DIAGNOSTIC AND SURGICAL

IMAGING NATOMY
CHEST • ABDOMEN • PELVIS
Michael P. Federle, M D , FACR
Professor ol Radiologv
Chief, Abdominal Imaging
University of Pittsburgh Medical Center
Pittsburgh, PA

Melissa L. Rosado-de-Christenson, MD
Clinical Professor of Radiology
The Ohio State University College ol Medicine
Columbus, OH
Adjunct Professor ot Radiology
The Uniformed Services University of the 1 Icalth Sciences
Itethesda, MI)

Paula J. Woodward, MD
Proressor ot Radiologv
Adjunct Professor of Obstetrics and dynecology
University of Utah School of Medicine
Salt Lake City, UT

Gerald F. Abbott, M D
Director of Chest Radiology
Rhode Island Hospital
Associate Prolessor of Diagnostic Imaging
Brown Medical School
Providence, Rl

Managing Editor
Akram M. Shaaban, MBBCh
Assistant Professor of Radiologv (Clinical)
University of Utah Medical Center
Salt lake City, UT

□
AMIRSYS
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III
 DIAGNOSTIC AND SURGICAL

IMAGING NATOMY
CHEST • ABDOMEN • PELVIS

l
 DIAGNOSTIC AND SURGICAL

IMAGING NATOMY
CHEST • ABDOMEN • PELVIS
Michael P. Federle, M D , FACR
Professor ol Radiologv
Chief, Abdominal Imaging
University of Pittsburgh Medical Center
Pittsburgh, PA

Melissa L. Rosado-de-Christenson, MD
Clinical Professor of Radiology
The Ohio State University College ol Medicine
Columbus, OH
Adjunct Professor ot Radiology
The Uniformed Services University of the 1 Icalth Sciences
Itethesda, MI)

Paula J. Woodward, MD
Proressor ot Radiologv
Adjunct Professor of Obstetrics and dynecology
University of Utah School of Medicine
Salt Lake City, UT

Gerald F. Abbott, M D
Director of Chest Radiology
Rhode Island Hospital
Associate Prolessor of Diagnostic Imaging
Brown Medical School
Providence, Rl

Managing Editor
Akram M. Shaaban, MBBCh
Assistant Professor of Radiologv (Clinical)
University of Utah Medical Center
Salt lake City, UT

□
AMIRSYS
Name* von know, content vnu trust
III
 u
AMIRSYS*
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First Edition
Text - Copyright Michael P. Federle, MD, FACR 2006

Drawings - Copyright Amirsys Inc 2006

(Compilation - Copyright Amirsys Inc 2006

All rights reserved. No [)art of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or media
or by any means, electronic, mechanical, photocopying, recording, or otherwise, without prior written permission from Amirsys Inc.

Composition by Amirsys Inc, Salt lake City, Utah

Printed in Canada by Friesens, Altona, Manitoba, Canada

ISBN-13: 978-1-931884-33-4
ISBN-10: 1-931884-33-1
ISBN-13: 978-1-931884-34-1 (International English Edition)
ISBN-10: 1-931884-34-X (International English Edition)

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Library of Congress Cataloging-in-Publication Data

Diagnostic and surgical imaging anatomy : chest, abdomen, pelvis /

Michael P. Federle ... |ct al.| ; managing editor, Akram M. Shaaban.
— 1st ed.
p. ; cm.
ISBN-13: 978-1-931884-33-4
ISBN-10: 1-931884-33-1
ISBN-13: 978-1-931884-34-1 (international English ed.)
ISBN-10: 1-931884-34-X (international English ed.)
1. Diagnostic imaging—Atlases. 2. Chest—Anatomy—Atlases.
3. Abdomen—Anatomy—Atlases. 4. Pelvis—Anatomy—Atlases.
5. Imaging systems in medicine—Atlases. I. Federle, Michael P.
II. Title: Chest, abdomen, pelvis.
jDNI.M: I. Thorax—anatomy & histology—Atlases. 2. Abdomen
—anatomy is histology—Atlases. 3. Magnetic Resonance Spectro-
scopy—Atlases. 4. Pelvis—anatomy & histology—Atlases. 5. Tomo­
graphy, X-Ray Computed—Atlases. WE 17 D536 20061
RC.78.7.D53D534 2006
616.07'S4—dc22
2006030831

iv
 To Mort Meyers, whose pioneering work opened iny eyes to the
value of understanding abdominal anatomy and pathophysiology.
MPF

1 dedicate this work to my family, especially my husband Dr. Paul J. C.hristenson, and my daughters
Jennifer and Heather who encouraged and supported me throughout this work. I learned a great deal
from my good friend and co-author Dr. Gerry Abbott, my co-author Ur. Akram Shaaban and our most
gifted illustrator, Mr. I.ane Rennion.
MRdC

To all my residents (past, present and future) who have endured endless
hours of being "pimped" on anatomy. Here are all the answers!
PJVV

To my great friend, mentor, and co-author. Melissa Rosado de Christenson; and,

to her husband. Dr. Paul Clhristenson for his patience, support and good friendship.
GFA

To my parents, I truly owe you everything

To my wife Inji, son Karim and daughter May, the jewels of my life, thanks for your
understanding and tremendous support.
AMS

V
vi
 DIAGNOSTIC AND SURGICAL IMAGING ANATOMY: CHEST, A B D O M E N , PELVIS

We at Amirsys, together with our distribution colleagues at I .WAV. arc proud to present DUi/uttnth ami Surtuul hnovint
\niiliiiny: < 'first. Abilimicn, I'ehis. the third in our brand-new Series of anatomy reference titles. All books in this best-selling series
are designed specifically to serve clinicians in medical imaging and each area's related surgical subspecialties. We locus on
anatomy that is generally visible on imaging studies, crossing modalities and presenting bullcted anatomy descriptions along
with a glorious, rich offering of color normal anatomy graphics together with in-depth multimodality. multiplanar high-
resolution imaging.

Each imaging anatomy textbook contains over 2,500 labeled color graphics and high resolution radiologic images, with
heavy emphasis on .i I'csla MR and state-of-the-art multi-detector CT It is designed to give the busv medical professional rapid
answers to imagine, anatomy questions. Each normal anatomy sequence provides detailed views of anatomic structures never
before seen and discussed in an anatomy reference textbook. For easy reference, each major area (chest, abdomen, pelvis) is
subdivided into separate sections that cover detailed normal anatomy ol all its constituents.

In summary, Oiugiitntii mill Survival finiK'iny Atintimiy: (hc\t. AMonwn. I't'lvh is a product designed with you, the reader, in
mind. Today's typical radiologic. and surgical practice settings demand both accuracy and efficients' in image interpretation for
clinical decision-making. We think you'll find this new approach to anatomy a highly efficient and wonderfully rich resource
that will be the core of your reference collection in anatomy. The new IJUlplOilk ami Siirvical /wiiiyHiy Anatomy: MiiMVlo^keh-Uil is
also now available. Coming in 2(X)7 are volumes on Ultrasound as well OS a subspecialtv- and podiatry-oriented text on Knee.
Ankle, and Foot.

We hope that you will sit back, dig in. and enjoy seeing anatomy and imaging with a whole different eye

Anne G Osborn. M l )
Executive Vice President and Editor-in-Chief, Amirsys Inc.

II. Kit' llam\hcrgcr. M i l

ClOJx Chairman. Amirsvs Inc.

Paula |. Woodward. Ml)

Senior Vice President N Medical Director. Amirsvs Inc.

It). Manasler, MD
Vice President K Associate Medical Director, \mirsys Inc.

VII
viii
 FOREWORD

As in the great age " f exploration when the coastal contours of a continent were lirst outlined .uul thereafter its rivers,
mountains, and Valleys penetrated, so was the terra incognita of the human hod) explored.

A work published in 154.) influenced the annals ot Western medicine forever. Pt" Hiinniiii Vorptnh Fulvicil. I.ihti Septum by
Andreas Vesalius. usually referred to as the Filbricu, was one of the first anatomy texts to systematically provide descriptions
derived from actual dissection of the human body. In controverting the ancient theory of (>alen, the second-century C>rcek who
had cast his shadow on medical science for over a thousand years, the Fabrii'tl was an incontestable breakthrough. Vesalius is
regarded as the l.olumbiis ol the human body, as a man who literally discovered a new world.

\natomy was the stepping-stone to the understanding of not onlv the body's structure hut also its (unctions and
malfunctions.
It was othei investigations in the sixteenth century on the vascular system and the venous valves complete with their
mechanical implications that were crucial for William Harvey's demonstration of the blood circulation. Harvey's 1628
publication Ue Main CorJis ("On the Motion of the Heart") established that the heart is a pump which causes the blood to
circulate through the body, passing from the arteries to the veins. It would remain lor Marcello Malpighi. founder of
microscopic anatomy, decades later in 1660, to diSCOVCl the capillaries. I'hese insights marked the step from anatomy to
physiology.

In 1761, tlte Italian physician and anatomist Giovanni Morgagni published On tin1 S'/fcv tiiul Causes of Disease, finally
establishing the direct relevance of anatomy to clinical medicine. Rudolph Virchow, the father of 11 in u 11 pathology, declared in
18V4 ihat, with Morgagni, 'Tin- new medicine begins".

Over time, surgeons became most adept in the knowledge ol anatoinv. Uy the early decades of the 21)"' century, the eminent
surgeon Harvey Gushing could testify that "from the publication of the hwriui almost to the present day the Intimate pursuit
of... anatomy has constituted the high road lor entrv into the practice of surgery."

today, it is the radiologist who is most facile with highly detailed anatomy and who - it must l>c emphasized demonstrates
this in viivi. This has fleet! brought about hy the revolution in diagnostic imaging. IWssectional anatomy has been superseded by
(rwvv-sectional imaging.

I his volume which deals with anatomy of the chest, abdomen and pelvis is authored by recognized experts with wide
experience and keen insight including: Melissa Rosado do ("hirstenson and dcrald Abbott (chest), Michael I'ederle (abdomen),
and I'.iul.i Woodward (pelvis). It not only reveals the complex mysteries of the Iwidy 's structure bul further indicates why
anatomical applications are still being made today. The information is presented in an engaging and render-friendly style.
Convoluted descriptions are abandoned as key anatomic principles are outlined in succinct format. Medical illustrations of
exquisite museum quality are combined with state-of-art diagnostic imaging. A distinctive feature is the frequent use of
pathologic examples Ul highlight certain anatomic structures or features that might otherwise be obscure. I he exciting
capabilities of ultrasonographv. computed tomograpy. and magnetic resonance imaging are beyond the wildest dreams o l
\nclreas Vesalius or llarvev < lushing. The reader cannot but lie struck hy the realization Ihat the state-of-art images often rival
and sometimes surpass the artist's depiction in accurate display.

Anatomy is so intimately linked to phvsiologv and patllologv that this textbook is a gem for any Student or practitioner
involved with the human body in modern medicine.

Morton A. Meyers. M l )
Emeritus Professor of Radiology and Medicine
Distinguished University I'rolessor
State University of New York at Stony Brook

IX
X
 While in medical school, I hated "Anatomy." Working with cadavers was not only unpleasant but was relatively
uniiiformative as well. Structures of vital importance, such as various ducts and blood vessels, were difficult to identify by dissection.
The anatomic drawings in our textbooks seemed to have little or no bearing on what I was observing in the anatomy lab or
operating room, and had even less apparent relevance to the practice of medicine or surgery.

When CT came along at the end of my residency, we all had to scramble to learn how to interpret these new cross-sections of
the body Existing texts were of limited help in interpretation of axial CT images, and even less help when MR arrived with its new
planes of section and unfamiliar display sequences. Once we gained lamiliaritv with these imaging tools, however, we realized that
we had access to detailed anatomic information inaccessible to even the most experienced anatomist. Experience interpreting
thousands of CT and MR interpretations has also made us appreciate the considerable variability from "conventional" depictions of
anatomy found in standard textbooks.

We feel that the combination ot vibrant medical illustrations and nniltiplanar, high resolution, cross sectional imaging is the
ideal way to teach anatomy today. We have included depictions of common anatomic variations and pathological process to
make the reader aware of the appearanie and relevance of altered morphology.

We hope that the ellorts ot our talented medical illustrators ami radiologist/authors will make the anatomy ot the chest,
abdomen and |)elvis "come alive" for our readers.

Michael r. Kderle. M i l , IACR

I'rotessor of Radiology
( hiet ot Abdominal Imaging
University ot Pittsburgh Medical Center
XII
ACKNOWLEDGMENTS

Illustrations
Lane R. Bennton. \ i s

Contributing Illustrators
Kiili Coombs, MS
lames A. Cooper. Ml)
Walter Stuart, Ml A

Image/Text Editing
Douglas Grant Jackson
Amanda Hurlailo
Melanle Hall
Karen M. Pealcr, BA. CCRC

Medical Text Editing

Akram M. Shaaban, MBIU h

Case Management
Roth l.alleur
Christopher Odekirk

Case Contributors
I eras B.ider. MI); bait Lake City. U l
Peter L. Chovke. Ml); Bethesda. M l )
Ralph Drosten, M l ) ; Salt lake City. U l
M. ROIKTI More?. BS; Colorado Springs, ( O
Douglas Green, M l ) : Salt lake City, H I '
|ii i (iiimey. M l ) ; Omaha, NE
Keyanoosh llosselnzadeh, Ml); Pittsburgh, PA
Anne Kennedy, M l ) ; Salt lake City, H I
Mark King. M l ) ; Columbus. OH
Howard Mann. Ml); Sail Like ( ity. U l
Chris McGann, MD; Sail Lake City, UT
Elizabeth Moore, ML); Davis. ( A
Mohamed Salama, MD, Salt lake ( i t y . UT
Jerrv Spn kman, MD; Gainesville, Fl
J Thomas Stocker, MD; Bethesda, Ml)
Diane ( . Strollo, MD; Pittsburgh, I'A
JadeJ. VVong-You-Cheong. MD; Baltimore, MD

Project Leads
Melissa A. Hoopes
Kaerli Main

xiii
\iv
 SECTIONS

PARTI
Chest

PART II
Abdomen

PART I I I
Pelvis
 Part II
Abdomen
Chest Overview 1-2 Embryology of the Abdomen 11-2
.Y/(7/wi Rasado-d&Cltristfttsutt, Ml) MUhad P. Federle, MD, FACK

Lung Development 1-38 Abdominal Wall 11-40

Melissa Rosado-de-t hristetiwn, Ml) Michael I'. Federle, MD, FACR
Airway Structure 1-64 Diaphragm 11-68
HeraldE Abbott, MD Mhhael l\ Federle, MD, FACK

Vascular Structure 1-88 Peritoneal Cavity 11-92

Melissa Rosado-de-Cbristenson, MO Mnliacl /'. Federle. MD. FACK

Interstitial Network 1-110 Vessels, Lymphatic System and 11-118

Gerald l:. Abbott, Ml) Nerves
Lungs 1-130 Mkhaet P. Federle. Ml), FACK
Melissa Rosado-de-Cbristenson. Ml) Esophagus 11-158
Hila 1-164 Mkltael P. Federle. MD. FACK
Mclh-.ii Rosado-de-Cbrittenwn, Ml) Gastroduodenal 11-174
Airways I-2U2 Michael /'. Federle. Ml). FAi.R
(Jeniltl F. Abbott, MD Small Intestine II-206
Pulmonary Vessels I-228 MU imel P. Federle. Ml), F\CR
Melissa Komilv-ilt -Chrislenwn. Ml) Colon 11-238
Pleura I-262 Michael P. Federle. MD, FACK
(ieiald P. Abbott. MD Spleen 11-272
Mediastinum I-296 Michael P. Federle, Ml), FAt R
Meliwa Rowdo-de-l hristensoil, Ml) Liver 11-298
Systemic Vessels I-334 MU had P. Federle. Ml). FACK
Melissa RasatkMle-Cliristetisoii, Ml) Biliary System 11-342
Heart 1-374 Michael P. Federle, MD, FACK
Melissii Rasada-de-Christensun, Ml) Pancreas 11-370
Coronary Arteries and Cardiac Veins 1-422 Michael P. Federle. MD. FACR
Akram M. Sbaaban, MHlH.b Retroperitoneum 11-400
Pericardium 1-442 Michael P. Federle. MD. FACK
Melissa Rosado-ae^ChrisU'lison, Ml) Adrenal 11-424
Chest Wall 1-462 Michael /'. Federle, MR, FACR
Ueiald F. Abbott, Ml) Kidney 11-446
Michael P. Federle, MD, FACR

xvi
Ureter a n d Bladder 11-484
MulunlP. Itdirle. Ml). I.XCK

Part III
Pelvis
Pelvic Wall and Floor II1-2
I'miUi /. Woodward. Ml) ft Akiiini M. Shiiiihiiii,
MHIH h
Vessels, Lymphatic System and 111-52
Nerves
I'tiulti I. Wouilwiinl, Ml) ft Akram M. Sluaban,
MHHCh

Female Pelvic Ligaments and Spaces 111-84

I'liulu /. Woodward, Ml)
Uterus 111-96
/'ni/lii /. Woodward, Ml)
Ovaries 111-118
Paula). Woodward, Ml)
Testes and Scrotum 111-130
Paula I. Woodward, Ml)
Penis and Urethra 111-154
Paula I. Woodward, Ml)
Prostate and Seminal Vesicles 111-170
Akram M. SIMUIHIII, MBfii h ft Paula /. Woodward,
Ml)
xviii
 DIAGNOSTIC AND SURGICAL

