emergency radiology - postgraduate medical journalemergency radiology. ii increased and this may...

Postgrad. med. J. (October 1967) 43, 625-638.

Emergency radiologyII. Medical emergencies

OSCAR CRAIGF.R.CSI F.F.R.

Consultant Radiologist,St Mary's Hospital, London, W.2, and Bolingbroke Hospital, London, S.W.11

THE RADIOLOGY of some common surgical emer-gencies seen by the Casualty Officer was describedin Part I. This paper considers the radiology ofsome of the common medical conditions.

Pneumothorax (Fig. 1)A pneumothorax may be either traumatic, spon-

taneous or artificial. The latter is rarely a problemto the Casualty Officer. Three varieties of pneumo-thorax are described:

(a) Open. In this the wound communicates withthe pleural cavity.

(b) Closed. This is the most common type andthe air in the pleural cavity is gradually absorbed.

(c) Valvular. In this variety as air drawn intothe pleural cavity cannot escape on expiration,tension increases resulting in mediastinal dis-placement and acute respiratory distress.

FIG. 2. Left-sided tension pneumothorax with medi-stinal shift to the right.

Radiological investigation consists of a postero-anterior film of the chest. If a pneumothorax isnot seen, but is clinically strongly suspected, afurther film in expiration should be taken. Thiswill reveal many small pneumothoraces readilymissed on a single inspiratory film.On the affected side the lung edge can be seen

inside the rib cage and parallel to it. Beyond thelung edge there are no vascular markings andthere is an increased translucency. Depending onthe quantity of air in the pneumothorax varyingdegrees of lung compression are seen. Tensionpneumothorax produces displacement of themediastinum to the opposite side (Fig. 2). Screen-ing or films in inspiration and expiration maydemonstrate a shift of the mediastinum to thenfferted chidp nn ingniratinn antd hqrlr trs thp. lin_allFG1LLUeft-sidepneumhopraffuaucte side on expirion-

FIG. 1. Left-sided pneumothorax. affected side on expiration.

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Oscar Craig

In the vast majority of cases of spontaneouspneumothorax, no underlying chest pathology canbe identified, and these cases are thought to bedue to the rupture of a small emphysematousbulla. Generalized emphysema rarely gives rise toa spontaneous pneumothorax, but localizedemphysema, secondary to tuberculosis, pneumo-coniosis, sarcoidosis, etc., may do so. Spontaneouspneumothorax has also been described complicat-ing both primary and secondary bronchialneoplasms. Patients with severe asthma maydevelop a spontaneous pneumothorax during anattack.Traumatic pneumothorax is frequently accom-

panied by traumatic lesions to the bones. Tearsof the diaphragm, ruptures of the oesophagus and'fractures' of the trachea or bronchi may producea pneumothorax. Mediastinal emphysema may bepresent also, in these conditions.A pneumothorax must be distinguished from

bullous emphysema. The presence of septa passingbetween the cysts and extending out to the chestwall is seen in bullous emphysema (Fig. 3).A hydropneumothorax or a haemopneumo-

thorax is recognized by the horizontal fluid levelseen in the hemithorax passing from the lateralchest wall to the lung edge. It is not infrequentlyseen following chest surgery or as a complicationof chest trauma. It can also result from infection

FIG. 3. Bullous emphysema with septa visible betweencysts.

FIG. 4. Consolidation in right upper lobe.

of a pneumothorax, the rupture of a lung abscessinto the pleural cavity, i.e. pyopneumothorax, orthe communication of an empyaema with thelung. It may be necessary to differentiate betweena hydropneumothorax and a lung abscess. Alateral film will help to localize the site of thefluid level and, on occasions, a film taken in thelateral decubitus position with a horizontal beamwill show the fluid just beneath the chest marginrunning in the pleural cavity.

It is not always possible to recognize under-lying lung pathology in either a pneumothorax ora hydropneumothorax. Follow-up films should beclosely examined for signs of parenchymal lesionsthat may be responsible.

