RADIOANATOMY OF

THORAX AND
MEDIASTINUM

VINITA SHARAN MD
Objectives
 To identify the ribs, sternum and thoracic
spine
 To identify the muscles of the chest wall
 To evaluate the diaphragm and costophrenic
sulci
 To identify the lungs, heart and great vessels
 To identify the trachea, carina and right and
left main stem bronchi
Imaging modalities
 Plain X-Ray
 CT scan
Chest radiograph- Views Required
 Most commonly done
Posteroanterior view (PA View)
 Lateral view
 Others
 Lordotic view – to look at the apical segment
 Right anterior oblique view to evaluate heart and

 Left anterior oblique view ribs

 Anteroposterior view – for bed ridden patients and
children
 Decubitus view – for evaluating pleural effusion or
pneumothorax
Chest Radiograph
 Look for symmetry and technique
 Structures
 Fissures
 Lung Parenchyma
 Trachea and bronchi
 Heart
 Pulmonary vasculature
 Bony structures
 Soft tissues
 Costo-phrenic angle
Chest Radiograph - Posteroanterior
View
Chest Radiograph - Lateral View
Bony Thorax
 The bony thorax comprises of
 Ribs
 Vertebral column
 Sternum
Ribs
 12 ribs on each side – may vary occasionally
 Forms greater part of the thoracic cage
 Bony arches arranged one below the other
 Gap between two ribs is the intercostal space
 Upper ribs less oblique than lower ribs
 The length of the ribs increase from 1st to 7th
and then decreases from 7th to 12th
 The breadth of the ribs decreases from up
downwards
Ribs
 The upper 7 ribs are connected through their
cartilages to the sternum – true ribs
 The cartilages of the 8th,9th and 10th ribs are
joined to the cartilage of the rib above – false
ribs
 The 11th and 12th ribs are free – floating ribs
Sternum
 Flat bone
 Forms anterior median part of the thoracic
cage
 Upper part is called the manubrium
 Middle part is called the body
 Lower tapering part is called the xiphoid
process
Sternum
 Manubrium is the quadrilateral upper part
 Thickest and strongest part
 Upper level of manubrium is at the upper
level of the 3rd thoracic vertebra
 Body is longer, narrower and thinner than the
manubrium
 Xiphoid process is the smallest part of the
sternum
Vertebral Column
 12 thoracic vertebra and intervening
intervertebral discs
 Thoracic vertebra recognized by presence of
costal facets on the sides
 There are two facets in most ribs
 The upper being near the upper border and
articulates with the numerically corresponding
rib
 The lower facet is near the lower border and
articulates with the next lower rib
Vertebral Column
 Body of the vertebra is heart shaped
 Pedicels are directed straight backwards
 Laminae overlap each other from above
 Transverse processes are large and directed laterally
and backwards from the junction of the pedicles and
laminae
 Spine is long and directed downwards and
backwards
 5th to 9th spine are longest and overlap each other
 Vertebral foramen is comparatively small and circular
Walls of the Thorax
 Coverings of the thoracic wall
 Skin
 Superficial fascia
 Deep fascia
 Extrinsic muscles

 Thoracic wall proper is formed by the

intercostal muscles
 Chest Radiograph - PA View

Clavicle

Scapula
Rib

Vertebra
Chest Radiograph – Lateral View
Chest Radiograph (PA View) –
Ribs
 Rib Sternum
Intercostal muscle

CT Scan of the
Chest

Vertebral
body

Transverse
process

Vertebral canal with spinal cord Spinous process

Soft Tissues And Spaces
Aorticopulmonary Window
Aorticopulmonary Window and
Retrosternal Space
Between the
ascending and
descending aorta is
the aorticopulmonary
window
Aorticopulmonary
window level
Diaphragm

Right hemidiaphragm
is slightly higher than
left hemidiaphragm
Right hemidiaphragm is
slightly higher than left
hemidiaphragm
Diaphragm

Right hemidiaphragm is
slightly higher than left
hemidiaphragm
Costophrenic Angle
Pleura
 Serous membrane lined by flattened
epithelium
 Two pleural sacs – one either side of
mediastinum
 Lungs have two layers
 Outer layer- parietal pleura
 Inner layer- visceral pleura

 Space between the – pleural cavity (potential

space)
Visceral Pleural Cavity
Pleura

Parietal
Pleura
Visceral
Pleura

Pleural
Space

Parietal
Pleura
Oblique Fissures
Indicated by a line
that runs from the
spinous process of
T2 vertebra around
the thorax to the
sixth
costochondral
junction
Similar on both sides
4. Right Oblique
Fissure
10. Left Oblique
Fissure
Oblique Fissures