MAGING NATOMY
CHEST • ABDOMEN • PELVIS
 PARTI
Chest

Chest Overview
Lung Development
Airway Structure
Vascular Structure
Interstitial Network
Lungs
Hila
Airways
Pulmonary Vessels
Pleura
Mediastinum
Systemic Vessels
Heart
Coronary Arteries and Cardiac
Pericardium
Chest Wall
 CHEST OVERVIEW
Left ventricle
Terminology o Aorta and branches
Abbreviations • Function
• Anteroposterior (AP) Pump action for systemic fc pulmonary circulations
• Postcroanterior (PA) Transport of deoxygenated blood to
• Image receptor (IR) capillar}-alveolar interlace
• Source-tO-lmage receptor distance (SID) Transport of oxygenated blood t o tissues
• Houmfield units (HU)
Chest Radiography |
[General Anatomy and Function Standard Chest Radiographs
Chest Wall • Imaging study of choice for initial assessment of
cardiopulmonarv disease
• Anatomy
<■ Spine • PA a n d left lateral chest r a d i o g r a p h s
Sternum Orthogonal views (at right angles to each other)
c Ribs 3 Analysis of orthogonal views for anatomic
o Clavicles localization of imaging abnormalities
Skeletal muscles Standard Radiographic Positioning
c Chest wall nerves and vessels • Upright patient
Skin a n d subcutaneous fat • lull inspiration a n d breath hold near total lung
• I-'unction capacity
' Pro\ides protection for lungs, cardiovascular • N o rotation or motion
structures and intrathoracic organs • Attempt to minimize overlying osseous structures
c Participates In l>ellows-like process of respiration • Area of interest closest to IK
Pleura • Radiographic technique
SID of 72 inches to minimize magnification
• \natomv
Central X-ray beam centered on thorax
Thin continuous m e m b r a n e
Parietal pleura: Lines n o n pulmonary surfaces <■ Beam collimation to include outer portion of chest
< Visceral pleura: Lines pulmonary surfaces wall
c Pleural space: Potential space Radiographic Projections
• Function • PA chest radiograph
Production a n d absorption of normal pleural fluid J Term PA: Describes posteroanterior direction of
■ Pleural fluid lubricates pleural surfaces X-ray beam traversing chest toward IR
■ Pleural fluid facilitates lung motion during • Anterior chest against IR
respiration < Head vertically positioned a n d chin on top of grid
o Clearance of abnormal pleural fluid dev ice
Airways ( Dorsal wrists o n hips a n d elbows rotated anteriorly
• Anatomy to move scapulae laterally
Shoulders moved caudally a n d squarely against IR to
Trachea bring clavicles below apices
o Main bronchi
• Left lateral chest radiograph
o Lobar bronchi
3 Term left lateral: Denotes that left lateral chest wall
Segments! bronchi is against IR
Bronchioles
Distal airways and alveoli X-rav beam traverses chest from right to left toward
• Function IK
3 Arms above head to move upper extremities away
Gas exchange during respiration
from lungs and mediastinum
o Protective mechanism against foreign particles
■ Ciliary escalator • AP chest radiograph
o Term AP: Describes anteroposterior direction of
■ Cough reflex
X-rav beam traversing chest toward IK
■ Air transfer to a n d from t h e alveolar-capillary
-| Supine and bedside (portable) radiography and
interface
imaging of sitting and semi-upright patients
Heart and Great Vessels ■ Neonates, infants a n d very young children
• Anatomy ■ Debilitated a n d unstable patients
Venae cavae ■ Seriously ill and bed ridden patients
Right atrium Distinctive features
i Right ventricle ■ Magnification of anterior structures (heart and
Pulmonary arteries mediastinum) farthest from IR; shorter SID
o Capillary network ■ Clavicles course horizontally and partially obscure
' Pulmonary veins apiies
I eft atrium ■ Ribs assume a horizontal course
 CHEST OVERVIEW
• Lateral d e c u b i t i i M h e s t radiograph
Recumbent position with right or left side down
Elevation of chest on radioluccnt support
frontal radiograph (APor PA) with horizontal X-ray
beam
Indications
■ Evaluation of pleura! fluid in dependent pleura!
space (X-rav beam tangential to tliiid-lung
interlace)
■ Evaluation of air in non-dependent pleura! space
(X-ray beam tangential to visceral pleura-air
interface)
• Apical lordotic I \ P or PA axial) chest radiograph
Superior angulation of X-ray beam from horizontal
plane of 15-20°
Distinctive features
■ \ntei ior osseous structures (c lav icles and first
anterior ribs) project superiorly above lung apices
■ Ribs course horizontally
■ Magnification (foreshortening) ot mediastinum
Indications
■ Kadiographir visualization ol apex, superior
mediastinum and thoracic inlet
■ 1 nhaiiced \ isualization ot minor fissure in
suspected right m i d d l e lolie atclcctasis
• Expiratory radiography
■ Evaluation of air trapping
Evaluation ot pneumothorax
■ 1 imited value
■ No clear difference in sensitivity or specificity for
diagnosis of pneumothorax
Radiographic Interpretation
• Assessment of patient's identity and proper placement
of right/left markers
• Imaging of entire thorax
Frontal r a d i o g r a p h s
■ Inclusion of all thoracic structures from larvnx to
costophrenic angles
■ Full inspiration with diaphragm below posterior
ninth rib
I ateral radiographs
■ Inclusion ol anteroposterior extent of chest wall
■ Inclusion of upper lung and posterior
costodiaphragmatic sulci
• Assessment of a p p r o p r i a t e radiographic positioning
No rotation
■ Spinous process o f T 3 (posterior structure)
centered between medial clavicles (anterior
stria tures) on frontal radiographs
■ Supcrimposition of right and left ribs posterior lo
vertebrae on lateral radiographs
Medial aspects of scapulae lateral to lungs oil Irontal
radiographs
Arms alxive thorax without superimposition on lung
and mediastinum on lateral radiographs
• Appropriately exposed radiograph
Visualization of peripheral pulmonary vasculature
Visualization ot pulmonary vessels and thoracic
vertebrae through heart on frontal radiographs
• Systematic evaluation
Assessment of multiple superimposed structures and
tissues
Assessment of all visible structures including
portions ot neck, shoulders and upper abdomen
Comparison to prior studies
• Challenge*
Evaluation ot retrocardiac lung
Evaluation ot rctrodiaphragmatic lung
Evaluation of apical lung
Radiographic Densities
• l o u r basii radiographic densities
Air
Water (fluid, blood and soft tissue)
■ at
Metal icalcium, contrast, metallic medical devices
foreign bodies)
• Silhouette sign
An intrathoracic process (mass, consolidation,
pleural tluid) that touches mediastinum or
diaphragm obscures visualization of their Ixirders on
radiograph)
< litical lor radiographic diagnosis ot
■ Ateleclasis
■ Consolidation
■ Puliuonarv e d e m a h e m o r r h a g e
■ Pleural elfusion
Computed Tomography J
General Concepts
• Imaging based on X-ray absorption by tissues with
diflering atomic numbers
» Display of differences in X-rav absorption in
cross-sectional format
• Excellent spatial resolution
• Enhanced v isualization ot structures of different tissue
density based on display ol a wide range of HU
measurements
W i n d o w w i d t h refers to number ot HI 1 displayed;
w i n d o w level refers to median (center) HU
I u n g w i n d o w (width of 1500 HU; level of -6<X) HU)
■ Evaluation of lungs, airways and air-containing
portions of gastrointestinal tract
Soft tissue or mediastinal w i n d o w (width of
.100-500 IIU; level of 30-50 HU)
■ Evaluation of vascular structures and soft tissues
of mediastinum and chest wall
Hone w i n d o w (widest width; level of +?() HU)
■ Evaluation of skeletal and calcified structures and
metallic ob|ects
Conventional CT
• Evaluation, localization and characterization of
abnormalities deteited on radiography
• 1 ocalization of lesions in preparation for C"I-guided
biopsy /drain age
Contrast-Enhanced CT
• Administration ot intravenous contrast
Evaluation of normal vessels
Evaluation ot vascular abnormalities
Distinction of vascular structures from adjacent soft
tissues
Determination of lesion/tissue e n h a n c e m e n t
 CHEST OVERVIEW
• Administration of enteric contrast
Evaluation of gastrointestinal tract Indications
I valuation of gastrointestinal perforations/leaks • Imaging of the heart and great vessels
• Distinction of vascular structures from adjacent soft
CT Angiography tissues without the use of contrast
• Vascular imaging • I valuation of mediastinum and bila
<- liming of contrast bolus • Evaluation ol chest wall and diaphragm
c Imaging of specific vascular structures
■ ("1 p u l m o n a r y a n g i o g r a p h v for evaluation of
tliromboi'iiibolic disease [Angiography |
• ( r a o r t o g r a p h y for evaluation of t r a u m a t i c
aortic injury, dissection and iiiieiirvsm Pulmonary Angiography
• Venous cathcterbation
High-Kesolulion CT • Canniilation of pulmonarv arterial system
• Technique • Indications
I bin-sections to minimize partial volume effects i Evaluation of congenital a n d acquired pulmonarv
High-resolution r e c o n s t r u c t i o n a l g o r i t h m vascular abnormalities
• Indications Evaluation of thromboembolic disease
Evaluation of diffuse inliltnttive l u n g disease ■ Decreasing utilization
Evaluation of patients with d y s p n e a and normal
radiographs Aortography
• Special techniques • Arterial cathcterizalion
I'rone i m a g i n g lor evaluation ot peripheral b.isilar • C'annulation of proximal aorta
lung disease • Indications
1
r x p i r a t o r y i m a g i n g for evaluation ot distal airways I.valuation of traumatic aortic and great \essel injury
1
disease Evaluation of congenital arterial vascular anomalies
1
Evaluation of caliber a n d integrity of aortic a n d
Special Techniques great vessel lumens
• M u l t i p l a n a r i m a g i n g with coronal a n d sagittal
reformations Bronchial Artery & Intercostal Arteriography
1 valuation of axially oriented structures and • Arterial catheteri/ation
abnormalities • Selective canniilation of bronchial/intercostal arteries
I valuation of anatomic location ot lung lesions in • Indications
relation to fissures Diagnosis and treatment of h e m o p t y s i s
Evaluation of chest wall a n d inediastinal
involvement b\ adjacent pulmonary lesions
• Surface-rendered t e c h n i q u e s fore-valuation of airway Other Chest Imaging Modalities
and vascular lumens
Virtual b r o n c h o s c o p v Radionuclide Imaging
Virtual angioscopy • \cntiliitimi-pcrfiision i m a g i n g
• Volume-rendered t e c h n i q u e s tor problem solving ' Evaluation of thromboembolic disease
and education Evaluation of pre- and post-operative lung function
• Positron emission t o m o g r a p h y
Determination of metabolic activity of lesions
Magnetic Resonance Imaging Staging of malignant neoplasms
■ Use of integrated IM I'-GT i m a g i n g
General Concepts
Ultrasound
• Application of radiofrequency to excite protons within
a magnetic field ■ Evaluation of pleural effusion
• Detection of signal emitted bv nuclei as they relax to tree vs. loculated
their original alignment with generation of an image riioracentesis planning
of their spatial distribution Biopsy planning
• Advantages of MR • I valuation of d i a p h r a g m a t i c m o t i o n
I \cellcnt contrast resolution
Multiplanar imaging
Intrinsic vascular "contrast'1
■ Increased soft tissue contrast
Technique
• Spin-echo sequences typically used in chest imaging
' II w e i g h t e d images
12 w e i g h t e d images
• Bright blood sequences
 CHEST OVERVIEW
STRUCTURES OF THE CHEST

Chest wall skeletal

structures
Airways
Thoracic great vessels

Pulmonary trunk

Chest wall muscle

Chest wall
subcutaneous tissue

■ _ ^ . . .

Graphic shows the complex and diverse structures and organs in the thorax. The chest wall skeletal and soft tissue
structures surround and protect the primary organs of respiration, the thoracic cardiovascular system, and the
proximal gastrointestinal tract. The apposed pleural surfaces create a potential space that normally contains a small
amount of fluid which lubricates the pleura and reduces friction during respiratory motion. The airways deliver
oxygen to the alveolar-capillary interface and carry carbon dioxide out to the environment. The heart and vessels
deliver deoxygenated blood to the capillary-alveolar interface and oxygenated blood to the peripheral organs and
tissues.
 CHEST OVERVIEW
PA CHEST RADIOGRAPH

Chest wall skeletal

structures
— Aorta

— Airways

Interlohar pulmonary
artery

— Heart

Lung

Normal posteroanterior chest radiograph shows the challenges inherent in the interpretation of radiographs of the
thorax. Chest radiographs display a wide range of structures and tissue types with significant superimposition of
structures of different radiographic density. Portions of the lung may he ohscured by overlying mediastinal soft
tissues and skeletal structures. Attention to radiographic image quality is of paramount importance for accurate
diagnosis of subtle abnormalities.
 CHEST OVERVIEW
LEFT LATERAL CHEST RADIOGRAPH

Trachea —

Sternum

- Thoracic vertebra
Heart —

1 iL'midiaphragrm

The left lateral chest radiograph is orthogonal (at 90") to the PA chest radiograph. It is a complementary view that
allows visualization of the retrocardiac left lower lohe and the retrodiaphragmatic lung hases. It also allows
evaluation of the thoracic vertebrae. As in the PA chest radiograph, multiple structures of various densities are
superimposed and must be evaluated in a systematic manner.
 CHEST OVERVIEW
PA CHEST RADIOGRAPHY, POSITIONING & COLLIMATION

>
O Chin over grid device
to
O
(A
o
I
o
X-ray beam travels In
posteroanterior
direction Scapula rotated off
lung

Hand pronated with

dorsal wrist on hip

Collimatlon of X-ray
beam
Lung apex included

X-ray beam centered

on chest
Least magnification of
heart & mediastinum

Costophrenic angle
Included

(Top) Graphic shows proper positioning for PA chest radiography. The patient is upright with the anterior chest
against the vertical IR, the chin over the top of the device, the arms flexed with the backs of the hands on the hips
and the shoulders internally rotated to move the scapulae off the lungs. The X-ray beam travels through the patient
in a posteroanterior direction. (Bottom) Graphic shows proper PA chest radiographic collimation for imaging the
lungs and mediastinum. The white target sign shows the centering of the X-ray beam. The blue overlay represents
the collimated X-ray beam that extends from the cervical airway superiorly to below the costophrenic angles
interiorly and includes the left and right skin surfaces. The anterior structures of the chest (shown in color) are
I closest to the IR and experience the least magnification.
8
 CHEST OVERVIEW
PA C H E S T R A D I O G R A P H Y

— Spinous process of T3

Medial clavicles —

Medial left scapula

Retrocardiac thoracic —
vertebra

I — Retrocardiac
pulmonary vessels

Retrod iaphragmatic
pulmonary vessels

Spinous process of T3

Medial right clavicle Medial left clavicle

Medial right scapula

Increased opacity of
left hemithorax

(Top) Well-positioned n o r m a l I'A chest radiograph. The scapulae are rotated off t h e lungs. The spinous process o f T3
is equidistant f r o m the medial clavicles. Proper c o l l i m a t i o n spans f r o m t h e cervical trachea superiorly t o below t h e
costophrenic angles Interiorly a n d includes the lateral aspects o f t h e chest w a l l . O p t i m a l exposure allows
visualization o f t h e peripheral p u l m o n a r y vessels, the vertebral bodies (visible t h r o u g h the m e d i a s t i n u m ) , and the
retrocardiac a n d retrodiaphragmatic p u l m o n a r y vessels. ( B o t t o m ) Poorly positioned PA chest radiograph w i t h
marked r o t a t i o n t o t h e r i g h t . The left medial clavicle overlies the spinous process of T3 and the right medial clavicle
is displaced t o t h e r i g h t of m i d l i n e . Increased density of t h e left h e m i t h o r a x results f r o m X-ray penetration of a
greater thickness o f left-sided chest w a l l soft tissues due t o r o t a t i o n .
 CHEST OVERVIEW
LEFT LATERAL CHEST RADIOGRAPHY, POSITIONING & COLLIMATION

Arms extended upward

Vertical image receptor

X-ray beam travels

from right to left

Left lateral chest

against grid device

Upper lung included Upper extremities

rotated off upper lung

X-ray beam centered

<m chest

Least magnification of
left-sided structures

Costophrenlc angle
Included

Collimation of X-ray
beam

(Top) Graphic shows proper positioning for left lateral chest radiography. The patient is upright with the left lateral
chest against the vertical image receptor and the arms extended upward for unobstructed visualization of the upper
lungs. The X-ray beam travels through the patient from right to left for a left lateral chest radiograph. (Bottom)
Graphic shows proper left lateral chest radlographlc collimation for imaging the lungs and mediastinum. The white
target sign shows the centering of the X-ray beam. The blue overlay represents the collimated X-ray beam that
extends from the cervical airway superiorly to below the costophrenlc angles inferiorly and includes the anterior and
posterior skin surfaces. The structures of the left chest (shown in color) are closest to the Imagereceptorand
experience the least magnification.
 CHEST OVERVIEW
LEFT LATERAL CHEST RADIOGRAPHY
o
O
u>
• ■

o
CD
if)

Anterior scapular
9
borders CD
Hila —
i
CO

— Intervertebral disk

— 1 eft posterior rib

Lett costophrenic angle —

— Right posterior rib

Right costophrcnic
angle

Humeri ~

Upper extremity soft

tissues

— I#ft posterior rib

— Right posterior rib

Left costophrenit angle —

— Right costophrcnic
angle

( l o p ) Well-positioned normal left lateral chest radiograph. The upper extremities are not visible. The hila are
centrally located. The thoracic intervertebral disks are visible. The posterior ribs are superimposed and project behind
the vertebrae. There is minimal magnification of the left posterior ribs, which appear sharper and smaller t h a n the
right posterior ribs. Proper collimation allows inclusion of t h e lung apices, the posterior costophrcnic angles and the
anterior and posterior skin surfaces. (Bottom) Poorly positioned left lateral chest radiograph. The skeletal and soft
tissue structures of the upper extremities obscure the anterior lungs and mediastinum. Rotation prevents
superimposition of the posterior ribs. The right posterior ribs appear larger and project behind the left posterior ribs.
The right costophrenic angle projects posterior t o t h e left. I
11
 CHEST OVERVIEW
AP CHEST RADIOGRAPHY, POSITIONING & COLLIMATION

