Study Smarter
Evidence of an enlarged left ventricle can be as follows:
a) displacement of cardiac apex inferiorly and posteriorly
b) boot shaped heart
c) Rigler’s sign (on the lateral film, from the junction of IVC and heart at the level of the diaphragm, measure 1.8 cm posteriorly and then 1.8 cm superiorly. If the cardiac shadow extends beyond this point then LV enlargement is suggested
This patient had rheumatic heart disease with mitral stenosis. Left atrial enlargement is suggested by the “double contour” sign, (i.e. 2 right heart borders), and the “ballerina” sign, an increase in the angle between the left and right main bronchi (also known as a “splayed carina”). Other signs of left atrial enlargement (not well seen here) include a straightening of the left heart border and elevation of the left main bronchus (specifically the upper lobe bronchus on the left lateral film), with a distance between this bronchus and the “double” heart border >7 cm. There is also cardiomegaly (cardiothoracic ratio >0.5), suggesting ventricular failure. Loss of angle between left pulmonary artery and left heart border also suggests ventricular enlargement. Prominent vasculature in bilateral lung fields, with cephalization (more prominent towards the upper fields), suggests pulmonary venous congestion, interstitial edema, and pulmonary hypertension. Mitral valve calcification is difficult to appreciate and better seen with fluoroscopy.
Advanced atherosclerotic calcification of the coronary arteries is noted in this lateral radiograph.
Calcification of the aortic valve (arrow) is best noted on the lateral projection in this elderly patient.
Note the markedly widened mediastinum in the AP view (below), which is suggestive of aortic aneurysmal/dissection disease. The CTs presented below show the “snowman” sign depicting the aneurysm, filling defects, and and extravasation.
Frontal radiograph demonstrates a hugely dilated aorta consistent with an aneurysm of the aorta. [Courtesy of Dr. N. Jaffer]
Note aortic and mitral valve replacements on this lateral radiograph.
This patient has suffered complete collapse of the right upper lobe. Note the opaque, atelectatic right upper lobe projecting over the superior right hemithorax. This image is a good example of the “S-sign” of Golden: The displaced minor fissure resembles an inverted “S” in contour. The collapse is most likely due to a mass in the region of the right superior lobar bronchus. The collapsed right upper lobe also demonstrates the “silhouette” sign; in this case, the adjacent superior vena cava’s border is obscured by the right upper lobe. There is mild elevation of the right hemidiaphragm, consistent with atelectasis on the right. Although not convincingly seen here, other indirect signs such as hilar and mediastinal shift can also be present with atelectasis. Multiple surgical clips are noted in the region of the thoracic inlet.
This patient has suffered complete collapse of the right middle lobe. Note the opaque, atelectatic right middle lobe projecting over the mid right hemithorax. The collapsed right middle lobe also demonstrates the “silhouette” sign; in this case, part of the adjacent right heart border is obscured by the atelectatic lobe. The lateral view demonstrates the flat, “pancake”-shaped right middle lobe. The minor fissure (black arrow) and major fissure (green arrow) approximate as the intervening lung tissue collapses.
This patient suffered complete collapse of the right lower lobe. The major fissure is clearly displaced inferiorly, the atelectatic lobe projects as a flat opacity, and the right hemidiaphragm is “silhouetted” (see below). Indirect signs of atelectasis include a right shift of the mediastinum. Other indirect signs such as compensatory hyperinflation, elevation of the right hemidiaphram, and hilar shift are not seen here. This study is an excellent example of the “silhouette” sign. In a normal chest x-ray, the diaphragm and mediastinal structures are visible because of the difference in radiodensity between lung and these structures (i.e there is an “interface” between the tissues). The “silhouette” sign refers to a loss of normally appearing interfaces, implying opacification due to consolidation (most common), atelectasis, mass, etc., in adjacent lung. In this case, the collapsed right lower lobe “silhouettes” the right hemidiaphragm. Note that the right heart border, adjacent to the right middle lobe, is clearly visible.
