THORAKS

LATERAL VIEW
Retrosternal
Hilus Space

■ The retrosternal clear space

■ The hilar region
■ The fissures
■ The thoracic spine
■ The diaphragm and posterior costophrenic sulci

Retrocardiac
Space Rt diaphragma

Post
costophrenicus
angle
CARDIAC

• The cardiothoracic ratio should be <50% in most normal adults on a standard postero-anterior frontal
radiograph taken with an adequate inspiration (about nine posterior ribs showing)
LEFT VENTRICLE
 • Dilatation of the left ventricle results to lateral and downward displacement of the
cardiac apex on frontal chest radiographs. 
CARDIOMEGALY • Left ventricular hypertrophy usually results to rounded appearance of the cardiac

(LV) apex.
• On lateral view, left ventricular enlargement manifests as posterior displacement of
the left ventricular margin.
LEFT ATRIUM
 • double density sign

• distance of the right border of the left atrium from the midpoint of the left mainstem
bronchus is more than 7 cm

CARDIOMEGALY • enlarged left atrial appendage (third mogul sign)

(LA) • uplifted left mainstem bronchus

• widening of the carinal angle (more than 90 degrees)

• atrial escape (the right border of the markedly enlarged left atrium goes beyond the right
atrial margin)
WIDENED
CARINAL
ANGLE

UPLIFTED LEFT
MAINSTREAM
BRONCHUS
> 7 CM
• prominence of the upper posterior cardiac convexity

• posterior displacement of the left mainstem bronchus (walking man sign)

 • not more than 50% of the cardiovascular height
RIGHT ATRIUM • not more than 5.5 cm from the midline
CARDIOMEGALY (RA)

• elongation of the right heart border

(length of right atrial convexity
exceeds 50% of the mediastinal
cardiovascular shadow)
• lateral bulging of the right heart
border (right atrial margin is more
than 5.5 cm from the midline)
RIGHT
VENTRICLE
 • Significant enlargement of the right ventricle may result to an uplifted cardiac
apex.
CARDIOMEGALY
• On lateral view, an enlarged right ventricle may result to retrosternal
RV fullness. The anterior cardiac border is in contact with greater than the lower 1/3
of the sternal length.
 • There is markedly 
enlarged cardiac silhouette with
sagging appearance of its margins
on both sides resulting to a 
water bottle configuration. 
EFUSI
PERICARDIUM • Pericardial fluid (yellow *)
outlined by paracardial fat (blue
arrows) and epicardial fat (orange
arrows), giving a three layered
appearance, known as an Oreo
cookie sign. 
ATRIAL SEPTAL
DEFECT
• can be normal in early stages when the atrial
septal defect is small
• signs of increased pulmonary flow (
pulmonary plethora or shunt vascularity)
• enlarged pulmonary vessels
• upper zone vascular prominence
• vessels visible to the periphery of the film
• eventual signs of pulmonary arterial hypertension

• chamber enlargement 
• right atrium
• right ventricle
• note: left atrium is normal in size unlike VSD or
PDA
• note: aortic arch is small to normal
VENTRICULAR SEPTAL DEFECT

• The chest radiograph can be normal

with a small VSD. 
• Larger VSDs may show
cardiomegaly (particularly 
left atrial enlargement although the
right and left ventricle can also be
enlarged).
• A large VSD may also show features
of pulmonary arterial hypertension, 
pulmonary edema, pleural effusion,
and increased pulmonary vascular
markings.
PATENT DUCTUS
ARTERIOSUS
• type A: conical ductus with prominent
aortic ampulla and constriction near
the pulmonary artery end
• type B: window-like (wide and very
short) ductus
• type C: tubular ductus without
constrictions
• type D: complex ductus with multiple
constrictions
• type E: elongated ductus with
constriction remote from the anterior
edge of the trachea (when viewed on
lateral angiography)
 • Pulmonary stenosis

TETRALOGY OF • VSD

FALLOT • Overriding aorta

• Hypertrophy right ventricular
• Chest radiographs may classically show a "boot-shaped" heart with an
upturned cardiac apex due to right ventricular hypertrophy and concave
pulmonary arterial segment.
• Most infants with tetralogy of Fallot, however, may not show this finding 2.
• Pulmonary oligemia occurs due to decreased pulmonary arterial flow. A
right-sided aortic arch is seen in 25%.
AORTIC VALVE STENOSIS

