Imaging The Mediastinum

Imaging the Mediastinum
Mediastinum

Bounded laterally by parietal pleura of each lung Superior margin is thoracic inlet
Defined by plane of 1st ribs
Inferior margin is diaphragm Tissue planes extend superiorly into neck around great vessels, trachea and esophagus Connects to abdominal cavity via esophageal, caval and aortic hiatuses Connects to lungs along hilar vessels and bronchi
Mediastinum
Radiologic anatomy
CXR CT
Normal or not? Compartments and their pathologies:

Anterior Middle Posterior
Radiologic Anatomy
Landmarks to look for on the chest radiograph:

Trachea Paratracheal stripe Descending aortic contour Azygo-esophageal contour
Pneumomediastinum with cervical emphysema
Tracheal air column
Should be straight Slight bend to right due to aortic arch on its left.
Trachea deviates to the left
Right Aortic Arch
Right paratracheal stripe
Extends from thoracic inlet to azygos vein Widens out at azygos vein No more than 3-4 mm thick
Aortic contour
Azygo-esophageal recess
Aortic contour and azygo-esophageal recess abnormal
Normal anatomy: CT/CXR correlation
Is the mediastinum wide?
First ask is it technical?
Positioning: rotated:? AP? Lordotic? Supine? Inspiration If so, repeat the film before proceeding to CT.
Then askIs it new? GET OLD FILMS before getting a CT unless time is critical.
Think about normal variants!
Vascular structures
Aortic anomalies Tortuous vessels Azygos vein
Lipomatosis Fat pads
Severe asthma on long term steroids
Mediastinal lipomatosis
Pericardial Fat Pad
Tortuous brachiocephalic vessels
70 year old with dysphagia

Tracheal air column
Esophageal cancer
Abnormal right paratracheal stripe
Hodgkins disease
Abnormal right paratracheal stripe
Check the old film!

Hematoma from line insertion
2 days earlier
Air fluid levels
Think bowel or abscess:

Hiatal hernia Zenker diverticulum Epiphrenic diverticulum Achalasia Mediastinal abscess
Achalasia
Zenker diverticulum
Hiatal hernia
Mediastinal abscess after CABG
Differential diagnosis of mediastinal masses
Traditionally, we divide the mediastinum into compartments. Likely diagnosis of mass depends on what is contained in each compartment These are not anatomic boundaries, and masses commonly cross over into compartments where they dont belong.
Posterior mediastinum
Paraspinal area Masses usually visible on lateral film overlying spine May obscure descending aorta contour
Posterior mediastinum
Neurogenic tumors

Schwannoma Sympathetic nerve tumors e.g. ganglioneuroma Neurenteric cyst, lateral meningocele
Lymph nodes (unusual as only area involved) Extramedullary hematopoesis Vertebral tumors, spurs
Schwannoma
Extramedullary hematopoesis
Chronic anemias, myelodysplasias
Lateral meningocele in NF-1
Anterior mediastinum
Space anterior to great vessels and heart, behind the sternum
Anterior mediastinum
Most common:
Lymphoma Thymic lesions Germ cell origin tumors Thyroid masses
Also:
Foregut cysts, nerve tumors, aortic aneurysm, etc.
Anterior mediastinal masses
thymic hyperplasia
teratocarcinoma
thymoma
teratoma
lymphoma
hemorrhage
Middle mediastinum
Contains heart, great vessels, esophagus, trachea, lymph nodes, nerves. CXR abnormality in paratracheal area, azygoesophageal recess, retrocardiac area May be difficult to see on lateral view
Middle Mediastinum

Lymph nodes Foregut cysts Vascular lesions e.g. aneurysm Bronchogenic carcinoma Hiatal hernia, other esophageal or GI lesions
Lymphoma
Cardiac evaluation
Remember: cardiothoracic ratio of about 0.5 applies only to good PA chest x-rays. Knowing which chambers form which cardiac contours can help identify what is enlarged. Look for accompanying signs:
Pulmonary venous engorgement and isolated LA enlargement suggests mitral stenosis. Dilated aorta and LV enlargement suggests aortic valve insufficiency.
Normal heart contours
Right atrium
Left atrium
Left ventricle
Left atrial enlargement-mitral stenosis
Mitral valve
Left atrial enlargement
Double density
Straightened left heart border
LA enlarged
LV normal
Enlarged ascending aorta in AS
Calcific Aortic Stenosis
Enlarged ascending aorta, normal arch, normal overall heart size
LVH
LV enlargement
Dilated cardiomyopathy multichanber enlargement
The End

Imaging The Mediastinum

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Imaging The Mediastinum

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Imaging the Mediastinum

Defined by plane of 1st ribs

Normal or not? Compartments and their pathologies:

Landmarks to look for on the chest radiograph:

Pneumomediastinum with cervical emphysema

Tracheal air column

Trachea deviates to the left

Right Aortic Arch

Right paratracheal stripe

Aortic contour and azygo-esophageal recess abnormal

Normal anatomy: CT/CXR correlation

Normal anatomy: CT/CXR correlation

Normal anatomy: CT/CXR correlation

Normal anatomy: CT/CXR correlation

Is the mediastinum wide?

First ask is it technical?

Think about normal variants!

Lipomatosis Fat pads

Severe asthma on long term steroids

Pericardial Fat Pad

Tortuous brachiocephalic vessels

70 year old with dysphagia

Abnormal right paratracheal stripe

Abnormal right paratracheal stripe

Check the old film!

Air fluid levels

Think bowel or abscess:

Mediastinal abscess after CABG

Differential diagnosis of mediastinal masses

Chronic anemias, myelodysplasias

Lateral meningocele in NF-1

Space anterior to great vessels and heart, behind the sternum

Foregut cysts, nerve tumors, aortic aneurysm, etc.

Anterior mediastinal masses

Normal heart contours

Left atrial enlargement-mitral stenosis

Left atrial enlargement

Straightened left heart border

Enlarged ascending aorta in AS

Calcific Aortic Stenosis

Enlarged ascending aorta, normal arch, normal overall heart size

Dilated cardiomyopathy multichanber enlargement

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