• Indicated by a line
that runs from the
spinous process of
T2 vertebra around
the thorax to the sixth
costochondral
junction
• Similar on both
sides
Oblique Fissures
Transverse Fissure
Runs from the
anterior border
of the lung
along the fourth
costal cartilage
to the oblique
fissure
Fissures

Runs from the anterior

border of the lung along
the fourth costal
cartilage to the oblique
fissure
MEDIASTINUM
MEDIASTINUM
 Superior
 Anterior
 Middle
 Posterior
Superior Mediastinum
 Located superior to the pericardium
 Above the horizontal plane passing through the
sternal angle to the intervertebral disc space between
T4-T5
 Contents
 Thymus
 Great vessels
 Phrenic and vagus nerve
 Esophagus
 Thoracic duct
 Prevertebral muscles
Trachea and Bronchi

•Angle of Carina
(angle between the
two main stem
bronchi)
•Should be less
than 60 degrees
 Superior Mediastinum on Chest
Radiograph

Thymus
Superior Mediastinum on Chest
Radiograph - Thoracic Duct
CT Scan of Superior Mediastinum
Superior Mediastinum
 First of all identify the trachea
 Easy to recognize as it is air-filled , central in location
 Consistent in position and round or oval in shape
 Many other structures have fairly consistent relation to it
 Esophagus
 Lies posterior to the trachea
 Depending on the position of the trachea in relation to
the vertebra it may be on one side – usually on the left
 Appears as a flattened structure of soft tissue
attenuation
 Small amounts of air or air and fluid may be seen
 Superior Mediastinum
 Great arterial branches of the aortic arch and great
veins
 At the thoracic inlet
 Brachiocephalic veins
 Most anterior and lateral vascular branches visible
 Lying immediately behind the clavicular head
 Vary in size but positions are relatively constant
 Brachiocephalic , left common carotid and left
subclavian arteries
 Are posterior to the veins and adjacent to the anterior and
lateral walls of the trachea
Superior Mediastinum
 Below the thoracic inlet
 Left brachiocephalic vein
 Crosses from left to right anterior to the arteries
 Joins the right brachiocephalic vein to form the
superior vena cava
 Suprerior Mediastinum
 Left subclavian artery
 Posterior most in location
 Adjacent ot the left side of the trachea – at 3 or 4 o’clock
position from tracheal lumen
 Left common carotid artery
 Anterior to the left subclavian artery – at 1 or 2 o’clock
position from tracheal lumen
 Variable in position
 Brachiocephalic artery
 Anterior and to the right of the tracheal lumen – about 11
o’clock position
 Variable size and shape
Suprerior Mediastinum
 Brachiocephalic artery
 Oval at origin and somewhat bigger than other
braches
 On higher level may be oval or elliptical –
because of its bifurcation into the right
suclavian and right common carotid artery
 May be tortuous
 Other than these structures – some veins and
lymphnodes , lower part of thyroid gland may
sometimes be visible
 Mediastinum
 At the aortic arch level
 Aortic arch
 Anterior aspect of arch is anterior to the trachea
 Arch passes to the left of the trachea
 Posterior arch is lying anterior and lateral to the spine
 Posterior part of arch is smaller

 Superior vena cava

 Anterior and to the right of the trachea
 Oval in shape

 Esophagus
 Similar appearance and position as at a higher level
Brachiocephalic vein

Internal jugular
vein joins
subclavian vein to
form
brachiocephalic
vein
 LBV
At the
Thoracic
Inlet
(six vessels
level)

RBV
Five
vessels
level
Left brachiocephalic
vein crosses to join
right brachiocephalic
vein
 Superior vena cava Left Brachiocephalic Vein crossing over to
the right to join the right Braciocephalic vein
to form the SVC

Azygous
vein
 Left Common
Superior vena Brachiocephalic carotid artery
cava trunk

Trachea
Esophagus Left Subclavian
artery
Arch of aorta
 Common
Superior vena Brachiocephalic carotid artery
cava trunk