• In early disease, the chest radiograph can be entirely normal or it may show 
dilatation of the ascending aorta with a normal heart size. Differentiation with 
hypertension can usually be made as in hypertension the entire descending aorta
is enlarged.
• However, late in the disease, the chest radiograph may reveal valvular calcifications
(if valvular aortic stenosis) and/or cardiomegaly with features of heart failure, such
as pulmonary venous congestion and pulmonary interstitial/alveolar edema. At
this stage, especially in the absence of valvular calcifications, it is not possible to
differentiate aortic stenosis from other causes of heart failure. 
• The ascending aorta (yellow dotted line) leading into the arch is dilated, whereas the
distal arch and descending aorta (red dotted line) are normal in size.
• The left heart border (blue dotted line) can be traced upwards along the
mediastinum to blend with the aortic arch, explaining why the medial (left) border of
the ascending aorta is not visible on x-rays. 
• Calcified aortic valve (green arrows) noted on CT. 
COARCATIO AORTA

• figure of 3 sign: contour

abnormality of the aorta
• inferior rib notching: Roesler sign
• secondary to dilated intercostal collateral vessels which form as a way
to bypass the coarctation and supply the descending aorta
• the dilated and tortuous vessels erode the inferior margins of the ribs,
resulting in notching
• seen only in long standing cases, and therefore not seen in infancy
(unusual in patients <5 years of age) 7
• seen in 70% of cases presenting in older children or adults
• if the coarctation is distal to either subclavian artery, then increased
flow occurs through the subclavian artery, forming a collateral pathway
via the internal thoracic artery, anterior intercostal artery, posterior
intercostal artery and then into the descending thoracic aorta
• usually the 4th to 8th ribs are involved; occasionally involves the 3rd to
9th ribs
• as the 1st and 2nd posterior intercostal arteries arise from the 
costocervical trunk (a branch of the subclavian artery) and do not
communicate with the aorta, these are not involved in collateral
formation, and the 1st and 2nd ribs do not become notched
• if bilateral rib notching: the coarctation must be distal to the origin of
both subclavian arteries, to enable bilateral collaterals to form
• if unilateral right rib notching
• then the coarctation lies distal to the brachiocephalic trunk but
proximal to the origin of the left subclavian artery
• or there may be a right sided aortic arch with aberrant left
subclavian artery distal to coarctation
• collaterals cannot form on the left, as the left subclavian
is distal to the coarctation
• if unilateral left rib notching, then this suggests an associated 
aberrant right subclavian artery arising after the coarctation
• the coarctation is distal to the origin of the left subclavian artery,
therefore collaterals form on the left
• collaterals cannot form on the right, as the aberrant right
subclavian artery arises after the coarctation
PULMONARY HYPERTENSION

• elevated cardiac apex due to

right ventricular hypertrophy
• enlarged right atrium
• prominent pulmonary outflow
tract
• enlarged pulmonary arteries
• pruning of peripheral
pulmonary vessels
• radiographic correlates of
underlying causes like
kyphoscoliosis, valvular heart
disease, or changes due to
interstitial lung disease can
also be noted in some cases
AORTA
ANEURYSM • The location and shape of thoracic aortic aneurysms are variable. An aortic
aneurysm, as aneurysms elsewhere, can be described as saccular or fusiform.

• In the case of fusiform dilatation, the term aneurysm should be applied when
the diameter is >4 cm 1.
RESPIRATORY
TUBERCULOSIS

• primary infection can be anywhere in the lung in children whereas

there is a predilection for the upper or lower zone in adults 1
• post-primary infections have a strong predilection for the upper
zones
• miliary tuberculosis is evenly distributed throughout both lungs
PRIMARY
TUBERCULOSIS

It is most common in infants and children and has the

highest prevalence in children under 5 years of age 1.
• parenchymal disease
• usually manifests as dense, homogeneous
parenchymal consolidation in any lobe
• however, predominance in the lower and
middle lobes (subpleural sites) is suggestive of
the disease, especially in adults 1
• lymphadenopathy
• miliary opacities

• clustered parenchymal opacification may give a 

galaxy sign

• pleural effusion
POST PRIMARY
TUBERCULOSIS
Parenchymal disease Airway disease

• ill-defined patchy • Central airway involvement

consolidation  results in bronchial stenosis
 which may lead to lobar
• clustered parenchymal collapse associated with
opacification may give rise to traction bronchiectasis and
a galaxy sign mucoid impaction. 
• cavitation usually develops Pleural disease
within the consolidation
• occurs in a minority of cases
• fibroproliferative disease with (18%)
coarse reticulonodular
densities • small pleural effusion