Lobar pneumoniaIt is necessary to recognize the classical appear-

ance of lobar consolidation, as it is seen inpneumococcal pneumonia but other causativefactors may produce an identical appearance, e.g.fungi, viruses, collagen diseases, reticuloses,neoplasms and even occasionally radiationtherapy. Pneumococcal pneumonia may produceno radiological signs for 'the first 24-48 hr, butthen exudation into the alveoli results in thedevelopment of a dense sharply defined opacity,with a lobar or segmental distribution (Fig. 4).The volume of the affected area may be slightly

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Emergency radiology. II

increased and this may cause minimal bulging ofadjacent fissures. These may be convex in shapeand are distinguishable from the concave fissureswhich shift towards a collapsed segment. In thepresence of consolidation the vascular markingsare obliterated and patent air-filled bronchi maybe visible coursing through the opaque lung seg-ment. Patent bronchi are not visible in collapsedareas and are not visible when the opacity is dueto fluid. The diaphragmatic and mediastinalborders are usually sharply defined and pul-monary consolidation does not result in any shiftof the heart or mediastinum. A significant fluidcollection may result in shift of the heart to theopposite side and collapse may produce shift tothe same side. When consolidation is identified ona postero-anterior chest film, it is necessary to takea lateral film to accurately localize it. An over-penetrated film may be required to identify thetranslucent bronchi. Lobar pneumonia may beaccompanied by a pleural effusion.

Bronchopneumonia (Fig. 5)This is characterized by multiple patchy areas

of consolidation, usually bilateral and basal butoften scattered throughout both lungs or onoccasions confined to one side. Rarely areas oflobar consolidation may occur. There are manycausative organisms including staphylococci,

FIG. 5. Patchy bronchopneumonic consolidation inboth lungs.

FIG. 6. Widened mediastinal shadow due to achalasia.Food debris visible in the oesophagus.

streptococci, which may follow epidemics of in-fluenza, whooping cough or measles, tuberclebacillus and Friedlander's bacillus. Pneuma-tocoeles are especially prone to complicatestaphylococcal pneumonia. In children, glandularenlargement in the mediastinum in staphylococcalbronchopneumonia may produce a radiologicalappearance similar to Hodgkin's disease.

Aspiration pneumonia may occur post-operatively or may complicate oesophageal lesionssuch as achalasia. Achalasia may be recognizedby the convex shadow of the oesophagus bulgingto the right of the mediastinum (Fig. 6). Contrastexamination of the gullet is indicated in cases ofrecurrent pulmonary infection to exclude lesionssuch as pharyngeal or oesophageal diverticula,achalasia, hiatus hernia and oesophageal strictureformation. Chronic aspiration pneumonia canlead to lung fibrosis.Lobar consolidation or patchy broncho-

pneumonic consolidation may complicate a proxi-mal bronchial carcinoma.

Lobar collapseIn the acquired form, bronchial obstruction

produces de-aeration of the affected segment.Bronchial obstruction may be due to: (a) pres-

sure from without, e.g. glandular mass, aneurysm,neoplasm; (b) intrinsic narrowing of the wall-tuberculous endobronchitis, adenoma, neoplasm;and (c) obstruction in the lumen-viscid sputum,foreign body, neoplasm.

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628 Oscar CraigOften more than one cause is operative. Com-

pression collapse may result from a large tensionpneumothorax or a pleural effusion.

Radiological investigation of suspected collapseshould include postero-anterior, lateral and over-penetrated postero-anterior films. Occasionallyoblique films or a lordotic view are of value.When the complete lung is collapsed the hemi-thorax is totally opaque and the trachea and heartare displaced to the affected side. The hemi-diaphragm is elevated but it is not possible torecognize its level in the uniform opacity. On theleft side it may be noted that air in the stomachis lying at a very high level.Lobar collapse (Figs. 7 and 8) produces a dense

opacity often with shift of the fissures towardsthe collapsed segment, and also in extreme casesshift of the heart and trachea.

