3

Recognizing Normal Pulmonary Anatomy

In this chapter, you will learn the normal anatomy of the lungs • Fig. 3.2 shows vessels and bronchi—normal lung markings.
as depicted by conventional radiographs and chest CT. To become • Virtually all of the “white lines” you see in the lungs on
more comfortable interpreting images of the chest, you should a chest radiograph are blood vessels. Blood vessels char-
first be able to recognize fundamental, normal anatomy to dif- acteristically branch and taper gradually from the hila
ferentiate it from what is abnormal (Box 3.1). centrally to the periphery of the lung. You cannot accurately
differentiate between pulmonary arteries and pulmonary
veins on a conventional radiograph.
THE NORMAL FRONTAL CHEST RADIOGRAPH • Bronchi are mostly invisible on a normal chest radiograph
• Fig. 3.1 displays some of the normal anatomic features visible because they are normally very thin-walled, they contain
on the frontal chest radiograph. air, and they are surrounded by air.

BOX 3.1 Which “System” Works Best

What is the best system to look at an imaging study, such as a chest x-ray?
I’m glad you asked. Trachea
3
Some individuals systematically look at imaging studies, such as chest radio-
graphs, from the outside of the image to the inside of the image; others look
at them from the inside out or from top to bottom. Some systems for reminding
you to examine every part of an image have catchy acronyms and Coracoid process- Head of clavicle
mnemonics. scapula
3
The fact is it does not matter what system you use as long as you Aortic
knob
look at everything on the image. So, use whatever system works for you, Move this Medial border-
but be sure to look at everything. “Looking at everything,” by the way, includes circle down scapula
Ascending
looking at all of the views available in a given study, not just everything aorta-
superior
on one view (do not forget the lateral chest radiograph in a two-view study Pulmonary blood vena cava Main
vessels pulmonary
of the chest). artery Left hilum-
Left pulmonary
Experienced radiologists usually have no system at all. “Burned-in” artery
Rght hilum-
images are bad for computer monitors, but they are great for radiologists. Right pulmonary
artery Descending
“Burned” into the neurons of a radiologist’s brain are mental images of what aorta
Right
a normal frontal chest radiograph looks like, what thoracic sarcoidosis looks atrium
like, and so on. Radiologists frequently use a “gestalt” impression of a study
Left
that they see in their mind’s eye within seconds of looking at an image. If the ventricle

image does or does not correspond to the mental image that resides in their
brains, then they systematically study the images. This is not magic; this
ability comes only with experience so, at least for now, you are probably not Cardiophrenic
quite ready to use the “gestalt” approach. Right breast
shadow
angle Cardiophrenic
Right angle Left
The most important part of the “system” you use in interpreting images is hemidiaphragm hemidiaphragm
a system in which you routinely increase your knowledge. If you do Costophrenic
Costophrenic
angle
not know what you are looking for, you can stare at an image for hours or angle

days or, in the case of the lateral chest radiograph, you can ignore an image Fig. 3.1 Well-Exposed Frontal View of a Normal Chest. Notice how
entirely, and the result will be the same: you will not see the findings. There the spine is just visible through the heart shadow. Both the right and
is an axiom in radiology: You only see what you look for and you only left lateral costophrenic angles are sharply and acutely angled. The white
look for what you know. So, if you do not know what to look for, you will line demarcates the approximate level of the minor or horizontal fissure,
never recognize the finding no matter what system you use or how long you which is usually visible on the frontal view. There is no minor fissure
stare at the image. on the left side. The white circle contains lung markings that are blood
By reading this book, you will gain the knowledge that will allow you to vessels. Note that the left hilum is normally slightly higher than the
recognize what it is you are looking at—the best system of all. right. The white numeral 3 lies on the posterior third rib, whereas the
black numeral 3 lies on the anterior 3rd rib.

14
 CHAPTER 3 Recognizing Normal Pulmonary Anatomy 15

• Pleura: normal anatomy upright, left lateral view of the chest. A left lateral chest
• The pleura is composed of two layers, the outer parietal x-ray (the patient’s left side is against the detector) is of great
and inner visceral layers with the pleural space between diagnostic value but is sometimes ignored by beginners
them. The visceral pleura is adherent to the lung and enfolds because of their lack of familiarity with the findings visible
to form the major (oblique) and minor (horizontal) in that projection.
fissures. • Why look at the lateral chest?
• Normally there are several milliliters of fluid, but no air, • It can help you determine the location of disease you
in the pleural space. already identified as being present on the frontal image.
• Neither the parietal pleura nor the visceral pleura is • It can confirm the presence of disease you may be unsure
normally visible on a conventional chest radiograph, except of on the basis of the frontal image alone, such as a mass
where the two layers of visceral pleura enfold to form the or pneumonia.
fissures. Even then, they are usually no thicker than a line • It can demonstrate disease not visible on the frontal image
you could draw with the point of a sharpened pencil. (Fig. 3.3).

Normal Pulmonary Vasculature

IMPORTANT POINTS
• In the upright position, the blood flow to the bases is normally greater
than the flow to the apices because of the effect of gravity. Therefore the
vessels at the base are normally larger in size than the vessels at the
apex of the lung.

• Normally, blood vessels branch and taper gradually from

central (the hila) to peripheral (near the chest wall) (Fig. 3.2).
• Changes in pressure or flow can alter the normal dynamics
of the pulmonary vasculature, some of which are described
in Chapter 12.
• For more on recognizing normal pulmonary vasculature
and an imaging approach to diagnosing heart disease in
adults, registered users can view “The ABCs of Heart Disease”
online.

Fig. 3.2 Normal Pulmonary Vasculature. The right lung is shown. In

THE NORMAL LATERAL CHEST RADIOGRAPH the upright position, the lower lobe vessels (black circle) are larger in
size than the upper lobe vessels (white circle) and all vessels taper
• As part of the standard two-view chest examination, patients gradually from central to peripheral (white arrow). Alterations in pulmo-
usually have an upright, frontal chest radiograph and an nary flow or pressure may change these relationships.

A B
Fig. 3.3 The Spine Sign. Frontal (A) and lateral (B) views of the chest demonstrate air space disease on the lateral image (B) in the left lower lobe
that may not be immediately apparent on the frontal image (look closely at A and you may see the pneumonia in the left lower lobe behind the
heart). Normally, the thoracic spine appears to get “blacker” as you view it from the neck to the diaphragm because there is less dense tissue
for the x-ray beam to traverse just above the diaphragm than in the region of the shoulder girdle (see Fig. 3.4). In this case, a left lower lobe
pneumonia superimposed on the lower spine in the lateral view (white arrow) makes the spine appear “whiter” (more dense) just above the
diaphragm. This is called the spine sign. Note that on a well-positioned lateral projection, the right and left posterior ribs almost superimpose on
each other (black arrow), a sign of a true lateral.
16 CHAPTER 3 Recognizing Normal Pulmonary Anatomy

• Figs. 3.4 and 3.5 display some of the normal anatomic features TABLE 3.1 The Lateral Chest: A Quick
visible on the lateral chest radiograph. Guide of What to Look for
Five Key Areas on the Lateral Chest X-Ray (See Fig. Region What You Should See
3.4 and Table 3.1) Retrosternal clear space Lucent crescent between sternum and
• The retrosternal clear space ascending aorta
• The hilar region Hilar region No discrete mass present
• The fissures Fissures Major and minor fissures should be pencil
• The thoracic spine point thin, if visible at all.
• The diaphragm and posterior costophrenic sulci Thoracic spine Rectangular vertebral bodies with parallel
end plates; disk spaces maintain height
The Retrosternal Clear Space from top to bottom of thoracic spine
• Normally, there is a relatively lucent crescent just behind Diaphragm and posterior Right hemidiaphragm slightly higher than left;
the sternum and anterior to the shadow of the ascending costophrenic sulci sharp posterior costophrenic sulci
aorta. Look for this clear space to “fill-in” with soft-tissue
density when there is an anterior mediastinal mass present
(Fig. 3.6).