• endobronchial spread with " • pleural thickening

tree-in-bud" appearance, best
appreciated on HRCT • pleural calcification

• healing results in fibrosis, Chest wall involvement

volume loss and traction
• Chest wall involvement
bronchiectasis
occurring due to direct
• lymphadenopathy occurs only extension from pulmonary
in 5% cases disease manifests as bone
and/or cartilage destruction
and cutaneous fistula
formation.
 MILIARY TUBERCULOSIS

• Miliary deposits appear as 1-3 mm diameter

nodules, which are uniform in size and
uniformly distributed.
BRONCHITIS

• acute bronchitis
• short-term process (<3 months in
length but typically lasting 2–10
days) with symptoms occasionally
lingering for 2–3 weeks post-
infection 6
• chronic bronchitis
• productive cough most days for ≥3
months in 2 consecutive years in
patients for whom other causes of
chronic cough have been
excluded 6
BRONCHIOLITIS

Plain radiograph

• Usually not detected at chest radiography but may manifest with

non-specific findings such as ill-defined small or hazy clustered
nodules or areas of air trapping characterized by hyperlucency
and/or oligemia .

CT - HRCT

• The presence of bronchiolitis is best assessed with HRCT. CT

features include one of a combination of

• centrilobular micronodules (often seen as tree-in-bud opacities),

• bronchial wall thickening

• bronchiolar dilatation (often referred to as bronchiolectasis)

• mosaic attenuation (and/or air trapping if expiratory imaging is

used)
THORAKS MASS

PULMONARY PLEURA EXTRA PLEURA

Acute angle Obtuse angle Obtuse angle
Menginfiltrasi pulmonary vasculer Displacement pulmo vasculer Displacement pulmo vasculer

Centralisasi pada pulmo Centralisasi pada dinding thoraks Centralisasi pada dinding thoraks
Batas tak tegas Batas tegas Batas tegas
Incomplete border sign
Pindah tempat saat respirasi
Displacement extrapleura fat ke Displacement extrapleura fat ke
luar dalam
Erosi ossa costae jarang Erosi ossa costae jarang Erosi ossa costae sering
LUNG MASS
PLEURAL MASS
PANCOAST
TUMOR

• Plain films demonstrate a soft

tissue opacity at the apex of
the lung.

• Occasionally rib involvement

or extension into the
supraclavicular fossa may be
evident. Lordotic views may
be helpful.
MEDIASTINUM
MASS
 • Airspace disease characteristically produces opacities in the
lung which can be described as fluffy, cloudlike, or hazy.
PNEUMONIA • Chest x-ray and CT are unable to differentiate bacterial pneumonia
from non-bacterial pneumonia
 • Atelectasis describes small areas of collapsed lung

• Atelectasis is usually seen on chest x-rays as small volume linear shadows, usually
peripherally or at the lung bases.

ATELECTASIS • The underlying cause (such as a lung tumor or pleural effusion) may also be visible.

• Lobar collapse will have a more typical and appearance based on the lobe involved,
whereas atelectasis can be more eccentric in position and appearance.
 • Displacement (shift) of the interlobar fissures (major and
COLAPS PULMO minor) toward the area of atelectasis
• Increase in the density of the affected lung
 • Chest x-rays are usually abnormal but are inadequate in the diagnosis or
quantification of bronchiectasis. 

• Tram-track opacities are seen in cylindrical bronchiectasis, and air-fluid levels may

BRONCHIECTASIS
be seen in cystic bronchiectasis.

• Overall there appears to be an increase in bronchovascular markings, and bronchi

seen end-on may appear as ring shadows 8.

• Pulmonary vasculature appears ill-defined, thought to represent peri-

bronchovascular fibrosis 8,9.
Pulmonary emphysema

• hyperinflation
• flattened hemidiaphragm(s): the most reliable sign
• increased and usually irregular radiolucency of the
lungs
• increased retrosternal airspace
• increased anteroposterior diameter of the chest • vascular changes
• widely spaced ribs • a paucity of blood vessels which are often distorted
• sternal bowing • pulmonary arterial hypertension
• tenting of the diaphragm • pruning of peripheral vessels
• saber-sheath trachea • an increased caliber of central arteries

• blunting of the lateral and posterior costophrenic • right ventricular enlargement

angles
ABCESS PULMONUM

• The classical appearance of

a pulmonary abscess is a
cavity containing a gas-fluid
level.