Centering of X-ray
beam

Supine patient

RadlographJc cassette

Bed or X-ray table

Right medial clavicle Left medial clavicle

Aortic arch

Right scapula Left scapula

Retrodiaphragmatic
pulmonary vessel

(Top) Graphic shows proper positioning for supine AP chest radiography. The patient's back is against the
radiographic cassette, the upper extremities are by the patient's sides. Internal rotation of the shoulders will minimize
the degree of superlmposition of the scapulae on the lateral upper lungs. The X-ray beam travels through the patient
in an anteroposterior direction. The heart and anterior chest structures are farthest from the cassette and experience
some magnification. (Bottom) Normal AP chest radiograph. The heart and great vessels appear mildly magnified.
The clavicles show a horizontal course and their medial portions obscure the lung apices. The medial scapulae project
over the lateral aspects of the lungs. Note that exposure factors and collimation are optimal with visualization of
retrocardiac vertebrae and vessels and retrodiaphragmatic vessels.
 CHEST OVERVIEW
PORTABLE A P CHEST R A D I O G R A P H Y , T R A U M A & INTENSIVE CARE
o
©
</>
■ ■

o
=r
Remote right clavicle CD
fracture c/>
•—t-

— Overlying external 9
CD
monitoring devices
.'.j propi...;.■■■'■•
positioned i
endotraiiK'al tube
I

Trauma board artifact

External monitoring
device

l.'mbilical vein catheter

tip in right atrium

I
External monitoring —
device
— Orogastric tube tip in
stomach

( l o p ) Supine bedside (portable) AP chest radiograph. Portable radiographs are used for i m a g i n g debilitated, seriously
i l l a n d traumatized patients. AP chest radiographs i n t h e s e t t i n g o f t r a u m a are o f t e n c o m p r o m i s e d b y t e c h n i c a l
factors related t o o v e r l y i n g radio-opaque m o n i t o r i n g a n d stabilizing devices. However, they provide a q u i c k
assessment of t h e integrity of t h e thoracic structures a n d t h e position of life support devices. ( B o t t o m ) Bedside AP
chest radiography is o p t i m a l for i m a g i n g neonates a n d infants, particularly those w h o are seriously i l l due to
congenital lesions a n d / o r prematurity. O n e day o l d i n f a n t b o m at 31 weeks gestation is u n d e r g o i n g treatment for
p r e m a t u r i t y and m i l d respiratory distress syndrome. Portable radiography allows assessment of life support devices
(endotracheal tube, u m b i l i c a l artery/vein catheters) a n d p u l m o n a r y parenchyma. I
\$
 CHEST OVERVIEW

i PA & AP CHEST RADIOGRAPHS

>
o Medial right clavicle —r-
w
CD
sz
O
■ ■ Medial lefl scapula
w
CD
O

Heart

Medial right clavicle

Medial left scapula

Heart

(Top) First of four normal radiographs of the same patient. On the I'A chest radiograph, the heart and mediastinum
are closest to the image receptor and undergo the least magnification. The medial clavicles curve inferiorly and do
not obscure the lung apices. The scapulae are rotated laterally and do not obscure the lateral aspects of the lungs.
(Bottom) On the AP chest radiograph, the heart and mediastinum appear slightly larger as they are farthest from the
image receptor and undergo some magnification. The clavicles exhibit a horizontal course and their medial aspects
obscure the lung apices. The medial portions of the scapulae overlie the lateral aspects of the lungs.

\A
 CHEST OVERVIEW
INSPIRATORY AND EXPIRATORY CHEST RADIOGRAPHS

Left posterior 10th rib

Right anterior 8th rib —

Apparent mediastinal —
widening

Apparent cardiac
Vascular crowding enlargement

— I.eft posterior 9th rib

Right anterior 6th rib

( l o p ) Normal PA chest radiograph obtained at full inspiration shows optimal visualization of the lung bases and the
retrocardiac and retrodiaphragmatic lung. A portion of the 8th anterior right rib is visible through the lung and
projects above the hemidiaphragm. A portion of the 10th posterior left rib is visible through the lung and projects
above the hemidiaphragm. (Bottom) Normal PA chest radiograph obtained at end expiration shows low lung
volumes. The lung bases are partially obscured with increased basilar density and vascular crowding with resultant
poor visualization of the retrodiaphragmatic lung. A portion of the right 6th anterior rib is visible through the lung
and projects above the hemidiaphragm. A portion of the left 9th posterior rib is visible through the lung and projects
above the hemidiaphragm.
 CHEST OVERVIEW
LATERAL DECUBITUS CHEST RADIOGRAPHY, POSITIONING & COLLIMATION

rfc.
Colltmatlon of X-ray
beam

^^H

w "" '
Lung apex included

f ^t»*"\ t o r i rt «"* f*( V f^lf

beam

Anns extended up

included

• Left side of chest raised

on radiolucent pad

Increased right lung

volume

■I
1 ■

Decreased left lung

volume

Normal left pleuial

space

(Top) Graphic shows proper lateral decubitus PA radiographic collimation for Imaging the lungs and mediastinum.
The white target sign shows the centering of the X-ray beam. The blue overlay represents the collimated X-ray beam
that extends from the cervical airway superiorly to below the costophrenic angles interiorly and includes the left and
right skin surfaces. The thorax is elevated on a radiolucent pad to ensure Inclusion of the dependent pleural surface
and chest wall. The antenor structures of the chest (shown in color) are closest to the image receptor and experience
the least magnification. (Bottom) Normal left lateral decubitus radiograph shows a larger lung volume in the
non-dependent right lung and volume loss manifesting as increased density in the dependent left lung. There is no
pleural thickening or fluid.
 CHEST OVERVIEW
APICAL LORDOTIC CHEST RADIOGRAPHY, POSITIONING O
O

O
CD
(/I

o
<
CD

Posterior shoulders
i
X-rays travel from CD
anterior to posterior at against image receptor
20" angle

Vertical Image receptor

1
Medial clavicles

Anterior 1st ribs

Right scapula Left scapula

Foreshortened
mediastinum

(Top) Graphic shows proper positioning for AP apical lordotic chest radiography. The patient Is upright with the
posterior shoulders against the vertical image receptor, the arras are internally rotated to move scapulae away from
the lungs. The X-ray beam travels through the patient from anterior to posterior and is centered at the manubrium
sternum and oriented superiorly at a 20° angle from the horizontal plane. (Bottom) Normal apical lordotic chest
radiograph projects the medial aspects of the clavicles off the lung apices. Note that the apex is partly obscured by
the anterior aspects of the first ribs and their costochondral junctions in this case. The mediastinum is foreshortened
and mildly magnified. The scapulae overlie a significant portion of the lateral lungs.
I
17
 CHEST OVERVIEW
RADIOGRAPHIC DENSITIES

Fat density

r Metal density in left

marker

Metal (calcium) density

in bone
Air density' in lung

Air density in stomach

Water density in
subcutaneous tissues &
liver

Fat density '

Metal density (calcium)

in skeleton
Air density in lung

Water density in soft

tissues
Water density (soft —
tissue) in mediastinum

— Air density in bowel

- Metal density in
Water density in clothing (snap)
abdomen

(Top) Normal PA chest radiograph shows the four radiographic densities. Air is present in the lungs bilaterally and
within the stomach. Water (or soft tissue) density is seen in the mediastinum, abdomen and subcutaneous tissues.
Fat density is visible between the normal soft tissues of the upper thorax. Metal density is noted in the skeletal
structures (calcium) and the metallic left marker. (Bottom) Normal PA chest radiograph shows the four radiographic
densities. Air density is present in the lungs and within bowel. Water (soft tissue) density is seen in the mediastinum,
abdomen and subcutaneous soft tissues. Fat is more difficult to demonstrate in this thin patient but is present
between the normal soft tissues of the upper chest. Metal is represented by the skeletal structures (calcium), the
metallic left marker and a snap on the patient's gown.
 CHEST OVERVIEW
R A D I O G R A P H I C DENSITIES, M E D I C A L DEVICES
o
a
Vt
••
O
CD
C/)

Sternal wires
9
CD
i
CD

Battery pack

Coronary sinus lead

Right ventricular loads

— tortuous i.iluliixl aorta

Battery pack

Sternal wires — I

- Coronary sinus lead

Ventricular leads —

(lop) First of two chest radiographs of a patient with a bivcntricular pacemaker and automatic iinplaritable
cardioverter defibrillator with a battery pack. Orthogonal radiographs allow accurate assessment of the integrity and
position of medical devices. PA chest radiograph shows two pacer leads in the right ventricle and one in the coronary
sinus. Ihe metallic battery pack obscures visualization ot the left mid lung. There is cardiomegaly and tortuosity and
calcification of the thoracic aorta. The lungs are clear. Sternal wires are present (Bottom) Left lateral chest
radiograph shows two right ventricular leads and a third lead in the coronary sinus. The left lung behind the battery
pack is now visible although superimposed o n the contralateral right lung. Cardiomegaly, aortic tortuosity and
calcification and sternal wires are again noted. I
r
 CHEST OVERVIEW
SILHOUETTE SIGN

Right hasilar airspace Left lower lol>c airspace

disease disease

Radio-opaque central —
catheter

Descending thoracic
Normal right lung base - aorta

(Top) First of two chest radiographs of a patient with imiltifocal pneumonia who presented with fever. AP chest
radiograph shows right basilar airspace disease manifesting as increased hasilar opacity and obscuration of the right
cardiac border. Left lower lobe airspace disease manifests with obscuration of t h e retrocardiac descending aorta.
Multifocal pneumonia was suspected clinically and was confirmed on chest Cf". (Bottom) PA chest radiograph
obtained two years earlier shows a normal appearance of the right lung base, visualization of the right cardiac border
and a normal left lower lobe with visualization of the retrocardiac descending aorta. A right internal jugular catheter
is also present. This case illustrates the value of the silhouette sign and the value of comparison with prior studies in
the diagnosis of subtle radiographic abnormalities.

**-?.J- *.*».
 CHEST OVERVIEW
ANATOMIC LOCALIZATION WITH ORTHOGONAL RADIOGRAPHS

lateral position of
medial clavicle related
to mild rotation

t ■ MIII left cosloplirenic

angle

— Bullet projects over left

upi>cr alxlomen

— Right posterior rib

Blunt left costophrenk"

angle
— Bullet

— 1 eft posterior rib

Normal right
hcmldiaphragm

(Top) first of two radiographs of the same patient. I'A chest radiograph shows a bullet over the soft tissues ot the
upper abdomen to the left of Ihe midline. 1 here is blunting of the left costophrenic angle related to remote trauma.
(Bottom) The orthogonal left lateral chest radiograph allows anatomic localization of the bullet in the soft tissues of
the posterior left chest wall. The patient is rotated. Note that the bullet projects posterior to the sharper, smaller and
anteriorly located left posterior ribs. The right posterior ribs appear less sharp and larger as they are farther from the
IR. The right and left hemidiaphragms can be confidently identified based on their relationship t o the corresponding
ipsilatcral ribs. PA and lateral radiographs allow anatomic localization of imaging abnormalities.
 CHEST OVERVIEW
DECUBITUS R A D I O G R A P H Y FOR EVALUATION O F C O M P L E X PLEURAL DISEASE

(lop) lirst of two chest radiographs of a patient with a left empyeina. I'A chest radiograph shows a large air-fluid
level in the left inferior hemithorax. (Bottom) Left lateral decubitus chest radiograph shows a discrepant length of
the air-fluid level (it appears longer than on the PA radiograph) indicating that the collection has an elongate shape.
Note the thick medial wall of the air and fluid collection. The findings are characteristic of a loculated pleural
collection. The presence of air indicates a communication with the tracheobronchial tree (bronchopleural fistula)
and the findings are diagnostic of a complicated empyema. In this case, the lateral decubitus radiograph allows
pleural localization of the abnormality and distinction from parenchymal disease.
 CHEST OVERVIEW
LORDOTIC CHEST RADIOGRAPHY FOR EVALUATION OF APICAL LESION

Right apical mass

Medial right clavicle

Medial right anterior

first rib

Spiculated right apical

mass

('lop) First of two radiographs of a patient with a right apical mass. I'A chest radiograph coned-down to the right
apex demonstrates an abnormal irregular apical mass and thickening of the medial aspect of the right apical pleura.
(Bottom) AP apical lordotic radiograph coned to the right upper lobe allows Visualization of the medial aspect of the
right apical lung by projecting the right medial clavicle and right first anterior rib above the lung a\xx. The
spiculated lateral border of this right apical non-small cell lung cancer is now visible.
 CHEST OVERVIEW
SILHOUETTE S I G N , LEFT LOWER LOBE AIRSPACE DISEASE

— Left lower lobe

consolidation

Obscuration ot left
hemidiaphragm

I eft lower lobe —

consolidation
— Obscuration of portion
Left major fissure — of left heniicliaphraKm

Left hemidiaphragni

Left |K).sterior rib

(Top) Hirst of two chest radiographs of a patient with left lower lobe consolidation. PA chest radiograph shows a left
basilar air space opacity that obscures the left hemidiaphragm. While the left hemidiaphragm is not visible, its
location is inferred by the presence of adjacent abdominal air-filled loops of bowel. The alveolar air in the left lower
lobe has been replaced by an inflammatory process producing the silhouette sign. (Bottom) Lateral chest radiograph
shows that the consolidation abuts the oblique fissure anteriorly and is located in the anteromedial basal segment of
the left lower lobe. The left lateral chest radiograph allows identification of the left (least magnified) ribs that are
closest to the IR and the ipsilateral left hemidiaphragm.
 CHEST OVERVIEW
SILHOUETTE S I G N , R I G H T M I D D L E LOBE AIRSPACE DISEASE

Right middle lobe

opacity obscures right
cardiac border

Right minor fissure —

Inferior aspect of right

Right middle lobe — oblique fissure
atelectasis

(lop) First of two chest radiographs of a patient with right middle lobe atelectasis. PA chest radiograph shows air
space opacity in the medial aspect of the right lower lung zone which obscures the right cardiac border. The location
of the process can be inferred by the inability to visualize the right cardiac border while the right hemidiaphragm is
visualized. Atelectasis has resulted in evacuation of the alveolar air from the right middle lobe producing the
silhouette sign. (Itottom) Lateral chest radiograph shows a triangular opacity that projects over the heart and
represents the atelectatic right middle lobe. I'ostero-interior displacement of the minor fissure and antero-superior
displacement of the inferior aspect of the right major fissure are typical of right middle lobe volume loss and
distinguish atelectasis from consolidation.
 CHEST OVERVIEW
CROSS-SECTIONAL ANATOMY

Skeletal structures

Great vessels

Airways
Pulmonary
vasculature

Muscle Subcutaneous fat

Graphic shows the cross-sectional appearance of the mid thorax and illustrates visualization of numerous organs and
tissues in cross-section. Cross-sectional imaging allows assessment of the various and diverse organs, structures and
tissues of the chest. The soft tissues of the chest wall consist of skin, subcutaneous fat and chest wall muscles.
Together with the skeletal structures, the soft tissues of the chest wall surround and protect the thoracic cavity and
its internal organs and tissues. The apposed pleura! surfaces form the pleural space. The pulmonary arteries and veins
course through the lungs. The mediastinal fat, mediastinal vascular structures, esophagus, central tracheobronchlal
tree and lymph nodes are also depicted.
 CHEST OVERVIEW
AXIAL CT, CROSS-SECTIONAL IMAGING

Pulmonary vastulaturc

^ - lung

Airways
Right ohliqiu fissure

- Skin

Subcutaneous fat -

Ascending aorta - Pulmonary artery

Esophagus

Chest wall skeletal struct tires -

( hest wall muscle

Sternal cortex

Sterna! marrow

Vertebral marrow
Vcrtebr.il cortex

(lop) Normal contrast-enhanced chest CT (lung window) allows evaluation of the lungs, pulmonary vasculature,
central tracheohronchial tree and pleura] surfaces. The mediastinum and chest wall are poorly evaluated in this
window setting. (Middle) Normal imenhanced chest CT (mediastinal window) allows evaluation of the soft tissue
structures of the mediastinum and the soft tissues and skeletal structures of the chest wall. The pulmonary
parenchyma, pleura and central tracheohronchial tree are not well evaluated. (Bottom) Normal contrast-enhanced
chest CT (bone window) allows optimal assessment of the skeletal structures with visualization of their cortices and
marrow spaces. Note improved skeletal visualization when compared to the mediastinal window image (previous
image). This window setting is also useful for evaluation of calcifications and metallic medical devices.
 CHEST OVERVIEW
i
E
UNENHANCED & CONTRAST-ENHANCED CT

<D
>
o
to
sz Pericardium —
O
■ •
■*■»
in i■ i i n , : i i . 1 . . : f a t —
0)
O — Heart

Right inferior -
pulmonary vein

Pulmonary arteries

— Interventricular septum

— Left ventricular
Right inferior ■ myocardium
pulmonary vein

-— Pulmonary arteries

(Top) l-irst of two normal chest CT images through the heart. Unenhanccd chest CT (mediastinal window) shows the
heart surrounded by epicardial fat and contained within the pericardium. The inferior pulmonary veins are visible
bilaterally. Note that individual cardiac chambers cannot be resolved. (Bottom) Contrast-enhanced chest CT
(mediastinal window) shows excellent visualization of the inferior pulmonary veins, pulmonary arteries and cardiac
chambers. The interventricular septum and the left ventricular myocardium are well demonstrated.

28
 CHEST OVERVIEW
SECTION THICKNESS & HIGH-RESOLUTION CT

Right upper lobe

bronchial branches — Left major fissure

Right major fissure

Right upper lobe Left major fissure

bronchial branches

(Top) Hrst of two images of a normal contrast-enhanced chest CT. Conventional chest CT (lung window) with 5 m m
slice thickness shows adequate visualization of the lung parenchyma, pulmonary vasculature and tracheobronchial
tree. The major fissures are visible as avascular bands coursing ohiiquely through the lungs. (Bottom) HRCT with 1.2
m m slice thickness at the same level as the previous image shows improved visualization of pulmonary detail. The
left major fissure is now seen as a distinct line. There is improved visualization of the bronchial walls and sharper
outlines of the pulmonary vessels.
 CHEST OVERVIEW
5 SUPINE & PRONE HRCT
91
'£
>
O
to
6
CD

Subpleural
ground-glass opacities

Normal lung bases

(lop) l-'irst ot two images of a normal HKCT in a patient with mild dyspnea. Supine HRCI" shows posterior subpleural
ground-glass opacity that is more prominent on the right. There is no architectural distortion or other abnormality,
(bottom) I'rone HKCT image shows complete clearance of basilar subpleural ground-glass opacities and confirms that
they related to dependent or supine atelectasis.