Fig. 3.4 Normal Left Lateral Chest Radiograph. There is a clear space behind the sternum (solid white arrow).
The hila produce no discrete shadow (white circle). The vertebral bodies are approximately of equal height and
their end plates are parallel to each other (double white arrows). The posterior costophrenic angles (solid black
arrow) are sharp. Notice how the thoracic spine appears to become blacker (darker) from the shoulder girdle
(black star) to the diaphragm because there is less dense tissue for the x-ray beam to traverse at the level of the
diaphragm. The superior surface of the right hemidiaphragm is frequently seen continuously from back to front
(dotted black arrow) because it is not obscured by the heart, whereas the heart normally touches the anterior
aspect of the left hemidiaphragm and obscures (silhouettes) it. Notice the normal space posterior to the heart
and anterior to the spine; this will be important in assessing cardiomegaly (see Chapter 12). The black line rep-
resents the approximate location of the major fissure; the white line is the approximate location of the minor
fissure. Both are frequently visible on the lateral view.
 CHAPTER 3 Recognizing Normal Pulmonary Anatomy 17

P A

Fig. 3.5 Normal Left Lateral Chest Radiograph, Additional Findings. Fig. 3.7 Arms Obscure Retrosternal Clear Space. In this example,
The left main pulmonary artery (white solid arrow) arches over the air- the patient was not able to hold her arms over her head for the lateral
filled left main bronchus (dotted black arrow), superior and posterior to chest examination, as patients are instructed to do in order to eliminate
the right main pulmonary artery (solid black arrow). Normally, the right the shadows of the arms from overlapping the lateral chest. The humeri
main pulmonary artery produces an opacity anterior to the distal trachea are clearly visible (white arrows) so even though the soft tissue of the
(T), but there should be only aerated lung posterior and inferior to the patient’s arms appears to fill in the retrosternal clear space (black arrows),
distal trachea. A, Anterior; P, posterior. this should not be mistaken for an abnormality such as anterior medi-
astinal adenopathy

DIAGNOSTIC PITFALL
• Be careful not to mistake the soft tissue of the patient’s superimposed
arms for “filling-in” of the clear space. Although patients are asked to hold
their arms over their head for a lateral chest exposure, many are too weak
to raise their arms. To avoid this pitfall, you should be able to identify the
patient’s arm by identifying the humerus (Fig. 3.7).

A B
Fig. 3.6 Anterior Mediastinal Adenopathy. (A) A normal lateral view shows a clear space behind the
sternum (white arrow). (B) Left lateral view of the chest demonstrates a soft-tissue density which is filling
in the normal clear space behind the sternum (black arrow). This represents anterior mediastinal lymph-
adenopathy in a patient with lymphoma. Adenopathy is probably the most frequent reason the retrosternal
clear space is obscured. Thymoma, teratoma, and substernal thyroid enlargement also can produce anterior
mediastinal masses, but do not usually produce exactly this appearance.
18 CHAPTER 3 Recognizing Normal Pulmonary Anatomy

The Hilar Region • The minor fissure lies at the level of the fourth anterior rib
• The hila may be difficult to assess on the frontal view, espe- (on the right side only) and is horizontally oriented (see
cially if both hila are slightly enlarged because comparison Fig. 3.4).
with the opposite normal side is impossible. The lateral view • Both the major and minor fissures may be visible on the
may help. Most of the hilar densities are made up of the lateral view, but because of the oblique plane of the major
pulmonary arteries. Normally, no discrete mass is visible in fissure, only the minor fissure is usually visible on the frontal
the hilar region on the lateral view (see Fig. 3.5). view.
• When there is a hilar mass, such as might occur with enlarge- • When a fissure contains fluid or develops fibrosis from a
ment of hilar lymph nodes, the hilum (or hila) will cast a chronic process, it will become thickened (Fig. 3.9). Thick-
distinct, lobulated, mass-like shadow on the lateral radiograph ening of the fissure by fluid is almost always associated with
(Fig. 3.8). other signs of fluid in the chest, such as Kerley B lines and
pleural effusions (see Chapter 12). Thickening of the fissure
The Fissures by fibrosis is the more likely cause if there are no other signs
• On the lateral projection, both the major and minor fissures of fluid in the chest.
may be visible as smooth, fine, white lines. The fissures demar-
cate the upper and lower lobes on the left and the upper, The Thoracic Spine
middle, and lower lobes on the right. • Normally, the thoracic vertebral bodies are roughly rectan-
• The major fissures course obliquely, roughly from the level gular in shape, and each vertebral body’s endplate parallels
of the fifth thoracic vertebra to a point on the diaphragmatic the endplate of the vertebral body above and below it. Each
surface of the pleura a few centimeters behind the sternum. intervertebral disk space becomes slightly taller than or

Fig. 3.8 Hilar Mass on Lateral Radiograph. Left lateral view of the chest shows a discrete, lobulated mass
in the region of the hila (black arrows). Compare this with the normal hilum in Fig. 3.5. This patient had
bilateral hilar adenopathy from sarcoidosis, but any cause of hilar adenopathy or a primary tumor in the hilum
would have a similar appearance.
 CHAPTER 3 Recognizing Normal Pulmonary Anatomy 19

Fig. 3.9 Fluid in the Major Fissures. Left lateral view of the chest shows thickening of both the right and
left major fissures (white arrows). This patient was in congestive heart failure and this thickening represents
fluid in the fissures. Normally, the fissures are either invisible or, if visible, they are fine, white lines of
uniform thickness no larger than a line made with the point of a sharpened pencil. The course of the major
fissure is usually from the level of the fifth thoracic vertebral body to a point on the anterior diaphragm about
2 cm behind the sternum. Notice the increased interstitial markings that are visible throughout the lungs,
which are due to fluid in the interstitium of the lung.

remains the same as the one above it throughout the thoracic

spine.
• Degeneration of the disk can lead to narrowing of the disk
space and the development of small, bony spurs (osteophytes)
at the margins of the vertebral bodies.
• When there is a compression fracture, most often from
osteoporosis, the vertebral body loses height. Compression
fractures very commonly first involve depression of the supe-
rior endplate of the vertebral body (Fig. 3.10).
• Do not forget to look at the thoracic spine when studying
the lateral chest radiograph for valuable clues about systemic
disorders (see Chapter 22).

