Diagnostic Radiology Chest and Cardiovascular

Imaging 3/E Edition Veena Chowdhury pdf download

https://ebookname.com/product/diagnostic-radiology-chest-and-
cardiovascular-imaging-3-e-edition-veena-chowdhury/

Get the full ebook with Bonus Features for a Better Reading Experience on ebookname.com
Instant digital products (PDF, ePub, MOBI) available
Download now and explore formats that suit you...

Chest Radiology PreTest Self Assessment and Review 1st

Edition Juzar Ali

https://ebookname.com/product/chest-radiology-pretest-self-
assessment-and-review-1st-edition-juzar-ali/

Grainger Allison s Diagnostic Radiology 6th Edition

Andy Adam

https://ebookname.com/product/grainger-allison-s-diagnostic-
radiology-6th-edition-andy-adam/

Diagnostic Imaging Brain 1st Edition Anne Osborn

https://ebookname.com/product/diagnostic-imaging-brain-1st-
edition-anne-osborn/

Operative Orthopaedics the Stanmore Guide Hodder Arnold

Publication 1st Edition Timothy W.R. Briggs

https://ebookname.com/product/operative-orthopaedics-the-
stanmore-guide-hodder-arnold-publication-1st-edition-timothy-w-r-
briggs/
Neuropsychological assessment of neuropsychiatric
neuromedical disorders 3rd ed 3rd Edition Igor Grant

https://ebookname.com/product/neuropsychological-assessment-of-
neuropsychiatric-neuromedical-disorders-3rd-ed-3rd-edition-igor-
grant/

Rage and Time A Psychopolitical Investigation Peter

Sloterdijk

https://ebookname.com/product/rage-and-time-a-psychopolitical-
investigation-peter-sloterdijk/

The complete idiot s guide to songwriting 1st Edition

Joel Hirschhom

https://ebookname.com/product/the-complete-idiot-s-guide-to-
songwriting-1st-edition-joel-hirschhom/

C Programming in Easy Steps Fourth Edition Mike Mcgrath

https://ebookname.com/product/c-programming-in-easy-steps-fourth-
edition-mike-mcgrath/

The Pearson Guide to SSC Combined Graduate Level 2nd

Edition Edgar Thorpe

https://ebookname.com/product/the-pearson-guide-to-ssc-combined-
graduate-level-2nd-edition-edgar-thorpe/
Adjuvant Analgesics 1st Edition David Lussier

https://ebookname.com/product/adjuvant-analgesics-1st-edition-
david-lussier/
 DIAGNOSTIC RADIOLOGY
CHEST AND CARDIOVASCULAR IMAGING
 AIIMS–MAMC–PGI IMAGING COURSE SERIES

Manorama Berry Sudha Suri Veena Chowdhury

PAST EDITORS

Sima Mukhopadhyay Sushma Vashisht

 DIAGNOSTIC RADIOLOGY
CHEST AND CARDIOVASCULAR IMAGING
THIRD EDITION

EDITORS
Veena Chowdhury MD
Director-Professor and Head
Department of Radiodiagnosis
Maulana Azad Medical College
New Delhi, India

Arun Kumar Gupta MD MNAMS

Professor and Head
Department of Radiodiagnosis
All India Institute of Medical Sciences
New Delhi, India

Niranjan Khandelwal MD Dip. NBE FICR

Professor and Head
Department of Radiodiagnosis
Postgraduate Institute of Medical Education and Research
Chandigarh, India

ASSOCIATE EDITORS
Sanjiv Sharma MD Anjali Prakash DMRD DNB MNAMS
Professor and Head Professor
Department of Cardiac Radiology Department of Radiodiagnosis
CN Center Maulana Azad Medical College
All India Institute of Medical Sciences New Delhi, India
New Delhi, India

JAYPEE BROTHERS MEDICAL PUBLISHERS (P) LTD.

New Delhi • St Louis (USA) • Panama City (Panama) • Ahmedabad • Bengaluru • Chennai
Hyderabad • Kochi • Kolkata • Lucknow • Mumbai • Nagpur
Published by
Jitendar P Vij
Jaypee Brothers Medical Publishers (P) Ltd

Corporate Office
4838/24 Ansari Road, Daryaganj, New Delhi - 110002, India, Phone: +91-11-43574357, Fax: +91-11-43574314
Registered Office
B-3 EMCA House, 23/23B Ansari Road, Daryaganj, New Delhi - 110 002, India
Phones: +91-11-23272143, +91-11-23272703, +91-11-23282021
+91-11-23245672, Rel: +91-11-32558559, Fax: +91-11-23276490, +91-11-23245683
e-mail: [email protected], Website: www.jaypeebrothers.com
Offices in India
• Ahmedabad, Phone: Rel: +91-79-32988717, e-mail: [email protected]
• Bengaluru, Phone: Rel: +91-80-32714073, e-mail: [email protected]
• Chennai, Phone: Rel: +91-44-32972089, e-mail: [email protected]
• Hyderabad, Phone: Rel:+91-40-32940929, e-mail: [email protected]
• Kochi, Phone: +91-484-2395740, e-mail: [email protected]
• Kolkata, Phone: +91-33-22276415, e-mail: [email protected]
• Lucknow, Phone: +91-522-3040554, e-mail: [email protected]
• Mumbai, Phone: Rel: +91-22-32926896, e-mail: [email protected]
• Nagpur, Phone: Rel: +91-712-3245220, e-mail: [email protected]
Overseas Offices
• North America Office, USA, Ph: 001-636-6279734, e-mail: [email protected]
[email protected]
• Central America Office, Panama City, Panama, Ph: 001-507-317-0160, e-mail: [email protected]
Website: www.jphmedical.com

Diagnostic Radiology: Chest and Cardiovascular Imaging

© 2010, Jaypee Brothers Medical Publishers

All rights reserved. No part of this publication should be reproduced, stored in a retrieval system, or transmitted in any
form or by any means: electronic, mechanical, photocopying, recording, or otherwise, without the prior written permission
of the editors and the publisher.

This book has been published in good faith that the material provided by editors is original. Every effort is made to
ensure accuracy of material, but the publisher, printer and editors will not be held responsible for any inadvertent error
(s). In case of any dispute, all legal matters are to be settled under Delhi jurisdiction only.

First Edition: 1996

Second Edition: 2003
Third Edition: 2010
ISBN 978-81-8448-868-5
Typeset at JPBMP typesetting unit
Printed at Ajanta Offset
 Contributors

Akshay Kumar Saxena MD Deep Narayan Srivastava MD MNAMS

Associate Professor Professor
Department of Radiodiagnosis Department of Radiodiagnosis
Postgraduate Institute of Medical Education All India Institute of Medical Sciences
and Research, Chandigarh, India New Delhi, India

Anupam Lal MD Gurpreet Singh Gulati MD

Associate Professor Associate Professor
Department of Radiodiagnosis Cardiovascular and Interventional Radiology
Postgraduate Institute of Medical Education Cardiothoracic Center
and Research, Chandigarh, India All India Institute of Medical Sciences
New Delhi, India
Anjali Prakash DMRD DNB MNAMS
Professor Jyoti Kumar MD DNB MNAMS
Department of Radiodiagnosis Assistant Professor
Maulana Azad Medical College Maulana Azad Medical College
New Delhi, India New Delhi, India

Anju Garg MD Kushaljit Singh Sodhi MD

Professor Assistant Professor
Department of Radiodiagnosis Department of Radiodiagnosis
Maulana Azad Medical College Postgraduate Institute of Medical Education and Research,
New Delhi, India Chandigarh, India

Arun Kumar Gupta MD MNAMS Madhavi Chawla MBBS DNB (Nuclear Medicine)
Professor and Head Senior Research Associate
Department of Radiodiagnosis Department of Nuclear Medicine
All India Institute of Medical Sciences All India Institute of Medical Sciences
New Delhi, India New Delhi, India

Ashu Seith Bhalla MD Mahesh Prakash MD

Associate Professor Assistant Professor
Department of Radiodiagnosis Department of Radiodiagnosis
All India Institute of Medical Sciences Postgraduate Institute of Medical Education
New Delhi, India and Research, Chandigarh, India

Atin Kumar MD MNAMS DNB Mandeep K Garg MD FRCR

Assistant Professor Assistant Professor
Department of Radiodiagnosis Department of Radiodiagnosis
Trauma Centre Postgraduate Institute of Medical Education
All India Institute of Medical Sciences and Research, Chandigarh, India
New Delhi, India
Mandeep Kang MD
Chetan Patel MBBS DRM DNB (Nuclear Medicine) Associate Professor
Associate Professor Department of Radiodiagnosis
Department of Nuclear Medicine Postgraduate Institute of Medical Education
All India Institute of Medical Sciences and Research, Chandigarh
New Delhi, India India
vi Diagnostic Radiology: Chest and Cardiovascular Imaging

Manavjit Sandhu MD Sanjay Thulkar MD

Professor Associate Professor
Department of Radiodiagnosis Department of Radiodiagnosis (IRCH)
Postgraduate Institute of Medical Education All India Institute of Medical Sciences
and Research, Chandigarh, India New Delhi, India

Niranjan Khandelwal MD Dip. NBE FICR Sapna Singh MD DNB MNAMS

Professor and Head Assistant Professor
Department of Radiodiagnosis Department of Radiodiagnosis
Postgraduate Institute of Medical Education Maulana Azad Medical College
and Research, Chandigarh, India New Delhi, India

Naveen Kalra MD Sanjiv Sharma MD

Associate Professor Professor and Head
Department of Radiodiagnosis Department of Cardiac Radiology
Postgraduate Institute of Medical Education All India Institute of Medical Sciences
and Research, Chandigarh, India New Delhi, India

Priya Jagia MD Shivanand Gamanagatti MD

Assistant Professor Assistant Professor
Department of Cardiac Radiology Department of Radiodiagnosis
All India Institute of Medical Sciences Trauma Centre
New Delhi, India All India Institute of Medical Sciences
New Delhi, India

Raju Sharma MD MNAMS

Additional Professor Smriti Hari MD
Assistant Professor
Department of Radiodiagnosis
Department of Radiodiagnosis
All India Institute of Medical Sciences
All India Institute of Medical Sciences
New Delhi, India
New Delhi, India

Rashmi Dixit MD Sumedha Pawa MD

Professor
Professor
Department of Radiodiagnosis
Department of Radiodiagnosis
Maulana Azad Medical College
Maulana Azad Medical College
New Delhi, India
New Delhi, India

Sameer Vyas MD Veena Chowdhury MD

Senior Research Associate Director Professor and Head
Department of Radiodiagnosis Department of Radiodiagnosis
Postgraduate Institute of Medical Education Maulana Azad Medical College
and Research, Chandigarh, India New Delhi, India

Sanjay Sharma MD FRCR DNB Vivek Gupta MD

Associate Professor Assistant Professor
Department of Radiodiagnosis Department of Radiodiagnosis
All India Institute of Medical Sciences Postgraduate Institute of Medical Education
New Delhi, India and Research, Chandigarh, India
 Preface to the Third Edition

The first edition of Diagnostic Radiology on ‘Chest and Cardiovascular Imaging’ was published in 1996. Rapid
advances in the field of imaging necessitated revision and the second edition was published in 2003.
Chest Imaging continues to be one of the most important and well-established subspecialities of Radiology.
Imaging of the lungs and mediastinum requires an understanding of both plain radiography as well as Computed
Topography (CT) and other imaging modalities. The phenomenal technical advances in the last few years have
changed the practice of chest as well as cardiovascular imaging while retaining the importance of conventional
imaging. Cardiovascular imaging has transitioned nearly completely in the past two decades from dependence
on X-ray angiography for definite diagnosis to noninvasive cross-sectional imaging techniques. The roles of MRI
and MDCT are under rapid evolution. Continuing education is therefore essential so that multimodality imaging
approach provides best patient care in a cost-effective manner.
We hope that this third edition will serve as a comprehensive updated reference book for postgraduates, practising
radiologists, and chest physicians.
We wish to take this opportunity to thank our faculty from Maulana Azad Medial College, All India Institute of
Medical Sciences and Postgraduate Institute of Medical Education and Research for their active contribution and
support without which this endeavor would not have been possible.
We would also like to thank Shri Jitendar P Vij (Chairman and Managing Director), Mr Tarun Duneja (Director-
Publishing) and Ms Samina Khan of M/s Jaypee Brothers Medical Publishers (P) Ltd, for their professional help and
cooperation in publishing this book in present form.