I
 CHEST OVERVIEW
INSPIRATORY & EXPIRATORY HRCT
o
©
ft
■ •

O
3-
CD

O
d
i
I
Minor fissure —

Normal lung
attenuation

Increased lung
Minor fissure attenuation on
expiratory imaging

(Top) First of two images from a normal HRC7T. Inspiratory high-resolution C r (coronal reconstruction) shows
normal homogeneous pulmonary attenuation. Note excellent visualization of vascular structures, central bronchi
and pleural surfaces. (Bottom) Expiratory HRCT (coronal reconstruction) at the same level as the previous image
shows elevation of the hemidiaphragms. decrease in lung volume a n d increased heterogeneous attenuation of the
lung parenchyma. Although lung attenuation is heterogeneous, there is n o evidence of air trapping. In this case, t h e
right lung apjiears slightly more lucent than the left on expiratory imaging.

I
n
 CHEST OVERVIEW
5 CT ANGIOGRAPHY, CORONAL & SAGITTAL RECONSTRUCTIONS

E
>
o
to
0)
O
Superior vena cava — Aortic arch

1
Pulmonary vasculaturc —
— Aortic valve

Right atrium — left ventricular

myocardium

Left main pulmonary

artery
Right main pulmonary —
artery

Pulmonary trunk — — Left atrium

Right ventricle —
— Descending aorta

(Top) First of two images from a normal CT angiogram of the chest. Coronal CT angiogram (mediastinal window)
allows visualization and evaluation of the cardiac chambers and the vascular lumens of the thoracic great vessels. CT
angtography also allows assessment of the peripheral pulmonary vasculature for exclusion of pulmonary
thromboembolic disease. (Bottom) Sagittal CT angiogram (mediastinal window) allows visualization of the
descending thoracic aorta and its branches. Note visualization of the right ventricle, the right ventricular outflow
tract, and the right and left main pulmonary arteries. Multiplanar reconstructions of CT angiogranis allow exquisite
visualization of the vascular lumens and cardiac chambers for evaluation of luminal enlargement, endoluminal
I thrombus or tumor, vascular disruption and congenital anomalies.
.32
 CHEST OVERVIEW
CT, VOLUME RENDERED TECHNIQUES

Superior pericardial
m reflection

" ?

Pulmonary vasculature

>~ <A Pericardium

f
< \
/

Left pulmonary artery

Descending aorta
Right inferior
pulmonary vein

(Top) First of two volume rendered CT images of the chest. The coronal volume rendered CT image of the anterior
chest shows the pulmonary vasculature and the superior extent of the pericardium. (Bottom) Posterior coronal
volume rendered CT image display allows distinction of pulmonary veins from pulmonary arteries and shows
portions of the descending thoracic aorta.
 CHEST OVERVIEW
AXIAL M R , CROSS-SECTIONAL I M A G I N G

Subcutaneous tat

— Anterior mediastinal
fat

Aortic arch
Superior vena cava —

— Spinal canal

Chest wall muscle

Internal mammary —
vessels

Ascending aorta —

— Pulmonary trunk

Superior vena cava

Left main pulmonary
artery

— Descending aoria
Thoracic vertebra —

(Top) Axial cardiac gated MR through the aortic arch shows excellent contrast resolution that allows evaluation of
mediastinal and chest wall structures. Note the distinction of the mediastinal and subcutaneous fat from adjacent
soft tissue structures. Visualization of the lungs is less optimal and is mildly compromised by motion. (Bottom) Axial
cardiac gated MR through the pulmonary trunk shows the value of MR in the evaluation of thoracic vascular
structures without tfie use of lodinated contrast. The internal mammary vessels are also demonstrated.
 CHEST OVERVIEW
C O R O N A L & SAGITTAL M R , CROSS-SECTIONAL I M A G I N G

Small axillary lymph

nodes

Superior aspect o f
pericardium

Right atrium —
i eft ventricular
myocardium

- Chest wall structures

I eft ventricular wall

Pericardium

(Top) C o r o n a l cardiac gated chest M R shows o u t s t a n d i n g i m a g i n g o f the m e d i a s t i n u m and d i a p h r a g m . N o t e the

excellent visualization of t h e cardiac chambers a n d ventricular m y o c a r d i u m . The pericardium is particularly well
visualized i n this case. ( B o t t o m ) Sagittal cardiac gated chest MR shows exquisite visualization o f soft tissue structures
in the chest w a l l . MR is used as a p r o b l e m solving m o d a l i t y for assessment o f mediastinal a n d chest wall t u m o r
invasion a n d is particularly useful for staging apical t u m o r s .
 CHEST OVERVIEW
CT EVALUATION OF APICAL LESIONS

Right apical mass -

Elevated right hemidiaphragm -

Centrilobular emphysema

Right apical mass

—
Absent tissue plane between
mass £* mediastinum

Right apical soft tissue mass

(Top) First of three images of a patient with a right apical non-small cell lung cancer. I'A chest radiograph shows the
right apical mass and elevation of the ipsilateral right hemidiaphragm. While this lesion can be better visualized with
apical lordotic radiography, CI" is the method of choice for the evaluation of thoracic malignancies. (Middle) Chest
CT (lung window) shows the right apical tumor and its spiculated lateral border. Note bilateral upper lobe
centrilobular emphysema. (Bottom) Chest (~T (mediastinal window) demonstrates the soft tissue mass with punctate
internal calcification. There is no tissue plane between the mass and the adjacent mediastinum, a finding that
suggests direct mediastinal involvement by the lesion. CT allows lesion localization and characterization and is used
for pre-operative staging of patients with lung cancer.
 CHEST OVERVIEW
CT EVALUATION OF SUBTLE KADIOGRAPHIC ABNORMALITIES

Subtle retrocardiac
lesion

— Left lower lobe mass

(Top) first of two images of an asymptomatic man with an incidentally discovered radiographic abnormality. I'A
chest radiograph shows a subtle left lower lobe retrocardiac opacity. (Bottom) Chest CI" (lung window) shows a left
lower lobe nodule which represented a primary lung adcnocarcinoma. CT allows accurate assessment of subtle
radiographic abnormalities, and may facilitate early diagnosis of primary malignancy as in this case.
 LUNG DEVELOPMENT
Ij General Concepts
Overview of Lung Development
• I <irynx and trachea
Origin of primitive larvnx from laryngotrachcal
groove
(formation of irachcnl hud and primitive trachea
Separation of primitive trachea from foregut and
developing esophagus
• Bronchi
I rat heal bud branches into two primitive bronchial
buds
Bronchial buds are precursors of bilateral main
bronchi
• I.ungs
Sequential branching of primitive bronchi
Formation of distinct pulmonary lubes
formation of clistim t pulmonary segments
• Distal airways and lung parenchyma
Interaction ol endodermal and mcsodcmial
elements allow normal lung development
Continued branching of primitive airways
Progressive vasculari/ation of surrounding
mcscnchymc
o Development ot al\eolar-capillary interface
o Postnatal airwav development and maturation
Concurrent Developmental Processes
• Pleural and diaphragmatic development
Developing lungs protrude into coelomic cavity
Separation of pleural and pericardial cavities
Diaphragmatic development
Pleural investment of lungs within bilateral
hemithoraces
• Vascular development
Pulmonary arterial development along developing
airwavs
Vasculogencsis within primitive mescruhyme to
lorm capillary network
Pulmonary vein and lymphatic development along
segmental boundaries
Developmental Stages
• Lmbryonic stage
• Pseudoglandiilar stage
• ( analicular stage
• Saccular stage
• \lveolar stage
^Embryonic Stage (26 Days-6 Weeks)
Laryngotracheal Groove
• Develops 26-28 days after fertilization
• Arises caudal to primitive pharvnx and fourth pair of
pharyngeal pouches
• Longitudinal growth
• I ndodermal derived structures
Iracheobronchial and pulmonary epithelium
Iracheobronchial glands
• Mesodermal derived structures
Iracheobronchial cartilage
Iracheobronchial connective tissue
Trai heobronchial smooth muscle
Respiratory Diverticulum or Lung Bud
• Develops four weeks alter fertilization
• Pouch-like outgrowth from caudal as|ieet of
larvngolracheal groov e
• Caudal growth
• Invested in mesodermal derived splanchnic
incsenchyme
Tracheal Bud
• Globular enlargement of distal lung bud
• Caudal growth from primordial pharynx
• Proximal communication with loregut through
primordial larvngeal inlet
Tracheoesophageal Septum
• I ongitudinal tracheoesophageal tolds form on either
side of developing tracheal bud
• Medial growth of bilateral tracheoesophageal folds
• formation of tracheoesophagciil septum from
midline fusion of tracheoesophageal folds
• Separation of primitive trachea from developing
esophagus
Primary Bronchial Buds and Branches
■ Branching ot primitive tracheal bud into right and left
branches (liftli week alter fertilization)
Right bronchial bud: 1 arger and verticallv oriented
I eft bronchial bud: Smaller and horizontallv
oriented
• Branching ot primary bronchial buds into two
primitive lobar bronchi
Right superior lobar bronchus: Right upper lobe
bronchus
Right inferior lobar bronchus: Primitive bronchus
inlermedius
■ Right middle lobe bronchus
■ Right lower lobe bronchus
I eft superior lobar bronchus: 1 ett upper lobe
bronchus
I ett inferior lobar bronchus: Lett lower lobe
bronchus
• Branching of primitive lobar bronchi into primitive
segmental bronchi
| Pseudoglandiilar Stage (6-16 Weeks)
Microscopic Morphology
• Gland-like appearance ol lung
• formation of tracheobronchial cartilages, mucus
glands and cilia bv thirteen weeks after fertilization
• Primitive airwavs lined bv endodermal derived
columnar epithelium
• Primitive airways surrounded bv mesodermal derived
mesenchymal tissue
• Absent alveolar-capillary interface
I m p o r t a n t Events
• formation of all major airwav elements
" Bronchial development complete to level ol
terminal bronchioles
 LUNG DEVELOPMENT
o
IT-
• All bronchopulmonary segments formed by seven • Formation of p r i m o r d i a l alveoli CD
weeks alter fertilization • Adjacent capillaries bulge into terminal saccules W

Physiologic Implications Important Events

■ Respiration not possible • Continued development of distal airwavs with
• No possibility of extrauterine sur\ i\ al primordial alveoli forming along respiratory
bronchioles and terminal saccules O
• Development ot t h i n alveolar-capillary m e m b r a n e CD
[Canalicular Stage (16-28 Weeks) <
Physiologic Implications
O
Microscopic Morphology • Presence of nearly mature alveolar-capillary interface
• Continued enlargement of primitive airwav lumens • Adequate surfactant production •a
• Continued thinning of airway epithelium • Respiration possible without external support 3
CD
• Lpithclial differentiation into type 1 a n d type 2 cells "3
• Airways separated by reduced but significant

J
mesenthvmal tissue I m p o r t a n t Factors for N o r m a l
Important Events Prenatal Lung D e v e l o p m e n t
• Continued vascularization of lung Volume Requirements
• Continued development of primitive airways
• Uiequate i n t r a t h o r a c i c v o l u m e required for normal
Terminal bronchioles give rise to two or more pulmonary development
respiratory bronchioles
• Factors predisposing to p u l m o n a r y hypoplasia
Respiratory bronchioles give rise lo .<-d alveolar
I n t r a t h o r a c i c masses and lesions producing mass
ducts effect
Development of .1 small number ol terminal
■ Pleural effusion
saccules
■ Space o c c u p y i n g thoracic congenital a n o m a l i e s
• I amellar inclusions within type 2 p n e u m o c y t e s in llioracic wall abnormalities
terminal saccules with potential lor surfactant
I Mrathoracic masses and lesions producing mass
production
effect
Physiologic Implications ■ Abdominal masses
• I imited surfactant production ■ Ascites
• Respiration is possible in late canaliculai stage h i t r a u t e r i n e v o l u m e reduction
• Possibility of neonatal survival with intensive care and ■ Oligoliydramnios
appropriate life support Circulatory Requirements
• Circulation affects pulmonary development
• Abnormal circulation may result in pulmonary
Saccular Stage (28-3b Weeks) hypoplasia
Microscopic Morphology
• Continued airway differentiation
• Continued thinning of airway epithelium Neonatal Lung
• Some capillaries abut and bulge into developing Clearance of Retained Fluid
alveoli
• External clearance
• Terminal sacs begin to approach the morphology of
Mouth
adult alveoli
Nasal cav ity
Important Events • Internal clearance
• Development ot increasing numbers of t e r m i n a l Ly mphatics
-saccules Capillaries
• Establishment Ol primitive alveolar-capillary First Breath
interface
• Diaphragmatic contraction
• Increased potential for surfactant p r o d u c t i o n
• Role of surfactant
Physiologic Implications •- Alveolar expansion results in surfactant discharge
• Respiration with adequate gas exchange is possible b\ tv pe 2 pneiimocytcs
• Survival of premature neonates with appropriate life Decreased surface tension of remaining
support intra-alveolar fluid
Increased surfactant activity with decreased surface
area
Prevention of alveolar collapse during expiration
Alveolar Stage (36 Weeks-8 Years) • Pulmonary vascular changes
Microscopic Morphology Fluid-filled lungs result in high resistance of
Continued thinning of epithelial lining of terminal pulmonary* circulation
sacs
 LUNG DEVELOPMENT
■ Small portion of cardiac output noes to lungs prior ■ Interruption of proximal trachc.il lumen
to birth < Foregut derived bronchi may communicate with
' Pulmonary expansion with first breath each other or arise directly from esophagus
■ Vascular vasodilatation • I sophagi al atresia and traeheoesophageal fistula
■ Increased pulmonary blood flow ^ A b n o r m a l course and a n o m a l o u s dorsal location
of t r a e h e o e s o p h a g e a l folds in early embryonic
Postnatal Lung Development development
• twenty four million t e r m i n a l sacs a n d alveoli ■ Interruption of primitive proximal esophagus
present at b i r t h compared to three h u n d r e d million o Traeheoesophageal fistula with communication
in a d u l l lungs between distal trachea and distal esoph.igeal
• Five-fold increase of alveolar numbers within first year segment
of life • l r a c h c o e s o p h a g e a l fistula
• Formation of 9 5 % of adult alveoli by 8 years of age Failure of c o m p l e t e midline fusion of
traeheoesophageal folds
-■ Abnormal communication between proximal
Disorders of Lung Immaturity trachea and esophagus
Transient Tachypnea of Newborn Abnormalities of Foregut Budding
■ Also known as relumed fetal l u n g fluid • Fxtralobar sequestration
• Neonatal respiratory distress in t e r m or prc-tcrm o Sujjcniumcrary foregut b u d induces primitive
infants mesenchyme to form lung parenchyma
• Imaging ■ Supernumerary lung tissue (sequestration)
i Normal volume develops in thorax, diaphragm or abdomen
Small pleur.il effusions ■ No communication with normal tracheobronchial
Increased interstitial opacities tree
i Resolution within o n e or two days D Neonatal respiratory distress from mass effect and/or
pulmonary hypoplasia
Respiratory Distress Syndrome Imaging
• Impaired capacity of type 2 p n e u m o e y t e s to replenish ■ Homogeneous soft tissue mass lypicallv located in
surfactant prior t o 16 weeks of gestation
left hemithorax
• Symptoms occur shortly after birth in premature ■ Systemic arterial supplv
infants
• Hronchogenic cyst
• Imaging
S u p e r n u m e r a r y o r a n o m a l o u s foregut b u d that
Low lung volumes does not induce development of lung parenchyma
' Opaque lung parenchyma with air bronchograms
■ Middle m e d i a s t i n a l mass in subcarinal location
Volume loss related to surfactant insufficiency
■ Unilociilar thin-walled cyst
• Ireatment
Symptomatic or asymptomatic older children and
( Prenatal steroids to accelerate lung maturation
young adults
Mechanical ventilatory support Imaging
■ Surfactant administration ■ Subcarinal middle mediastinal spherical mass
Nitric oxide gas ■ I'hin-walled cystic lesion with fluid characteristics
■ May exhibit soft tissue characteristics because of
character of fluid content
Disorders Related to
Tracheobronchial Morphology Abnormalities of Distal Airway Development
■ Bronchial atresia
Central Tracheobronchial Tree Foeal in-utero vascular c o m p r o m i s e of portion of
• Horizontal course of left main bronchus distal bronchial wall
• Vertical course of right main bronchus ■ Focal bronchial atresia
• Propensity for a s p i r a t i o n into right side ■ Near normal distal airway development
Oral secretions ' Asymptomatic adults
< Ingested material > Imaging
foreign bodies ■ Round, tubular or branching opacity representing
mucocole distal t o atretic airway
■ Surrounding hyperluoenl lung
[Developmental Disorders
Abnormal Tracheo-Esophageal
Development
• Iraehcal apldsia/agcncsis
o A b n o r m a l course and a n o m a l o u s v e n t r a l location
of t r a c b e o e s o p h a g e a l folds in early embryonic
development
 LUNG DEVELOPMENT
EARLY LUNG DEVELOPMENT

Primordial heart Branchial arches

1 rarheal bud (4-5

weeks) Respiratory
dlverticulum (4 weeks)

Primitive lung (5 6
weeks) Foregut denved
esophagus

+_m

It

Graphic shows the development of the primitive lung. The respiratory dlverticulum arises from the laryngotracheal
groove near the primordial esophagus caudal to the 4th pharyngeal pouches. The sequential evolution of the
respiratory diverticurum to the trachea! bud and the primitive lung is shown. Note the close relationship of the
developing tracheobronchial tree and lungs to the primitive esophagus.
 LUNG DEVELOPMENT
EMBRYONIC STAGE

