Dr. Flip Otto Dept. of Radiology Universitas Academic Hospital • Mediastinal devisions • Content of mediastinum • Mediastinal contours on PA chest radiograph • Cross sectional anatomy of mediastinum • Mediastinal lines and stripes on conventional radiography and CT correlation • Mediastinal spaces • Mediastinal lymphnodes Devisions used to describe location of pathological processes: • Superior mediastinum: • Above line from lower border T4 to sternal angle • Anterior mediastinum: • Between anterior part of heart and sternum • Middle mediastinum: • Occupied by heart and its vessels • Posterior mediastinum: • Between posterior part of heart and thoracic spine 4 3 5 6 1 7 2 1-trachea 4-left brachiocephalic vein 6-left common carotid artery 2-oesophagus 3-right braciocephalic vein 5-right brachiocephalic artery 7-left subclavian artery 4 5 1 2 3 1-trachea 4-superior vena cava 2-aortic arch 5-arch of azygos vein 3-oesophagus 7 3 2 6 8 10 9 1 11 5 12 4 1-main pulmonary trunk 2-right pulmonary artery 3-ascending aorta 4-descending aorta 5-left main bronchus 6-right main bronchus 7-superior vena cava 8-oesophagus 9-azygos vein 10-azygoesophageal recess 11-left superior pulmonary vein 12-left descending lower-lobe artery 3 1 4 6 7 1-aortic root 4-left atrium 7-azygos vein 2-right ventricular outflow tract 5-descending aorta 2 5 3-right atrial appendage 6-oesophagus 2 5 1 3 7 6 8 1-right atrium 4-left ventricle 6-descending aorta 2-right ventricle 3-left atrium 5-left ventricular outflow tract and aortic valve 7-oesophagus 8-azygos vein 4 3 4 2 1 5 1-descending aorta 2-fundus of stomach 4-oesophago-gastric junction 3-inferior vena cava 5-spleen • Lines: • Anterior junction line • Posterior junction line • Stripes: • • • • Right paratracheal stripe Left paratracheal stripe Posterior tracheal stripe Posterior wall of bronchus intermedius • Interfaces: • • • • Right paraspinal line Left paraspinal line Aortic-pulmonary stripe Azygo-oesophageal recess Volume loss in right lung with rightward displacement of anterior junction line following a right middle lobectomy Widening of right paratracheal stripe caused by a large ectopic parathyroid adenoma. Note diffuse osteopenia from hyperparathyroidism. Widening of left paratracheal stripe with mass effect on the trachea due to large thyroid carcinoma and associated supraclavicular lymphadenopathy Widening of the posterior tracheal stripe due to dilated esophagus in a patient with achalasia. Diffuse bandlike thickening of the posterior wall of the bronchus intermedius in a patient with pulmonary oedema. Abnormal bulge in right paraspinal line inferiorly due to mediastinal hematoma from multiple right sided transverse process fractures and an associated hemothorax. Focal lateral bulge in left paraspinal line due to extensive esophageal varices in patient with liver cirrhosis. Abnormal contour of the aortic-pulmonary stripe due to lymphoma with anterior mediastinal lymphadenopathy within the prevascular space. Abnormal contour and right lateral convexity of distal third of azygoesophageal recess due to a large hiatal hernia. • Four named spaces surrounding the central airways: • • • • Pretracheal space Aortopulmonary window Subcarinal space Right paratracheal space Abnormal bulge in AP window due to significant soft tissue mass within AP window and subcarinal space compatible with metastatic lymphadenopathy in a patient with bronchogenic carcinoma. Also widened right paratracheal stripe due to lymphadenopathy and left lower lobe consolidation. • American Thoracic Society definitions of regional lymph node stations • • • • • • • • • • • • • X 2R 2L 4R 4L 5 6 7 8 9 10R 10L 11 Supraclavicular nodes Right upper paratracheal nodes Left upper paratracheal nodes Right lower paratracheal nodes Left lower paratracheal nodes Aortopulmonary nodes Anterior mediastinal nodes Subcarinal nodes Paraesophageal nodes Right or left pulmonary ligament nodes Right tracheobronchial nodes Left tracheobroncheal nodes Intrapulmonary nodes • Traditional frontal and lateral chest radiography remains a valuable tool in the evaluation of chest disease despite increased reliance on CT, therefore familiarity with anatomic basis of mediastinal lines and stripes as seen on radiography imperative. • Knowledge of normal anatomic structures within different mediastinal divisions helps guide formulation of appropriate differential diagnosis • Butler, P., Mitchell, A.W.M., Ellis, H. (1999). Applied Radiological Anatomy. Cambridge: Cambridge University Press • Ellis, H., Logan, B.M., Dixon, A.K. (2007). Human Sectional Anatomy – Atlas of body sections, CT and MRI images, 3rd ed. London: Hodder Arnold • Gibbs, J.M., Chandrasekhar, C.A., Ferguson, E.C. et al. (2007). Lines and Stripes: Where did they go? – From Conventional Radiography to CT. Radiographics, 27:33-48. • Netter, F.H. (2011). Atlas of Human Anatomy, 5th ed. Philadelphia: Saunders Elsevier • Ryan, S., McNicholas, M., Eustace, S. (2011). Anatomy for diagnostic imaging, 3rd ed. London: Saunders Elsevier
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