sign seen in CCF due to pulmonary venous hypertension ("hands-up" sign or stag-antler's sign). Q

  1. CXR features Atrial septal defect (ASD)
    1. The three types of ASD include ostium secundum or fossa ovalis defect, sinus venosus defect, and endocardial cushion defects (ECD).
    2. If the left to right shunt (ASD) produces a shunt ratio greater than 2:1, the heart is obviously enlarged, involving RA and RV.
    3. QThere is no enlargement of the LA, except in few cases of ECD or Lutembacher syndrome.
    4. The heart in ASD is sometimes displaced to left.
    5. The ascending aorta and its arch tend to appear smaller than normal, probably due to the rotation of ascending aorta by enlarged RA and RV, causing saggital alignment of the aortic arch (Small aortic knuckle).
    6. The central pulmonary arteries are enlarged and there is a variable degree of pulmonary plethora, depending on the size of shunt.
    7. QSeptal lines (Kerley B lines) in a patient of ASD should always suggest an associated mitral valve abnormality (ECD or Lutembacher syndrome).
    8. QThe “great hilar dance” sign characterizes ASD on fluoroscopy.
    9. QThe "Goose-neck" deformity is seen in ASD on cardioangiography.
  2. QCXR signs of Eisenmenger syndrome
    1. Prominence of the pulmonary arterial segment and large right and left main pulmonary arteries and their branches.
    2. The peripheral lung fields are oligemic due to pruning of peripheral pulmonary arteries.
    3. Ventricles (right and left) return to normal size.
  3. Pulmonary venous hypertension (PVH)
    It is caused by increased resistance to blood flow in the pulmonary veins, due to obstruction or reduced compliance within the left atrium, at the mitral valve, or within the left ventricle.
Causes of Pulmonary Venous Hypertension And Pulmonary Oedema
  1. Left ventricular outflow obstruction, e.g. aortic coarctation, aortic stenosis, hypoplastic left heart
  2. Left ventricular failure
  3. Mitral valve disease
  4. Left atrial myxoma
  5. Fibrosing mediastinitis
  6. Pulmonary veno-occlusive disease
It is divided into 3 grades of severity:
  1. Grade I PVH:
    1. Reversal of normal gravity dependent gradient of pulmonary blood flow with diameter of upper lobar vessels greater than that of lower lobe vessels (earlies X-ray sign of PVH). Q
    2. Enlargement of right superior pulmonary vein with loss of hilar angle (lateral concavity of hilum)
    3. Loss of visibility of mid and distal portions of right descending pulmonary trunk
  1. Grade II PVH:
    1. Interstitial pulmonary edema
    2. Pleural effusion
  1. Grade III PVH:
    1. Alveolar pulmonary edema with bilateral fluffy alveolar opacities
    2. Cardiomegaly (left atrial enlargement)
  1. Kerley Lines
    As pulmonary venous pressure rises, the upper lobe veins distend. They initially reach the size of, and eventually become larger than, the lower lobe vessels (thus reversing the normal ‘gravity-dependent’ pattern). This is described as ‘upper lobe venous diversion’ and is often the first recognized radiological sign of pulmonary venous hypertension . If the pulmonary venous pressure continues to rise and exceeds the plasma oncotic pressure, fluid will begin to accumulate in the lung interstitium. The accumulation of fluid in the interstitial space also causes: indistinctness of vessel margins and bronchial walls; increased opacity of all or portions of the lung pulmonary clouding; perihilar clouding; peribronchial thickening; reticulated parenchymal pattern in the lower lung zone; and subpleural oedema transient pleural thickening. This is known as interstitial pulmonary oedema. Radiologically this is associated with the appearance of interstitial (Kerley B) lines. These lines represent thickening of interlobular septa (as a result of fluid accumulation) within the lung. They were classified into two groups:
    1. Kerley A lines are approximately 4 cm in length and are most conspicuous in the upper and mid portions of the lung. They are deep septal lines (lymphatic channels) that radiate from the hila into the central portions of the lungs but do not reach the pleura. Their presence normally indicates a more acute or severe degree of oedema.
    2. Kerley B lines are shorter (1 cm or less) interlobular septal lines, found predominantly in the lower zones peripherally, and parallel to each other but at right angles to the pleural surface.
    3. Persistent septal lines are sometimes seen in noncardiac diseases such as lymphangitic carcinomatosis, lymphangiomyomatosis pneumoconiosis, or central lymphatic obstruction by tumour or irradiation.

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