Primitive mesenchyme
Plane of section
Tracheoesophageal fold

Trachea! bud Trachea! bud

Primitive airway epithelium
ttrf
i|^V

Plane of section Foregut

Tidcheoesophageal fold

Primitive trachea
Primary bronchial buds

Foregut VC;

W^m
■ 1*
Plane of section 1 Foregut

Mldllne fusion of
tracheoesophageal folds
Primitive trachea

Primary bronchial buds

Foregut
i■
(Top) Graphic shows the tracheal bud, a ventral outpouching of the foregut surrounded by mesodermal derived
mesenchyme and lined by endodermal derived epithelium. The axial plane of section (right) shows communication
between the tracheal bud and the foregut. The formation of bilateral longitudinal tracheoesophageal folds is shown.
(Middle) Graphic shows early branching of the tracheal bud into primary bronchial buds which will form the right
and left main bronchi. The longitudinal tracheoesophageal folds (right) continue to migrate medially to fuse in the
midline. (Bottom) Graphic shows further vertical development of the primary bronchial buds. Note that the right
bronchial bud is vertically oriented and the left follows a more horizontal course. The tracheoesophageal folds fuse in
the midline to separate the trachea from the esophagus.
 LUNG DEVELOPMENT
EMBRYONIC STAGE O
3"
a

C
13
Endodermal derived CQ
epithelium
O
CD
<
CD.
O
T3
3
CD
Mesodermal derived 3
mesenchyme

Primary bronchial buds

Foregut

Endodermal derived
epithelium
Left bronchial bud

Right bronchial bud

Mesodermal derived
mesenchyme

Foregut —

(Top) Graphic shows the development and morphology of the bronchial buds as they Invaginate into the primitive
mesenchyme. The bronchial buds are the precursors of the main bronchi and determine their anatomic orientation
in adulthood. (Bottom) Photomicrograph (Hematoxylin and Eosin stain) of a coronal section through the primitive
thorax of a 4 mm embryo shows the bronchial buds invaginating into the surrounding mesenchyme. The foregut is
located dorsal to the plane of section. Note that the right bronchial bud Is larger and courses in a more vertical
direction than the left bronchial bud. These structures are the precursors of the central tracheobronchial tree.
(Courtesy J. Thomas Stacker, MD, Uniformed Services University of the Health Sciences, Bethesda, MD).
I
43
 LUNG DEVELOPMENT
EMBRYONIC & PSEUDOGLANDULAR STAGES
c
CD
E
_o
CD Left superior bronchial bud
> Right superior bronchial bud

a Left inferior bronchial bud

c Right inferior bronchial bud

Primitive mesenchyrae
U Foregut

Left superior bronchial bud:

Right supenor bronchial bud: Right Left upper lobe bronchus
upper lobe bronchus

Right inferior bronchial bud: Left inferior bronchial bud: Left

Bronchus intermedius lower lobe bronchus

Primitive mesenchyme
Foregut

Right upper lobe

Left upper lobe

Right middle lobe

Right lower lobe Left lower lobe

(Top) Graphic shows the developing tracheobronchial tree at 28 days of gestation. The right and left bronchial buds
begin to divide into right and left superior and inferior bronchial buds. The developing tracheobronchial tree is
surrounded by primitive mesenchyme. (Middle) Graphic shows developing tracheobronchial tree at 42 days of
gestation with continued elongation and branching of the bronchial buds to form rudimentary lobar bronchi.
Further growth and branching of the distal primitive airway forms rudimentary segmental bronchi. The rudimentary
bronchus intermedius gives rise to primitive right middle and right lower lobe bronchi. (Bottom) Graphic shows
tracheobronchial development at 56 days of gestation with continued branching of the primitive airways. The
primitive mesenchyme surrounds the developing airways forming rudimentary lung lobes.
 LUNG DEVELOPMENT

Trachea

Left upper lobe

Right upper lobe bionchial branches
bronchial branches

V-

Right middle lobe

bronchial branches

Left lower lobe

Right lower lobe
4 bronchial branches
bronchial branches

Graphic shows tracheobronchial development at approximately 10 weeks of gestation. Note airway differentiation
into rudimentary lobax bronchial branches (shown in different colors) and segmental bronchial branches. Note that
the green and red bronchial branches represent different portions of the primitive left upper lobe. Recognizable lung
lobes are present. By the end of the pseudoglandular stage of lung development all major elements of the airways are
formed. The interaction between the primitive tracheobronchial tree and the surrounding primitive mesenchyme
induces the development of lung parench i
 LUNG DEVELOPMENT
PSEUDOCLA.VDULAK & CANALICULAR STAGES
c
E
CL
o
>
a XK«encbymal
C->t JioUve tlKue

CO
0)
.c
O

Air* ay epithelium
Capillaries

Developing airway

II -.M nchymal
cctii . live tissue

Airw ay eplthertum
Capillaries

DneIopl\<g airway

(Top) Graphic stows the primitive airway In the psoudoglind"lar si3ge of devei <pirn-Lt (6-16 weeks). The airways are
blind ending tubukc. Tlitre is no alveolar-capillary interface as conneefve tissue sepantes the thick-walied primitive
airway from the pulmonary c ipillarie*. R«<.pir itioa is not pa.jibl*'. (Bottom) Graphic sh-'MS the primitive airway in
the c.i.alioilar stage of ckvelopEw-.t (16-28 we*ics). T i e airway lum..n has ev Urged and the airway epithelium has
thinn-J. There is an increased n u " t e r of vessvis within the primitive mesv-nchyme a, .d s- .me of the ve.v.!s abut the
airway wall. Respiration is possible at the end of this stage of lung development, but these infants require intensive
care and support for survival.
I
4(>
 LUNG DEVELOPMENT

MLwnc'tymal
connective tissue

Airway epithelium

Developing airw.iy
Capltaries

Mcsenchymal
connective ti c

Ain*sy epithelium

Developing air* ay

Capillaries

(Top) Graphic shows the developing airway in the saccular stage of lung development (28-36 week«). The airway
lumen continues to enlarge. The lining epitheii am corr n iues to thin. More numerous c iplllaries abut the wall of the
primitive airway and some bulge into the airway lumen. The alveolar-capillary Interface continues to mature.
Respiration is possible and many infants born at this stage of pulmonary development survive with proper medical
management and support. (Bottom) Graphic shows the developing airway In the alveolar stage of pulmonary
development (36 weeks-8year«). The airway li»raen conHr ues to enlarge and there is Lss M rounding connective
tissue. The airway epithelium is thin and many capillaries bulge into the airway lumen establishing mature
alveolar-capillary interfaces. Airway development continues after birth and into childhood.
 LUNG DEVELOPMENT
PSEUDOGLANDULAR AND CANALICULAR STAGES

VL - ^ o
Q
«> % — Primordial airways

0' • •
-<£
FYmitKe mesenchyme
:_\ o
«<t <£>
^ £? o
fi£ >3 A CS^P w«

0 ,$
a*
t> ■0 (GH — Columnar eph helium

■<3.#'

5<

PrlmitiTe alrvnys
Primitive mesenci yme

Airway epithelium

(Top) Photomicrograph of fetal lU'.g (Hematoxylin and Ersln stain) at 10 weeks of ge- ta< on in the pseudoglandular
st !ge ot lung development shows the gland-like microiopic morphology of the l:ing. P i e primordial airways are
lined by columnar epithelium and svparcter! by a significant quantity of primitrve nvsenchytne. (Courusy J. Thomas
Stocker, MD, Uniformed Services Univenity of the Health Science?, Bethe<al->, MD). (Bottom) Photomicrograph of
fetal liJug (Hem tfoxylin and F*«in stain) at 24 weeks of gestation in the cmaliorfar st ige ot iung development shows
tiie enlarging airrv,iy IritQCdf. Some of the airway epithelium his thinned and there Is less Intervening prtralMve
mesenchyme. (Courtesy J. Thomas Stocker, MD, Uniformed Services University of the Health Sciences, Bethesda,
MD).
 LUNG DEVELOPMENT
ALVEOLAR STAGE

v
r~\
!s> <-\- Alveolar-capillary
interface

Capillary network

Photomicrograph (Hematoxylin and Eosln stain) of normal lung at 38 weeks of gestation in the alveolar stage of lung
development demonstrates formation of adult-like alveoli and alveolar-capillary interfaces that allow the process of
respiration. (Courtesy J. Thomas Stocker, MD, Uniformed Services University of the Health Sciences, Bethesda, MD).
 LUNG DEVELOPMENT
N O R M A L PREMATURE LUNG

Normal —
cardiomediastinal
silhouette

— Normal lung

Mildly symptomatic premature infant born at 33 weeks of gestation. AP chest radiograph shows normal lung
volumes and a normal cardiomediastinal silhouette. The patient responded to conservative management and
required no further imaging.
 LUNG DEVELOPMENT
IMMATURE LUNG, TRANSIENT TACHYPNEA OF NEWBORN

bndotracheal tube tip

Small right pleural -

effusion Small left
pneumothorax

Deep sulcus sign

UVC tip

(Top) First of two radiographs of a term infant with retained fetal fluid who presented with tachypnea and
respiratory distress at birth. AP chest radiograph shows coarse linear opacities in the perihilar regions and a small
right pleural effusion. A small left pneumothorax manifests with a subtle pleural line and a deep sulcus sign. The
endotracheal tube is appropriately ix>sitioned. The tip of the umbilical vein catheter (UVO is visualized. (Bottom) AP
chest radiograph obtained 48 hours later shows that the patient has been extubated. The lungs are clear and have
normal volume. The pleural effusion and pneumothorax have resolved. The findings are consistent with retained
fetal fluid or transient tachypnea of the newborn. While the etiology of this condition is not completely understood,
lung immaturity is thought to play a role in its pathogenesis.
 LUNG DEVELOPMENT
IMMATURE LUNG, RESPIRATORY DISTRESS SYNDROME

— Endotracheal tube tip

Monitoring device —I

Air bronchograms —
Oranular appearance of
lungs

— Persistent granular
Left PIC C tip opacities with
improved lung volume

— Ort>gastric tube tip

(Top) First of two portable chest radiographs of a pie-term infant born at 26 weeks of gestation who developed
respiratory distress syndrome. AP chest radiograph shows a granular appearance of the lungs and air bronchograms.
The pulmonary opacities result from a combination of atelectasis and retained fluid. There is no pleural effusion. The
endotracheal tube is appropriately positioned. (Bottom) AP chest radiograph at ten days of age shows that the
patient has been extuhated. The lung volumes have improved with residual granular appearance An orogastric tube
and a peripherally inserted central catheter (PICO are noted. Approximately 60-80% of prc-tcrm infants born before
28 weeks of gestation develop respiratory distress syndrome.
 LUNG DEVELOPMENT
MORPHOLOGY & ORIENTATION OF MAIN BRONCHI

^^^
■T*W
tffe*

■fc^

>«^«
BES^^I » — ■ ^ »

^ c >^o^> " * - ^ Y

^KSJSN

Primitive left main

bronchus
Primitive right main
bronchus

SISS
*

S8
H'^_

Graphic shows the morphology and orientation of the central airways at 28 days of gestation. Note that the
primordial right main bronchus is more vertically oriented and larger than the left. As a result, the right lung is more
susceptible to aspiration of foreign bodies and secretions.

V ^
 LUNG DEVELOPMENT
BRONCHIAL ORIENTATION, ASPIRATED MOLAR IN THE BRONCHUS INTERMEDIUS

Hndotracheal tube

Chest tube

Chest tube

Aspirated tooth

Trauma board artifact

— Nasogastric tube

Aspirated molar — Lett chest tube

Right chesl tube

Left lower lobe
atelectasis

(lop) hirst of two images of a patient who was involved in a motor vehicle collision and aspirated a dislodged molar
AP portable chest radiograph demonstrates a molar within the bronchus intermedius. Note bilateral chest tubes,
appropriately positioned life support devices and trauma board artifacts. The vertical orientation of the right main
bronchus makes it susceptible to aspiration of foreign bodies and secretions. (Bottom) Contrast-enhanced chest CT
(mediastinal window) demonstrates a dense round calcification in the lumen of the bronchus intermedius
representing the aspirated molar. Bilateral chest tubes and a nasogastric tube are also present. Note atelectasis of the
left lower lobe. (Courtesy Diane C Strollo, MD, University of Pittsburgh, Pittsburgh, PA).
 LUNG DEVELOPMENT
EMBRYONIC STAGE, TRACHEOESOPHAGEAL FISTULA & ESOPHAGEAL ATRESIA

Esophageal catheter

Trachea —

Tracheoesophageal
tistula

Esophagus

—
Contrast in atretic
proximal esophagus

Gastric air

(Top) Esophagram of a young infant with congenital tracheoesophageal fistula that manifested with recurrent
pulmonary infection. A catheter cannulates the proximal esophagus for administration of contrast. Note the
abnormal communication between the anterior esophagus and the posterior trachea (tracheoesophageal fistula). The
fistula is thought to result from partial failure of midline fusion of the tracheoesophageal folds. (Bottom)
Esophagram of a neonate with esophageal atresia shows contrast in the atretic proximal esophageal pouch. A
tracheoesophageal fistula is not visible but its presence is inferred from visualization of gastric air. This anomaly is
thought to result from abnormal dorsal location of the tracheoesophageal folds which interrupt the esophageal
lumen and fail to properly divide the trachea from the esophagus.
 LUNG DEVELOPMENT
EMBRYONIC STAGE, TRACHEAL ATRESIA

Esnphagcal catheter —

— Esophagus

— Left main bronchus

Right bronchi —

AP post mortem radiograph of an infant with tracheal atresia. Contrast is administered via an cndoiuminal catheter
and opacifies the esophagus and anomalous right and left bronchi that arise from its lateral walls. This anomaly is
thought to result from abnormal ventral location of the tracheoesophageal folds which interrupt the lumen of the
developing trachea. Because the bronchi originate as foregut derived structures, they maintain their primitive
communication with the esophagus.
 LUNG DEVELOPMENT
EMBRYONIC STAGE, EXTRALOBAR SEQUESTRATION

[%.

, ■ - "

k^^S

■
Right bronchial bud

Anomalous foregut
bud

?*Z*W **.--^
Foregut
Primitive
mesenchyme

>>£-<

- ' ■ ■ ■ - ■ "

^ «o«
X
i ^ .

Graphic shows the proposed pathogenesis of extralobar sequestration. An anomalous supernumerary bud from the
primitive foregut comes in contact with the surrounding primitive mesenchyme and induces the development of
lung parenchyma. In most cases of extralobar sequestration the original connection with the foregut involutes
resulting in "sequestered" but otherwise normal lung tissue that has a systemic blood supply.
 LUNG DEVELOPMENT
EMBRYONIC STAGE, EXTRALOBAR SEQUESTRATION

— Extralobar
sequestration
Hypoplastic lung & —
mediastinum

Inverted
hemidiaphragm

— Soft tissue edema

Hypoplastic left lung

Large left hydrothorax

Heart

Hypoplastic right lung

(Top) First of two post mortem MR images of an infant with extralobar sequestration. Coronal Tl MR shows the
sequestered lung in the left hemithorax. A large left pleural effusion and a smaller right pleural effusion are also
noted. There is severe pulmonary hypoplasia with most of the lung and the mediastinum located within the right
hemithorax. Note inversion of the left hemidiaphragm by the large hydrothorax. Abdominal ascites and edema of
the soft tissues of the chest wall are consistent with fetal hydrops. (Bottom) Axial T) MR shows the large left
hydrothorax and severe pulmonary hypoplasia. Severe soft tissue edema is again noted. Normal lung development
requires adequate intrathoracic volume. In this case, mass effect from the large extralobar sequestration and
hydrothorax interfered with normal lung development and resulted in pulmonary hypoplasia.
 LUNG DEVELOPMENT
EMBRYONIC STAGE, BRONCHOGENIC CYST

Right bronchial bud

Anomalous foregut
bud

k )

No contact with
primitive
mesenchyme

Foregut

Graphic shows the proposed pathogenesls of bronchogenic cyst. An anomalous supernumerary bud from the
primitive foregut does not come in contact with the surrounding primitive mesenchyme and fails to induce the
formation of lung parenchyma. The original communication with the foregut typically involutes resulting in a blind
ending pouch or cyst. Because the anomalous bud develops in the same way as the primitive central airways, Its wall
contains bronchial components, hence the term "bronchogenic".
 LUNG DEVELOPMENT
E M B R Y O N I C STAGE, B R O N C H O G E N I C CYST

Bronchus intcmiedius

Thin enhancing cyst

wall

— Mass effect on left

atrium

Water attenuation -
contents

(Top) First of two axial CT images of a young man with a middle mcdiastinal (subcarinal) bronchogenic cyst.
Contrast-enhanced chest CT (mcdiastinal window) at the level of the carina demonstrates a thin-walled spherical
cyst with water attenuation contents in the subcarinal region. The cyst produces mass effect on the right pulmonary
artery and the bronchus intermedius. (Bottom) Contrast-enhanced chest CT (medtastinal window) at the level of the
left atrium shows the spherical subcarinal cystic lesion with nonenhancing water attenuation contents and a thin
enhancing wall. The lesion produces mass effect on the left atrium. The morphology and location of the lesion are
characteristic of bronchogenic cyst.
 LUNG DEVELOPMENT
PSEUDOGLANDULAR STAGE, BRONCHIAL ATRESIA

Distal airway
enlargement

Bronchial atieala

Blind ending atretic

airway

Mucocele

Graphic shows the proposed pathogenesis of bronchial atresia. This anomaly probably develops during the
pseudoglandulai stage of lung development when all the elements of the tracheobronchial tree are present and is
thought to result from compromise of the blood supply to a small length of the airway wall. The atretic bronchus
ends blindly at the point of atresia. The distal airway Is not Immediately affected but Its seaetlons cannot be cleared.
With time a mucus plug or mucocele develops and enlarges the airway lumen. After birth, air trapping occurs distally
around the mucocele resulting in hyperlucent lung parenchyma.
 LUNG DEVELOPMENT
PSEUDOGLANDULAR STAGE, BRONCHIAL ATRESIA
o
3"

C
Zi
CO
o
CD
i.
o
■o
3
CD
=3

Branching rounded
opacities

Surrounding
hyperlucent lung
parenchyma

Branching mucocele -

(Top) First of two axial CT images of an asymptomatic young man with bronchial atresia. Contrast-enhanced chest
CT (lung window) demonstrates branching rounded opacities located centrally in the right lower lobe and
surrounded by hyperlucent lung parenchyma. Air distal to the bronchial airesia and around the mucocele is thought
to reach the distal lung via collateral air drift. (Bottom) This image shows that the branching opacities exhibit
intrinsic low attenuation and do not enhance with contrast. The branching opacities represent the mucocele that
develops distal to the point of atresia. The findings are diagnostic of bronchial atresia.