Veena Chowdhury
Arun Kumar Gupta
Niranjan Khandelwal
Sanjiv Sharma
Anjali Prakash
 Preface to the First Edition

It is with great pleasure the faculty of Department of Radiodiagnosis at All India Institute of Medical Sciences,
Maulana Azad Medical College, New Delhi, and Postgraduate Institute of Medical Education and Research,
Chandigarh present the second book in the series on Diagnostic Radiology. This book is devoted to Emergency
and Chest Radiology and has been written to provide the radiologist in training, in practice or teaching, physician
and surgeon, an integrated review of the role of various imaging modalities and roentgen features seen in diseases
of the chest and in acute emergency situations, both medical and surgical, including trauma.
The plain chest radiograph remains the initial imaging modality for various chest diseases and its interpretation
continues to be a great challenge. Importance of chest radiograph in the diagnosis of various diseases has been
dealt with in depth in all the chapters. Technique of CT and its recent advances in the evaluation of chest diseases
and potential of MRI for evaluation of thoracic lesions are covered in separate chapters. Detailed discussion on the
clinicopathological aspects and radiology in common thoracic diseases like tuberculosis, nontubercular infections
and malignancy, role of HRCT in specific conditions and infections in immunocompromised hosts are included. All
the chapters provide information about the recent developments in various fields.
Importance of having diagnostic technical facilities and role of a radiologist in handling the patient in acute
emergency are highlighted. The increasing use of US and CT as an initial examination in the assessment of
acute abdominal conditions has tended to diminish awareness of the value of plain radiography. The role of plain
radiograph, US and CT in nontraumatic acute abdomen are covered in separate chapters.
Trauma is one of the leading cause of morbidity and mortality. The incidence and severity have sharply increased
during the past few decades, primarily because of the increased use of high speed travel. A disciplined approach
to the assessment of trauma provides confident interpretation and avoids errors of misdiagnosis. Computed
tomography has revolutionized evaluation of a patient with head injury and it remains the first modality of choice.
The diagnostic evaluation of patient with craniofacial injury remains problematic because of anatomic complexity
of this region, wide spectrum of fracture types, and diversity of soft tissue complication. The proper approach
to radiographic diagnosis of appendicular trauma begins by obtaining the appropriate radiographs of each site.
Awareness of the common, the often missed and the probable associated injuries improve interpretation and make
assessment of radiographs much easier.
The role of the radiologist in the management of abdominal trauma has expanded considerably in the recent
years. Earlier urography, scintigraphy and angiography played an important role in trauma care. The modalities of
CT and interventional radiology have improved the assessment of an injured patient and facilitated nonoperative
therapy for some injuries.
The proliferation of imaging modalities has increased the possibility of performing inappropriate and unnecessary
investigations. The comprehensive discussion on the indications and importance of various imaging techniques in
the practice of emergency and chest radiology, a systematic approach for imaging a patient with trauma affecting
different organ system are covered in this book.
We hope that the reader may find this book both instructive and informative for the improved use of radiological
resources which in turn will serve the common goal of good health care for the benefit of patients everywhere.
We wish to take this opportunity to thank our faculty colleagues from AIIMS, MAMC, and PGI for their active
support, cooperation and timely submission of the manuscripts. We owe immense gratitude to Prof K Subbarao and
Prof Ratni B Gujral who have been kind enough to submit their contributions well in time.
Manorama Berry
Sima Mukhopadhyay
Sudha Suri
 Contents

CHEST IMAGING

Techniques, Normal Anatomy And Basic Patterns In Chest Diseases

1. Chest X-ray: Technique and Anatomy......................................................................................... 1
Mahesh Prakash, Manavjit Sandhu
2. MDCT Chest: Technique and Anatomy...................................................................................... 13
Deep Narayan Srivastava, Atin Kumar, Shivanand Gamanagatti
3. Basic Patterns of Lung Diseases............................................................................................... 28
Sumedha Pawa

Pulmonary Infections And The Pulmonary Interstitium

4. Radiographic Manifestations of Pulmonary Tuberculosis...................................................... 60
Mandeep Kumar Garg, Naveen Kalra
5. Nontubercular Pulmonary Infections........................................................................................ 69
Anju Garg
6. Imaging of the Tracheobronchial Tree....................................................................................... 90
Ashu Seith Bhalla, Raju Sharma
7. Imaging of Interstitial Lung Disease........................................................................................ 117
Smriti Hari, Sanjay Sharma, Deep Narayan Srivastava
8. Pulmonary Manifestations in Immunocompromised Host.................................................... 134
(HIV and Solid Organ Transplant Patients)
Mandeep Kang
9. Chest in Immunocompromised Host
(Hematological Infections and Bone Marrow Transplant)..................................................... 145
Sanjay Sharma, Sanjay Thulkar

Mediastinum, Lung Nodules And Masses

10. Imaging the Mediastinum......................................................................................................... 154
Raju Sharma, Ashu Seith Bhalla, Arun Kumar Gupta
11. Imaging of Solitary and Multiple Pulmonary Nodules........................................................... 178
Veena Chowdhury, Sapna Singh
12. Lung Malignancies.................................................................................................................... 212
Sanjay Thulkar, Smriti Hari, Arun Kumar Gupta

Emergency Chest
13. Intensive Care Chest Radiology............................................................................................... 236
Akshay Kumar Saxena, Kushaljit Singh Sodhi
14. Imaging in Pulmonary Thromboembolism.............................................................................. 246
Kushaljit Singh Sodhi, Akshay Kumar Saxena
xii Diagnostic Radiology: Chest and Cardiovascular Imaging

15. Imaging in Thoracic Trauma..................................................................................................... 259

Atin Kumar, Shivanand Gamanagatti

Pleura And Diaphragm

16. Pleura.......................................................................................................................................... 272
Anjali Prakash
17. Imaging of the Diaphragm and Chest Wall.............................................................................. 301
Sameer Vyas, Anupam Lal

Interventions In Chest
18. Bronchial Artery Embolization................................................................................................. 315
Shivanand Gamanagatti, Ashu Seith Bhalla
19. Diagnostic and Therapeutic Interventions in Chest............................................................... 328
Naveen Kalra, Mandeep Kang, Anupam Lal

CARDIOVASCULAR IMAGING

Cardiac Imaging
20. Chest X-ray Evaluation in Cardiac Disease............................................................................ 341
Sanjiv Sharma, Gurpreet Singh Gulati, Priya Jagia
21. Imaging in Ischemic Heart Disease......................................................................................... 349
Gurpreet Singh Gulati, Sanjiv Sharma, Priya Jagia
22. Imaging Approach in Children with Congenital Heart Disease............................................. 366
Priya Jagia, Sanjiv Sharma, Gurpreet Singh Gulati
23. Imaging in Cardiomyopathies.................................................................................................. 376
Priya Jagia, Gurpreet Singh Gulati, Sanjiv Sharma
24. Imaging Evaluation of Cardiac Masses................................................................................... 384
Gurpreet Singh Gulati, Priya Jagia, Sanjiv Sharma
25. Imaging Diagnosis of Valvular Heart Disease......................................................................... 399
Priya Jagia, Sanjiv Sharma, Gurpreet Singh Gulati
26. Imaging of the Pericardium...................................................................................................... 409
Jyoti Kumar

Nuclear Medicine
27. Nuclear Medicine in CVS and Chest........................................................................................ 423
Chetan D Patel, Madhavi Chawla

Vascular Imaging
28. Imaging of Aorta........................................................................................................................ 437
Niranjan Khandelwal, Vivek Gupta
29. Imaging of Peripheral Vascular Disease................................................................................. 459
Rashmi Dixit
Index........................................................................................................................................................... 483
 CHEST IMAGING
Techniques, Normal Anatomy and Basic Patterns in Chest Diseases

1 Chest X-ray: Techniques and Anatomy

Mahesh Prakash, Manavjit Sandhu

INTRODUCTION • There is poor visibility of mediastinum, retro cardiac and

Chest X-ray is the most commonly performed radiological subphrenic areas when lungs are well seen.
investigation around the world and it forms an integral part of • Lungs may be obscured by high contrast of bones.
the routine study of individual case along with and as important • Inadequate detail of airway and lung apices.
as physical examination and laboratory investigations. The
Chest radiograph nearly constitutes 50 to 60 percent of the Technical Advances
total work load of the radiology department of any large or Following technical advances have been developed over
small general hospital. The cornerstone of the radiological the years to overcome limitation of the conventional chest
diagnosis of the chest diseases is chest radiograph. All other radiograph
radiological procedures including bronchography, computed • High kV technique
tomography (CT) and magnetic resonance imaging (MRI) are • New film screen combinations
strictly ancillary.1 • Beam equalization radiography
The techniques, various radiographic projections and • Digital chest radiography.
normal anatomy of lungs, mediastinum and diaphragm as
demonstrated on plain chest radiographs have been discussed High kV Technique
herewith. In this technique we use more than 120 kV. The coefficient of
X-ray absorption of bone and soft tissue approach each other
CONVENTIONAL CHEST RADIOGRAPHY at high kV and thus the lungs are not obscured by bones. It has
Conventional film screen radiography using kV range of better penetration of the mediastinum which provides more
50-85 depending on patient’s build is the standard and most details of airway. Short exposure time with high kV allows
commonly used technique for chest evaluation. The benefits less scatter radiation to reach intensifying screens and results
of this technique include low cost, high spatial resolution, in sharp details of structures within the lungs. However,
operation simplicity and dependability. The important high kV results in greater scatter radiation as compared to
factors that influence the contrast in the radiograph include conventional radiography. Use of an air gap of 6 inches is
kilovoltage, shape of sensitometric curve of film, exposure required to reduce scatter radiation.2
parameters and conditions of film processing. At low kV, the
difference in attenuation by soft tissue and bone or air and New Screen Film Combinations
bone is large, resulting in high contrast. Calcified lesions, Fine details on radiograph is principally determined by screen
pleural plaque, pulmonary nodules are well delineated in film system. Generally, medium speed system is preferred
low kV radiograph. However, some of the limitations of which provided better visualization of small vessels, fissures
conventional chest radiograph are given here. and depiction of abnormalities. The major advance in screen
2 Techniques, Normal Anatomy and Basic Patterns in Chest Diseases