The Diaphragm and Posterior Costophrenic Sulci

• Because the diaphragm is composed of soft tissue (muscle)
and the abdomen below it contains soft-tissue structures such
as the liver and spleen, only the upper border of the dia-
phragm, abutting an air-filled lung, is usually visible on con-
ventional radiographs.
• Even though we have one diaphragm that separates the thorax
from the abdomen, we do not usually see the entire diaphragm
Fig. 3.10 Osteoporotic Compression Fracture and Degenerative Disk
from side-to-side on conventional radiographs because of Disease. Do not forget to look at the thoracic spine when studying the
the position of the heart in the center of the chest. Therefore lateral chest radiograph for valuable information about a host of systemic
radiographically we refer to the right-half of the diaphragm diseases. In this study, there is loss of stature of the eighth thoracic
as the right hemidiaphragm and the left-half of the diaphragm vertebral body owing to osteoporosis (black arrow). Compression frac-
as the left hemidiaphragm. tures frequently involve the superior endplate first. There are small
osteophytes present at multiple levels from degenerative disk disease
• How to tell the right from the left hemidiaphragm on the (white arrows).
lateral radiograph:
20 CHAPTER 3 Recognizing Normal Pulmonary Anatomy

• Pleural effusions accumulate in the deep recesses of the cos-

tophrenic sulci with the patient upright, filling in their acute
angles. This is called blunting of the costophrenic angles (see
Chapter 8).
• It requires only about 75 mL of fluid (or less) to blunt the
posterior costophrenic angle on the lateral projection, whereas
it takes about 250 to 300 mL to blunt the lateral costophrenic
angles on the frontal projection (see Fig. 3.11 and Table 3.1).

NORMAL CT ANATOMY OF THE CHEST

• By convention, CT scans of the chest, like most other radio-
logic studies, are viewed with the patient’s right on your left
and the patient’s left on your right. If the patient is scanned
in the supine position, as most usually are, the top of each
image is anterior and the bottom of each image is
posterior.

IMPORTANT POINTS
Fig. 3.11 Blunting of the Posterior Costophrenic Sulcus by a Small
Pleural Effusion. Left lateral view of the chest shows fluid blunting the • Chest CT scans are usually “windowed” and displayed in at least two
posterior costophrenic sulcus (solid white arrow). The other posterior formats designed to be viewed as parts of the same study, in order to
costophrenic angle (solid black arrow) is sharp. The pleural effusion is optimize anatomic definition.
on the right side because the involved hemidiaphragm can be traced
anteriorly farther forward (dotted black arrow) than the other hemidia-
phragm (the left), which is normally silhouetted by the heart and not
visible anteriorly. • Lung windows are chosen to maximize our ability to image
abnormalities of the lung parenchyma and to identify
normal and abnormal bronchial anatomy. The mediastinal
structures frequently appear as a homogenous white density
• The right hemidiaphragm is usually visible for its entire on lung windows.
length from front to back. Normally, the right hemidia- • Mediastinal windows are chosen to display the medias-
phragm is slightly higher than the left, a relationship that tinal, hilar, and pleural structures to best advantage. The
tends to hold true on the lateral radiograph as well as the lungs usually appear completely black when viewed with
frontal. mediastinal windows.
• The left hemidiaphragm is seen sharply posteriorly but • Bone windows are also used often as a third way of dis-
is silhouetted by the muscle of the heart anteriorly (i.e., playing the data, demonstrating the bony structures to
its edge disappears anteriorly) (Fig. 3.11). their best advantage.
• Air in the stomach or splenic flexure of the colon • It is important to know that the displays of these different
appears immediately below the left hemidiaphragm. windows are manipulations of the data obtained during
The liver lies below the right hemidiaphragm and bowel the original scan and do not require rescanning the patient
gas is usually not seen between the liver and the right (see Fig. 1.4).
hemidiaphragm.
Normal CT Anatomy of the Lungs
The Posterior Costophrenic Sulci (Posterior • CT scans of the lungs reveal additional and more detailed
Costophrenic Angles) anatomy than conventional radiographs. With computer
• Each hemidiaphragm produces a rounded dome that indents reconstruction of thin-section CT images, the lungs can be
the central portion of the base of each lung, like the bottom visualized in any plane, although the three most common
of a wine bottle. This produces a depression or sulcus that are the axial (transverse), sagittal (lateral), and coronal
surrounds the base of each lung and represents the lowest (frontal) (Fig. 3.12).
point of the pleural space when the patient is upright. • Blood vessels are visible for almost their entire course from
• On a frontal chest radiograph, this sulcus is most easily viewed hilum to pleural surface. Pulmonary arteries can be differenti-
at the outer edge of the lung as the lateral costophrenic sulcus ated from pulmonary veins (Fig. 3.13).
(also called the lateral costophrenic angle) and on the lateral • Bronchi and bronchioles are also visible and, as a rule, bronchi
radiograph as the posterior costophrenic sulcus (also known are normally smaller than their accompanying pulmonary
as the posterior costophrenic angle) (see Figs. 3.1 and 3.4). artery (Fig. 3.14).
• Normally, the costophrenic sulci are sharply outlined and • The trachea is usually oval in shape and about 2 cm in
acutely angled. diameter.
 CHAPTER 3 Recognizing Normal Pulmonary Anatomy 21

Ao
Ao
Ao PA PA
PA
S
RA LV LA
Ao LV

A B C
Fig. 3.12 Axial (A), Coronal (B), and Sagittal Views (C) of the Thorax. The three standard planes for
imaging the thorax are shown above. Remember that the data were all acquired at the time of the same
scanning session, but thin-section acquisition allows digital reformatting in any plane. The left main bronchus
(black arrow) and the right main bronchus (white arrow) are seen in A. Ao, Aorta; LA, left atrium; LV, left
ventricle; PA, pulmonary artery; RA, right atrium; S, superior vena cava.

Fig. 3.13 MIP of Pulmonary Vasculature. MIP (or MIPs if pleural) Fig. 3.14 Bronchus-Artery Relationship. The normal relationship
stands for maximum intensity projections; it is a way to display certain between the bronchus (solid white arrow) and its accompanying pul-
structures of a given density preferentially making them stand out more monary artery (dotted white arrow) is that the artery is usually larger
easily. It is a computer post-processing manipulation of the same data than the bronchus. In bronchiectasis, that relationship is reversed with
acquired at the time of the original scan. It produces an image that looks the bronchus becoming larger than the artery (signet-ring sign) (see
like an angiogram and is used particularly for CT angiography (as here) Chapter 11).
and is also utilized for finding pulmonary nodules (see also Video 3.1).
 CHAPTER 3 Recognizing Normal Pulmonary Anatomy 21.e1

eVideo 3.1 MIPs of Pulmonary Vasculature. Maximum intensity

projections of the pulmonary vasculature are shown here from the top
to the bottom of the thorax. The patient had been given intravenous,
iodinated-contrast for a CT pulmonary angiogram, which was negative
for pulmonary embolus. MIPs is a way of displaying an image that
highlights certain structures in the series of images. Here, the MIPs
images look like an angiogram and can be used particularly for CT
angiography.
22 CHAPTER 3 Recognizing Normal Pulmonary Anatomy

• In most people, there is a space visible just underneath the • The major fissure demarcates the upper lobe from the lower
arch of the aorta but above the pulmonary artery, which is lobe on the left and the lower and middle lobes on the right.
called the aorto-pulmonary window. The aortopulmonary On the right, the minor fissure demarcates the middle lobe.
window is an important landmark because it is a favorite The middle lobe’s analog on the left is the lingular segment
location for enlarged lymph nodes to appear. At or slightly of the left upper lobe. (Fig. 3.18).
below this level, the trachea bifurcates at the carina into the • The minor fissure travels in the same horizontal plane as
right and left main bronchi (Fig. 3.15). the plane of an axial CT image so the minor fissure is
• Slightly more inferior are the right and left main bronchi normally not visible except in the sagittal or coronal planes.
and the bronchus intermedius. The right main bronchus Although as with the major fissures, the location of the
will appear as a circular, air-containing structure which will minor fissure can be inferred by an avascular zone between
then become tubular as the right upper lobe bronchus comes the right upper and middle lobes (see Fig. 3.17A).
into view. There should be nothing but lung tissue posterior
to the bronchus intermedius. The left main bronchus will
appear as an air-containing circular structure on the left (Fig.
3.16).

