4 курс / Лучевая диагностика / ЛУЧЕВАЯ ДИАГНОСТИКА

ed above a dome of a diaphragm. The heart widely lays on a diaphragm («laying heart»). An enlarged left ventricle in the second oblique view prominents backward. The shadow of an aorta is usually uniformly dilated. At a fluoroscopy in the area of an apex of heart and aortic arch the very intensive and high amplitude pulsation is detected. In a direct AP view the considerable enlargement and protuberance of an arc of a left ventricle on the left contour (1), elongation and protuberance of an arc of a uprising aorta on the right contour (2) is detected. In oblique projections — the enlargement of an arc of a left ventricle and the aortic arc.

At the addition of the functional failure of the mitral valve, there would be the signs of a pulmonary venous hypertension, the contrasted esophagus is shifted on an arc of major radius owing to enlargement of the left atrium. Later there is possible the enlargement of a right ventricle.

X-ray diagnostics of stenosis of an aortal ostium

Etiology: the main reasons are the atherosclerosis, rheumatic disease, lues. The isolated aortic stenosis is seldom, more often it is combined with incompetence.

Pathologic mechanism of a lesion: owing to an aortic stenosis the ejection of a blood from left ventricle is impeded. The excessive amount of a blood in a left ventricle results in its dilatation and hypertrophy of its myocardium, with prevailing of a hypertrophy. The high flow rate of a blood which is coming out through a narrow hole results in major rising of pressure in an aorta and its dilatation. At a decompensation of a stenosis the functional failure of the mitral valve appears because of dilation of its lumen.

X-ray image

In a period of compensation the heart is of normal size, in some cases the minor enlargement of a left ventricle is detected. In a direct AP projection the small enlargement of the fourth arc on the left contour of heart is detected. (On the chart there are the signs of enlargement of a left ventricle).

In patients with the severe stenosis the shape of heart is aortal: the arc of a left ventricle is enlarged and rounded, in a direct AP view the waist of the heart is well expressed and concave, the apex of the heart is rounded, shifted downwards and visualized as if under a diaphragm, sometimes on a background of a gas bubble of a stomach. In the second oblique view the enlargement of an arc of a left ventricle (1) backward is detected. The pulsation of a left ventricle (at a roentgenoscopy) is slow, deep and strong, weakened at a decompensation. The dilation of an initial part of aorta (2) and intensifying of its pulsation in this arc. Revealing of aortal valves calcification is possible.

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A B C D

Figure 4.4 Pulmonary stenosis. (A) Frontal and (B) lateral views show striking poststenotic dilatation of the pulmonary artery (arrow) in addition to filling of the retrosternal air space, indicating right ventricular enlargement.

Cor pulmonale (primary pulmonary hypertension). (C) Frontal and (D) lateral views of the chest in a patient with primary pulmonary hypertension show marked globular cardiomegaly with prominence of the pulmonary trunk and central pulmonary arteries.

The peripheral pulmonary vascularity is strikingly reduced. Right ventricular enlargement has obliterated the retrosternal air space on the lateral view

A B

C D

Figure 4.5 Essential (idiopathic) hypertension. (A) Frontal and (B) lateral views of the chest demonstrate characteristic tortuosity of the aorta (arrows), especially the ascending portion. Because the elevated blood pressure has caused left ventricular hypertrophy without dilatation, of the cardiac silhouette remains normal. Coronary artery calcification (arrows) in ischemic heart disease.

(C) Frontal and (D) lateral views of the chest

At a reduced function of a left ventricle and decompensation of a valve lesion the functional failure of the mitral valve is possible, there would be the signs of a pulmonary venous hypertension; the contrasted esophagus is shifted on an arc of major radius owing to enlargement of the left atrium. Later the enlargement of a right ventricle is possible.

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Clinical examples of radiography at diseases heart and great vessels

A B C

Figure 4.6 (A) Ventricular septal defect. The heart is enlarged and somewhat triangular, and there is an increase in pulmonary vascular volume. The pulmonary trunk is very large and over-shadows the normal-sized aorta, which seems small by comparison.

(B) Trilogy of Fallot. Decreased pulmonary vascularity with prominent poststenotic dilatation (arrow) of the pulmonary artery. There is enormous right atrial and moderate right ventricular enlargement. (C) Ebstein's anomaly. In addition to decreased pulmonary vascularity,thereisenlargementoftherightatrium,causingupwardandoutwardbulging of the right border of the heart (squared appearance). Widening of the right side

of the superior portion of the mediastinum (arrows) reflects marked dilatation of the superior vena cava due to right ventricular failure

A B C

Figure 4.7 (A) Aortic insufficiency. Marked dilatation of the ascending aorta (arrows), suggesting some underlying aortic stenosis. The left ventricle is enlarged with downward and lateral displacement of the cardiac apex. Note that the cardiac shadow extends below the dome of the left hemidiaphragm (small arrow). (B) Congenital aortic stenosis. Small aortic arch with moderate enlargement of the left ventricle. (C) Bronchogenic carcinoma.

Bilateral upper extremity venogram shows virtual occlusion of the superior vena cava by a large oat cell tumor in the right hilar and perihilar region

A B C D

Figure 4.8 Aneurysm of the thoracic aorta. (A) Frontal and (B) lateral views of the chest demonstratemarkeddilatationofboththeascendinganddescendingportionsofthethoracic aorta (arrows, B), producing anterior and posterior mediastinal masses, respectively. Aneurysm of the descending aorta. (C) Frontal view of the chest demonstrates a localized bulging of the descending aorta (arrows). (D) Lateral view in another patient shows aneurismal dilatation of the lower thoracic aorta (arrows). Note the marked tortuosity of the remainder of the descending aorta

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Ultrasound examination of heart

Allows to estimate the sizes of the heart chambers, the thickness of myocardium, to estimate morphology and motions of valves, character of a blood motion in heart and large vessels (dopplerography); to determine a minor amount of a fluid in a pericardial cavity (figure 4.9-C with comparison to A-B). Gives a possibility to visualize the heart chambers in various planes.

A B C

Figure 4.9 Constrictive pericarditis. (A) Coronal T1-weighted MR image shows abnormally thickened pericardium (arrows) outlined by epicardial and mediastinal fat.

(B) Contrast CT shows dense pericardial calcification (arrows) in a patient with a history of hemopercardium. (C) Two-dimensional echocardiographic view in a patient with both a pleural and pericardial effusion. The echo-free space anterior and immediately posteriortotheheartispericardialfluid.Theparietalpericardiallayerdividestheposterior pericardial fluid from the pleural fluid. The location of the descending thoracic aorta in relation to the fluid is often helpful in distinguishing pleural from pericardial fluid. The descending aorta is seen in cross section behind the heart. Pericardial fluid lies between

the heart and the aorta while pleural fl uid is seen posterior to both the heart and the aorta. Ao, aorta; dAo, descending aorta; LA, left atrium; LV, left ventricle

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Учебное издание

Ермолицкий Николай Михайлович

ЛУЧЕВАЯ ДИАГНОСТИКА (на английском языке)

Учебно-методическое пособие для студентов 3 курса факультета по подготовке специалистов

для зарубежных стран учрежденийвысшегомедицинскогообразования

Вдвух частях Часть 1

2-е издание

Редактор Т. М. Кожемякина

Компьютерная верстка Ж. И. Цырыкова

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