63
 AIRWAY STRUCTURE
• Structure
[General Anatomy and Function ■ No alveoli iti airwav walls
Airways ■ No gas exchanging epithelium
• Tubular, pipe-like structures • Transitional / o n e
• Conduct air through thtfir lumens o Function
• \natomic c o m p o n e n t s (proximal to distal) ■ Air conduction
Trachea ■ Respiration
Bronchi Components
Bronchioles ■ Respiratory b r o n c h i o l e s
Terminal bronchioles ■ Alveolar d u c t s
Respiratory bronchioles Branching pattern
Alveolar ducts ■ Dichotomous
o Alveolar sacs ■ Symmetric
Alveoli ■ Frequently t r i c h o t o m o u s or ciuadrivial
Structure
Airway Branches ■ Airway walls contain alveoli
• Mrway generations ■ Enable gas exchange
i 2.i generations of dichotomous branching beyond • Respiratory / o n e
trachea! carina Function
2-12 generations (typically b-8) between terminal ■ Respiration only
bronchioles and alveolar sacs ■ Gas exchange
4-29 (typical!) 10) alveoli per alveolar sac Components
• Mrway types ■ Alveoli
Bronchi ■ Alveolar sacs
■ larger than I m m in diameter Branching pattern
■ I'aper and branch ■ Dichotomous
■ Give rise to non-cartilaginous bronchioles Structure
Bronchioles ■ Thin walls
» 1 m m or less in diameter ■ Contact with capillary membrane
■ Most distal bronchiole lined by respiratory
epithelium is terminal bronchiole
Terminal b r o n c h i o l e s Airway Structure
■ Most distal conducting airway
■ Ciivfi rise to appro\imatcl\ three generations of Trachea
respirators bronchioles • Connects larynx to main bronchi
Respiratory bronchioles • Microscopic a n a t o m y
■ Imreasing numbers of alveoli extend from their Epithelium
walls ■ I'sctidostratilicd ciliated c o l u m n a r epithelium
■ (.iive rise to three generations of alveolar ducts ■ Goblet cells
Mveolar d u c t s Submucosal structures
■ Series of alveoli adjacent t o one another ■ Submucosal seromucinous glands
■ Terminate in alveolar sacs Mural horseshoe-shaped incomplete cartilage rings
Alveolar sacs (16-20)
• Croups or clusters ot most distal alveoli Posterior membranous portion with transverse
o Alveoli s m o o t h muse le b u n d l e s
• Functional anatomv
Airway Function ( i l i a propel mucus to laryngeal inlet
• Air conduction through airway lumens Submucosal s e r o m u c i n o u s g l a n d s secrete water,
• Exchange ot gas l>etwecn inspired air and blood electrolytes and iiuicin into airwav lumen
Delivery ol oxygen t o alveoli
Delivery of carbon dioxide to atmosphere Bronchi
• Connect trachea to muscular bronchioles
Functional and Structural Airway Zones • Microscopic anatomy
• Conducting zone 1 pilhclhim
Function ■ Pseudnstratified ciliated c o l u m n a r epithelium
■ Mr conduction only ■ Goblet cells
(. o m p o n e n t s < Submucosal structures
■ Trachea ■ Seromucinous glands
■ Bronchi ■ Smooth muscle bundles
■ Bronchioles Crescent-shaped masses of cartilage
Branching pattern
■ DieImtomous: 1'arent airway divides into two
Muscular Bronchioles
■ Asymmetric: Variable diameter • less than 1 mm in diameter
• Microscopic a n a t o m v
 AIRWAY STRUCTURE
i Fpithclium Respiratorv bronchioles
■ Pscudostratified ciliated columnar epithelium Alveolar ducts
transitions t o ciliated cuhoidal e p i t h e l i u m Alveolar sacs
Submucusal structures Alveoli
■ Spirally arranged smooth muscle Accompanying vessels and connective tissue
■ Connective tissue • Pulmonary functional unit of gas exchange
Absence of cartilage • Acinar diameter of 6-10 m m
• 2.S.000 acini in a lung volume of 5.25 L
Terminal Bronchioles
• Last conducting bronchioles Secondary Pulmonary Lobule
• Thin walls, decreased diameter • Smallest discrete unit of lung surrounded In
• Microscopic anatoim connective tissue a n d interlobular septa
I ined with ciliated c o l u m n a r t o cuhoidal • Structure
epithelium Supplied by lobular bronchiole: A pre-terminal
No goblet cells bronchiole that gives rise to
Smooth muscle and connective tissue in walls " Smaller pre-terminal bronchioles
■ terminal bronchioles
Respiratory Bronchioles ■ Respiratory bronchioles
• Between terminal bronchioles and alveolar ducts Supplied bv lobular arterv and branches
• Microscopic anatomv c Margmated by interlobular septa containing
Lined with ciliated simple cuhoidal epithelium pulmonary veins and lymphatics
I non-ciliated in distal portions; • Morphology
Smooth muscle and connective tissue in walls Irregularly polyhedral shape
Walls interrupted by delicate air pockets (alveoli) c 1.0-2.5 cm in diameter
Alveolar Ducts
• Between respiratory bronchioles and proximal
alveoli/alveolar sacs | Collateral Channels ~~|
• Straight tubular spaces bounded entirely bv alveoli Alveolar Pores (Pores of Kohn)
• Microscopic anatomy • Round or oval fenestrations
Rands of smooth muscle in walls distinguish them
• Measure approximately 2-10 microns
from alveoli
• Allow communication between adjacent alveoli
Alveoli and Alveolar Sacs Canals of L a m b e r t
• Small, cup-shaped structures
• Direct communication between alveoli and
Outpouchings ot respiratory bronchioles, alveolar
respiratory, terminal and pre-terminal bronchioles
ducts, alveolar sacs
• function
Demarcated by thin walls (septa)
i May provide only intra-acinar accessory
■ Adult lungs contain approximately .MM) million
alveoli communication
c May provide inter-acinar communication facilitating
• Microscopic anatomy of alveolar septa
collateral ventilation
Continuous flattened scjuamous epithelium
■ Type I epithelial cells (squamous pneumocvt.es)
cover 9 3 % of alveolar surface
■ Type 2 cells (rounded nuclei) produce surfactant
Imaging-Anatomic Correlations
Vlveolar macrophages Trachea
■ Intra-alveolar migratorv cells • Posterior wall configuration on C I indicates phase ot
■ Participate in lung defense mechanisms respiration
Overlving capillaries Bows outward during suspended inspiration
Intervening interstitial tissue flattens and bows inward during expiration

!
Bronchi/Bronchioles
[Fundamental Units of Lung Structure • Bronchi < 2 m m in diameter not normally visible on
HRCr
Primary Pulmonary Lobule • Bronchioles rarely visible within I cm of pleural
• All alveolar ducts, alveolar sacs, and alveoli distal to surface on HRCT
the last respiratory bronchiole
Includes blood vessels, nerves and connective tissue Secondary P u l m o n a r y Lobule
20-25 million p r i m a r y p u l m o n a r y lohules in • Not generally visible in normal individuals
human lungs • Most developed and most apparent in lung periphery
• No clinical or imaging significance • Interlobular septa at lower limits of thin-section CT
resolution
Acinus Subpleural septa are approximately 0.1 m m thick
• Portion of lung distal to t e r m i n a l bronchiole i n c l u d i n g
 AIRWAY STRUCTURE
Most often seen in apices, anteriorlv and near <■ Foci i.J-10 mm) of centrilobular low attenuation
mediastinal pleura ( I ow attenuation surrounding centrilobular artery
c I ocation may lie inferred by identification of septal Imperceptible walls
veins • Pathologic correlation
• Lobular bronchioles at lower limits of thin-section ( I C e n t r i l o b u l a r ( p r o x i m a l a c i n a r . centriacirrar)
resolution emphysema
o Not normallv \isible ■ Involves proximal acinus
c lobular bronchiole measures approximatelv I mm ■ Distention and destruction of respiratory
in diameter bronchioles
Visibility correlates with wall thickness (0.15 mm) ■ Fnlarged airspace in central acinus with relatively
< location may be inferred by identification of normal distal acinus
centrilobular arterv ( Most severe involvement of up|»er lobes and
superior segments of lower IOIK-S
Acinus
• Normal acini are not visible on imaging Lobular l o w Attenuation: Panlobular
• Experimental tilling of a single acinus results in a Emphysema
rosette appearance and progresses t o a spherical • C1 features
opacity < Diffuse extensive areas of low attenuation
\cinar/airspjce nodule Reduced size of pulmonarv vessels
• Pathologic correlation
P a n l o b u l a r (panaclnar) e m p h y s e m a
Anatomic Distribution of Selected ■ Affects entire acinus and all acini in secondary
Diseases pulmonary lobule
■ Diffuse or lower lobe predominance
Centrilobular Nodules: Infectious ■ Association with cx-1-antitrypsin deficiency
Bronchiolitis Lobular Low Attenuation: Paraseptal
• ( 1 features
Small nodules Emphysema
■ Variable attenuation • ( I features
■ Size range from a few m m to 1 cm luvtapleural cystic areas near interlobular septa.
c Centrilobular location large vessels and bronchi
■ Situated 5-10 m m from plcural surface Frequent association with centrilobular emphysema
• Pathologic correlation • Pathologic correlation
I n f l a m m a t o r y (cellular) b r o n c h i o l i t i s Affects periphery of pulmonary acinus and
■ Inflammation/infiltration of centrilobular subpleural secondary pulmonary lobules
bronchioles I nlarged alveolar ducts
■ Involvement of surrounding interstitium and i Predominant upper lobe involvement
Association with bullous disease
alveoli
Ltiologies: bacterial, mvcobaclerial. fungal a n d Lobular Low Attenuation: Constrictive
viral inlci lions
Bronchiolitis
Tree-in-Bud Opacities: Small Airways • CT features
Infection Mosaic attenuation; mosaic perfusion
• CT features Patchy distribution
Peripheral linear branching Air-trapping on expiratory Cl
Associated centrilobular nodules • Pathologic correlation
■ Variable attenuation < Concentric narrowing of membranous bronchioles
■ Clustering of nodules by tibrosis with resultant air flow obstruction
■ Situated several nun from pleural surface ■ Air-trapping
■ Findings resemble the appearance of a trcc-ln-bud ■ Mosaic a t t e n u a t i o n 'perfusion
• Pathologic correlation Acinar Nodules: Infection
Small airways infection
• CT features
a Dilated centrilobular bronchioles
i ft-10 m m fluffy nodular opacities
■ Pilling ol broncbiolar lumens with inflammatory
• Pathologic correlation
fluid/cells
i Inflammation of terminal a n d respirators
Peribronchiolar inflammation
bronchioles
Ftiologies: Mvcobaclerial infection,
Sparing of distal air spaces
h r o n c b o p n e u m o n i a , infectious b r o n c h i o l i t i s
Airway dissemination of infection
Centrilobular Low Attenuation: ■ luberculosis
■ Early varicella p n e u m o n i a
Centrilobular Emphysema
• CT features
 AIRWAY STRUCTURE
OVERVIEW OF AIRWAY STRUCTURE

fw

Secondary pulmonary
lobules Airway generations

Alveolar sacs & alveoli

Terminal bronchiole

Alveolar duct
Respiratory bronchiole

Graphic representation of 24 airway generations branching dlchotomously from the trachea to the most distal
airways that comprise the secondary pulmonary lobule (SPL). The SPL Is the smallest unit of lung surrounded by
connective tissue septa and has a polyhedral shape. Each SPL contains the distal branches of a lobular bronchiole and
its accompanying pulmonary (lobular) artery. The acinus is comprised of the airways distal to a terminal bronchiole
with each SPL containing twelve or fewer acini. The terminal bronchiole gives rise to two or three respiratory
bronchioles which in turn give rise to three alveolar ducts each terminating In alveolar sacs and alveoli. The
respiratory bronchiole is characterized by its alveolated wall. The alveolar duct wall Is covered with alveoli. The
alveolar sacs terminate in clustered alveoli.
 AIRWAY STRUCTURE
CD BRONCHI, BRONCHIOLES & ACINI
i_

CO
>%
CO

O Large airways

Medium airways

Small airways
(bronchioles)

Acinus: Structures
distal to a terminal
bronchiole

Graphic telescoping depiction of an airway illustrating the decreasing size of the different airway types and the
structural changes of the airway wall with a decreasing number and size of cartilage plates. Cartilage plates are
present in large and medium-size airways but gradually become smaller and less numerous in the medium bronchi.
The walls of small airways (bronchioles) do not contain cartilage. Distal clusters of alveoli and alveolar sacs form
acini, the pulmonary functional unit of gas exchange. The acinus is denned as the airways, vessels and supporting
structures distal to a terminal bronchiole.

I
(i8
 AIRWAY STRUCTURE
MICROSCOPIC STRUCTURE OF THE TRACHEA, BRONCHI & BRONCHIOLES

Respiratory epithelium
Goblet cell

II
Basement membrane
Connective tissue

Smooth muscle
bundles

Cartilage
Seromudnous gland

Respiratory epithelium
Goblet cells

Smooth muscle

Connective tissue

(Top) Graphic shows the microscopic structure of the large cartilaginous airways. These airways are lined by
pseudostratified ciliated columnar (respiratory) epithelium that rests on a basement membrane. The dlia participate
in the mucoclliary escalator that pushes overlying mucin in a cephaiad direction and provides clearance of seaetions
and particulate matter. Submucosal loose connective tissue beneath the basement membrane contains smooth
muscle bundles and seromudnous glands. Cartilage plates are found beneath the submucosal layer. (Bottom)
Graphic shows the microscopic structure of the bronchioles which are lined by respiratory epithelium. Goblet cells
contribute to airway mucus production and are interspersed between columnar ciliated cells. Smooth muscle bundles
are spirally arranged in the submucosa. There are no cartilage plates or bronchial glands.
 AIRWAY STRUCTURE
CT IMAGING ANATOMY OF THE LARGE AIRWAYS

Trachea

Right upper lobe — Left main bronchus

bronchus

Right main bronchus

(Top) First of four normal CT images of the large airways. The trachea is the largest conducting airway. Its thin wall is
supported by anterolateral "C"-shaped cartilages with a posterior membranous portion. The cartilaginous rings
contribute to t h e round morphology exhibited by the trachea during inspiration. (Bottom) Right and left main
bronchi arise from the trachea at the tracheal carina. The main bronchi give rise t o lobar bronchi.
 AIRWAY STRUCTURE
CT I M A G I N G A N A T O M Y O F T H E LARGE AIRWAYS

— Left lower lobe

bronchus

Bronchus imermedlus —

Segments! bronchi
Segmental bronchi

(Top) The right main bronchus gives rise to the right upper lobe bronchus and the bronchus intermedius. The left
main bronchus gives rise to left upper and left lower lone bronchi, (Bottom) I ach lobar bronchus gives rise to
segmental bronchi which in turn continue to branch into bronchioles. The smallest normally visible airways are
bronchioles. The small airways distal to the muscular bronchioles are not visible with current imaging modalities.
 AIRWAY STRUCTURE
INSPIRATORY HRCT, LARGE AIRWAY MORPHOLOGY

— Trachea

Main bronchi

Main bronchi

— Lobar bronchi
Bronchus intcrmcdius

First of two normal I IRCT sequences that show changes in large airway morphology with the phase of respiration.
Inspiratory HRCf shows the round shape of the large airways during inspiration. The cartilage plates provide support
to the anterolateral airway walls and contribute to the morphologic features of the normal airways.
 AIRWAY STRUCTURE
EXPIRATORY HRCT, LARGE AIRWAY MORPHOLOGY

Trachea

— Main bronchi

— Lobar bronchus

Bronchus intermedius —

Expiratory HRCT shows the altered large airway morphology during expiration. The "C"-shaped trachea! cartilages
support the anterolatcral airway wall during expiration Because there is no cartilage in the posterior membranous
tracheal wall, it becomes convex towards the airway lumen. Similar findings are noted in the main bronchi and
bronchus intermedius; their posterior walls appear flat during expiration. These morphologic changes in the large
airways permit differentiation between inspiratory and expiratory CT images.
 AIRWAY STRUCTURE
RADIOGRAPHY, LARGE AIRWAY CARTILAGE CALCIFICATION

Calcified tracheal —
cartilages

Calcified bronchial
cartilages

Calcified tracheal —
cartilages

(Top) first of four images of an elderly patient with normal tracheal calcification. Coned down PA chest radiograph
shows calcified tracheal and bronchial cartilages manifesting as thin white lines along the airway walls. (Bottom)
Coned down lateral chest radiograph shows calcification of the tracheal wall manifesting as a thin white line that is
best seen along the anterior tracheal wall. The corrugated appearance of the calcification likely relates to the
discontinuous nature of the individual "C"-shaped tracheal cartilages along the length of the airway.
 AIRWAY STRUCTURE
CT, LARGE AIRWAY CARTILAGE C A L C I F I C A T I O N