• In general, abscesses are

round in shape and appear
similar in both frontal and
lateral projections.
ASPERGILOMA

• An aspergilloma can be seen as a mass within a 

cavity. 

• The mass is typically spherical or ovoid.

• The air around the aspergilloma takes a

crescentic shape, termed the Monod sign, which
is distinct from the air crescent sign in
recovering invasive aspergillosis. 

• On different positioning of the patient, the mass

can be shown to be mobile. 
EFUSI PLEURA
EFUSI
PLEURA
MASIF
EMPYEMA
PLEURAL
PNEUMOTHORAX
• visible visceral pleural edge is seen as a very thin, sharp white line

• no lung markings are seen peripheral to this line

• peripheral space is radiolucent compared to the adjacent lung

• lung may completely collapse

• mediastinum should not shift away from the pneumothorax

unless a tension pneumothorax is present (discussed separately)
• subcutaneous emphysema and pneumomediastinum may also
be present
TENSION
PENUMOTHORAKS

• ipsilateral increased intercostal spaces

• contralateral shift of the mediastinum

• depression of the hemidiaphragm
PNEUMOMEDIASTINUM

• subcutaneous emphysema

• gas anterior to pericardium: pneumopericardium

• gas around pulmonary artery and main branches: 

ring around artery sign

• gas outlining major aortic branches: tubular artery sign

• gas outlining bronchial wall: double bronchial wall sign

• continuous diaphragm sign: due to gas trapped posterior to 

pericardium

• gas between parietal pleura and diaphragm: extrapleural

sign

• gas in pulmonary ligament

• Naclerio V sign
• Posteroanterior chest x-ray: A1)
Radiological findings of
pneumomediastinum such as gas
around ascending aorta (arrows),
gas in neck tissues and
subcutaneous emphysema
(arrowhead) and Naclerio V sign.
A2)

• Normal chest radiograph on twelfth

postoperative day. B1) Earth-heart
Sign: The cardiac silhouette appears
to be flattened. This sign reflects
cardiac compression caused by
tension pneumomediastinum. B2)

• Normal cardiac silhouette on

twelfth postoperative day after gas
drainage.
 • elevated thymus: thymic wing sign
PNEUMOME • gas crossing the superior
DIASTINUM mediastinum: haystack sign (the
heart appears like a haystack in a

PEDIATRIC Monet painting)

 • On both chest radiographs and CT, appearances are characteristic,
the heart being partially or completely surrounded by gas, with the
PNEUMOPERICARDIUM pericardium sharply outlined by gas density on either side. 

• Continuous diaphragm sign may be present.

EDEMA
PULMONUM

• upper lobe pulmonary venous diversion (

stag's antler sign)
• increased cardiothoracic ratio/cardiac silhouette size:
useful for assessing for an underlying cardiogenic cause
or association
• features of pulmonary interstitial edema:
• peribronchial cuffing and perihilar haze
• septal (Kerley) lines
• thickening of interlobar fissures

• features of pulmonary alveolar edema:

• air space opacification classically in a batwing distribution 
• may have air bronchograms

• pleural effusions and fluid in interlobar fissures (including

'vanishing' pulmonary pseudotumor)
• Kerley A lines (orange)

• These are 2-6 cm long oblique lines that are <1 mm thick
and course towards the hila. They represent thickening of
the interlobular septa that contain lymphatic connections
between the perivenous and bronchoarterial lymphatics
deep within the lung parenchyma. On chest radiographs
they are seen to cross normal vascular markings and
extend radially from the hilum to the upper lobes. HRCT is
the best modality for the demonstration of Kerley A lines.

• Kerley B lines (Blue)

• These are thin lines 1-2 cm in length in the periphery of

the lung(s). They are perpendicular to the pleural surface
and extend out to it. They represent thickened subpleural
interlobular septa and are usually seen at the lung bases.

• Kerley C lines (green)

• Kerley C lines are short lines which do not reach the

pleura (i.e. not B or D lines) and do not course radially
away from the hila (i.e. not A lines).

• Kerley D lines

• Kerley D lines are exactly the same as Kerley B lines,

except that they are seen on lateral chest radiographs in
the retrosternal air gap 2.