In the upper lobes the postero-anterior filmmay show an opacity which widens the superiormediastinum. The tracheal deviation to the in-volved side is an important sign.

Collapse of the middle lobe and lingula pro-duces an ill-defined opacity lateral to the hilumand often merging with the heart shadow, andobscuring its outline. The lateral view is especiallyhelpful as it showed a dense opacity with shift ofthe fissures. The opacity passes downwards fromthe hilum towards the sternum.

Collapse of the lower lobe on the right producesa linear opacity passing downwards from thehilum outside the heart border. This is harder to

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FIG. 7. Ill-defined opacity lateral to the right heartborder.

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FIG. 8. Lateral film shows opacity to be due to acollapsed middle lobe.

see when involving the left lower lobe as it maylie behind the heart shadow. An overpenetratedfilm to show this area is most helpful. The col-lapsed segment may be obvious on the lateral viewbut occasionally no opacity is seen as this col-lapsed segment lies in the paravertebral gutter. Itis in these cases that a right or left posterioroblique view of the chest is most helpful. Lowerlobe collapse is often accompanied by a displace-ment of the hilum downwards on the affected side.Often a compensatory expansion of the other

lobes occurs in the presence of collapse. Thisresults in an increased translucency of the remain-ing lung and a 'fanning out' of the vascular mark-ings.

Pleural effusion (Fig. 9)Pleural fluid collects primarily in the posterior

and lateral parts of the costo-phrenic recess. Theearliest radiological sign may be minimal bluntingof the costophrenic angles. A small lamellareffusion may pass upwards from the costophrenicangle along the rib margin.

Larger effusions produce a dense opacity whichhas a concave upper border and is highest later-



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Emergency radiology. 11

FIG. 9. Large right pleural effusion.

ally. The lateral film shows an opacity which ishighest posteriorly. A pleural effusion producesshift of the mediastinum to the opposite side.This may be extreme in the presence of a hemi-thorax totally opaque due to fluid. The shift ofthe mediastinum to the opposite side distinguishesfluid from total collapse when the mediastinumpasses to the same side. When no shift occurs inthe presence of fluid it usually indicates an under-lying atelectasis or rarely a rigid mediastinum.Adhesions or collapse may alter the shape of theeffusion and even reverse the curve.

In most cases it is not possible to determine thecause of the effusion radiologically, as the under-lying lung is obscured. A careful search should,however, be made for any obvious lung, bone orheart disease. There may be evidence of apicaltuberculosis, mediastinal glandular enlargement,heart enlargement and vascular engorgement. Theribs may show evidence of lytic or osteoblasticsecondary deposits. Pleural effusions frequentlycomplicate lobar or bronchopneumonia. There aremany causes of pleural effusion which may giveno other radiological evidence in the chest, e.g.Meig's syndrome, collagen diseases and nephroticsyndrome. Fluid may spread into the fissures pro-ducing spindle-shaped deformities visible in theoblique or horizontal fissures on the lateral film(Fig. 10). These may produce ill-defined opacities inthe line of the fissures in the postero-anterior view.

Interlobar effusions may be found in theabsence of a free pleural effusion.

FIG. 10. Spindle-shaped interlobar effusion in theoblique fissure.

FIG. 11. Encysted lateral parietal effusion.

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Oscar Craig

Encysted effusion (Fig. 11)Encysted effusions may be: (a) parietal, (b)

interlobar, and (c) mediastinal. The most commonvariety is a parietal effusion and usually situated:(i) laterally along the chest wall, or (ii) posteriorlyoverlying the spine. The opacity is dense and inthe lateral view well demarcated and convextoward the lung. In the postero-anterior view thedensity of the opacity may be slightly less in itsupper part.

Mediastinal effusions are not uncommon fol-lowing cardiac surgery. Rarely they becomeencysted.Tapping of an encysted effusion may inadver-

tently introduce air and the radiological appear-ances may simulate a lung abscess.