— Calcified trachcal
cartilages

Calcified bronchial —
cartilages

(lop) Contrast-enhanced chest CT (mediastinal window) coned-down to the mediastinum shows calcification of
individual tracheal cartilages. (Bottom) Contrast-enhanced chest CT (mediastinal window) coned-down to the
mediastinum shows calcification of individual hronchial cartilages. An axial image just below the tracheal Carina
shows calcified cartilages in the main bronchi. Calcification of tracheal and bronchial cartilages may occur normally
in elderly individuals, enhance visualization of the airway wall on radiography, and allow identification of individual
calcified cartilages on CT.
 AIRWAY STRUCTURE
SMALL AIRWAY STRUCTURE & THE SECONDARY PULMONARY LOBULE

Lobular bronchiole
Terminal bronchiole

Canal of Lambert

Respiratory bronchiole
Pores of Kohn

Alveolar ducts

M M

Graphic shows the structure of a portion of a pulmonary acinus within the secondary pulmonary lobule. The acinus
is comprised of the structures distal to a terminal bronchiole. The terminal bronchiole is the last conducting airway
and gives rise to two or more respiratory bronchioles, which are transitional airways characterized by their alveolated
walls. Each respiratory bronchiole gives rise to three alveolar ducts which are airways lined by alveoli. Alveolar ducts
terminate in alveolar sacs and alveoli. Pores of Kohn provide communication between adjacent alveoli. Canals of
Lambert provide communication between various airways within an acinus as well as between adjacent acini and
facilitate collateral ventilation.
 AIRWAY STRUCTURE

Alveoli

Alveoli

Terminal bronchiole

Respiratory bronchiole

Alveolar duct

High-power photomicrograph (Hematoxylin and Eosin stain) shows the microscopic structure of the small airways.
The terminal bronchiole is the last purely conducting airway and gives rise to respiratory bronchioles which are
characterized by their partially alveolated walls. The alveolar duct is a tubular space lined by alveoli.
 AIRWAY STRUCTURE
MICROSCOPIC SiRUCTURE OF THE ALVEOLI

Al\t.i»s
Tight cell junction

Type 1 prvjmocyfcs

CapUlaiit s

Alveolar m- -Qphage

Graphic s h a m the microu'opk' '.tructuje of the al*eol'. T ie ab-eoUr-capillary intefa.-e!' the principal site of
revpiration wlvre the aive- il c« -i . in c r tact with the rich capillary n-twork of the lung, Inspired ■ xyge. is
deliver^ to the capillaries *iid cart- -n d t o t t k is delivered to the al; Kay. T">e type 1 pncu- rxyte Is i flat ctll with
tight c-fl jun lions that lines the ahci lai surface. Tue tight cell junctions p i e w i t permeibility at fluid into tlie
alveolar spate. The type 2 pnrunr-cyte i«. a larger poJygonal cell that pK*hiccfl *i« factant and pxa ev*-« Jrcuiatinjg
vasoactive substances. The alveolar macrophage is a migratory cell that forms part of the defense mechanisms of the
lung.
 AIRWAY STRUCTURE

Aiveoli

CaplliarU »

Alveolar capillary
Interface

High-power photout'urograph (HeirMtoxylin an<! Fosln stain) shows the microscopic structure of rt,e alveoli. The fiat
thin mtute of the alveour prioiwnocyU s facilitate gas exvfi vige with a^la* ent c.tpill me< n tbe alveolar c 'pllliry
interface. The three hundred million alveoli in human lungs provide an enormous suiface area (70 meters squared)
for gas exchange.
 AIRWAY STRUCTURE
TREE-IN-BUD

Buds correspond to
pertbronchlolar
Leafless tree branches Inf .":u;:^3tory tissue

7
•J
correspond to dilated
bronchioles

i>

Photograph of a leafless tree-in-bud illustrates the origin of the term "tree-in-bud" opacities used to describe the CT
findings of cellular bronchlolitls. The small tree branches correspond to dilated centrilobular bronchioles filled with
inflammatory cells and/or fluid on HRCT; the round buds correspond to peribronchiolar inflammatory tissue.
Photograph by Gerald F. Abbott, MD
 AIRWAY STRUCTURE
TREE-IN-BUD OPACITIES, INFECTIOUS BRONCHIOLITIS

Tree-in-bud opacities

Tree-in-bud opacities -

■— Acinar nodular
opacities

(lop) Coned down HRCT of an immune compromised patient with tuberculosis shows multifocal tree-in-bud
opacities (short linear opacities with terminal nodular opacities). This finding is a direct sign of hronchiolitis that
results from thickening and filling of the lumens of terminal bronchioles with associated cellular infiltration and
inflammation of the surrounding distal airways. (Bottom) Coned down thin-section chest CT of a patient with
bronchopneumonia shows exuberant tree-in-bud opacities that form earlv acinar nodules in the right lower lobe.
 AIRWAY STRUCTURE
CENTRILOBULAR & PANLOBULAR LOW ATTENUATION, EMPHYSEMA

Centriacinar artery

Proximal acinar (centrilobular) -

emphysema

Centrilobular emphysema -

Tanlobular involvement of -
emphysema

Relatively spared lung parenchyma -

(Top) HRCI of the right lung apex shows round foci of low attenuation with imperceptible walls representing
centrilobular (proximal acinar) emphysema. The hypcrluccnt foci arc confined to the center of the secondary
pulmonary lobule. The centrilobular artery may manifest as a dot in the center of the emphysematous space.
(Middle) HRCT of the right upper lobe shows more advanced centrilobular emphysema with larger areas of
centrilobular lucency. (Bottom) HRCT of the right lung base of a 45 year old man with panacinar emphysema
secondary to alpha-l-antitrypsin deficiency shows hyperlucent lung parenchyma with a paucity of normal vessels.
The entire acinus is affected by the lung destruction. Lung parenchyma of higher attenuation indicates areas of
relative sparing. Contributed by Mark A. King, MD, The Ohio State university, Columbus, OH.
 AIRWAY STRUCTURE
PANLOBULAR LOW ATTENUATION, PARASEPTAL EMPHYSEMA & BULLOUS DISEASE
o

0)

— Distal acinar
emphysema —\

c
3
Centrtacinar artery

Bullac

Distal acinar
(parascptal)
emphysema

Interlobular septum

(Fop) First of two HRCT images of 45 year old man with dyspnea shows extensive parascptal (distal acinar)
emphysema and bullous disease. Section through the carina shows extensive right upper lobe hullae. There is also
mild paraseptal emphysema in the medial left upper lobe and along the left major fissure. In spite of extensive lung
destruction, centrilobular arteries are still visible as dot-like opacities in the central portion of secondary pulmonary
lobules. (Bottom) HRCT image through the lung bases shows the characteristic appearance of paraseptal emphysema
manifesting as a peripheral arcade of cystic structures with well-defined walls in the subpleural aspect of the right
upper lobe. The destroyed secondary pulmonary lobules are marginatcd by interlobular septa. Paraseptal emphysema
may be associated with bullous disease. I
«3
 AIRWAY STRUCTURE
LOBULAR LOW ATTENUATION, CONSTRUCTIVE BRONCHIOL1TIS

Normal lung
parenchyma

Centrilobular artery
surrounded by
hypcrlutcut lung

liluil.ii air t r a p p i n g

(Top) First of four CT images of a patient with constrictive bronciiiolitis secondary t o smoke inhalation injury.
Inspiratory axial HRCT shows very subtle heterogeneity of lung attenuation. (Bottom) Expiratory axial HKCT shows
mosaic attenuation secondary to air trapping. The normal lung parenchyma exhibits increased attenuation on
expiratory imaging. Abnormal lung parenchyma manifests with multifocai hilateral areas of lobular air trapping.
Some of these exhibit polyhedral shapes and represent air trapping in adjacent secondary pulmonary lobules. The
central lobular artery is visible in association with some of the affected secondary pulmonary lobules.
 AIRWAY STRUCTURE
LOBULAR LOW ATTENUATION, CONSTRICTIVE BRONCHIOLITIS

Areas of normal lung — — Relatively hyperluccnt

density areas ot lung
parenchyma

Air trapping -

( i-nlriu 'hulai
pulmonary artery

Air trapping outlines

individual secondary
pulmonary lobules

(Top) Coronal reconstruction of an inspiratory HRCT shows mild heterogeneity of the lung parenchyma bilaterally.
Areas ot hyperlucency are interspersed with areas of normal lung density resulting in mosaic attenuation of the lung
parenchyma. (Bottom) Coronal reconstruction of an expiratory HRCT accentuates the pulmonary heterogeneity by
demonstrating multifocal areas of lobular air trapping. These manifest as polyhedral foci of hyperlucent lung
parenchyma. Several affected individual secondary pulmonary lobules exhibit hyperlucency on expiratory imaging.
Central "dots" within the secondary pulmonary lobules represent centrilobular pulmonary arteries. The findings are
characteristic of constructive bronchiolitis,
 AIRWAY STRUCTURE
ACINAR N O D U L E S , B R O N C H O P N E U M O N I A

Acinar opacities

— Acinar opacities

— Acinar nodules

(Top) l-irst of two radiographs of a patient with active tuberculosis shows the imaging appearance of the abnormal
acinus. I'A chest radiograph shows bilateral areas of consolidation predominantly involving the upper lobes and
superior segments of the lower lobes. Multiple indistinctly margined acinar nodular opacities result from
bronchogenic spread of the infection. (Bottom) PA chest radiograph toned-down to the left lower lobe shows
multiple indistinctly margined round opacities representing intra-acinar inflammatory exutlatc. Acinar nodules are a
radiographic manifestation of bronchogenic spread of infection, characteristic of tuberculosis.
 AIRWAY STRUCTURE
ACINAR NODULES, BARIUM ASPIRATION

Acinar nodules
opacified by aspirated
barium

Acinar nodules —
opacified b y aspirated
barium

(lop) First of two images of a patient who aspirated barium contrast agent shows multiple high attenuation acinar
nodular opacities in the right middle lobe. PA chest radiograph coned-down to the right lower lung shows acinar
rosettes of metallic density representing barium within the pulmonary acini. Each acinar nodule measures 6-10 mm
in diameter. (Bottom) Unenhanced chest (H (bone window) coned-down to the right middle lobe shows
barium-opacified acinar nodules, some forming clusters within secondary pulmonary lobules. The normal pulmonary
acinus is not visible on imaging studies and is only identified when filled with fluid, cells or barium.
 VASCULAR STRUCTURE
■ Communication between pulinonarv and
O v e r v i e w o f Pulmonary Vascular systemic circulations
Structure ■ I ocated in the walls ot larger airways
■ Functionally closed in normal individuals
Arteries ■ May become patent in disease states
• Dual arterial supply with pulmonary and systemic ltroiirhi.il arteries to pulmonary veins
components ■ Communication between systemic and
• Pulmonary arterial system pulmonary circulations
Pulmonary circulation ■ ( communication between capillary bed of
Conduit from right ventricle to capillary-alveolar bronchial wall and pulmonary veins
interface Pulmonary veins to lymphatics
• Briiinlii.il arterial system ■ (ommunication with arierial channels
Systemic circulation ■ Communication with venous channels
( onduit from aorta to airway walls, vessel walls and
visceral pleura
Veins | General A n a t o m y and Function
• Dual venous drainage with pulmonars and systemic Anatomy
components • Pulmonary circulation
• Pulmonary \enous svstem Pulinonarv arteries
Pulmonary circulation c Capillary network
Conduit from alveolar-capillary interlace to Id I Pulmonary veins
atrium • Systemic circulation
Venous drainage of the lung Bronchial arteries
• 'I rue bronchial venous system Non-bronchial systemic arteries
■ Conduit from perihilar bronchi and vessels to the c True bronchial veins
azvgos Venous system • Pulmonary lymphatics
Venous drainage of the walls of central vessels and Complex network of vascular channels
tracheobronchial tree ■ Reservoir lymphatics: Broad, ribbon like
Other Systemic Vessels ■ ( o n d u i t lymphatics: lubular
• Sources of collateral blood supply to the lung from the ■ S.iculolubiilar lymphatics: Plexiform complex
systemic circulation around vessels and bronchi
• I'ulmonarv ligament arteries Bronchus-associated l y m p h o i d tissue ( B A N )
Aortic branches located in the pulmonary ligament liilrapiilmonary lymph nodes
Supply esophagc.il plexus Intrapulmonarv peribronchial Ivmph nodes
Supply medial visceral pleura Function
o Ma\ supplv adjacent lung parenchvma • Pulmonary circulation
- Potential source ol blood supplv to intralobar Pulmonary arteries
sequestrations ■ Collection ol deoxygenated blood from the right
• Subclavian and axillary arteries cardiac chambers
• Intercostal arteries ■ ( onduit of deoxygenated blood to pulmonary
• Inferior phrenic arteries capillary-alveolar interface
Lymphatics Pulmonary alveolar-capillary network
• Vascular channels ■ (.as exchange
Pulmonary veins
• Collection of Ivmphatic fluid
• Conduit ot lymphatic fluid towards hila ■ ( olleclion ol oxygenated hlofxl from the
alveolar-capillarv network and conduit of
Relationship of Vascular Structures oxygenated blood to lelt atrium and systemic
• \natomy circulation
v lironchoartcrial bundle is a single connective tissue ■ Collection of blood from capillary beds of
sheath that contains bronchial/bronchiolar walls, vessel walls and
■ Pulmonary arteries visieral pleura and conduit to left atrium
■ Bronchi • Systemic circulation
■ Bronchial arteries Bronchial arteries
I ymphatics located along ■ Conduit of oxsgenated blood from the aorta to
■ Bronchi to level of respiratory bronchioles the airway walls, vessel walls and visceral pleura
■ Pulmonary arteries I rue bronchial veins
■ Pulmonary veins ■ ( o n d u i t of de-oxygenated blood from central
■ Interlohular and connective tissue septa vessel/bronchial walls to a<cygos system
■ Visceral pleura! connective tissue • Lymphatics
• Vascular anastomoses Drainage of lymphatic lltiicl towards the hila
I'ulmonarv to bronchial arteries
 VASCULAR STRUCTURE
Occasional lymphatic drainage to abdominal Ivinph 0 Surface area of 70 mz
nodes
Microscopic Anatomy
• 1 ined by Hat endothclial cells on a basement
| Pulmonary Arteries membrane
• Loose endothelial cell junctions
General Concepts Permit passage of low molecular weight proteins
• Pulmonary trunk arises from the right ventricle
• Dichotomous branching into right a n d left main
Imaging Anatomy
pulmonary arteries • Below the resolution ol clinical 1 1 ' scanners
• Pulmonary artery branches
Lobar
Segmental [ P u l m o n a r y Veins
C Suhscgmeiltal
General Concepts
Physiology • Right and left pulmonary veins
• Low pressure pulmonary circulation • Sources of venous drainage
• Minimal flow through lung apices Efferent alveolar capillaries
Rapid increase in cardiac output accommodated Uronchial/vascular wall capillary networks
through recruitment of closed capillaries in c Visceral pleura
underperfused upper lung / o n e s
Microscopic Anatomy
• Muscular arteries constrict in response to hypoxia
• Small pulmonary veins indistinguishable from small
C Ventilation pcrfusioii m a t c h i n g to prevent
arteries
hypoxemia
• Mural smooth muscle cells and elastic lamina
Microscopic Anatomy Imaging Anatomy
• Proximal large arteries
• P u l m o n a r y veins travel in the p e r i p h e r y of l u n g
" Elastic arteries
units
• Distal small arteries
Acinus
< Transition to muscular arteries at level of
Lobule
bronchioles
Segment
I.xtcrnal elastic l a m i n a
• Pulmonary vein branches
Muscular media
Septal veins in periphery of secondary pulmonary
c Internal elastic l a m i n a
lobule
• Smallest arteries: Loss of smooth muscle in vessel wall
■ Visible along interlobular septa; help define the
Muscle in media thins as artery size decreases boundaries ot secondary pulmonary lobules
' Single elastic l a m i n a dislaliy
■ 0.5 mm in diameter
Difficult distinction between arteries and arterioles
■ Arcuate or branching structures identified 1.0-1.5
due to varying amounts of muscle in vessel walls
cm from pleural surface
■ Term "artertole" not applicable t o the pulmonary
c Veins in periphery of subsegments and segments
circulation 1
Veins in periphery of lobes
Imaging Anatomy Superior p u l m o n a r y veins
• Pulmonary arteries course alongside the bronchi ■ Drainage of upper lobes and right middle lobe
Medial to bronchi in the upper lobes Inferior p u l m o n a r y veins
I aleral to bronchi in the middle lobe, lingula and ■ Drainage of lower lobes
lower lobes c Variable anatomy of central pulmonary veins at
• Accessory branches directly penetrate the lung anastomosis with left atrium
• Lobular arteries of the secondary pulmonary lobule
Typically dominant lobular branch in center of
lobule (centrilobulan [Bronchial Arteries
Manifest as central dot-like opacities within 1 cm of
pleural surfaces
General Concepts
• Variable origin from systemic circulation
c Single right b r o n c h i a l artery from third intercostal
artery
Capillary N e t w o r k | Two left b r o n c h i a l arteries from descending aorta
Anatomy • Vascular supply to
• Origin from distal most pulmonary arteries Subepithelial capillary plexus along airway length
• Surround alveoli of respiratory bronchioles, alveolar from trachea to terminal bronchioles
ducts, alveolar sacs and alveoli c Peribronchial. perivascular connective tissue
• Respiratory surface with enormous surface area Vessel walls: Great vessels, pulmonary arteries and
■ Approximately 300 million alveoli veins
Approximately 1 (MX) capillaries per alveolus
 VASCULAR STRUCTURE
t I'aratracheal. carinal. hilar and intrapulmonarv Lobular artery: Central dot-like structure
lymphoid tissue approximately 1 m m in diameter
Visceral pleura c Intralobular acinar arteries: Vessels as small as 0 2
r
' Lsophagus m m in diameter resolved on thin-section CT
• Numerous anastomoses t o other systemic mediastinal
Bronchial Artery
• travel in close relationship to (within) walls of • Courses within airway wall
bronchi and bronchioles • Ramifies as airway wall (subepithelial) capillary
network
Microscopic Anatomy
• Muscular m e d i a Pulmonary Vein
o High pressure systemic c i r c u l a t i o n • Intralobular p u l m o n a r y veins drain into septal
• Prominent i n t e r n a l clastic l a m i n a p u l m o n a r y veins
• No external elastic lamina o Septal veins are visible on CI' and measure
approximately 0.5 m m in diameter
Imaging Anatomy 0 located approximately 5-10 m m from arteries
• Typically inapparent • Each lobular (septal) pulmonary vein drains two or
• Visualization of central bronchial arteries in several more adjacent lobules
disease states with collateral circulation to the lung • Tributaries from
c Alveolar capillary network
c Bronchial artery-derived airway wall
Bronchial Veins (subendothelial) capillary network
c Visceral pleural capillaries
General Concepts
• True bronchial veins only in the perihilar regions Lymphatics
• Drainage to azvgos and hemiazygos systems • Peribronchovascular lymphatics
o Alongside lobular pulmonary arteries and airwavs
Imaging Anatomy • Perilobular lymphatics
• Generally not visible on imaging studies o Along interlobular septa and pulmonary veins
• Visceral pleural lymphatics
• Intercommunication via anastomotic channels
Pulmonary Lymphatics o Peribronchovascular to perilobular
o Peribronchovascular to pleural
General Concepts
• Dilfuse and complex p u l m o n a r y l y m p h a t i c n e t w o r k
• L y m p h a t i c channels along
n
.Anatomic Correlates of Selected
Bronchi
■ lo level of respiratory bronchioles i Diseases
Vessels Random Pulmonary Nodules
■ Pulmonary arteries • Diseases
■ Pulmonary veins I l e m a t o g e n o u s metasta.ses
t onnective tissue septa O Miliary infection
■ Interlobular septa
• CT features
o Intralobular interstitium
<J Nodules randomly distributed in relation to the
o Visceral pleura structures of the secondary pulmonary lobule
Microscopic Anatomy Some nodules may exhibit a relationship to small
• I hin endothelium pulmonary arteries
• Fndoluminal valves direct flow towards hila ■ Helpful finding lo suggest hematogenous
• Not normally visible on histologic specimens mechanism of dissemination
o May become prominent in certain disease states Perilymphatic Pulmonary Nodules
Imaging Anatomy • Diseases
• Generally not visible on imaging studies Sarcoidosis
I.ymphangitic carcinoinalosis
• CT features
, Vascular Structure of Secondary Nodules located along the lymphatic channels of
the secondary pulmonary lobule
Pulmonary Lobule ■ Peribronchovascular
Lobular Pulmonary Artery ■ Interlobular septal
■ Nubpkur.'.l
• I . a h lobular pulmonary' arterv supplies a single lobule ■ Centrilobular
• Courses alongside the distal airway
• Ramifies as the alveolar capillary network
• Imaging
 VASCULAR STRUCTURE
PULMONARY VASCULAR STRUCTURE, PULMONARY ARTERIES