film system has been the introduction of faster rare earth a. Interposing a customized filter unique to the patient
phosphor screen and development of wide latitude film. that would attenuate the beam over the lungs and allow
The improved light emission from rare earth phosphor over increased radiation exposure over the mediastinum.
traditional calcium tungastate crystal screen results in short b. Modulation of exposure for each part of the chest by
exposure time and thus sharp image. electronic feed back system.
Another important development is the introduction of The first one lacks practicality, the latter one is the principle
asymmetric screen film system, the asymmetric zero cross used in technique of beam equalization radiography that
over screen film system. It was introduced by Eastman Kodak utilizes screen film receptors by increasing X-ray exposure
in 1990 called insight thoracic imaging system.3 This uses in the thicker, denser part of chest while keeping the lung
different emulsion on either side of film base and different exposure unchanged, thereby reducing the dynamic range of
front and back intensifying screens. In addition layers of intensities that ultimately reach the image recorder.5,6
absorbing dye in the film base prevent crossover of light Oldelft from Netherlands introduced in 1986 the Advanced
between two emulsions so that both screen film combinations Multiple Beam Equalization Radiography (AMBER) which is
operate independently. The front side has high resolution the only commercially available system for chest radiography.
screen and high contrast film emulsion. This combination This system has horizontal X-ray fan beam which is
optimizes visualization of fine details in lungs. The back divided into 20 adjacent beam segments, each of which is
side consists of high speed screen and film emulsion with independently controlled by its own intensity modulator
low maximum density. This combination provides adequate located in front of X-ray tube and corresponding exposure
visualization of high attenuating areas eg. mediastinum detector between patient and image recorder. As the fan beam
without over penetration of lungs. Patient dose reduction up scans the patient, the detector array measure local X-ray
to 30 percent has been reported.4 intensity passing through the patient and an electronic feed
Dupont in 1993 introduced an ultravision screen film back mechanism dynamically adjust each of beam modulators
system. In this system, screens use a high density rare earth such that dense areas are imaged at higher exposure levels.
phosphor (yattrium tantalate) which emits ultraviolet light This increases signal to noise ratio in the denser areas of chest
that diffuses substantially less than the lower energy wave and shift the background film optical density in these areas on
length visible light. The film emulsion used is symmetric. to higher contrast portion of H and D curve.
These combinations of film screen system have provided The advantage of this technique are:
increased information that can be recorded and displayed. • Better delineation of mediastinum, retrocardiac and
The asymmetric system is slightly superior particularly retrodiaphragmatic areas.
for visualization of mediastinal and retro diaphragmatic • Improved visualization of lung apices in lateral view.
structures. The improved image sharpness achieved with The reported disadvantage of AMBER are:
these systems potentially can improve visualization of subtle • Decreased contrast between consolidation and normal
parenchymal abnormalities. lung.
• Edge artifacts occur where there are abrupt changes in
BEAM EQUALIZATION RADIOGRAPHY radiolucency, e.g. lung heart interface ,lung diaphragm
Screen film system provides acceptable image-contrast of interface.
chest radiograph in most situations. However, the relatively • Dark halo around the heart may simulate pneumo-
narrow range of film sensitivity limits image contrast in mediastinum.
poorly penetrated areas of chest. The technique of beam • Active imaging areas is limited to upright 14” × 17”
equalization radiography refers to varying the intensity of orientation so it is not possible to acquire transverse image
X-ray beam passing through various parts of chest so as to of chest.
produce a chest radiograph with uniform density of areas with • Exposure parameter to be set manually
extremely variable attenuation differences on the same film. • Difficulty in comparing the radiograph of patient with
This can be achieved by two methods: previous one using conventional technique
 Chest X-ray: Techniques and Anatomy 3

• This system can not be used on bed side and for patient on can be reduced without degradation of image quality and
stretcher. multiple images can be acquired in short-time.9,10
• Radiation dose is about 50 percent more than conventional Dual energy imaging is a new technique which utilizes
chest radiograph. a receptor with two layers, each of which records different
The experience till date is not clearly indicative of the energy components of X-ray beam and is possible for a
justification of additional expense even though images are computer to analyze and separate the components of dual
more informative and this seems to have limited its popularity energy in order to display both soft tissue and bone images of
in clinical use. the same radiograph.6 Dual energy imaging is one of the few
areas in which digital radiography has proved of diagnostic
DIGITAL RADIOGRAPHY advantage over conventional chest radiography.
Advances in electronics and computer technology over the Temporal subtraction imaging is used to improve the
past decades, have led to development of digital radiography visual assessment of chest radiograph. This technique aim to
or computed radiography system. This is different from selectively enhance areas of internal change by subtracting
conventional film based analogue system where the film is in the patient’s previous radiograph from the current one.
direct contact with intensifying screen and there is no storage Studies have shown that temporal subtraction improves the
of information as digits in computer. In digital radiography, visual perception of subtle abnormalities such as pulmonary
image detection can be completely separated from image nodules, infiltrative opacities and diffuse lung disease.11,12
display. The data of image is stored in the computer and can Digital tomosynthesis is a technique that has evolved
be retrieved, displayed, quantified, manipulated and hard from conventional tomography and solves many of the
copied whenever required.6 problems associated with conventional tomography. Digital
Digital system using phosphor technique in which the entire Tomosynthesis can produce an unlimited number of section
receptor is exposed by conventional radiography equipment images at arbitrary depths from single set of acquisition
was introduced by Fuji in 1980 and is the most widely used images. This technique is another method for improving
technique for general digital radiography. This technique is detection of subtle lesions such as pulmonary nodules.13,14
based on reusable imaging plate coated with photostimulable
phosphor material. When exposed to X-ray, a portion of Digital Radiography and Chest
X-rays is absorbed as to release stored energy as light and Major advantage of digital radiography lies in the control
intensity of light measured and digitized. The resultant digital of display of optical density of radiographs in portable
image is then preprocessed for contrast and spatial resolution chest X-ray examination with dynamic range and control
before display. Imaging plate is ready for reuse after exposure processing. It improves visibility of tubes and lines
to room light. superimposed on the mediastinum. Although it may not offer
Introduction of selenium detector system is an important any significant advantage over conventional film screen
development in digital chest radiography. Unlike storage system, Digital radiography improves visibility of normal
phosphor detector which requires laser stimulation for lung structures, thus one has to be careful in distinguishing
image acquisition, selenium based detector capture image prominent blood vessels from interstitial disease. To avoid
information as charge pattern and thus image can be read this misinterpretation, mild to moderate edge enhancement is
directly, eliminating image noise.7,8 Also selenium is more required for better visualization of interstitial disease. Due to
efficient in detection of X-rays. smaller size of digital radiograph there is a definite learning
Flat panel detectors are relatively new development in the curve to adjust to digital radiograph and one may have to
technology. Depending on the material, there are two type of interpret the film from a closer distance.
flat panel detectors, indirect type use a phosphor screen like Numerous observe performance studies have shown that
cesium iodide to convert the X-ray to light photons. Direct digital radiography can equal conventional film radiography
flat panel detectors use instead a photoconductive layer, most in virtually any specific task. However, for this, post
commonly amorphous selenium that converts X-ray energy processing of the digital image is required to match the digital
directly to charge. By using flat panel detectors, patient dose radiograph to the task. A problem inherent in all forms of
4 Techniques, Normal Anatomy and Basic Patterns in Chest Diseases

digital manipulation is that enhancement of the image for one Patient Respiration
purpose, degrades it for another. Respiration must be fully suspended, preferably at total
There have been conflicting reports about whether digital lung capacity (TLC). It has been shown that in erect chest
chest radiography can be satisfactorily interpreted on high radiographs, normal subjects routinely inhale to approximately
resolution television monitors, as distinct from laser printed 95 percent of TLC without coaxing;15 thus, such radiographs
films. Recent studies suggest that 2 K × 2 K monitors may can be of value in estimating lung volume and, by comparison
be adequate for making primary diagnosis on digital chest with subsequent radiographs in appreciating an increase or
radiograph. decrease in volume as a result of disease.

RADIOGRAPHIC PROJECTIONS Film Exposure

Posteroanterior View (PA View) Exposure factors should be such that the resultant radiograph
The most satisfactory and standard radiographic view for permits faint visualization of the thoracic spine and the inter-
evaluation of the chest is posteroanterior view with patient vertebral disks on the PA radiograph so that lung markings
standing (Figure 1.1). Visualization of lungs is excellent behind the heart are clearly visible. Exposure should be as short
because of inherent contrast of the tissues of the thorax. as possible, consistent with the production of adequate contrast.
The diagnostic accuracy of chest disease is partly related Unfortunately, all too frequently technical factors are such
to the quality of radiographic images. It is incumbent on all that optimal radiographic density is achieved over the lungs
radiologists to ensure that images on which their diagnostic generally but without adequate exposure of the mediastinum
impression is based are of the highest quality. Careful attention or the left side of the heart, a tendency that seriously limits
to several variables is necessary to ensure such quality. radiological interpretation, moderate overexposure can be
easily compensated for by bright illumination; underexposure
Patient Positioning on the other hand cannot be compensated for by any viewing
Positioning must be such that the X-ray beam is properly technique and since it prevents visualization of vital areas of
centered, the patient’s body is not rotated, and the scapulas the thorax, should not be tolerated in any circumstances. With
are rotated sufficiently anteriorly so that they are projected perseverance, it is always possible to overcome problems of
away from the lungs. On properly centered radiographs, the underexposure.
medial ends of the clavicles are projected equidistant from the For a PA chest radiograph, the mean radiation dose at
margins of the vertebral column. skin entrance should not exceed 03 mGy per exposure and
the exposure time should not exceed 40 msec.16 An optimally
exposed radiograph presents the lung at a mid gray level
(average optical density, 1.6 to 1.9). (Optical density is
a measurement of the ability of the film to stop light (film
blackness), and it is equal to the logarithm of light incident on
the film over light transmitted by the film (D = log IO/It). The
focal film distance should be at least 180 cm (72 inches) to
minimize magnification16 (Focal film distance is the distance
between the focal spot of the X-ray tube and the radiograph).