The Fissures
• Depending on slice thickness, the fissures will be visible either
as thin white lines or by an avascular band up to 2 cm thick
as they travel obliquely through the lungs (Fig. 3.17).

Ao
T

PA
RMB
C LMB
BI
RMB
LMB

A B
Fig. 3.15 Coronal and Axial CT at Carina. A. The trachea (T) bifurcates at the carina (C) into the right main
bronchus (RMB) and left main bronchus (LMB). After the origin of the right upper lobe bronchus (dotted
white arrow), the bronchus intermedius (BI) gives rise to the right lower lobe bronchus (dotted black arrow)
and middle lobe bronchus (not shown). The left upper lobe bronchus is shown (solid black arrow). The aor-
topulmonary “window” (solid white arrow) lies between the aorta (Ao) and the pulmonary artery (PA). B.
Just distal to the carina, the right main bronchus (RMB) gives rise to the upper lobe bronchus (white arrow).
The left main bronchus (LMB) is also seen at this level.
 CHAPTER 3 Recognizing Normal Pulmonary Anatomy 23

RUL

RUL

RML

RML

RLL
RLL

Fig. 3.16 Bronchus Intermedius. Distal to the origin of the right upper Fig. 3.17 Fissures Seen on Axial and Coronal Reformatted Views.
lobe bronchus is a short bronchial section called the bronchus inter- (A) The major fissure is seen as a thin white line on the axial view of
medius (solid black arrow). The bronchus intermedius divides into the the right lung (solid white arrow) and the minor fissure can be seen
middle and lower lobe bronchi more caudal to this image. There is anterior to the major fissure (dotted white arrow). (B) The minor fissure
normally nothing but lung tissue posterior to the bronchus intermedius; is seen as a faint white line (dotted white arrow), whereas the major
soft tissue in this location would suggest a tumor or adenopathy. The fissure travels obliquely at this level and is represented by an avascular
left main bronchus is shown by the dotted black arrow. zone that surrounds the fissure (solid white arrows). RLL, Right lower
lobe; RML, right middle lobe; RUL, right upper lobe.

RUL

LUL

RML

RLL LLL
H

A B
Fig. 3.18 Lobes and Fissures-Sagittal of Right (A) and Left (B) Lungs. (A) The major fissure (solid white
arrows) demarcates the right lower lobe (RLL) from the upper (RUL) and middle lobes (RML). On the right,
the minor fissure (dotted white arrows) demarcates the middle lobe, separating the upper and lower lobes
anteriorly. (B) The major fissure is seen on the left (solid white arrows). The analog of the middle lobe on
the left is the lingula, part of the left upper lobe. A portion of the heart (H) is seen on the left. LLL, Left
lower lobe; LUL, left upper lobe.
24 CHAPTER 3 Recognizing Normal Pulmonary Anatomy

TAKE HOME POINTS

• The best “system” to use for carefully looking at any imaging study is one normally. When visible, they are very thin lines of uniform size about 1 to
based on a solid knowledge base of the appearance of normal anatomy and 2 mm in thickness.
the most common deviations from normal. • The thoracic spine should appear to become blacker from the upper to the
• Virtually all of the lung markings on chest radiographs are composed of pul- lower portion of the spine, owing to greater overlying soft tissue more supe-
monary blood vessels; most bronchi are too thin-walled to be visible on riorly. Increased density at the base, such as a pneumonia, can produce the
conventional radiography. reverse of this normal pattern, which is called the spine sign.
• Normal pulmonary vasculature tapers gradually from central to peripheral • On the lateral view, the left hemidiaphragm will be obscured (silhouetted)
and the vessels are normally larger at the base than at the apex on an upright anteriorly by the heart. The right hemidiaphragm is usually higher than the
chest radiograph. left and can be seen in its entirety from front to back.
• The lateral chest radiograph can provide invaluable information and should • The costophrenic angles are normally acute and sharply outlined. Pleural
always be studied, when available. effusions and scarring may cause blunting of the costophrenic angles.
• Five key areas to inspect on the lateral projection include the retrosternal • CT scans of the chest display much more detail than conventional radiographs
clear space, hilar region, fissures, thoracic spine, and diaphragm/posterior and, owing to rapid acquisition of very thin slices, can be displayed in any
costophrenic sulci. plane using the original data set. The planes most commonly used are the
• There is normally a retrosternal “clear space” on a lateral radiograph that axial, sagittal, and coronal.
can “fill-in” with a mediastinal mass or adenopathy, such as in lymphoma. • The normal anatomy of the trachea and main bronchi is outlined.
• Although the pulmonary arteries themselves can normally be seen in the hila • Both the major and minor fissures are visible on CT either as thin white
on the lateral projection, a discrete mass in the hilum is abnormal and should lines or avascular bands depending on the orientation of the fissure relative
alert to the possibility of tumor or adenopathy. to the plane in which the scan is displayed.
• The minor fissure, not the major fissure, will usually be visible on a frontal
view. On the lateral view, both the major and minor fissures can be seen

More information on recognizing normal pulmonary anatomy is available to registered users online.
 4
Recognizing Normal Cardiac Anatomy

Emphasizing conventional radiography first, we will begin with The Normal Cardiac Contours
an assessment of heart size, then describe the normal and abnor- • The normal cardiac contours comprise a series bumps and
mal contours of the heart on the frontal radiograph and, finally, indentations visible on the frontal chest radiograph. They are
discuss the normal anatomy of the heart as seen on computed demonstrated in Fig. 4.2.
tomography (CT) and magnetic resonance imaging (MRI).

EVALUATING THE HEART ON CHEST

RADIOGRAPHS
Recognizing a Normal-Sized Heart
UPRIGHT PA

IMPORTANT POINTS
• You can estimate the size of the cardiac silhouette on the frontal chest
radiograph using the cardiothoracic ratio, which is a measurement of Aortic
Knob
the widest transverse diameter of the heart compared with the widest Ascending
Aorta Main
internal diameter of the rib cage (from inside of rib to inside of rib at Pulmonary
Artery
the level of the diaphragm) (Fig. 4.1).
“Double
Density” Site of
Left Atrium Left Atrial
Enlargement
• In most normal adults at full inspiration, the cardiotho-
racic ratio is less than 50%. That is, the size of the heart is Right
Atrium Left
usually less than half of the internal diameter of the thoracic Ventricle
rib cage.

Fig. 4.2. Normal Cardiac Contours Seen in the Frontal Projection.