Posteriorly encysted pleural effusions may haveto be differentiated from carcinoma, neurofibromaand neurenteric cysts.

Calcified pleura (Fig. 12)This usually produces a characteristic appear-

ance of bizarre dense areas of calcification over-lying the lung field. The most common causes aretuberculous pleural effusions and haemothorax.Calcification of the pleura can occur in fine linearstreaks in asbestosis.

Tuberculosis (Fig. 13)The radiological appearances of pulmonary

tuberculosis are so varied as to be outside thescope of this paper. Suffice it to say that the fol-lowing may occur: lobar consolidation, broncho-pneumonia, infiltration, patchy irregular upperzone infiltration with cavitation or linear fibrosis.Single round opacities due to tuberculomata maysimulate primary peripheral carcinoma or asecondary deposit.

Mediastinal glandular enlargement in thiscountry was invariably seen only in children inprimary infection. In immigrants adult glandularmediastinal tuberculosis is not infrequently seen.It is important for the Casualty Officer to befamiliar with miliary tuberculosis and its maindifferential diagnosis.

In miliary tuberculosis the lungs are coveredwith multiple small opacities of approximately1 mm in size. Usually these are ma al in theupper zones and fade off towards the base.Usually there is no pleural effusion. Althoughmiliary tuberculosis may affect adults, it is mostcommon in children and may rarely be accom-panied by enlarged mediastinal glands. Withbronchopneumonic spread the opacities are larger,i.e. 2-4 mm. These frequently tend to coalesce.Cavitation may occur early in the broncho-pneumonic form. Miliary tuberculosis may have

FIG. 12. Bizarre calcification - pleural in origin.

FIG. 13. Tuberculosis. Multiple opacities are super-imposed over the upper zones.

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Emergency radiology. II 631

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FIG. 14. Sarcoidosis. Linear and nodular lungopacities. Peribronchial glandular enlargement and oneright paratracheal gland enlarged.

to be distinguished from other causes of bilaterallung shadowing such as:

(a) Sarcoidosis (Fig. 14)In this the glandular enlargement is frequently

the earliest manifestation. The glands have a

peribronchial distribution and are most oftenenlarged bilaterally. Although the peribronchialenlargement predominates, paratracheal glandularenlargement may also occur.Pulmonary infiltrations vary, and may consist of

a coarse linear infiltration with or without nodularopacities. The nodules may vary in size frommillet seed opacities 0'5 mm in diameter to largeropacities 2-3 mm in diameter. Diagnosis is easywhen only peribronchial glandular enlargementoccurs but is relatively difficult when pulmonaryinfiltrations occur without any glandular enlarge-ment.

(b) Pneumoconiosis (Fig. 15)Three stages can be recognized in pneumo-

coniosis: (i) pre-nodular, (ii) nodular, and (iii)progressive massive fibrosis.The appearances in the lung fields vary greatly

depending on the dust responsible, and varyingdegrees of nodulation or reticulation may occur.The linear reticulation may consist of lines Awhich are coarse linear opacities radiating fromthe hilum, lines B which are short narrow linesfound at the bases and passing transversely to end

at the pleural margin, and lines C which are finelines producing a network shadowing over thelungs. They are, respectively, due to involvementof the deep, intercommunicating and superficiallymphatics. Diffuse linear shadowing is not acharacteristic of tuberculosis. The nodules varygreatly in size and usually commence around thehilum. In the stage of progressive massive fibrosislarge opacities occur in the upper zones accom-panied by a great deal of fibrosis. The appearancesmay be due to associated tuberculosis in somecases, but this is not invariable. In difficult cases,the history of an industrial dust exposure is mosthelpful. Where the radiological appearances wouldinclude this, the patient should be questioned forboth his present and past occupations.

(c) Secondary deposits (Fig. 16)These opacities characteristically vary in size

and are maximal at the bases. They are largerthan the millet seed opacities of miliary tuber-culosis.

(d) Haemosiderosis (Fig. 17)The most common form is the secondary type.