Kilovoltage
A high kilovoltage technique appropriate to the film speed
should be used;10 for PA and lateral chest radiographs, the
recommended kVp is 115 to 150 kVp. Since the coefficients
of X-ray absorption of bone and soft tissue approximate each
other in the higher kilovoltage ranges, radiographic visibility
Figure 1.1: Normal chest X-ray PA view in standing position of the bony thorax is reduced with only slight change in
 Chest X-ray: Techniques and Anatomy 5

the overall visibility of lung structures. Furthermore, the of aerated lung overlying the spine. Both diaphragms are
mediastinum is better penetrated, thereby permitting visibility visible throughout their length except the left anteriorly where
of lung behind the heart and the many mediastinal lines and it merges with the heart (Figure 1.2). The diaphragm of the
interfaces whose identification is so important to the overall side closer to the film is also more sharply defined. The ribs
assessment of both the mediastinum and lungs. This technique of the side away from the film appear wider.
can produce chest radiographs superior in all respects to those
obtained with other techniques in addition to better penetration Anteroposterior View (AP View)
of the mediastinum. High kilo-voltage also results in lower This is sometimes the only projection that is possible in very
radiation exposure than does lower kilo-voltage. The only sick patients and usually it is obtained in wards and ICUs
drawback of the high kilovoltage techniques is the diminished with portable X-ray machines. The quality is usually poor.
visibility of calcium that results from the lower coefficient of In this view the scapulae cannot be projected out of the lung
X-ray absorption; however this shortcoming has not proved fields. The ribs and clavicle are more horizontal and the heart
troublesome in practice. is magnified as compared to the PA view (Figure 1.3). AP
view is sometimes very helpful in deciding whether a small
Grids and Filters questionable pulmonary opacity on the PA view is genuine,
When using a grid, at least a 10:1 aluminum interspace grid by altering its relationship to the overlying ribs and vascular
with a minimum of 103 lines per inch recommended by the shadows.20 It is also useful in differentiating free and loculated
American College of Radiology.16 An alternative option uses pleural fluid.
an air gap technique in which a space of 15 cm (6 inches) is
interposed between the patient and the X-ray.17 Since the air Decubitus View
gap reduces radiation scatter by distance dispersion, no grid The cross-table lateral decubitus views are helpful in
is required. When this technique is used a constant focal film determining the confines of the cavity and demonstrating
distance of 10 feet is recommended. In a comparative study small pneumothorax or pleural effusions. The dependant
of air gap and grid techniques, it was shown that the former hemidiaphragm normally rises considerably in this view.
can provide contrast equal to those obtained with grids;18
of the various combinations of distances possible. A focal Lordotic View
distance of 10 feet with an air gap of 6 inches provides a good This view is obtained either with patient leaning backward in
compromise. Patient exposure with an air gap technique was lordotic position or more commonly, with cranial tilt of the
comparable to a no-grid, no-air gap technique and was less
than that obtained with a grid.

Lateral View
The lateral view is the most important supplement to standard
PA chest radiograph since much of the lung and mediastinum
is hidden on the PA film. Right or left lateral view, depending
on the area of interest closer to the film is obtained. The lateral
view helps in localization of different lobes and segments and
often this is the only view that will provide this information.19
Important observations on lateral film of the chest include the
clear spaces, vertebral translucency and outline of diaphragms.
There are two spaces of increased translucency where both
lungs lie closest. These are retrosternal and retrocardiac areas.
Retrosternal space normally measures less than 3 cm at its
widest point. Vertebral bodies normally are progressively
more translucent caudally because of increase in the volume Figure 1.2: Right lateral X-ray of normal chest
6 Techniques, Normal Anatomy and Basic Patterns in Chest Diseases

preferred to lateral views in case of bilateral disease since the

superimposition of two lungs is significantly obviated (Figure
1.5). The left posteroanterior oblique view is particularly
useful for better demonstration of trachea and its divisions.

SPECIAL RADIOGRAPHIC TECHNIQUES

Inspiratory-Expiratory Radiography
Comparison of radiographs exposed in full inspiration and
maximal expiration may supply useful information in two
specific situations. The main indication is the investigation of
air trapping, either general or local. The former is exemplified
by asthma or emphysema. In both these abnormalities,
diaphragmatic excursion is reduced symmetrically and lung
density changes little between expiratory and inspiratory
radiographs to demonstrate these features convincingly,
Figure 1.3: Anteroposterior view (AP) view of chest. expiration must be forced and preferably timed. When air
The clavicle and ribs are more horizontal in position
trapping is local as in bronchial obstruction or lobar emphy-
X-ray tube. It is particularly useful for clear demonstration sema, the expiratory radiograph reveals decreased ipsilateral
of lung apices. It is important in confirming middle lobe and diaphragmatic elevation, a shift of the mediastinum toward
lingular abnormalities. The clavicles are projected above the the contra lateral hemithorax and relative absence of density
lung fields and anterior and posterior parts of the ribs usually change involved broncho-pulmonary segments.
overlap each other (Figure 1.4). The lower chest is highly The second indication for expiratory-inspiratory radio-
distorted in this view. graphy is when pneumothorax is suspected and the visceral
pleural line is not visible on the standard inspiratory radio-
Oblique View graph or the findings are equivocal. In these situations, a film
Right or left posterior oblique views are obtained with degree taken in full expiration may show the line more clearly.
of obliquity best determined with fluoroscopy. These are

Figure 1.4: Lordotic view of chest. The Figure 1.5: Right oblique view of normal chest
clavicles are projected superior to apex
 Chest X-ray: Techniques and Anatomy 7

Valsalva and Müller Maneuvers NORMAL ANATOMY ON CHEST X-RAY

The Valsalva and Müller maneuvers respectively consisting The normal roentgen anatomy of the chest as seen on chest
of forced expiration and inspiration against a closed glottis radiographs can be described in following headings.
may aid in determining the vascular or solid nature of intra
thoracic masses. A change in size indicates a vascular lesion. Trachea
Lack of change in size, however, is not helpful because it may Trachea is a straight tube, midline in the upper part and deviates
occur with solid lesions or with insufficient effort. Although slightly to the right around the aortic knuckle. It shortens and
potentially helpful these maneuvers are seldom used in deviates more to right on expiration. Its caliber is even with
clinical practice. decreasing translucency as it is traced caudally. On plain chest
radiograph the upper limits of coronal diameters in adults are
Bedside/Portable Radiography 21 mm (in females) and 25 mm (in males); sagittal diameters
The number of requests for radiographic examination of are 23 mm (in females) and 27 mm (in males).25 The right
the chest with a mobile apparatus at a patient bedside has tracheal margin (right paratracheal stripe) can be traced down
increased enormously since its introduction owing partly to to the right main bronchus. It is 4 mm or less in thickness and
the growth of Intensive Care Units (ICUs) and partly to the measured above the azygos vein.26 The left paratracheal line
introduction of complex cardiovascular surgical procedures is rarely visualized. After the age of 40 years, calcification
that require close post operative surveillance. of the cartilage rings of the trachea is a common finding.27
Such radiographs are almost invariably technically inferior The enlarged azygos vein, which lies in the angle between
to those obtained in the standard manner in the radiology the right main bronchus and trachea, may be normally seen
department itself. This inferior quality derives from multiple as a round opacity in the tracheobronchial angle in the supine
factors, some of which are uncontrollable (e.g. the patient’s chest film.
supine position, a short focal film distance and the restricted
ability of many such patients to suspend respiration or to Tracheobronchial Divisions
achieve full inspiration). Other factors, however, including the The trachea divides into right and left main bronchus usually
technical ones used in the exposure, are subject to control.21 at D5 or D6 level in adults. The left main bronchus is longer
Frequently, these radiographs are over exposed or under and has more acute angle with trachea as compared to right
exposed, sometimes to a degree that limits or even precludes main bronchus.
recognition of the subtle changes that are so important in the The right main bronchus divides into upper lobe bronchus
radiologist either accepting an inferior product or arranging and bronchus intermedius. The upper lobe bronchus divides
a repeat examination, with associated patient discomfort, into apical, posterior and anterior segmental bronchi. The
increased radiation exposure and increased cost. Some of bronchus intermedius divides into middle and lower lobe
these problems can be minimized by using a wide latitude bronchi. Middle lobe bronchus has medial and lateral
screen film combination. An alternative technique that is branches. The lower lobe bronchus has five branches; each for
rapidly replacing the screen film combination for bedside superior, anterior, lateral, posterior and medial basal segments
radiographs is digital radiography since it allows satisfactory of lower lobe. Absence of middle lobe on left side modifies
images to be obtained over a wide range of X-ray exposures. the bronchial division on left side. The left main bronchus
From the various studies in the literature it seems reasonable divides into upper and lower lobe bronchi. The upper lobe
to conclude that daily routine chest radiographs are indicated bronchus has two divisions; the upper division divides into
in ICU patients with acute cardiac or pulmonary problems, apico-posterior and anterior branches to supply upper lobe, the
in patients receiving mechanical ventilation, patients admitted lower division supplies the lingula with superior and inferior
for cardiac monitoring, or ICU patients admitted because of branches. The lower lobe bronchus on left side divides similar
extra thoracic disease. Chest radiographs are recommended to the right side except the absence of separate medial basal
after insertion of endotracheal tubes, central venous lines, branch. Major tracheobronchial divisions are illustrated in the
chest tubes and intra aortic balloons.22-24 Figures 1.6A and B.
8 Techniques, Normal Anatomy and Basic Patterns in Chest Diseases

Figure 1.7: Line diagram showing the position of major fissure on

lateral chest radiograph (Reproduced with permission)

5 cm behind the costophrenic angle on the left and just behind

the angle on the right side28(Figure 1.7).
The right lung has an additional fissure, the minor
(horizontal) fissure. It can be drawn on chest PA film from
right hilum to the sixth rib in axillary line (Figure 1.8). It
separates the middle lobe from right upper lobe. There are some
accessory fissures, which are occasionally seen. The azygos
lobe fissure, so called because it contains the azygos vein on
right and hemiazygos vein on left within its lower margin,

Figures 1.6A and B: Diagrammatic representation major tracheo-

bronchial division as seen on frontal (A) and lateral (B) orientation:
(1-apical, 2-posterior and 3-anterior segments of upper lobe; 4-lateral
segment of middle lobe/superior lingula, 5-medial segment of middle
lobe/inferior lingula, 6-superior, 7-medial basal, 8-anterior basal,
9-lateral basal and 10-posterior basal segments of lower lobe)

Lungs
The lungs are divided into three lobes on the right side and
two lobes on the left side by the interlobar fissures. The major
(oblique) fissures on both sides are similar. It runs obliquely
forwards and downwards (upper portion facing forward and
laterally and the lower portion facing backward and medially),
passing through the hilum. On a lateral view, it starts at the
level of fourth or fifth thoracic vertebra to reach the diaphragm Figure 1.8: Line diagram showing the position of minor fissure on PA
chest radiograph (Reproduced with permission)
 Chest X-ray: Techniques and Anatomy 9

is commonly seen on the right side with an incidence on 0.4 boundaries between various segments are complex and with
percent.28 It appears as a hairline with slight lateral convexity the rare exception of accessory fissure, the segments are not
running across the right upper zone to end in a comma like divided by septae. Although many pathological process may
expansion (azygos vein) near the hilum. The azygos lobe is predominate in one segment or another, these usually never
the area of the lung medial to the azygos fissure. The left sided confirms precisely to whole of just one segment since collateral
horizontal fissure, similar to the minor fissure on the right, air drift occur across segmental boundaries. However, infor-
separates the lingular from the other upper lobe segments. The mation of segmental involvement in disease process is
superior accessory fissure separates the apical from the basal particularly important to surgeons since these segments can
segments of the lower lobes. The inferior accessory fissure be removed separately. These bronchopulmonary segments
separates the medial basal from the other basal segments. are designated as per the divisions of segmental bronchi.
There is lot of overlap of bronchopulmonary segments on a
Bronchopulmonary Segments PA view of chest but they project separately on a lateral view.
Bronchopulmonary segments of individual lobes are based on Their approximate location as seen on frontal and lateral
the subdivisions of lobar bronchi. These segments represent radiographs is illustrated (Figures 1.9A to D).
the volume of the lung, which is supplied by an integral and The radiographic density of the two lungs is symmetrical on
relatively constant segmental bronchus and blood vessels. The a well-taken PA film. If the patient is rotated, the hemithorax