On the right side of the heart, the first contour is the ascending aorta.
Where the contour of the ascending aorta meets the contour of the
right atrium, there is usually a slight indentation which is where the
left atrium may appear when it enlarges (called the double-density
sign). The right heart border is formed by the right atrium. On the left,
the first contour is the aortic knob, a radiographic structure formed by
Fig. 4.1 The Cardiothoracic Ratio. To estimate the cardiothoracic ratio, the foreshortened aortic arch superimposed on a portion of the proximal
the widest diameter of the heart (upper double arrow) is compared descending aorta. The next contour below the aortic knob is the main
with the widest internal diameter of the thoracic cage from the inside pulmonary artery, before it divides into a right and left pulmonary
of the right rib to the inside of the left rib (lower double arrow). The artery. Just below the main pulmonary artery segment there is normally
widest internal diameter of the thorax is usually at the level of the a slight indentation where an enlarged left atrium/left atrial appendage
diaphragm. The cardiothoracic ratio should be less than 50% in most may appear on the left side of the heart. The last contour of the heart
normal adults on a standard PA frontal radiograph taken with an adequate on the left is formed by the left ventricle. The descending aorta almost
inspiration (about nine posterior ribs showing). disappears with the shadow of the spine.

25
26 CHAPTER 4 Recognizing Normal Cardiac Anatomy

IMPORTANT POINTS Therefore the heart may not appear enlarged at first with
lesions such as aortic stenosis, coarctation of the aorta,
Key Points About the Cardiac Contours pulmonic stenosis, or systemic hypertension. When the
• The ascending aorta should normally not project farther to the right than
ventricular wall becomes thicker, the lumen actually
the right heart border (i.e., the right atrium).
becomes smaller and it is only when the muscle begins to
• The aortic knob is normally less than 35 mm (measured from the edge of
the air-filled trachea) and will normally push the trachea slightly to the
fail and the heart decompensates that the heart visibly
right. enlarges on chest radiographs.
• The main pulmonary artery segment is usually concave or flat. In younger, • Cardiomegaly, as recognized on chest radiographs, refers
females it may normally be convex outward. to enlargement of the cardiac silhouette produced by ven-
• The normal left atrium does not contribute to the border of the heart on tricular enlargement, not by isolated enlargement of the
a nonrotated frontal chest radiograph. atria. For example, the cardiac silhouette usually appears
• An enlarged left atrium and left atrial appendage "fills-in" and straightens normal in size when there is isolated atrial enlargement,
the normal concavity just inferior to the main pulmonary artery segment such as left atrial enlargement in early mitral stenosis.
and may sometimes be visible on the right side of the heart as well. • In general, the most marked chamber enlargement
• The lower portion of the left side of the heart border is made up of the left
will occur from volume overload rather than pressure
ventricle. Remember that the left ventricle is really a posterior ventricle
increases so that the largest chambers are usually produced
and the right ventricle is an anterior ventricle.
• Normally, the descending aorta parallels the spine and is barely visible
by regurgitant valves rather than stenotic valves. There-
on the frontal radiograph of the chest. When it becomes tortuous or fore the heart will usually be larger as a result of aortic
uncoiled, it swings farther away from the thoracic spine toward the patient’s regurgitation than aortic stenosis and the left atrium will
left (Fig. 4.3). usually be larger in mitral regurgitation than mitral stenosis
(Fig. 4.4).

GENERAL PRINCIPLES EVALUATING THE HEART ON CARDIAC CT

• As you interpret cardiac abnormalities, no matter what imaging • CT scanning of the heart is done using a fast, multislice CT
modality is being used, the following principles hold true: scanner, usually with intravenous iodinated contrast and
• The ventricles respond to obstruction to their outflow electrocardiographic (ECG)-gated acquisition to reduce motion
by first undergoing hypertrophy rather than dilatation. artifacts.

A B C
Fig. 4.3 Appearances of the Aorta. (A) Normal. The ascending aorta is a low-density, almost straight edge
(solid white arrow) and does not project beyond the right heart border (dotted white arrow). The aortic knob
is not enlarged (double arrow) and the descending aorta (solid black arrow) almost disappears with the
shadow of the thoracic spine. (B) Aortic stenosis. The ascending aorta is abnormal as it projects convex
outward (solid white arrow) almost as far as the right heart border (dotted white arrow). This is secondary
to post-stenotic dilatation. The aortic knob (double arrow) and descending aorta (solid black arrow) remain
normal. (C) Systemic hypertension. Both the ascending (solid white arrow) and descending aorta (solid
black arrow) project too far to the right and left, respectively. The aortic knob is enlarged (double black arrow).
 CHAPTER 4 Recognizing Normal Cardiac Anatomy 27

A B
Fig. 4.4 Heart Size with Stenotic Versus Regurgitant Valve. (A) There is post-stenotic dilatation of the
ascending aorta (white arrow) from turbulent flow in this patient with aortic stenosis. Notice that the cardiac
silhouette is not enlarged (dotted black double arrows) even though this lesion produces left ventricular
hypertrophy. (B) This patient has aortic regurgitation. Note the enlarged cardiac silhouette (solid black
double arrows) due to an extremely large left ventricle. Volume overload will cause a greater increase in
chamber size than will increased pressure alone.

• Both cardiac CT and cardiac MRI use ECG-gating, which

allows for a series of images to be obtained either prospectively
or retrospectively over several cardiac cycles and parsed
together with powerful computer algorithms.
• Cardiac CT can be used to evaluate the coronary arteries,
valves and search for cardiac masses. By reconstructing mul-
tiple phases of the cardiac cycle, it is also possible to analyze
wall motion and evaluate ejection fraction and myocardial
perfusion. L
• The three standard planes for viewing CT images of the heart
are the axial, sagittal, and coronal. Figs. 4.5 to 4.10 demon- I
R
strate the major normal CT anatomy of the heart and great
vessels. C
T
Normal Cardiac CT Anatomy S
• We cover only a few of the major anatomic landmarks demon-
strable on chest CT, and all of the scans used will be contrast-
enhanced (i.e., in the scans shown, the patient will have had an
injection of intravenous contrast to opacify the heart chambers
and blood vessels). It is best to read the text in conjunction
with its associated photograph. Any references to “right” or
“left” mean the patient’s right or left side, not yours.
• We will start at the top of the chest and progress inferiorly, Fig. 4.5 Five-Vessel Level. At this level, you should be able to identify
highlighting the major structures visible at six key levels. the lungs, the trachea (T) and the esophagus (white arrow). Depending
This is a good way to systematically study every CT study of on the exact level of the image, several of the great vessels will be
the chest. visible. The right brachiocephalic vein (R) is the vessel to the right of
the trachea (T). The left brachiocephalic vein (L) lies just posterior to
Five-Vessel Level (Fig. 4.5) the sternum. From the patient’s right to the patient’s left, the arteries
you see may include the innominate artery (I), left common carotid
• At this level, you should be able to identify the lungs, the (C), and left subclavian arteries (S).
trachea, and the esophagus. The trachea is black because it
contains air; it is usually oval in shape and about 2 cm in
diameter. The esophagus lies posterior and either to the left
or right of the trachea. The esophagus is usually collapsed,
but may contain swallowed air.
28 CHAPTER 4 Recognizing Normal Cardiac Anatomy

S
AA

T T
A

A B
Fig. 4.6 Aortic Arch Level. (A) Mediastinal window and (B) lung window. (A) At this level, you should
be able to identify the aortic arch (AA), superior vena cava (S), and azygos vein (A). The white arrow
points to air in the esophagus. (B) The same image as (A), but windowed to better visualize lung anatomy.
Lung windows are chosen to maximize our ability to image abnormalities of the lung parenchyma and to
identify normal and abnormal bronchial anatomy. T, Trachea.