This is usually a complication of mitral valvedisease or less often other causes of recurrent leftheart failure. The opacities are usually maximal

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FIG. 15. Pneumoconioisis. Peri-hilar and basal distri-bution.



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632 Oscar Craig

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FIG. 16. Carcinomatosis. Large basal opacitiespresent.

around the hilum and at the bases. The charac-teristic contour of mitral valve disease is readilyrecognized.

(e) Lymphangitis carcinomatosa and Hamman-Rich Syndrome

These usually produce streaky shadowing withlittle if any nodulation.

Lines A and B seen in pneumoconiosis are alsooften seen in lymphangitis carcinomatosa.

Lung abscess (Fig. 18)Lung abscess may result from: (a) aspiration,

(b) pneumonia, (c) septic emboli, (d) carcinoma,(e) infection in bronchiectasis, and (f) fungusinfections.Lung abscesses may be solitary or multiple. The

more common solitary type usually commences asan area of consolidation on the right side. It isseen most often in the lower lobes especially theapical segment, or the posterior segment of theupper lobe. It is often surrounded by an area ofNecrosis produces a fluid level. Friedlander'soedema which produces blurring of its margin.pneumonia is particularly liable to form largeabscess cavities and this may produce an increasein volume of the affected area. Staphylococcalpneumonia gives rise to multiple lung abscessesoften bilateral and associated with enlarged hilarglands. Pneumatocoeles commonly occur as aresult of staphylococcal infection. Other complica-tions of abscess formation are tension cavities,

FIG. 17. Haemosiderosis. Fine peri-hilar and basalshadowing.

pleural effusion, interlobar effusion, empyema andpyopneumothorax.

Radiological investigation includes a postero-anterior film and a lateral for accurate localiza-tion. An overpenetrated postero-anterior film isoften helpful to study the cavity wall and the hilarregions for signs of glandular or neoplasticmasses. Tomography may be necessary to studythe cavity wall. In cases of cavitating neoplasm

FIG. 18. Lung abscess left lower lobe with fluid level.



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Emergency radiology. II 633

the wall is thickened and irregular and has mul-tiple polypoid-like areas projecting into the cavity.An area of adjacent atelectasis or streaky shadow-ing may be indicative of malignancy. Fungusinfection in a pre-existing cavity will produce amycetoma which often has a crescent-shaped airtranslucency capping the opacity lying in thecavity.

Carcinoma (Figs. 19 and 20)There are many ways in which bronchial car-

cinoma may present radiologically. The follow-ing may be seen:

(1) An irregular mass in the hilum.(2) A peripheral round or irregular opacity.(3) An area of atelectasis with or without an

associated hilar mass.

(4) An abscess distal to a hilar mass which mayor may not be obvious radiologically.

(5) An area of pneumonic consolidation distalto a proximal neoplasm.

(6) A cavitating peripheral mass.

(7) Obstructive emphysema.Other complications of bronchial carcinoma

may dominate the picture, such as pleural effusion,pericardial effusion, invasion of a rib directly orby deposit.A peripheral bronchial carcinoma often presents

late and may even be found incidentally. It maybe round or oval and well demarcated. This typeof lesion has to be differentiated from other causesof a 'coin lesion' such as tuberculoma, secon-dary deposit, hamartoma, arteriovenous mal-formation, adenoma or lung abscess. Tomographycan greatly assist in the differentiation. Theopacity may have irregular streaky linear opacitiesaround it due to lymphangitis carcinomatosa ordirect neoplastic infiltration. The presence of anotch or 'hilum' in the opacity is said to stronglyfavour a primary malignant lesion. Calcificationin the opacity is strongly against a primarybronchial neoplasm and suggestive of a tuber-culoma or a hamartoma. 'Pop-corn' calcificationsuggests hamartoma. Satellite nodules may be seenin tuberculoma. The 'feeding' vessel may be seenin arterio-venous malformation. Tomography ofthe hilum may be necessary to distinguishbetween a neoplastic mass, a glandular mass or avascular opacity. The finding of an area of bron-chial stenosis may indicate neoplastic infiltration.