Figures 1.9A to D: Line diagram showing approximate locations of various bronchopulmonary segments. A. upper and middle lobe/lingula on
PA projection, B. Lower lobe on PA projection, C. Right lung on lateral projection, D. left lung on lateral projection (key same as figure 1.6)
10 Techniques, Normal Anatomy and Basic Patterns in Chest Diseases

closer to the film appears more radiodense. Both PA and hemidiaphragm. The bracheocephalic (innominate) vessels,
lateral views are necessary to localise a lesion in one or more superior vena cava and right atrium form the right mediastinal
of the pulmonary segments. Since the normal bronchi are not border. Rarely a dilated aorta may also contribute. The left
visualised in the peripheral lung fields, it is difficult to make border is formed by left subclavian artery, aortic knuckle, left
out the boundary of different pulmonary segments on plain atrial appendage and left ventricle.
radiographs of the chest. The radiological division of the mediastinum can be
ascertained on a lateral chest radiograph by two imaginary
Hilum and Pulmonary Vasculature lines (Figure 1.10). The first line is drawn from the diaphragm
The structures contributing to the formation of the hilum are upward along the posterior border of heart and anterior border
the pulmonary arteries and their main branches, upper lobe of the trachea into the neck. A second line is drawn connecting
pulmonary veins, the major bronchi and lymph glands. Of all a point on each thoracic vertebra, 1cm behind their anterior
the structures in the hilum, only the pulmonary arteries and borders. The anterior mediastinum is in front of the first line,
upper lobe veins significantly contribute to the hilar shadows the middle mediastinum is between the two lines and the
on a plain radiograph. Normal lymph nodes are not seen. The posterior mediastinum is behind the second line.
left hilum is usually 0.5 to 2 cm higher than the right. Both The anterior mediastinum contains thymus, heart with
hila are of equal density and size with a concave lateral border pericardium, great vessels and occasionally, aberrant thyroid.
on PA film. Middle mediastinum contains trachea and oesophagus. Nerve
The diameter of the normal descending branch of right roots and descending thoracic aorta are the main contents of
pulmonary artery is between 10-16 mm in males and posterior mediastinum. Normal lymph nodes and adipose tis-
9-15 mm in females. The course of the pulmonary vessels can sue is seen in all divisions of mediastinum. Conventional PA
be described by dividing them into three zones depending upon and lateral views of the chest are the first radiological inves-
their positions in the lungs, i.e. hilar, mid lung and peripheral. tigation in any suspected mediastinal abnormality. However,
Mid lung vessels extend from hilum upto 2 cm from the chest a lesion may not be detected if it is not large enough to cause
wall. Peripheral vessels are present in other 2 cm of the lung contour abnormality in the lung-mediastinum interphase.
fields and these are rarely seen on a normal chest radiograph. In neonates and young children the normal thymus is seen
The pulmonary veins have fewer branches and are straighter. as a triangular sail shaped structure with well-defined borders,
The distinction between intrapulmonary arteries and veins sometimes wavy in outline. Its borders project from one or
is difficult and seldom useful so that they are collectively both sides of the mediastinum.
referred to as pulmonary vasculature. The pulmonary vessels
taper gradually as they proceed peripherally. On erect PA
chest radiographs; the upper zone vessels are comparatively
narrower than lower zone vessels because of the effect of
gravity. The bronchial vessels are normally not seen on chest
radiograph.

Pleura
Normal pleura is not visible on chest radiographs. The
mediastinal surface of the pleura can occasionally be demons-
trated near the midline in a well-penetrated chest radiograph.

Mediastinum
It is a space lying between two lungs. It is bounded by sternum
anteriorly, dorsal spine posteriorly and pleural sacs on both
sides. The borders of the heart and mediastinum are clearly Figure 1.10: Line diagram showing radiological divisions of the
defined except where the heart is in contact with the left mediastinum (Reproduced with permission)
 Chest X-ray: Techniques and Anatomy 11

Mediastinal Lines and Interfaces CONCLUSION

As the two lungs approximate anteriorly, four layers of Chest radiography still remains the first investigation in the
pleura and anterior mediastinum separate them forming diagnosis of various chest diseases. Knowledge of normal
a septum called as anterior junctional line. On PA film this anatomy has utmost importance in proper diagnosis of disease
line is oriented from upper right to lower left of the sternum. process on chest X-ray. Conventional radiograph may have
Similarly, posterior junctional line is produced by the technical limitation in some situations like critically ill
posterior approximation of the lungs behind the oesophagus patients in ICU; however, recent advances in electronics and
and anterior to spine. On PA film, the posterior junctional computer technology have resulted in development of digital
line usually projects through the air column of trachea. imaging which improves diagnostic quality of chest imaging.
Adjacent to the vertebral bodies runs the para spinal lines.
Azygoesophageal recess is formed by contact of right lower REFERENCES
lobe with esophagus and azygos vein. The recess is frequently 1. Fraser RS, Muller NL, Colman N, et al. The normal lung. In:
identified on a well-penetrated PA film as an interface that Fraser RS, Muller NL, Colman N, Pare PD (Eds) Diagnosis of
Diseases of Chest 4th edition, Philadelphia: WB Saunders Co
extends from the diaphragm below to the azygos arch above. 1999;299.
Typically, it is seen as a continuous arch concave to the right. 2. MacMohan H, Vyborny C. Technical advances in chest
It may be straight in young adults.28 The paraspinal lines are radiography. AJR 1994;163:1049-59.
3. Bunch PC. Performance characteristic of asymmetric zero-
usually 1 to 2 mm wide on PA film.
cross over screen film system. SPIE Proc Med Imaging IV
1992;1653:46-65.
Heart 4. Swension SJ, Grey JE, Brown LR, et al. A new asymmetric
Normally two thirds of the cardiac shadow lies to the left of screen film combination for conventional chest radiology:
evaluation of 50 patients AJR 1993;160:483-86.
the midline and one-third to the right. In normal individuals, 5. Chotas HG, Floyd CE jr, Ravin CE. Film based chest
the transverse diameter of the heart on PA film is usually in radiography: AMBER Vs asymmetric screen film system.
the range of 11.5 to 15.5 cm. It is less than 11.5 cm in about 5 AJR 1993;161:743-47.
6. Hansell DM. Technical consideration. In peter Armstrong,
percent of people and only rarely exceeds 15.5 cm in heavy,
Alam G. Wilson, Paul Dee, David M Hansell (Eds): Imaging
stocky individuals. Assessment of cardiac size by determining of diseases of chest (2nd ed) Mosby 1995;1-14.
cardiothoracic ratio is more useful. Cardiothoracic ratio of 7. Neitzei U, Maack I, Gunther-Kohfahl S. Image quality of
50 percent is accepted widely as the upper limit of normal, digital chest radiography system based on selenium detector.
Med Phys 1994;21:509-16.
however, it exceeds 50 percent in at least 10 percent of normal
8. Chotas HG, Floyd CE jr, Ravin CE. Memory artifact related
individuals.29 The cardiothoracic ratio may be upto 60 percent to selenium based digital radiography system. Radiology
in neonates.30 1997;203:881-83.
9. Samei E, Flynn MJ. An experimental comparison of detector
performance for direct and indirect digital radiography system.
Diaphragm Med Phys 2003:30:608-22.
In most individuals it has a smooth dome shape. The peak or 10. Samei E. Performance of digital radiography detectors: factors
the highest point of the dome is medial. Flattening of the dome affecting sharpness and noise. In: Samei e. Flynn MJ. eds 2003
can be measured on PA view by dropping a perpendicular from syllabus: categorical course in diagnostic radiology physics-
advances in digital radiography. Oak Brook, III: Radiological
mid point of the dome to the line connecting costophrenic Society of North America 2003:49-61.
and cardiophrenic angles of the same side. The distance is 11. Abe H, MacMahon H. Engelmann R, et al. Computer
normally greater than 1.5 cm.31 In approximately 90 percent aided diagnosis in chest radiography: results of large scale
observer tests at the 1996-2001 RSNA scientific assemblies.
of normal individuals, the right hemidiaphragm is 1.5 to
Radiographics 2003:23:255-65.
2.5 cm higher than the left. In rest, either the domes are at 12. Okazaki H, Nakamura K, Watanabe H, et al. Improved
the same level or the right diaphragm may be at the slightly detection of long cancer arising in diffuse lung diseases on
higher level. The discrepancy in the levels of the diaphragms chest radiographs using temporal subtraction. Acad Radiol
2004:11:498-505.
is related to the position of the cardiac apex and not to the
13. Dobbins JT 3rd. Godfrey DJ. Digital X-ray tomosynthesis:
position of the liver. A difference greater than 3 cm in the current state of the art and clinical potential. Phys Med Biol
levels of two hemidiaphragms is significant.32 2003:48:R65-R106.
12 Techniques, Normal Anatomy and Basic Patterns in Chest Diseases

14. Godfrey DJ. McAdams HP. Dobbins JT 3rd. Optimization of 23. Gray P, Sullivan G, Ostryzniuk P, et al. Value of postprocedural
the matrix inversion tomosynthesis (MITS) impulse response chest radiographs in the adult intensive care unit. Crit Care
and modulation transfer function characteristics for chest Med 1992;20:1513.
imaging. Med Phys 2006:33:655-67. 24. Hill JR, Horner PE, Primack SL. ICU Imaging. Clin Chest
15. Crapo RA, Montague T, Armstrong J. Inspiratory lung volume Med 2008;29(1):59-76,vi.
achieved on routine chest films. Invest Radiol 1979;14:137. 25. Breatnach E, Abbott GC, Fraser RE: Dimensions of the
normal human trachea. AJR 1984;142:903-06.
16. American college of Radiology: ACR standard for the
26. Savoca CJ, Austin JHM, Goldberg HI. The right paratracheal
performance of pediatric and adult chest radiography.
stripe. Radiology 1977;122:295.
American College of Radiology, Reston, VA, 1997:27.
27. Murfitt J. The normal chest: Methods of investigation
17. Jackson FI. The air gap and improvement, and an improvement and differential diagnosis. In Sutton D (Ed): Textbook of
by anteroposterior positioning for chest roentgenography. Am Radiology and Medical Imaging, 4th edition. Churchill
J Roentgenol 1964;92:688. Livingstone 1987;2:326-67.
18. Trout RD, Kelly JP, Larson VL. A comparison of air gap 28. Mukherjee S, Gupta R. Imaging in chest diseases. In: Pande
and grid in roentgenography of the chest. Am J Roentgenol JN (Ed): Respiratory Medicine in the Tropics. 1st edition.
1975;120:404. Delhi, Oxford University Press 1998;90.
19. Felson B. The roentgen work-up. In Felson B (Ed) Chest 29. Muller NL. The normal chest. In: Muller NL, Fraser RS,
Roentgenology. Philadelphia: WB Saunders Co 1, 1988. Colman NC (Eds): Radiologic Diagnosis of Diseases of the
Chest. 1st edition. Philadelphia: WB Saunders Company, 1,
20. Flower CDR, Armstrong P. Techniques. In: Graingern RG,
2001.
Allison D (Eds). Diagnostic Radiology. 3rd edition. New
30. Edwards DK, Higgins CB, Gilpin EA: The cardio-thoracic
York: Churchill Livingstone 1997;201.
ratio in newborn infants. AJR 1981;136:136.
21. Wandtke JC. Bedside chest radiography. Radiology 31. Lennon FA: Simon 6. The height of the diaphragm in the chest
1994;190:1. radiographs of normal subjects. Br J Radiol 1965;38:937.
22. Fong Y, Whalen G, Hariri RJ, et al. Utility of routine chest 32. Flower CDR, Verschakelan JA. The diaphragm. In: Grainger
radiographs in the surgical intensive care unit. Arch Surg RG, Allison D (Eds). Diagnostic Radiology. 3rd edition. New
1995;130:764. York: Churchill Livingstone 1997;270.
 2 MDCT Chest: Techniques and Anatomy

