Normal & Variants

Case 47

Normal & Variants / , , , , , ,

This radiograph demonstrates bilateral cervical ribs, right greater than left. They are congenital and may be of no clinical significance. In some individuals, it can cause or contribute to thoracic outlet syndrome by compressing the subclavian vein, artery, and/or nerve. Cervical ribs may be resected in these cases.

There is also an incidental small, dense (likely calcified) nodule in the right lower lung and a probable calcified right hilar lymph node. This patient lives in an endemic area for Histoplasma capsulatum. Remote infection is the most likely etiology.

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Case 45

Lines/Tubes/Devices, Normal & Variants / , , ,

This radiograph demonstrates unusual but ultimately inconsequential pacemaker lead positioning. A dual chamber pacemaker generator pack projects over the left hemithorax. The right ventricular lead takes the expected course through the left brachiocephalic vein, superior vena cava, right atrium, and tricuspid valve and terminates in the expected position of the right ventricle. The right atrial lead, however, courses to the left of the aorta. There are no secondary signs to suggest an inadvertent extravascular course. The best explanation for this appearance is a persistent left superior vena cava. This is a normal variant and connects the left subclavian vein to the coronary sinus. Ultimately, the lead ends up in the right atrium. It is not clear in this case why this positioning was chosen rather than placing both leads in the right (normal) SVC.

The exam is otherwise unremarkable.

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Case 37

Normal & Variants / ,

This radiograph demonstrates a hazy right paramedian opacity with an indistinct right heart border. This is a typical radiographic appearance of pectus excavatum. A lateral radiograph or a prior CT (if available) could be used to confirm. The primary differential consideration would be a right middle lobe pneumonia or potentially a mediastinal mass if the sternal depression is severe enough to cause deformation of the mediastinal contours (not seen in this case).

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Case 24

Lines/Tubes/Devices, Normal & Variants / , , ,

This radiograph demonstrates a left upper extremity peripherally inserted central catheter (PICC) with tip terminating in a persistent left SVC. The presence of a persistent left SVC was confirmed on review of prior cross sectional imaging. A PICC in the internal thoracic vein can have a similar appearance on AP/PA radiographs, however a lateral radiograph easily distinguishes the two as a persistent left SVC will course centrally and the internal thoracic vein will course anteriorly.

The radiograph is otherwise unremarkable.

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Case 8

Normal & Variants / ,

This case demonstrates bilateral eventration of the diaphragm. Eventration is the result of localized atrophy of the diaphragmatic muscle or localized replacement with fibroelastic tissue, which gives the diaphragm an irregular contour on imaging. It can be part of normal aging, as in this case, congenital, or post-traumatic. The study is otherwise unremarkable.

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Case 3

Normal & Variants / ,

This radiograph demonstrates true dextrocardia, which was confirmed by reviewing multiple past radiographs. If no prior radiographs are present, discussion with the technologist to ensure that the image was not inadvertently mirrored would be appropriate. The study is otherwise unremarkable.

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