If elevation of one dome of the diaphragm ispresent then screening will be helpful to detectparadoxical movement common with diaphrag-matic paralysis.

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FIG. 20. Peripheral carcinoma left lower lobe.



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Mediastinal massesOccasionally a patient may present in the

casualty department with chest pain, dyspnoea,dysphagia, cyanosis, venous engorgement in theneck and oedema of the upper limbs and neck.These changes can be produced by large massesin the superior mediastinum. The most commoncause for this is glandular enlargement due toHodgkin's disease, lymphosarcoma, reticulum cellsarcoma or rarely lymphatic leukaemia. Rarely abronchial carcinoma may produce massive glan-dular enlargement with compression. Other causesof superior mediastinal masses such as retrosternalthyroid, dermoids, teratoma, thymoma, neuro-genic cysts and aortic aneurysms may rarely belarge enough to produce these symptoms.

Radiological investigation consists of a postero-anterior film and a lateral view. Glandular en-largement is most often bilateral and presents acharacteristic lobulated outline (Fig. 21). Thesingle solid masses may be differentiated by theirposition in the mediastinum. In the anteriormediastinum, thyroid, dermoid, teratoma andthymoma are most common. Calcification may beseen in thyroid adenoma and thymoma. Theremay be bone or dental elements in dermoids.Glandular masses and aneurysms arise in themiddle mediastinum but may grow into theanterior compartment. A posteriorly situated massis usually a neurogenic tumour or more rarely aneurenteric cyst.

Further examinations such as barium studies,screening for pulsation and angiography may benecessary. Tomography may clearly show thebilateral lobulated character of glandular masses.The reticuloses may produce secondary changes

I1G. 21. Hodgkin's glands in superior mediastinum.

FIG. 22. Pulmonary oedema. Butterfly perihilarshadowing, sparing apices, bases and periphery.

in the lungs, such as streaky linear infiltration,patchy nodular opacities, which may even cavitate,or areas of atelectasis or consolidation.

Tuberculosis rarely causes massive paratrachealglandular enlargement in natives of this country,but is being seen more often nowadays in immi-grants.

Left heart failureIn acute cases, pulmonary oedema may occur.

This presents as a bilateral peri-hilar shadowingreferred to as butterfly or bat's-wing shadowing(Fig. 22). It spares the apices, bases and the peri-phery. Rarely, unilateral pulmonary oedema maybe seen.

Chronic heart failure or the early stages of leftheart failure may produce vascular engorgementin the hila and lungs, septal B lines at the bases,and pleural effusion. The outflow tract of the rightventricle may be prominent. A common causefor this is mitral stenosis (Fig. 23). In this thepulmonary outflow tract is prominent, there isenlargement of the left atrium which may producea small bulge on the left heart border below thepulmonary artery, and a double shadow behindthe right heart border. The left atrium can be solarge as to form part of the right heart border

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Emergency radiology. 11

FIG. 23. Mitral heart disease with aneurysmal enlarge-ment of the left atrium, enlargement of upper lobevessels, prominence of pulmonary conus segment, andseptal B lines.

radiologically, or even to extend beyond it. Anoverpenetrated postero-anterior film may showwidening of the carina. Calcification may occa-sionally be seen in the valve.When right heart failure occurs the superior

vena cava may enlarge and widen the medias-tinum. There may also be right atrial enlargementand engorgement of the liver.To determine specific chamber, enlargement it

may be necessary to take oblique views. Screeningand barium swallows are helpful to show thenature and the extent of the enlargement.

Dissecting aneurysm (Fig. 24)Although this may be chronic, it is more com-

mon for dissecting aneurysm to present acutelywith severe chest pain and shock. The clinicalpicture may strongly mimic coronary thrombosis.The dissection may spread proximally into thepericardial sac and produce death from cardiactamponade. It may spread distally down thethoracic aorta and produce occlusion of the majoraortic arch vessels.