Deep Narayan Srivastava, Atin Kumar, Shivanand Gamanagatti

INTRODUCTION AND TECHNIQUES • Evaluation of acute aortic syndromes (dissection, tran-

Posteroanterior and lateral chest radiographs, together form section)
the initial imaging modality to evaluate chest pathology. • Demonstration of pulmonary embolism
Computed tomography (CT) is however being increasingly • Identification of complications post thoracic surgery
used, as important adjunct to plain films for detection, diag- (mediastinal haematomas, complex pleural collections)
nosis, and characterization of lung and mediastinal disease. In the nonacute setting,
• Further evaluation of nodules, hilar or mediastinal masses
COMPUTED TOMOGRAPHY identified on a chest radiograph
The introduction of spiral (helical) computed tomography • Lung cancer diagnosis and staging
(CT) in the early 1990s constituted a fundamental evolution- • Assessment of congenital anomalies of the thoracic great
ary step in the ongoing refinement of CT imaging, replacing vessels
the discontinuous acquisition of data in conventional CT with • Characterization of interstitial lung disease
volumetric data acquisition. In 1998 several CT manufacturers • Identification of bronchiectasis/small airways disease
introduced Multi Detector CT (MDCT) systems, which pro- • Detection of pulmonary metastases from known extra-
vided considerable improvement in data acquisition speed and thoracic malignancy
longitudinal resolution, and more efficient use of X-rays.1-3 With MDCT systems, different section widths are achieved
These systems typically offered simultaneous acquisition of by collimating and adding together the signals of neighbouring
four sections with a gantry rotation time of 0.5s. Since then, detector rows. The Somatom Sensation 4 system, for example,
there has been further rapid improvement in scanner perform- uses the adaptive array detector design and has eight detector
ance with increased numbers of detector rows and faster tube rows. Their widths in the longitudinal direction range from
rotation; currently, systems with 16, 32, 40, 64, 128, 256 and 1 to 5 mm at the iso centre and this arrangement allows the
320 active detector rows are available. Rotation times of the following collimated section widths: two sections at 0.5 mm,
X-ray tubes have decreased from 0.5s to 0.33s per rotation four at 1 mm, four at 2.5 mm, four at 5 mm, two at 8 mm and
and even less. The faster data acquisition enables not only bet- two at 10 mm. Currently, there is a trend amongst thoracic
ter coverage in a single breath-hold, but also results in a sig- radiologists towards acquiring high-resolution (1–1.25 mm
nificant reduction in patient movement artifacts. In pediatric thickness) volumetric images which can then be reconstructed
practice this has meant less frequent need for sedation.4 at 1.25–5 mm intervals for interpretation depending on the
The introduction of MDCT has expanded the clinical clinical question. Hence, from the same dataset, both narrow
indications for CT. sections for high spatial resolution detail or three-dimensional
(3D) post-processing, and wide sections for better contrast
Indications for CT of the Chest resolution or quick review, can be derived. The convenience
In the acute setting, of a single protocol is particularly useful for patients with
• Chest trauma suspected focal and interstitial lung disease.
14 Techniques, Normal Anatomy and Basic Patterns in Chest Diseases

Thin section reconstructions are recommended for volume-

tric assessment and characterization of pulmonary nodules,
the evaluation of interstitial lung disease and the evaluation
of pulmonary embolism, whereas 3–5 mm reconstructions
are usually adequate for the initial assessment of mediastinal
masses and for lung cancer staging studies. In younger
patients, however, a more critical approach should be adopted
with the CT examination being tailored to the specific clinical
question being asked, to avoid unnecessary radiation dose.5-7
With the introduction of 16- and 64- detector, 128 and
256 MDCT systems has allowed the goal of truly isotropic
imaging. Isotropic imaging means, each image data element
i.e. voxel is of equal dimensions in all three spatial axes, and
forms the basis for image display in any arbitrarily chosen
imaging plane.
The acquisition of volumetric high-resolution data has Figures 2.1A to C: Line diagram showing the value of different
pitches. With smaller the pitch (C) there is overlap of slices and with
particularly revolutionized the noninvasive assessment of higher pitch there is increase in interslice gap (A)
vascular disease in the chest. Many anatomical features of the
chest do not conform to a single two-dimensional (2D) axial Dose Considerations
plane and full exploitation of isotropic MDCT data requires Despite the undisputed clinical benefits of MDCT, there is the
2D and 3D postprocessing techniques to exploit the added issue of increased radiation compared to single-detector CT
advantage of improved z-axis resolution and coverage. Various to consider. In a CT X-ray tube, a small area on the anode
post processing techniques and their clinical applications are plate emits X-rays that penetrate the patient and are registered
mentioned in Table 2.1. by the detector. A collimator between the X-ray tube and the
patient, the pre-patient collimator, is used to shape the beam
Definition of Spiral Pitch and establish the dose profile. In general, the collimated dose
An important parameter for characterizing helical CT is profile is a trapezoid in the longitudinal direction. In the
the pitch, which according to International Electrotechnical umbral region, X-rays emitted from the entire area of the focal
Commission specifications, is defined as p = TF/W, where TF spot fall on the detector; however, in the penumbral regions,
is the table feed per rotation and W is the total width of the only a part of the focal spot illuminates the detector—the
collimated beam.8 With four sections at 1 mm collimation and pre-patient collimator blocking off other parts. With single-
a table feed of 6 mm per rotation, the pitch is p = 6/(4 × 1) detector CT, the entire trapezoidal dose profile can contribute
= 1.5. This definition holds true for both single- and multi- to the detector signal, and thus the relative dose utilization of
detector row CT systems. In the early days of four-detector a single-detector CT system can be close to 100 percent. With
CT, the term detector pitch was introduced, which accounted MDCT, only the plateau region of the dose profile is used to
for the width of a single section in the denominator. For the ensure an equal signal level for all detector elements. The
sake of uniformity, the term detector pitch should no longer penumbral region is then discarded, either by a post-patient
be used.9 collimator or by the intrinsic self-collimation of the MDCT,
Faster table speed for a given collimation, resulting in a and represents ‘wasted’ dose. The relative contribution of the
higher pitch, is associated with a reduced radiation dose (if penumbral region decreases with increasing section width
other data acquisition parameters, including tube current, are and with an increasing number of simultaneously acquired
held constant) because of a shorter exposure time. There is one images. Thus, the relative dose utilization with four-section
disadvantage of using a higher pitch is that there is interslice 1 mm collimation CT is 70 percent or less depending on the
gap, which may result in missing of smaller lesions (Figures scanner type, whereas with 16-section CT systems, dose
2.1A to C). efficiency can be improved to 84 percent.
 MDCT Chest: Techniques and Anatomy 15

The CT parameters that affect radiation dose include Another recommendation comprises acquisition of the
gantry geometry, tube current and voltage, acquisition modes, entire chest using a 1 mm collimation (MDCT) at 120 kVp and
collimation, pitch and gantry rotation time. Reduction in tube 10–40 mAs depending on the body habitus of the individual.14
current is the most practical means of reducing CT radiation At a tube current of 10 mAs, the effective radiation dose is
dose. A 50 percent reduction in tube current can halve effective 0.27 mSv; equivalent to just five conventional PA chest
radiation dose.10 It has been suggested that in MDCT, it is radiographs. In the pediatric population, some institutions
possible to reduce tube current markedly (to between 40 favour the use of 1 mAs/kg for imaging the thorax; an
and 70 mAs) in chest examinations without affecting image approach that significantly reduces radiation dose (Figures
quality.11,12 On a 64-detector MDCT, the dose for a volumetric 2.2A to D).
high-resolution (1 mm sections) acquisition of the thorax in Tube potential (peak voltage) determines the incident
a 70 kg adult can be as low as 3.6 mSv if parameters of 120 X-ray mean energy, and variation in tube potential causes
kVp and 90 mAs (pitch of 1) are used.11,12 In lung cancer a substantial change in CT radiation dose. The effect of
screening examinations, tube current can be remarkably low tube voltage on image quality is complex, since it affects
and yet yield images of diagnostic quality. It has been shown both image noise and tissue contrast. Thus, the image
that images obtained at an effective tube current of 20 mAs quality ramifications of a decrease in tube voltage to reduce
are of equal diagnostic utility to those obtained at 50 mAs for radiation exposure must be carefully examined before being
the detection of 6 mm simulated nodules.13 implemented. For chest examinations, 120 kVp is commonly

Figures 2.2A to D: Axial CT of a child with solitary intrapulmonary metastasis from Osteosarcoma. Standard-dose CT technique (175 mAs) in
lung and mediastinal window settings (A and B). Follow-up CT using low-dose technique (25 mAs), demonstrating the growth of the metastasis
(C and D). A significant increase in noise can only be observed in the mediastinal window settings
16 Techniques, Normal Anatomy and Basic Patterns in Chest Diseases

used. In thin patients (<50 kg) and in the paediatric population, angiography of the thorax; the most common indications
100 kVp is recommended; the use of 80 kVp has been found being the evaluation of the pulmonary arterial tree in suspected
to be associated with unacceptable beam hardening even in pulmonary embolism, the aorta and lung cancer staging studies.
the smallest of patients.15 Intravenous enhancement is influenced by several factors:
With helical CT systems, beam collimation, table speed and body size and cardiac output of the patient, the concentration
pitch are interlinked parameters that affect diagnostic image and volume of contrast material, the rate and duration of the
quality. Faster table speed for a given collimation, resulting in injection, the delay between the injection and the initiation of
a higher pitch, is associated with a reduced radiation dose (if data acquisition, the duration of data acquisition and whether
other data acquisition parameters, including tube current, are bolus tracking or a set delay is used. With single-detector
held constant) because of a shorter exposure time. However, CT, protocols are relatively straightforward. A volume of
this is not true for some multidetector systems that use an 100 ml of 150 mg/ml of iodine injected at a rate of 2.5 ml/s
effective milliampere–second setting (defined as milliampere after a 25s delay is recommended for general thoracic work.18
seconds divided by pitch). Here, the effective milliampere– Suggested protocols for evaluating the pulmonary arterial
second level is held constant (by automatic tube current tree using single-detector CT use between 120 and 140 ml of
adjustment) irrespective of pitch value, so that radiation 240–300 mg/ml of iodine injected at a rate of 3–4 ml/s with
dose does not vary as pitch is changed.16 Caution should be
exercised when extrapolating dose reduction strategies from
single- to multi-detector CT systems.
Automatic tube current modulation is a technical innovation
that can substantially reduce patient dose. There are two
methods used currently with CT systems: z-axis modulation
and angular (x- and y-axis) modulation. In z-axis modulation,
tube current is adjusted to maintain a user-selected quantum
noise level in the image data. z-axis modulation attempts to
render all images with similar noise, independent of patient
size and anatomy. In angular modulation, the tube current
is adjusted to minimize X-rays in projections (angles) that
have less importance for the reduction of overall image noise
content. With this technique, the tube output is adapted to
the patient geometry during each rotation to compensate for
strongly varying X-ray attenuation in asymmetric body regions
such as the shoulders (Figure 2.3). A recent investigation of
CT imaging studies in children in whom angular modulation
was used demonstrated a mean reduction of 22 percent in dose
without loss of image quality.17
Ultimately, the complexity of the interrelationships
between the different CT parameters and dose requires a close
collaboration between radiologists and medical physicists
to ensure that the radiation burden to patients is as low as
possible without diagnostic accuracy being compromised.