• Depending on the exact level of the image, several of the • In most people, a space is visible just underneath the arch of
great vessels will be visible. The venous structures tend to the aorta, but above the pulmonary artery called the aorto-
be more anterior than the arterial. The brachiocephalic pulmonary window. The aortopulmonary window is an
(innominate) veins lie just posterior to the sternum. important landmark because it is a favorite location for
enlarged lymph nodes to appear.
Aortic Arch Level (Fig. 4.6) • At or slightly below this level, the trachea bifurcates at the
• At this level, you should be able to identify the aortic arch, carina into the right and left main bronchi.
superior vena cava, and azygos vein.
• The aortic arch forms an upside-down U-shaped tube. If the
scan skims the very top of the arch, it will appear as a comma- Main Pulmonary Artery Level (Fig. 4.8)
shaped tubular structure with roughly the same diameter • At this level (it may require more than one image to see all
anteriorly as posteriorly. To the right of the trachea will be of these structures), you should be able to identify the main,
the superior vena cava into which the azygos vein drains. right and left pulmonary arteries, the right and left main
bronchi, and the bronchus intermedius.
Aortopulmonary Window Level (Fig. 4.7) • The left pulmonary artery is higher than the right and
• At this level you should be able to identify the ascending and appears as a direct continuation of the main pulmonary
descending aorta, superior vena cava, and uppermost aspect artery. The right pulmonary artery originates at a 90°
of the left pulmonary artery (maybe). angle to the main pulmonary artery and crosses to the
right side.
• On the right, the main bronchus will appear as a circu-
IMPORTANT POINTS
lar, air-containing structure that will then become tubular
• As we scan lower and through the opening of the upside-down U-shaped as the right upper lobe bronchus comes into view. The
aortic arch, the ascending aorta will appear as a rounded density ante- bronchus intermedius then gives rise to the right middle
riorly, whereas the descending aorta will appear as a separate rounded and lower lobe bronchi. There should be nothing but lung
density posterior and to the left of the spine. The ascending aorta usually
tissue posterior to the bronchus intermedius. On the left,
measures 2.5 to 3.5 cm in diameter and the descending aorta is slightly
smaller at 2 to 3 cm.
the main bronchus will appear as an air-containing circular
structure.
 CHAPTER 4 Recognizing Normal Cardiac Anatomy 29

AA
S P
AA

S
P

DA LV
RA

A B
Fig. 4.7 Aortopulmonary Window Level, Axial (A) and Coronal Views (B). (A) At this level you should
be able to identify the trachea (T), ascending (AA) and descending aorta (DA), superior vena cava (S),
and possibly the uppermost aspect of the left pulmonary artery (P). In most people, there is a space visible
just under the arch of the aorta and above the pulmonary artery called the aortopulmonary window (white
arrow). (B) Coronal reformatted CT enables us to also see the right atrium (RA), superior vena cava (S),
pulmonary artery (P), left ventricle (LV), aortic valve (black arrow), left atrial appendage (white arrow),
and origin of the great vessels (white circle).

AA
MPA
S

RPA
LB LPA
RB
BI

DA

A B
Fig. 4.8 Main Pulmonary Artery Level (A) Mediastinal Window and (B) Lung Window. (A) At this level,
you should be able to identify the main (MPA), right (RPA), and left pulmonary arteries (LPA), the right
(RB) and left main bronchi (LB), and the superior vena cava (S). The left pulmonary artery passes anterior
to the descending aorta (DA). The right pulmonary artery passes posterior to the ascending aorta (AA)
and crosses to the right side. (B) Distal to the takeoff of the right upper lobe bronchus is the bronchus
intermedius (BI). The posterior wall of the right upper lobe bronchus is 2 to 3 mm in thickness with only
aerated lung normally posterior to it (white arrow).
30 CHAPTER 4 Recognizing Normal Cardiac Anatomy

RVOT

RA LV
Ao

RV
IVS
LA LV

RA

DA

DA

Fig. 4.9 High Cardiac Level. At this level, you should be able to identify
the left atrium (LA), right atrium (RA), aortic root (Ao), and right Fig. 4.10. Low Cardiac Level. At this level, you should be able to
ventricular outflow tract (RVOT). The left atrium occupies the pos- identify the right atrium (RA), right ventricle (RV), left ventricle (LV),
terior and central portion of the heart. One or more pulmonary veins and interventricular septum (IVS). The right ventricle is more heavily
may be seen to enter the left atrium (white arrow). The right atrium trabeculated (solid white arrow) and has a thinner wall (dotted white
produces the right heart border and lies anteriorly and to the right of arrow) than the wall of the left ventricle (solid black arrows). DA, Descend-
the left atrium. DA, Descending thoracic aorta; LV, Left ventricle. ing thoracic aorta.

High Cardiac Level (Fig. 4.9) • When seen, the normal pericardium is about 2 mm thick
• At this level, you should be able to identify the left atrium, and is usually outlined by mediastinal fat outside the peri-
right atrium, aortic root, and right ventricular outflow tract. cardium and epicardial fat on its inner surface.

IMPORTANT POINTS USES OF CARDIAC CT

• An important anatomic relationship is the relative locations of the right • Cardiac CT scanning is used for evaluation of the coronary
ventricular outflow tract (and pulmonic valve) and the aortic root, especially arteries, the presence of cardiac masses, abnormalities of the
in congenital cardiac lesions. The right ventricular outflow tract lies aorta (including aortic dissection), and pericardial diseases.
anterior, lateral, and superior to the root of the aorta. The Pulmonic • Cardiac CT also allows for the imaging and three-dimensional
valve lies Anterior, Lateral and Superior to the aortic valve (you can remember reconstruction of the coronary arteries and quantitative
that relationship using the acronym “PALS”). measurement of the amount of coronary artery calcium.
The administration of intravenous contrast allows for evalu-
ation of vessel patency with identification of thrombus in the
Low Cardiac Level (Fig. 4.10) lumen or plaque in the vessel wall.
• At this level, you should be able to identify the right atrium,
right ventricle, left ventricle, and interventricular septum. Calcium Scoring
• The right atrium continues to form the right border of the • Calcium scoring is based on the premise that the amount
heart. The right ventricle is anteriorly located, just behind of calcium detectable in the coronary arteries is related to
the sternum, and demonstrates more trabeculation than the the degree of coronary atherosclerosis and that quantify-
smoother-walled left ventricle. The left ventricle produces ing the amount of calcium may help predict future cardiac
the left border of the heart and normally has a thicker wall events related to coronary artery disease, such as heart attack.
than the right ventricle. The scoring is usually done by calculations that combine
• With intravenous contrast filling the chambers, you should the amount and density of calcium in the coronary arteries
be able to see the interventricular septum between the right visualized on unenhanced CT of the heart. The absence of
and left ventricles. coronary artery calcification has a high negative predictive
 CHAPTER 4 Recognizing Normal Cardiac Anatomy 31

A B
Fig. 4.11 Coronary Artery Calcification and Scoring. (A) Dense calcification is seen, mostly in the left
anterior descending coronary artery (white circle). (B) The calcium scores are shown superimposed on the
areas of calcification. A score of zero means no calcium is detectable, which correlates with a low likelihood
of a cardiac event in the near future. The higher the calcium score, the higher the risk of adverse cardiac
events in the long term. Scores of 100 to 300 correlate with a mild to moderate risk of a heart attack or
other cardiac events over the next 3 to 5 years. A score greater than 300 indicates the greater likelihood of
severe disease and a heart attack risk, as is seen in this image.