Postero-anterior and lateral films should beobtained if possible, but frequently the first X-rayis an antero-posterior portable film on the ward.This projection unfortunately often exaggeratesthe width of the mediastinum.

In cases of dissection the aorta is dilated andwidened. It often has an ill-defined border and anaccompanying mediastinal reaction produces ahazy mediastinal outline. There is frequently aleft pleural effusion, which may be blood-stained.The aortic knuckle may be elevated and displacedto the left. Loss of parallelism of the aortic wallsand local 'bulges' are very suggestive signs. Theradiological signs, however, are often very slightand contrast examinations may be necessary forconfirmation. It is helpful if previous chest X-raysare available for comparison. Dissectinganeurysms may lead to enlargement of the leftventricle.A dissection can become chronic and there may

even be calcification visible in the false passage.The mortality rate is exceedingly high, but theresults of operative treatment are improving.

Pericardial effusion (Fig. 25)There are many causes of pericardial effusion

amongst which the following need consideration:(1) rheumatic disease, (2) acute viral infection,(3) collagen disorders, D.L.E., etc., (4) coronaryinfarction, (5) tuberculosis, (6) acute septicaemicconditions, (7) nephritis, nephrosis and uraemia,(8) secondary to neoplastic disease, (9) myx-oedema, and (10) trauma.The fluid lies in the postero-inferior recess and

may pass undetected radiologically. At this stagethe opacity caused by the inferior vena cava, best

FIG. 24. Dissecting aneurysm of the aorta.

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636 Oscar CraigF

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FIG. 25. Overpenetrated film to show cardiac shapein pericardial effusion.

seen on the lateral view, is obliterated. As morefluid accumulates the normal contours of theheart are altered, the borders are straightened andthen the heart becomes globular in shape. Bothcardiophrenic angles remain acute. A bariumswallow will demonstrate displacement of theoesophagus backwards. A film taken supine mayoccasionally show bulging of the cardiac waist bymobile fluid as compared to the appearance on anerect postero-anterior film. Although screening isfrequently performed in these cases to demon-strate a diminished amplitude of cardiac pulsation,this may also occur with myocarditis which is oneof the main conditions in the differential diag-nosis. In difficult cases it may be necessary toperform special procedures to diagnose pericardialeffusion. These consist of cardiac catheterization,which alone may demonstrate the 'thickness oftissue' beyond the arterial wall, angiocardiographyand sometimes carbon dioxide injection into theheart chambers.

Eventually the effusion may lead to right heartfailure with dilatation of the superior vena cava,engorgement of neck veins and enlargement ofthe liver. Pulmonary congestion may also bepresent.

Cerebro-vascular accidentsThe diagnosis of cerebral embolus, thrombosis

or haemorrhage when suspected clinically isusually confirmed or refuted by angiography. It isoften necessary to primarily exclude an intra-

cranial tumour, and for this the first investigationis usually a skull X-ray. In all these cases it iswise to also obtain a chest X-ray to exclude aprimary bronchogenic carcinoma which mayproduce an intracerebral metastasis. It is difficultfor the non-radiologist to interpret skull X-raysbut the following points may be noted.The choroid plexus is frequently calcified on

both sides and shows as symmetrical mottledopacities above and behind the pituitary fossa.Rarely the choroid may calcify on one side only.Irregular calcification may be seen in a tumourmass and this applies to both glioma and menin-gioma. Meningioma may produce changes in theoverlying bone. The common sites for meningiomaare along the sagittal suture line, the sphenoidalridges, the olfactory grooves, in the parasellarregion and in relationship to the falx. The mostcommon change is an area of thickening andsclerosis in the bone overlying the tumour. Theremay even be superficial spicule formation. Thegrooves for the meningeal vessels seen on theplain skull films may be enlarged. Rarely menin-

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FIG. 26. Fractured femur. Edges show patchy rare-faction due to osteolytic metastasis.



