Age >61

Case 58

Emergency & Trauma / , , , , ,

This radiograph shows a left layering pleural effusion. This appearance is the result of pleural fluid layering in the basal and posterior pleural space due to gravity in a semi-recumbent position. Despite the image being labeled as “UPR” (upright), portable exams performed with the patient in a bed or gurney are rarely fully upright. As the x-ray photons pass through the effusion, they create a gradient effect in the craniocaudal direction as photons pass through more and more fluid relative to air the the more inferior they are relative to the patient. There is often some degree of compressive atelectasis associated with effusions, which contribute to this effect. This implies that the fluid is not loculated.

If the combined effusion and atelectasis is large enough to cover the entire hemidiaphragm, as in the case, there is “silhouetting” of the diaphragm and it is no longer distinguishable on radiography. The heart borders can also be silhouetted in the same way, but the effusion must be large enough to cover the entire heart.

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Case 49

Lines/Tubes/Devices / , , , ,

This radiograph demonstrates a transvenous phrenic nerve stimulator. The lead travels from the generator under the skin into the right subclavian vein, right brachiocephalic vein, left brachicephalic vein, and terminates in the left pericardiophrenic vein, which drains the superior diaphragm and pericardium. This allows the device to stimulate the left phrenic nerve, which courses alongside the left percardiophrenic vein (and artery). This device is approved for the treatment of central sleep apnea under the brand name Remedē.

This patient also has sternal wires from a prior, unrelated open sternotomy.

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Case 41

Chronic & ILD, ICU/Surgery / , , , , , , ,

This is a patient who received a unilateral lung transplant for idiopathic pulmonary fibrosis. Fibrosis is evident in the right lung with resultant bronchiectasis and volume loss. While pulmonary fibrosis can be identified on radiographs, classification of the pattern of fibrosis requires CT. The transplanted left lung is clear.

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Case 38

Malignancy / , , , , ,

This radiograph demonstrates a well circumscribed mass in the left upper chest. There is no silhouetting of the posterior arch and proximal descending aorta, placing the mass outside of the posterior mediastinum. The finding is subtle, but the anterior left 1st rib should project over the mass but is not visualized. This finding localizes the mass to the anterior chest wall with 1st rib involvement. This patient has a diagnosis of multiple myeloma, which favors plasmacytoma as the diagnosis.

Also partly visualized is a left proximal humerus repair using fixation hardware and cement osteoplasty, necessitated by prior pathologic fracture in the setting of a myelomatous lesion. The exam is otherwise normal.

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Case 25

Mediastinum / ,

This radiograph demonstrates a large hiatal hernia projecting over the mediastinum. In this case there is air within the gastric lumen which greatly aids in identification. In situations where air is not present within the herniated stomach, it can have the appearance of an abnormal cardiomediastinal silhouette. Review of prior images may assist with identification of a hernia, if available.

The exam is otherwise unremarkable.

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Case 21

Chronic & ILD, Lines/Tubes/Devices / , , , , , , ,

This radiograph demonstrates several findings:

First, this is a COPD patient with very few lung markings seen in the right upper lobe due to severe emphysema.

Second, this patient has undergone endobronchial valve placement leading to complete lobar atelectasis in the left upper lobe. The valves themselves are visible projecting over the left hilum. There is expected volume loss in the left hemithorax, with increased opacity in the left lung due to superimposition of the collapsed left upper lobe and aerated left lower lobe.

Third, a named sign is demonstrated: The luftsichel sign (German for “air crescent”), which is seen as a crescentic lucency in the paramedian left upper lung and indicates left upper lobe collapse. The lucency is created by a portion of the aerated left lower lobe that insinuates itself between the mediastinal wall and the collapsed upper lobe.

Fourth, there is an incidentally noted small hiatal hernia seen as a rounded opacity projecting just to the left of midline at the level of the diaphragm. Diaphragmatic eventration is also noted.

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Case 16

ICU/Surgery, Lines/Tubes/Devices / , , , , , , , , , , ,

This radiograph shows a malpositioned enteric tube which is looped in the oropharynx/hypopharynx and projects over the lower neck. There are a number of incidental findings including an appropriately positioned endotracheal tube, a loop recorder projecting over the left hemithorax, sternotomy wires with a prosthetic aortic valve, and a Watchman™ left atrial appendage occlusion device which is difficult to see on the default window and level. Linear subsegmental atelectasis is seen in the left lung base.

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Case 14

Lines/Tubes/Devices / , , , , ,

This radiograph shows a malpositioned left upper extremity PICC (peripherally inserted central catheter). The catheter takes an unexpected superior turn after entering the superior vena cava and is beginning to course medially, consistent with placement in the azygous vein. A lateral radiograph would provide further confirmation if available, but in this case the location can be confidently deduced with just an AP view. The study is otherwise unremarkable.

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