Intravenous Contrast Medium Enhancement

The following section will cover the basic principles of intra- Figure 2.3: Image to show the automatic tube current modulation.
With this technique, the tube output is adapted according to the patient
venous enhancement as applied to the evaluation of pulmonary geometry. Note: Tube current is higher in the region of shoulder than
disease. Intravenous enhancement is used routinely for CT in the regions of lungs
 MDCT Chest: Techniques and Anatomy 17

either a fixed delay of 20s or the use of automated triggering wide range of densities on a single image. For this reason,
mechanisms.19-21 With advances in CT technology, however, a thoracic CT examination requires viewing in at least two
the way contrast medium is delivered has had to be rethought. settings in order to demonstrate the lung parenchyma and
A CT study acquired using a 16 detector system in <10s the soft tissues of the mediastinum. Furthermore, it may
leaves little room for error, and imaging at peak enhancement be necessary to adjust the window settings to improve the
requires not only precise timing but careful tailoring of the demonstration of a particular structure or abnormality.
volume and rate of delivery of contrast medium. One dilemma Preferred window settings for thoracic CT vary between
for fast CT is the chance of contrast medium still being institutions, but some generalizations can be made. For the
injected when data acquisition is complete. Protocols for CT soft tissues of the mediastinum and chest wall a window width
angiography of the chest using MDCT are still being refined, of 300–500 HU and a centre of +40 HU are appropriate. For
but it is generally accepted that the faster acquisition times of the lungs a wide window of approximately 1500 HU or more
MDCT require a faster rate of injection, a higher concentration at a centre of approximately –600 HU is usually satisfactory
of contrast medium and possibly a reduced volume. Typical (Figures 2.4A to C). The window settings have a profound
injection parameters for four-detector MDCT are 100–150 ml influence on the visibility and apparent size of normal and
of 240–320 mg/ml of iodine injected at a rate of 3–4 ml/s. For abnormal structures. The most accurate representation of an
64-detector MDCT, some institutions have experimented with object appears to be achieved if the value of the window level
90–120 ml of 320–370 mg/ml of iodine injected at 3.5–5 ml/s. is halfway between the density of the structure to be measured
A recent study using a four-detector system evaluated the and the density of the surrounding tissue. For example, the
influence of iodine flow concentration on vessel attenuation.22 diameter of a pulmonary nodule, measured on soft tissue
There was significantly better visualization of fourth-, fifth- settings appropriate for the mediastinum, will be grossly
and sixth-order pulmonary arteries using a protocol based on underestimated (Figures 2.5A and B).25 It is also important
90 ml of 400 mg/ml of iodine when compared with 120 ml to remember that when inappropriate window settings are
of 300 mg/ml. An injection rate of 4 ml/s was used in both used, smaller structures (e.g. peripheral pulmonary vessels)
groups. A specific application of contrast enhancement is in are proportionately much more affected than larger structures.
the differentiation between benign and malignant pulmonary
nodules and the reader is referred to two papers for details of HIGH RESOLUTION COMPUTED
this protocol.23,24 TOMOGRAPHY (HRCT)
For the majority of patients being investigated exclusively for
Window Settings suspected interstitial lung disease, interspaced (as opposed to
The density within each voxel is represented by a Hounsfield volumetric) high-resolution CT (HRCT) remains an adequate
Unit (HU) value. In the thorax these units encompass a examination and should be used for younger patients. This is
wide range, from aerated lung (approximately –800 HU) to because the dose of interspaced HRCT is considerably lower
ribs (+700 HU). No single-window setting can depict this than a volumetric high-resolution acquisition. Even when

A B C
Figures 2.4A to C: Axial CT images (A to C) to show various window values used to view the CT images
18 Techniques, Normal Anatomy and Basic Patterns in Chest Diseases

A B
Figures 2.5A and B: CT images to show the importance of different window settings in evaluating lung nodule. The diameter of a pulmonary
nodule is grossly underestimated in mediastinal window as compared to lung window

Table 2.1: Showing various post processing techniques and their clinical applications
Postprocessing technique Technical considerations Clinical applications
Multiplanar and curved multiplanar 2D techniques that provide alternate viewing Evaluation of the large airways and pulmonary
reconstructions (MPR and CMPR) perspectives, usually with conventional emboli, particularly for interpretative difficulties
(Figure 2.6A) window settings. Images are obtained by on axial sections either due to partial volume
a reordering of the voxels into 1 voxel-thick averaging or the inability to differentiate periarterial
tomographic sections, excluding those voxels from endoluminal abnormalities
outside the imaging plane
Maximum Intensity Projection(MIP) X ray is cast through CT data and only Main use in Vascular imaging and in the evaluation
(Figure 2.6B) data that are above an assigned value are of micronodular disease (more accurate
displayed, thus reducing all data in the line of identification of nodules versus vessels, and more
the ray to a single plane. Sliding slabs of 5–10 precise characterization of nodule distribution)
mm are commonly used
Minimum intensity projection (MinIP) Similar to MIP, but only data below an May improve conspicuity of subtle density
(Figure 2.6C) assigned value are displayed and thus it is differences of lung parenchyma and therefore
best suited for showing areas of low density highlight regions of emphysema or air trapping
Shaded surface display (SSD) (Figure This technique reformats data around Evaluation of chest wall abnormalities
2.6D) athreshold that defines the interface of
tissues. SSD does not reveal any internal
detail
Volume rendering (Figure 2.6E) Volume rendering is a unique form of Used in angiographic examinations and also to
3D visualization. In this process a ray is evaluate large airway abnormalities
projected through the dataset and a weighted
representation of all the HU encountered is
displayed depending on their representation
within the tissues. Voxels that are only
partially filled with a density of interest are
also included. The resultant images contain
depth information whilst maintaining 3D
spatial relationships
Virtual bronchoscopy (Figure 2.6F) Surface rendering and volume rendering are Virtual endoscopic or perspective volume
used to produce endoscopic simulations of rendering images are not widely applied as they
the airway seldom give information that cannot be obtained
by MPR. However, virtual CT bronchoscopy
used in association with 3D techniques providing
extraluminal information can provide additional
information such as safe routes for tracheobron-
chial biopsy. Monitoring the position of airway
stents is another potential application of this
technique
Exploring the Variety of Random
Documents with Different Content
The text on this page is estimated to be only 26.85%
accurate

SINCLAIR, LORD SINCLAIR 591 XV. JAMES, fifteenth Lord,

born 3 July 1803 ; captain in the Grenadier Guards; elected a
Representative Peer December 1868 to April 1880 ; died at Pera,
near Constantinople, 24 October 1880. He married, at Ohipstead, 14
September 1830, Jane, eldest daughter of Archibald Little of
Shabden Park, Surrey ; she died at Ramleh, Egypt, 12 June 1887,
aged seventy-five, and had issue : — 1. CHARLES WILLIAM,
sixteenth Lord. 2. Archibald, commander Royal Navy; born 2 October
1833, died 2 March 1872. 3. James Chisholme, born 21 November
1837 ; in Madras Civil Service 1857-82; died 23 September 1902,
unmarried. 4. Lockhart Matthew, born 25 July 1855; educated at
Wellington College and at Cooper's Hill ; late Superintending
Engineer Public Works Department and Secretary to the
Government, Central Provinces, India, Public Works Department,
O.I.E. 26 June 1902; married, 30 July 1881, Ellen Mary Margaret,
daughter of Surgeon Major-Gen eral William Roche Rice, C.S.I., M.D.,
and has issue. 5. Mary Agnes, born 4 July 1840. 6. Helen, born 10
July 1842, died 19 August 1849. XVI. CHARLES WILLIAM, sixteenth
Lord, born at Shabden Park 8 September 1831 ; educated at Royal
Military College, Sandhurst ; entered the Army in 1848 ; served in
the 57th Foot in the Crimea 1854-55, being severely wounded in the
attack on the Redan ; and as Assistant Adjutant-General to the
Forces on the Bosphorus 1855-56, served in India during the Mutiny,
and also in the New Zealand War 1861-62, as acting Assistant
Military Secretary ; Representative Peer since 1885 ; married, 6
October 1870, Margaret Jane, younger daughter of James Murray of
Bryanston Square, London, and has issue : — 1. Archibald James
Murray, Master of Sinclair, captain 2nd Dragoons, Royal Scots Greys ;
served in South Africa 1899-1902; born 16 February 1875; married,
31 January 1906, Violet Frances, only child of John Murray Kennedy,
M.V.O., of Knocknalling, Kirkcudbright.
The text on this page is estimated to be only 25.61%
accurate

592 SINCLAIR, LORD SINCLAIR 2. Charles Henry Murray,

born 19 December 1878 ; captain Seaforth Highlanders ; served in
South Africa 1899-1902. 3. Ada Jane, born 27 July 1871. 4. Margaret
Helen, born 23 April 1873, married, 1 October 1902, to Alick
Christian Fraser, second son of Alexander Caspar Fraser of
Mongewell Park, Oxford, and has issue : — (1) Sheila Helen, born 23
February 1904. (2) Brenda Margaret, born 16 January 1907. 5.
Georgina Violet, born 29 March 1877, married, 19 January 1910, to
Major Harry Miller Davson, R.A. CREATION.— Lord Sinclair about
1449, confirmed 26 January 1488-89. ARMS (recorded in Lyon
Register). — Quarterly : 1st and 4th, azure, a lymphad sails furled
and oars in saltire, within a double tressure flory counterflory or, for
Orkney; 2nd and 3rd, azure, a full-rigged three-masted ship under
sail or, sails proper, for Caithness ; on an escutcheon en surtout,
argent, a cross engrailed sable, for Sinclair. CREST. — A demi eagle,
wings expanded, proper. SUPPORTERS. — Two griffins sable, armed,
beaked and winged or. MOTTO.— Feight. [F. j. G.] END OP VOL. VII.
Printed by T. and A. CONSTABLE, Printers to His Majesty at the
Edinburgh University Press
The text on this page is estimated to be only 27.61%
accurate