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Emergency radiology. 11 637

gioma may produce an area of skull rarefactionoverlying the tumour.Other signs of intracranial masses may be seen,

such as a shift of the calcified pineal gland morethan 3 mm to one side. Raised intracranial pres-sure may produce changes in the sella turcica.There may be erosion of the tips of the posteriorclinoids. The dorsum sellae is not usually thinnedin these cases. In cases of intrasellar masses thedorsum sellae may be thinned but the posteriorclinoids are preserved. Intrasellar lesions alsodeepen the floor of the pituitary fossa oftenasymmetrically and undermine the anterior clinoidprocesses. When raised intracranial pressuredeepens the floor of the fossa, it is usually asymmetrical change. Routine skull views requiredin cases of suspected intracranial lesions include:

(1) Postero-anterior skull view.(2) Lateral projection.(3) Towne's view. This is an antero-posterior

view with the chin well flexed. It is the best viewon which to judge pineal shift and also to see thepresence of bilateral choroid calcification.

(4) Submento-vertical view. This demonstratesthe base of the skull.

Special areas to examine are: the foramenspinosum which may enlarge in the presence of ameningioma or an anterio-venus malformation,

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FIG. 27. Chest X-ray showing lytic expanding riblesions due to multiple myeloma.

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FIG. 28. Cyst-like areas in the tibia due to hyper-parathyroidism.

the nasopharyngeal region which can be closelyexamined in cases where nasopharyngeal neo-plasms are suspected and the area of the jugularforamen which may show erosions if a glomusjugulare tumour is present.

If the pituitary fossa appears unusual thenspecial coned views can be taken. It should beremembered that some thinning of the dorsumsellae may be within normal limits in patients over60 years of age.

Bone diseaseIt would be impossible in the space available to

discuss the many features of 'bone disease'. How-ever, three conditions will be mentioned whichmay present as a pathological fracture, namely,secondary deposits, myelomatosis and hyper-parathyroidism. The edges of any fracture shouldbe carefully examined for signs of irregularrarefaction, and the surrounding bone for signs oflytic or osteoblastic lesions. If any doubt existsthen a skeletal survey should be performed. This



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Oscar Craig

will consist of X-rays of the skull, proximal longbones, spine, ribs and pelvis. Secondary depositsmay be osteolytic, osteoblastic or mixed (Fig. 26).Irregular areas of rarefaction may be seen involv-ing ribs, pelvis, femora, humeri or spine. Theremay be areas of vertebral collapse with preserva-tion of the disc spaces. The deposits often involvethe pedicles of the vertebrae. Except in veryadvanced cases, the peripheral bones are spared.Myelomatosis involves the medullary bone andmay produce scalloping of the cortex from within.There may be multiple lytic areas in the ribs andthese may produce expansion (Fig. 27). Soft tissueshadowing may occur with the rib lesions and alsowith the vertebral lesions and this appearance isalmost pathognomonic. When myeloma involvesthe vertebrae the pedicles are usually spared.Rounded lytic skull lesions are often seen, and themandible is involved more often by myeloma thanby secondary carcinoma.Hyperparathyroidism (Fig. 28) may produce

multiple cyst-like lesions, often resembling giantcell tumours when single, or fibrous dysplasia or

even deposits when multiple. There may be anoverall bony rarefaction. This also can be thesole manifestation of carcinomatosis or myelo-matosis. A diagnostic feature of hyperpara-thyroidism is the presence of subperiosteal resorp-tion seen most often in the middle phalanges ofthe fingers. In extreme cases it can even involvethe long bones. The skull may show a 'speckledosteoporosis' and there may be loss of the laminadura of the teeth.

SummaryThe radiological features of some common

medical conditions involving the lungs, heart andbones which may present in the casualty depart-ment are described. A brief reference is made tothe necessary films required as a first step in theradiological investigation.

AcknowledgmentsI wish to thank Dr P. Cardew and the staff of the Photo-

graphic Department, St Mary's Hospital Medical School,for their great help in preparing the prints of the X-rays.

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