Pulmonary artery
value for significant luminal narrowing. The higher the calcium Aorta
Left main
score, the greater the risk for a future cardiac event (Fig. 4.11). coronary artery
Right coronary
• Although calcium scoring is primarily used for risk analysis artery Left anterior
of asymptomatic patients, coronary CT angiography (CCTA) descending artery
is primarily used in patients with acute or chronic chest pain. Left circumflex Circumflex artery
Like calcium scoring, a negative CCTA has a high negative artery
predictive value (i.e., a negative study effectively excludes Diagonal branch
obstructive coronary artery disease). Posterior of left anterior
descending descending artery
• One potential drawback to cardiac CT is the radiation dose
delivered to the patient, which historically had been relatively artery
Left circumflex
high. Numerous methods are now being utilized to reduce marginal artery
that dose so that the procedure can now be performed at a Marginal
branch of right
dose well below the average annual background radiation coronary artery Left anterior
dose. descending artery
Fig. 4.12 The two main coronary arteries are the left (also known as
Coronary CT Angiography: Normal Anatomy the left main) and the right coronary artery. The left coronary artery
divides almost at once into the circumflex artery and left anterior
• Coronary CT angiography (CCTA) compares favorably in descending artery (LAD). The LAD, in turn, gives rise to diagonal
accuracy with invasive (catheter) coronary angiography, long branches and septal branches (not shown). The circumflex artery has
held as the reference standard in studying the coronary arter- marginal branches. The right coronary artery courses between the
ies (eVideo 4.1). right atrium and right ventricle to the inferior part of the septum. It gives
rise to a large acute marginal branch and, in most people, the posterior
• Normal coronary artery anatomy has many variations. Only
descending artery (PDA). The PDA supplies the inferior wall of the
the most common branching is described here (Fig. 4.12). left ventricle and inferior part of the septum. (Revised from Bruce NH,
• The two main coronary arteries are the left (also known as Ray R. Cardiovascular disease. In: Kumar P, Clark M, eds. Kumar and
the left main) and the right coronary artery. Clark’s Clinical Medicine, 8th ed. London: Elsevier; 2012, pg. 673.)
 CHAPTER 4 Recognizing Normal Cardiac Anatomy 31.e1

eVideo 4.1. Catheter Angiogram of Right Coronary Artery. Under

fluoroscopic guidance a catheter is inserted in the groin and directed
retrograde in the aorta into the aortic sinus of the right coronary artery.
Iodinated contrast is injected and fills the right coronary artery (white
arrow), which continues on to the posterior descending coronary
artery (blue arrow). The heart motion is digitally suspended to allow
the arrows to be seen. This is a diseased right coronary artery with
areas of significant narrowing from atherosclerosis.
32 CHAPTER 4 Recognizing Normal Cardiac Anatomy

Ao

RVOT
Ao

SVC

LV
Lumen

LA

Fig. 4.13 CT Coronary Angiogram, Left Coronary Artery. The left

coronary artery (LCA) arises from the left coronary cusp at the aortic IVS
valve. It divides almost at once into the circumflex artery (white arrow)
and left anterior descending artery (LAD) (black arrow). Ao, Aorta; LA,
left atrium; RVOT, right ventricular outflow tract; SVC, superior vena cava.

RV

• The left coronary artery (LCA) arises from the left coronary
cusp at the aortic valve. It divides almost at once into the
circumflex artery and left anterior descending artery (LAD)
(Fig. 4.13). The LAD, in turn, gives rise to diagonal branches
and septal branches. The circumflex artery has marginal Fig. 4.14 CT Coronary Angiogram, Left Anterior Descending (LAD)
Coronary Artery. The LAD (white arrow) travels in the anterior inter-
branches. ventricular groove and continues to the apex of the heart. It supplies
• The LAD travels in the anterior interventricular groove and most of the left ventricle and also the AV-bundle. Ao, Aorta; IVS, inter-
continues to the apex of the heart (Fig. 4.14). It supplies most ventricular septum; LV lumen, left ventricular lumen; RV, right ventricle.
of the left ventricle and also the atrioventricular (AV)-bundle,
serving the anterior part of the septum with septal branches
and the anterior wall of the left ventricle with diagonal branches.
• The circumflex artery (see Fig. 4.13) lies between the left • If the posterior descending artery is supplied by the right
atrium and left ventricle and supplies obtuse marginal vessels coronary artery, then the coronary circulation is said to
to the lateral wall of the left ventricle. be right-dominant.
• The right aortic sinus gives rise to the right coronary artery • If the posterior descending artery is supplied by the cir-
(RCA), which courses between the right atrium and right cumflex artery, a branch of the left coronary artery, then
ventricle to the inferior part of the septum (Fig. 4.15). the coronary circulation is called left-dominant.
• In most people, the first branch of the RCA is the conus • If the posterior descending artery is supplied by both the
branch that supplies the right ventricular outflow tract. In right coronary artery and the circumflex artery, then the
most people, a sinus node artery arises as a second branch coronary circulation is called codominant.
of the RCA. The next branches are diagonals that supply the
anterior wall of the right ventricle.
• The large acute marginal branch supplies the lateral wall of IMPORTANT POINTS
the right ventricle and runs along the margin of the right
• The overwhelming majority of the population is right-dominant, about
ventricle above the diaphragm. The RCA continues in the AV 10% are left-dominant, and the remainder are codominant. A left-dominant
groove posteriorly and gives off a branch to the AV node (see coronary artery system is associated with an increased risk of nonfatal
Fig. 4.12). myocardial infarction and increased overall mortality.
• In most people, the posterior descending artery (PDA) is a
branch of the RCA. The PDA supplies the inferior wall of the
left ventricle and inferior part of the septum (see Fig. 4.15). • It is possible to perform an emergent CT scan that will allow
• Coronary artery dominance for the simultaneous evaluation of coronary artery disease,
• The artery that supplies the posterior descending artery aortic dissection, and pulmonary thromboembolic disease,
determines coronary artery dominance. the so-called triple scan (triple rule-out) for patients who
 CHAPTER 4 Recognizing Normal Cardiac Anatomy 33

present with acute chest pain. Such scans have been shown
to improve clinical decision making and allow for earlier
discharge from the hospital.

CARDIAC MRI
• MRI can be used to obtain anatomic and functional images
of the heart with a combination of ECG-gating and rapid
acquisition of images. Respiratory motion, which would also
contribute to blurring the image, can be reduced by having
patients hold their breath for short periods of time while the
images are acquired. (eVideo 4.2)
• Cardiac MRI can depict scarring from a myocardial infarc-
tion, perfusion of the heart, anatomic defects or masses and
LV
can assess the function of the valves and cardiac chambers.
• Cardiac MRI can be performed without intravenous con-
trast or with intravenous contrast (Gadolinium: see Chapter
21). Cardiac MRI is particularly useful in children as a way
of evaluating congenital heart disease after other studies
(e.g., echocardiography) produce inconclusive or conflict-
ing information.