RECENT PUBLICATIONS. SCOTTISH HISTORY AND

ARCHAEOLOGY. Celtic Scotland : A History of Ancient Alban, By the
late WILLIAM F. SKENE, D.C.L., LL.D., Historiographer-Royal for
Scotland. Second Edition, carefully revised by the Author with a new
Index to the Entire Work. 3 vols. demy 8vo, illustrated with Maps.
45s. VOL. I. HISTORY AND ETHNOLOGY. 15s. VOL. II. CHURCH AND
CULTURE. 15s. VOL. III. LAND AND PEOPLE. 15s. The Four Ancient
Books of Wales. Containing the Cymric Poems attributed to the
Bards of the Sixth Century. By WILLIAM F. SKENE, D.C.L. With Maps
and Facsimiles. 2 vols. 8vo. 42s. net. The Story of lona, By the Rev.
EDWARD CRAIG TRENHOLME, M.A., of the Society of St. John the
Evangelist, Cowley. With 40 Full-page Plates from Photographs and
other Illustrations from Drawings by FRANCES M. RICHMOND. Also
Maps and Plans. Demy 8vo. 8s. 6d. net. ' No one should be so
fascinated with lona as to neglect the effort to understand it. To that
end this volume is a real help.' — Times. The Castellated and
Domestic Architecture of Scotland, from the Twelfth to the
Eighteenth Century. By DAVID MACGIBBON and THOMAS Ross,
Architects. 5 vols., with about 2000 Illustrations of Ground Plans,
Sections, Views, Elevations, and Details. RoyalSvo. 42s.eachvol.net.
(Vols. I. and II. may only be had in sets.offive volumes.) The
Ecclesiastical Architecture of Scotland from the Earliest Christian
Times to the Seventeenth Century. By DAVID MACGIBBON and
THOMAS Ross. 3 vols. With Illustrations. Royal 8vo. 42s. each vol.
net. Scottish Kings : A Revised Chronology of Scottish History, 1005-
1625, with Notices of the Principal Events, Tables of Regnal Years,
Pedigrees, Calendars, etc. By Sir ARCHIBALD H. DUNBAR, Bart.
Demy 8vo, with 4 Maps, 2nd edition. 12s. 6d. net. ' A volume which
no one who has the good fortune to possess will ever allow to be
out of easy reach when he is engaged in any studies relating to
Scottish history.' — The Guardian. A Short Account of the Affairs of
Scotland in the Years 1744, 1745, 1746. By DAVID, LORD ELCHO.
Printed from the Original Manuscript at Gosford. With a Memoir and
Annotations by the Hon. EVAN CHARTERIS. Demy 8vo. Illustrated.
15s. net. Popular Tales from the Norse. By Sir GEORGE WEBBE
DASENT, D.C.L. With an Introductory Essay on the Origin and
Diffusion of Popular Tales. New Edition. With a Memoir by ARTHUR
IRWIN DASENT. Demy 8vo. 10s. 6d. Place-Names of Scotland. By
the Rev. JAMES B. JOHNSTON, B.D., Falkirk. Second Edition. Revised
and Enlarged. Crown 8vo. 6s.net. Scotland as it was and as it is : A
History of Races, Military Events, and the Rise of Commerce. By the
late DUKE OF ARGYLL. Illustrated. Demy 8vo. 7s. 6d. The Life of St.
Margaret, Queen of Scotland. By TURGOT, Bishop of St. Andrews.
Edited by WILLIAM FORBES-LEITH, S. J. Third Edition. Crown 8vo.
3s. 6d. net. The Gospel Book of St. Margaret : Being a Facsimile
Reproduction of Queen Margaret's copy of the Gospels preserved in
the Bodleian Library, Oxford. Edited by WILLIAM FORBES-LEITH, S.
J. A few copies remaining in Large Paper at £5, 5s., or Small Paper
at £3, 3s. net. EDINBURGH : DAVID DOUGLAS, 10 CASTLE STREET.
The text on this page is estimated to be only 27.30%
accurate

RECENT PUBLICATIONS. RHIND LECTURES IN

ARCHAEOLOGY, ETC. Scotland in Early Christian Times. By JOSEPH
ANDERSON, LL.D., Keeper of the National Museum of the Antiquaries
of Scotland. (Being the Rhind Lectures in Archaeology for 1879 and
1880.) Profusely Illustrated. 2 vols. demy 8vo. 12s. each vol.
Scotland in Pagan Times. By JOSEPH ANDERSON, LL.D. (Being the
Khind Lectures in Archaeology for 1881 and 1882.) Profusely
Illustrated. 2 vols. demy 8vo. 12s. each vol. The Past in the Present.
What is Civilisation ? (Being the Rhind Lectures in Archaeology
delivered in 1876 and 1878.) By the late Sir ARTHUR MITCHELL,
K.C.B. , M.D., LL.D. With 148 Woodcuts. Demy 8vo. 15s. Ogham
Inscriptions in Ireland, Wales, and Scotland. (Being the Rhind
Lectures in Archaeology for 1884.) By the late Sir SAMUEL
FERGUSON. Demy Svo. 12s. Heraldry in Relation to Scottish History
and Art. (Being the Rhind Lectures in Archaeology for 1898.) By Sir
JAMES BALFOUR PAUL, LL.D., F.S.A.Scot., Lord Lyon King of Arms.
Illustrated. Demy Svo. 10s. 6d. net. The Edwards in Scotland, A.D.
1296-1377. (Being the Rhind Lectures in Archaeology for 1900.) By
JOSEPH BAIN, F.S.A.Scot. Demy Svo. 2s. 6d. net. Origins of Pictish
Symbolism. With Notes on the Sun Boar, and a new reading of the
Newton Inscriptions. By the late EARL OF SOUTHESK. Small 4to. 9s.
Archaeological Essays. By the late Sir JAMES SIMPSON, Bart. Edited
by the late JOHN STUART, LL.D. 2 vols. 4to. 21s. Early Travellers in
Scotland, 1295-1689. Edited by P. HUME BROWN. Demy Svo. 14s.
Tours in Scotland, 1677 and 1681. By THOMAS KIRK and RALPH
THORESBY. Edited by P. HUME BROWN. Demy Svo. 5s. By-ways of
History : Studies in the Social Life and Rural Economy of the Olden
Time. By the late JAMES COLVILLE, M.A., D.Sc., Examiner in History,
University of Glasgow. Crown Svo. 6s. Recollections of a Tour made
in Scotland, A.D. 1803. By DOROTHY WORDSWORTH. Edited by the
late J. C. SHAIRP. Third Edition. Crown Svo. 5s. Notes of Caithness
Family History. By the late JOHN HENDERSON, W.S. 4to. In Cloth.
21s. net. The Life of a Regiment : The History of the Gordon
Highlanders from 1794 to 1898. Including an Account of the 7oth
Regiment, from 1787 to 1881. By Lieut. -Colonel C. GREENHILL
GARDYNE. With Illustrations. 2 vols. Demy Svo. 42s. net.
EDINBURGH : DAVID DOUGLAS, 10 CASTLE STREET.
The text on this page is estimated to be only 27.60%
accurate

The most important Work on Scottish Family History which

has yet been published. THE SCOTS PEERAGE EDITED BY SIR
JAMES BALFOUR PAUL, LL.D. LORD LYON KING OF ARMS. The
edition is strictly limited to 500 copies, and the greater proportion of
these has already been subscribed for. The price of each volume,
consisting of upwards of 600 pages royal 8vo, is 25s. net to
Subscribers for the complete work. Single volumes may be had at
30s. net. Subscriptions are invited for the remaining sets at the
original price. EXTRACTS FROM PRESS NOTICES OF VOLUME VI. '
Fully maintains the lofty standard of its predecessors.' — Glasgow
Herald. ' Continues to justify the claim made on its behalf that it is
the most important work on Scottish family history which has yet
been published.' — Scotsman. ' The volume will take a worthy place
among those that have preceded it. The whole is a work conceived
on a generous scale and carried out with great ability.' — Banff
Journal. ' It is a model of scholarship stamped throughout with
accuracy and honesty of purpose.' — Dundee Advertiser. VOLUME I. '
No future historian of Scotland will be able to neglect this important
work when he attempts to trace the history of any noble family. . .
An important addition to peerage literature.' — Athenaeum. ' Fulness
of reference has been a special aim, and the Peerage seems likely in
this respect to set a notable example. . . . The illustrations form a
striking and important feature. . . . All concerned with this fine
production are to be congratulated on its inception and the
execution so far as it has gone, and scholars generally will not
hesitate to acknowledge their obligation.' — Notes and Queries. ' As
a careful resume of genealogical research, the work is an immense
advance on its predecessors, and although no genealogy extending
for centuries can be anything but imperfect, it is due to the
contributors to say that their work on almost every page bears the
evidence of careful and exhaustive research. . . . Many of the articles
are models of their kind.' — Academy. EDINBURGH: DAVID
DOUGLAS, 10 CASTLE STREET.
The text on this page is estimated to be only 27.18%
accurate

VOLUME II. ' Worthy of much praise.' — Athenaeum. ' The

second volume of the new Scots Peerage, edited, on the foundations
provided by Douglas and Wood, by Sir James Balfour Paul, with the
help of nearly twoscore writers who are experts in genealogy,
heraldry, and family history, confirms the impression made by its
predecessor that this ambitious enterprise will provide a book of
reference which can be safely consulted as an authority on an
intricate and often obscure field of study.' — Scotsman. ' The
features which characterised the first volume of this Peerage —
minute research, nice balancing of evidence, rejection of the
legendary, and judicious use of historic illustration, together with the
beautiful presentation of coats of arms — maintain their high
standard in the second. The best test of success is the sustained
interest of the book, even for the general reader.' — Glasgow Herald.
VOLUME III. * As this valuable work proceeds, the necessity for a
thorough overhauling of the pedigrees of the nobility of Scotland
becomes more and more apparent. It is not, of course, pretended
that the Scots Peerage will settle all the knotty points which have
long perplexed students of Scottish genealogy, indeed the new light
thrown by modern discoveries may be said to have increased these
difficulties tenfold, but the mere fact that the ground has been
cleared and the difficulties fairly faced, will do much to bring about a
solution of the problems which still require to be elucidated.' — The
Genealogist. ' More and more apparent with each successive volume
become the merits of this splendid Peerage. An important task is in
the way of being most admirably discharged.' — Notes and Queries.
VOLUME IV. ' It is a real pleasure to comment on the production of a
work so capably, thoroughly, and conscientiously executed as The
Scots Peerage.' — The Scottish Historical Review. ' The Scots
Peerage continues to be a very handy compendium of Northern
genealogy. Moreover, it is a delightful book to look at and to handle.'
— Notes and Queries. ' Must be accepted as the most authentic
guide to the extinct, dormant, and extant Peerage of Scotland.' —
Dundee Advertiser. VOLUME V. 'The present instalment yields ample
illustrations of the antiquity, the historical importance, the romantic
episodes, and the strange vicissitudes attached to the story of the
Scots Peerage.' — Scotsman. ' Considering the varied mass of detail,
the intricacies of descent, and the necessity of accuracy and
condensation this magnificent undertaking one must hold is making
gratifying progress, on which the learned editor and his expert
contributors are to be genuinely congratulated.' — Glasgow Herald.
'Each succeeding instalment bears eloquent testimony to the care
and scholarly research which Sir James Balfour Paul and his learned
contributors bring to the discharge of their duty.' — Dundee
Advertiser. EDINBURGH : DAVID DOUGLAS, 10 CASTLE STREET.
The text on this page is estimated to be only 29.86%
accurate

PLEASE DO NOT REMOVE CARDS OR SLIPS FROM THIS

POCKET UNIVERSITY OF TORONTO LIBRARY
Welcome to our website – the ideal destination for book lovers and
knowledge seekers. With a mission to inspire endlessly, we offer a
vast collection of books, ranging from classic literary works to
specialized publications, self-development books, and children's
literature. Each book is a new journey of discovery, expanding
knowledge and enriching the soul of the reade

Our website is not just a platform for buying books, but a bridge
connecting readers to the timeless values of culture and wisdom. With
an elegant, user-friendly interface and an intelligent search system,
we are committed to providing a quick and convenient shopping
experience. Additionally, our special promotions and home delivery
services ensure that you save time and fully enjoy the joy of reading.

Let us accompany you on the journey of exploring knowledge and

personal growth!

ebookname.com