Trachea
Esophagus Subclavian
artery/vein
 Superior vena cava

Azygous
vein
Arch of aorta
Azygos Vein
draining into
the SVC
Anterior mediastinum
 Smallest division of the mediastinum
 Located anterior to the pericardium or
pericardial sac
 Contains the thymus in childhood
Middle Mediastinum
 Contains the pericardium and heart and
immediately adjacent part of the great
arteries
 Phrenic nerves
 Main bronchi
 Root of the lungs
Posterior Mediastinum
 Located posterior to the pericardium
 Anterior to the body of the inferior eight
thoracic vertebrae
 Contents
 Esophagus
 Thoracic aorta
Chest Radiograph – Anterior
Mediastinum
Chest Radiograph - Middle
Mediastinum
Chest Radiograph - Middle
Mediastinum
Posterior Mediastinum -
Esophagus (Esophagogram)
CT Scan of Mediastinum
 Anterior
 Middle
 Posterior
Mediastinum
 This is where the action is
 Important group of lymph nodes
 Aorta
 Pulmonary arteries
 Superior vena cava
Mediastinum
 Pretracheal or anterior paratracheal space-
 Aorticarch on left, superior vena cava and
mediastinal pleura on the right and trachea
posteriorly
 Triangular fat filled space contains important
middle mediastinal lymph nodes of the
pretracheal chain
Mediastinum
 Prevascular space – anterior mediastinum
 Anterior to the aorta and superior vena cava
 Roughly triangular
 Part of the anterior mediastinum and contains
the thymus, lymph nodes and fat
 Mediastinum
 At level slightly below the aortic arch
 Ascending and descending aorta are two separate
structures
 Ascending aorta (25-35 mm) is slightly larger than
descending aorta (20-30mm)
 Trachea bifurcates at the carina into right and left
mainstem bronchus
 At carina trachea assumes oval or triangular shape
Mediastinum
 On right side
 the arch of the azygous vein joins the posterior
wall of the superior vena cava and passes
above the right main-stem bronchus and hence
is seen at a higher level than the bronchus
 Passes along the mediastinum to the right and
anterior of the spine
Mediastinum
 On the left side
 Aorticopulmonary window
 Under the aortic arch but above the pulmonary
artery
 Contains fat, middle mediastinal lymph nodes
and recurrent laryngeal nerve
 Aorticopulmonary window lymph nodes freely
communicate with the pretracheal lymph nodes
 Mediastinum
 Below the level of the carina
 Azygoesophageal recess
 Part in association with the esophagus and azygous
vein
 Important due to adjacent subcarinal lymph nodes
and esophagus
Mediastinum
 The main pulmonary artery divides into the
right and left arteries
 Left is slightly higher than the right – usually 1
cm above
 Left appears as a continuation of the main
artery and is directed posterolaterally and to
the left
 Right arises at an angle of 90 degrees to the
main artery and crosses in front of the carina or
main bronchi
 Mediastinum
 The main pulmonary artery is most anterior arising
from the right ventricle
 Right ventricle is anterior and to the right of the
left ventricle
 Superior vena cava is seen entering the right
atrium
 Between the right atrium and the main pulmonary
artery the aortic root arises from the left ventricle
Mediastinum
 Left atrium is located posteriorly appearing
larger than the right atrium
 On each side the pulmonary veins can be
seen entering the left atrium
 Esophagus is seen in the retrocardiac area
Mediastinum
 Near the level of the diaphragm the inferior
vena cava is seen as an oval structure
entering the posterior right atrium
 Azygous vein is seen in the same location as
higher up
 Hemiazygous vein is seen on the left side
behind the descending aorta
 Paravertebral nodes lie in association with
the azygous and hemiazygous veins
Mediastinum
 Normal pericardium and pericardial contents
is visible as a 1 to 2 mm stripe of soft tissue
attenuation paralleling the heart and outlined
by mediastinal fat and epicardial fat
 Prevascular
space

Pretracheal
space
Between the
ascending and
descending aorta is
the aorticopulmonary
window
Aorticopulmonary
window level
1.Superior vena
cava
2. Ascending aorta
3. Descending
aorta
4. Trachea
5. Right lung
6. Left lung
7. Sternum
 Aortic sac Pulmonary
trunk

Right
atrium

Left
atrium

Descending aorta
 Left Pulmonary
Aortic sac
artery

Superior
vena cava

Left Pulmonary Artery Level Descending aorta

Right pulmonary Pulmonary
artery trunk

Left
pulmonary
artery

Right
Pulmonary
Artery Level
Left Atrial
Level
 Aortic sac Pulmonary
trunk

Superior
Vena
Cava
entering
Right
atrium

Left
atrium

Descending aorta
1.Right Atrium
2.Left Atrium
3.Right Ventricle
4.Left Ventricle
5.Descending
Aorta
6. Transverse
Process of T7
7.Right pulmonary
artery branch
8.Left pulmonary
artery branch
Four Chamber Level
Right atrium Right Ventricle Interventricular
Septum

Left
Ventricle

Three Chamber Level

Azygoesophageal recess
Thanks For Your Attention