Normal Cardiac MRI Anatomy

• One of the benefits of MRI is that its images can be displayed
in any plane. Besides the axial, sagittal, and coronal planes,
Fig. 4.15 CT Coronary Angiogram, Right Coronary Artery. The right several additional views are typically used in cardiac MRI
aortic sinus (black arrow) gives rise to the right coronary artery (RCA) that allow for the best visualization of the heart. They are
(white arrow), which courses between the right atrium and right ventricle
called the horizontal long axis (otherwise known as the four-
to the inferior part of the septum. In most people, as here, the RCA
continues to the posterior descending artery. LV, Left ventricle. chamber view), vertical long axis, short axis, and three-
chamber views.
• The anatomy of the heart in the axial, sagittal, and coronal
planes is the same as that seen on CT (Fig. 4.16).
• The horizontal long axis (four-chamber) view resembles an
axial view and is best used for evaluating the left ventricle’s
septal and lateral walls and apex, the right ventricular free

Ao
Ao PA

RV LA
LV
RV
LV

A B C
Fig. 4.16 Cardiac MRI, Axial, Coronal, and Sagittal Planes. These three planes produce images the same
as those on CT (see Fig. 3.12). (A) The axial view at this level shows the right (RV) and left ventricles (LV)
and the descending aorta (arrow). (B) This coronal image demonstrates the right atrium (solid arrow), left
ventricle (LV), aorta (Ao), and main pulmonary artery (dotted arrow). (C) The sagittal image at this level
shows the right ventricle (RV), pulmonary artery (PA), left atrium (LA), and aorta (Ao). In all of these
images, the blood is depicted as “bright” (white).
 CHAPTER 4 Recognizing Normal Cardiac Anatomy 33.e1

eVideo 4.2. MRI, Four-Chamber View of the Heart. This is a cine loop
of a four-chamber view of the heart (horizontal long-axis view) in systole
and diastole. Anterior is up and the patient’s right is on your left. The
blue arrow points to the right ventricle; the red to the left ventricle.
Such motion studies can help in determining cardiac dyskinesia and
valvular dysfunction.
34 CHAPTER 4 Recognizing Normal Cardiac Anatomy

Ao

PA

RV LV

A P
LA

LV

RA LA

P Fig. 4.18 Cardiac MRI, Vertical Long Axis View. The vertical long
Fig. 4.17 Cardiac MRI, Horizontal Long Axis View. This is another axis or two-chamber view demonstrates the left ventricle (LV) sepa-
standard view of the heart with MRI called the horizontal long axis rated from the more posterior left atrium (LA) by the mitral valve area
or four-chamber view. The right (RV) and left ventricles (LV) are (black arrow). Pulmonary veins drain into the left atrium (white arrow).
separated by the interventricular septum (solid white arrow). Posterior The aorta (Ao) sits atop the pulmonary artery (PA). A, Anterior; P,
to each of them are the right atrium (RA) and left atrium (LA), sepa- posterior.
rated by the regions of the tricuspid (dotted white arrow) and mitral
valves (solid black arrow), respectively. A, Anterior; P, posterior.

wall, and for the size of the cardiac chambers. The mitral
and tricuspid valves are especially well visualized in this view
(Fig. 4.17).
• The vertical long axis view resembles a sagittal view and is
best used in the evaluation of the anterior and inferior walls
and apex of the left ventricle (Fig. 4.18).
• The short axis view depicts the left and right ventricles in
a way that is useful for making volumetric measurements
(Fig. 4.19). RV LV
A P
• Because MR images of the heart are already obtained with
three-dimensional volumes in both end-systole and end-
diastole, computer-based measurements of ventricular
mass, end-diastolic volume and end-systolic volume can
be made, and from them, stroke volume and ejection
fraction can be calculated without intervention.
• The three-chamber view, which is similar to a coronal view,
is particularly helpful in assessing the mitral and aortic valves,
left atrial size, and the walls of the left ventricle (Fig. 4.20).
• Depending on the MRI pulse sequence used to obtain the
images, blood can be depicted as either black (usually using Fig. 4.19 Cardiac MRI, Short Axis View. This is a standard view of
the heart with MRI called the short axis view. The right ventricle (RV)
something called a spin echo pulse sequence) and most often
lies anterior to the left ventricle (LV), separated by the interventricular
used for anatomic evaluation or bright (i.e., white, usually septum (solid white arrow). Note the normally thicker wall of the left
using something called a gradient echo pulse sequence), most ventricle (dotted white arrow) than the right ventricle. A, Anterior; P,
often used for functional evaluation (Fig. 4.21). posterior.
 CHAPTER 4 Recognizing Normal Cardiac Anatomy 35

Ao
PV ASW
LVOT
LV
LA

ILW

Fig. 4.20 Cardiac MRI, Three-Chamber View. The three-chamber view is similar to a coronal view and
shows the aorta (Ao), left ventricular outflow tract (LVOT), left ventricle (LV), left atrium (LA), pulmo-
nary veins (PV), the anteroseptal wall (ASW), and inferolateral wall (ILW) of the left ventricle (which are
abnormally thickened in this person).

Ao

Ao

P
A B
Fig. 4.21 Cardiac MRI, Bright Blood and Black Blood Images. With different imaging algorithms, MRI is
capable of displaying the same tissues with differing appearances. (A) and (B) are both axial sections through
the heart, showing the right ventricle (solid white arrows), the left ventricle (dotted white arrows), and the
aorta (Ao). (A) The bright blood technique is used to assess cardiac function, whereas (B) the black blood
technique is usually better at depicting cardiac morphology. A, Anterior; P, posterior.
36 CHAPTER 4 Recognizing Normal Cardiac Anatomy

TAKE HOME POINTS

• In adults, a quick assessment of heart size can be made with the cardiotho- • For patients who present with acute chest pain, it is possible to perform
racic ratio, which is the ratio of the widest transverse diameter of the heart an emergent CT scan for the simultaneous evaluation of coronary artery
compared with the widest internal diameter of the rib cage. In normal adults, disease, aortic dissection, and pulmonary thromboembolic disease
the cardiothoracic ratio is usually less than 50%. (triple rule-out scan).
• The normal contours of the heart are reviewed. • MRI can be used to obtain anatomic and functional images of the heart.
• The ventricles respond to obstruction to their outflow by first undergoing Cardiac MRI can show scarring from a myocardial infarction; depict perfusion
hypertrophy rather than dilatation. On plain films, cardiomegaly is primarily of the heart, anatomic defects, or masses; and can assess the function of the
produced by ventricular enlargement. The most marked chamber enlarge- valves and cardiac chambers.
ment will occur from volume overload rather than pressure overload. • Several specific views that are typically used in cardiac MRI that allow for
• Normal CT anatomy of the major structures is described at six levels in the the best visualization of the heart are described. They are called: the horizontal
chest (from top to bottom): five-vessel view, aortic arch, aortopulmonary window, long axis (otherwise known as the four-chamber view), vertical long
main pulmonary artery, upper cardiac, and lower cardiac levels. axis, short axis, and three-chamber views.
• Cardiac CT scanning uses a fast, multislice CT scanner, usually with intra- • Cardiac function is usually evaluated with MRI sequences producing bright
venous iodinated contrast and ECG-gated acquisition to reduce motion blood images, which are so-called because the blood is depicted with increased
artifact. signal intensity.
• Cardiac CT scanning is used to evaluate the coronary arteries, the presence • Cardiac morphology is usually evaluated with MRI sequences producing
of cardiac masses, abnormalities of the aorta (including aortic dissection), “black blood” images. These images allow for anatomic assessment of the
and pericardial diseases. cardiac structures without interference from the bright blood signal.
• Normal coronary artery anatomy is described. The artery that supplies the
posterior descending artery determines coronary artery dominance. The
overwhelming majority of the population is right-dominant.

More information on recognizing normal cardiac anatomy is available to registered users online.