Pulmonary artery

Bronchial artery

Bronchiole

Lobular pulmonary Terminal bronchiole

artery

Bronchial wall
capillaries

Pulmonary veins

Capillary network
Interlobular septum

■W

Graphic shows the complexity of the vascular components of the secondary pulmonary lobule which reproduces (in
miniature) the structural morphology of the lung with respect to the organization of vascular structures, airways and
lymphatics. The pulmonary arteries travel alongside the airways, supply the capillary network that surrounds the
alveoli and bring deoxygenated blood to the capillary-alveolar Interface. The bronchial arteries travel within the
airway wall and supply the capillary networks within the walls of the airways.
 VASCULAR STRUCTURE
CT, PULMONARY VASCULATURE

Pulmonary arteries

Pulmonary vein —
Left atrium

First of two contrast-enhanced maximum intensity projection CT images of the lungs shows the complex nature of
the pulmonary vasculature. Coronal image shows visualization of numerous overlapping blood vessels. Peripheral
pulmonary arteries are identified by visualization of their origin from the main pulmonary arteries. Peripheral
pulmonary veins are identified hy visualization of their drainage into the central pulmonary veins and the left
atrium.
 VASCULAR STRUCTURE
CT, PULMONARY VASCULATURE

Pulmonary artery

Pulmonary vein

Contrast-enhanced oblique coronal maximum intensity projection CT image of the left pulmonary vascular tree.
Pulmonary arteries are distinguished from pulmonary veins based on visualization of their central vascular
connections. Note the near vertical course of the large pulmonary arteries of the left lower lobe and the more
horizontal course of the major left lower lobe pulmonary veins.
 VASCULAR STRUCTURE
CT ANCIOCRAPHY, PULMONARY ARTERIES

Pulmonary artery

Pulmonary artery -

— Bronchus

— Pulmonary artery

Bronchus

Pulmonary vein

(Top) First of two oblique coronal reconstructions from a normal CT pulmonary angiogram (lung window) of a 21
year old woman with chcsi pain shows the relationship of the pulmonary arteries to the adjacent bronchi. CT of the
right pulmonary arterial tree shows that the arteries course medial to the bronchi in the right upper lobe and lateral
to the bronchi in the lower lobes. (Bottom) CT pulmonary angiogram of the left pulmonary arterial tree shows the
left interlobar pulmonary artery located posterolateral to a left lower lobe bronchus. The adjacent pulmonary vein is
located anteromedtal to the bronchus. The pulmonary arteries carry deoxygenated blood from the right ventricle to
the capillary-alveolar interface.
 VASCULAR STRUCTURE
CT, PULMONARY ARTERIES

Right main pulmonary ——| Pulmonary trunk

artery

Left interlobar
pulmonary artery

I— Pulmonary trunk

Left main pulmonary

artery

(Top) First of two images from a normal contrast-enhanced chest CT (mediastinal window) shows adequate
enhancement of the vascular structures of the mediastinum. The pulmonary trunk gives rise to the right and left
main pulmonary arteries. The right main pulmonary artery is visualized in its entirety as it courses anterior to the
bronchus intermedius and posterior to the ascending aorta and superior vena cava. Note a small amount of air in the
non-dependent portion of the pulmonary trunk that resulted from the intravenous contrast injection. (Bottom) CT
section obtained below the tracheal carina demonstrates the bifurcation of the pulmonary trunk into right and left
main pulmonary arteries. Note the horizontal course of the left main pulmonary artery into the left lung.
 VASCULAR STRUCTURE
MICROSCOPIC FEATURES, PULMONARY & BRONCHIAL ARTERIES

Smooth muscle

Pulmonary arteries
Bronchial artery

Interstitial connective Bronchiole

tissue

:
■ . > - ' ■ % " '

High-power photomicrograph (Hematoxylln and Eosin stain) of normal lung demonstrates a bronchiole lined by
pseudostratined cuboldal epithelium. Note the adjacent pulmonary artery branches which travel alongside the
bronchus in the bronchovascular sheath and the intervening loose interstitial connective tissue. The muscular
pulmonary arteries exhibit circularly oriented smooth muscle located between internal and external elastic laminae.
Bronchial arteries are intimately related to their corresponding airway walls and are described as traveling within
them.
 VASCULAR STRUCTURE
RELATIONSHIP OF PULMONARY ARTERIES TO AIRWAYS

Pulmonary artery

Bronchus

Pulmonary vein —

IHilmonary vein
Pulmonary arteries

(Top) First of two images from a normal contrast-enhanced chest CT (lung window) shows the relationship of the
pulmonary arteries and veins to the adjacent airways. CT section at the level of the aortic arch shows the vascular
structures of the upper lobes. The pulmonary arteries are located medial t o the adjacent bronchi. The pulmonary
veins arc located lateral to the bronchi. (Bottom) CT image at the level of the heart shows that the lower lobe
pulmonary arteries are located lateral to adjacent bronchi. The pulmonary veins course along connective tissue septa
that surround the pulmonary segments. In clinical practice, scrolling through sequential stacks of images permits
tracing the peripheral vessels to their central portions to distinguish arteries from veins.
 VASCULAR STRUCTURE
THE CAPILLARY-ALVEOLAR INTERFACE

L I M .

Endotheiial cell
junction

A5>

Capillaries

Pulmonary
IntersUtium

Alveolar-capillary
interface

Endotheiial cell
junction

JU

Graphic shows the relationship of the capillary network to the alveoli. The capillary-alveolar interface is the site of
gas exchange. The large number of capillaries provides an enormous surface area for respiration. The thin vascular
endothelium and the thin alveolar wall cells facilitate the process of gas exchange. Loose endotheiial cell junctions
permit passage of intiavascular low molecular weight substances.

■
 VASCULAR STRUCTURE
MICROSCOPIC FEATURES OF CAPILLARY-ALVEOLAR INTERFACE

1 J\

I i

Capillary network

Alveolar wall

W-

■
High-power photomicrograph (Hematoxylln and Eosin stain) of normal lung shows the thin alveolar walls and the
numerous capillaries associated with each alveolus. The capillaries and other vascular structures are easily identified
as they contain red blood cells in their lumens. The many capillaries associated with each alveolus provide an
enormous surface area for respiration.
 VASCULAR STRUCTURE
CT ANGIOGRAPHY, PULMONARY VEINS

Pulmonary artery

Pulmonary vein — 1 Left atrium

Pulmonary artery

— Pulmonary vein

(Top) First of two oblique coronal reconstructions from a normal CT pulmonary angiogram (lung window) of a 21
year old woman with chest pain shows the right central pulmonary veins as they enter the left atrium. The
pulmonary veins carry oxygenated blood from the lungs to the left cardiac chambers for delivery to the tissues.
(Bottom) Oblique coronal CT of the left lung demonstrates the left central pulmonary veins located medial to an
adjacent bronchus. The left pulmonary artery is easily identified by noting its connection to the pulmonary trunk as
it arises from the right ventricle. The left pulmonary artery courses over the left main bronchus to supply the left
lung.
 VASCULAR STRUCTURE
CT, PULMONARY VEINS

— Left superior
pulmonary vein

Left atrium —

Right inferior Left atrium

pulmonary vein

Right pulmonary artery

branches

(lop) first of two images from a normal contrast-enhanced chest CT (mediastinal window) shows adequate
enhancement of the central vascular structures. CT section at the level of the left atrium shows the left superior
pulmonary vein. There are characteristically two left and two right pulmonary veins although the number and
morphology of the central pulmonary veins are variable. (Bottom) CT section at the level of the inferior aspect of the
left atrium shows the right inferior pulmonary vein. Note the branches of the right pulmonary artery located lateral
to the right lower lobe bronchi.
 VASCULAR STRUCTURE
VEINS OF SECONDARY PULMONARY LOBULE

lfc"H?
A

Septal pulmonary vein

Bronchial wall
capillaries

Septal pulmonary vein

Pulmonary artery

Intralobular
pulmonary vein

Alveolar capillaries

Intedobular septum

,v
Graphic shows the vascular anatomy of the secondary pulmonary lobule (SPL). The veins are found in the
intedobular septa that define the boundaries of the SPL. Intralobular pulmonary veins arise from the capillary
network that surrounds the alveoli and drain Into septal veins. The septal pulmonary veins drain more than one SPL
The pulmonary veins also drain the subendothellal capillary network of the airway walls and the visceral pleura.
 VASCULAR STRUCTURE
CT, N O R M A L SECONDARY P U L M O N A R Y LOBULE

Septa! pulmonary veins -

St-piiil pulmonary vein

— I.obular pulmonary
artery

(Top) first of two axial images of a normal contrast-enhanced chest CT (lung window) shows the vessels of the
normal secondary pulmonary lobule. Coned down CT of the right lower lobe shows the peripheral pulmonary vein
branches that demarcate the boundaries of the secondary pulmonary lobules. Note that the interlobular septa are not
always visible in normal individuals but their location can be inferred through identification of the septa) veins.
(liottom) Coned down CT of the left lower lobe shows pulmonary veins outlining secondary pulmonary lobules. The
vessels in the center of the space bound by the septal veins represent the central lobular arteries of the secondary
pulmonary lobules. Note that vascular structures are not visible in the subpleural lung parenchyma.
 VASCULAR STRUCTURE
THE PULMONARY LYMPHATICS

Hilar lymph node

Intrapulmonaiy
lymph nodes
. ■
Intrapulmonaiy
lymph node

Peri vascular
lymphatics

Peribronchlal
lymphatics

Subpleural lymphatics

Graphic shows the complex lymphatic network of the lungs. The pulmonary lymphatics are found along bronchi,
vessels, and in the subpleural connective tissue. Collecting lymphatics also course within the pulmonary connective
tissue septa. The lymphatic network becomes organized as small Intrapulmonary lymph nodes that typically occur at
the bifurcations of large airways.
 VASCULAR STRUCTURE
LYMPHATICS OF SECONDARY PULMONARY LOBULE

Perlbronchovasculai
ni
■
lymphatics Pulmonary lymphatics

Collecting lymphatic
channels
i
Pertvascular lymphatics
II
' ■

Perilobular lymphatics

Visceral pleural
lymphatics

«,
r- • w '&tZ~
\*
. .. •
W^~
* * < $
'vr.
iS^'iv,;
5>
'rlVW.^
„« V
Subpleural vessels * •>
:.v, « 1j*v:.«'
**, - « ~ZF * r-t*>4 »
s~<. \ *«r«%
>• >
X."> ■**

:
Subpleuial lymphatic <^A
<!»: Mesothellal cells of the
~<n" visceral pleura
>•

(Top) Graphic shows the complex lymphatic channels within the secondary pulmonary lobule (SPL).
Peiibronchovascular lymphatics course along the airway walls to the level of the respiratory bronchioles. Perilobular
lymphatics course in the interiobular septa and sunound the pulmonary veins. Visceral pleural lymphatics are also
illustrated. Pulmonary lymphatics are numerous and complex interconnecting vascular structures. Understanding
the structure and anatomic location of the lymphatics of the SPL Is important in identifying a perilymphatu:
distribution of disease on thin-section CT. (Bottom) High-power photomicrograph (Hematoxylln and Eosln stain)
shows a visceral pleural lymphatic channel surrounded by loose connective tissue and visceral pleural vessels, likely
pulmonary veins.
 VASCULAR STRUCTURE
RANDOM NODULES & NODULES RELATED TO SMALL VESSELS, PULMONARY METASTASES

Random nodule

Angiocentric nodule

Random nodules

Angiocentric nodule

(lop) Contrast-enhanced chest Cl" (lung window) of a patient with metastatic thyroid carcinoma demonstrates the
random distribution of hcmatogenous metastatic nodules. Some of the nodules exhibit a relationship to small
pulmonary vessels occurring at the distal ends of small pulmonary artery branches. This finding is characteristic of
hcmatogenous dissemination of disease and can be seen in secondary neoplasia, hcmatogenous infection, vasculitis
and embolic disease. (Bottom) HRCT of a patient with metastatic colon cancer demonstrates tiny spherical
well-defined metastatic pulmonary nodules that exhibit a random distribution. Some of the nodules occur at the
distal ends of pulmonary arteries denoting their hematogenous route of dissemination.
 VASCULAR STRUCTURE
R A N D O M N O D U L E S , M I L I A R Y TUBERCULOSIS

Random nodule

Random nodules

(Top) First of two sections from a high-resolution CT (lung window) of a patient with miliary tuberculosis. HRC1
through the right upper lobe shows multifocal tiny pulmonary nodules throughout the lung that exhibit a random
distribution. In this case some of the nodules are located in the subpleural lung parenchyma and along interlobular
septa. (Bottom) HRCT through the right lower and right middle lobes shows profuse micronodules that exhibit a
random distribution although some of the nodules are located in the subpleural lung parenchyma along the
interlobar fissure. Although the mode of disease dissemination in this case is heniatogenous it is difficult to associate
the nodules to small pulmonary vessels.
 VASCULAR STRUCTURE
PERILYMPHATIC N O D U L E S , SARCOIDOS1S

Peribronchial nodules
— Septa! nodules

Perivasiular nodules

Suhpk-iiriii nodules

Subpleural nodules

Peribronchial nodules
Peribronchial nodules —

Subpleural nodules

(Top) First of two HRCT images of a patient with sarcoidosis shows a perilymphatic distribution of pulmonary
nodules representing granulomas. Supine HRCT shows nodules arranged in the anatomic distribution of the
pulmonary lymphatics and located along vascular structures, along airways and along the pleural surfaces and the
interlobular septa. (Bottom) Prone IIRCT shows persistence of posterior subpleural micronodules. The beaded
appearance of the left interlobar fissure results from micronodules situated along subpleural lymphatics. Note the
irregular thickening of the bronchial walls consistent with peribronchial nodules. This case is representative of the
characteristic perilymphatic distribution of the granulomas seen in patients with sarcoidosis. Silicosis and coal
worker's pneunioconiosis can produce similar findings.
 VASCULAR STRUCTURE
PERILYMPHATIC N O D U L E S , L Y M P H A N G I T I C C A R C I N O M A T O S I S
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Nodular septal — U)
thickening O
Interlobular septa c_
outline a secondary 0)
pulmonary lobule -^
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r-t-
—I

c
a
rz
-1
Central artery within CD
secondary pulmonary
lobule

Nodular septal Secondary pulmonary

thickening lobule

Nodular pleural
thickening

Thickened interlobular — I'cribronchial nodular

septa thickening

( l o p ) HRC.r (lung window) of a patient with Ivmphangitic carcinomatosis sliows smooth and nodular thickening of
the interlobular septa, which demarcate the boundaries of the secondary pulmonary lobules. The central dot-like
structures within the secondary pulmonary lobules represent the lubular arteries. (Bottom) HIM I (lung window)
through the right lower and middle lobes of a patient with Ivmphangitic carcinomatosis shows a beaded appearance
of the right interlobar fissure, smooth and nodular thickening of the interlobular septa and peribronchial thickening.
Lymphangitic carcinomatosis is characterized by tumor in pulmonary lymphatics a n d desmoplasia in the
surrounding inrerstitium, and exhibits a perilymphatic distribution on C I. 1 y m p h o m a , leukemia and other
lymphoproliferative disorders can also produce these findings. I
!()<)
 INTERSTITIAL NETWORK
[Terminology Peripheral (Subpleural)
• Situated between pleura and lung parenchyma
Abbreviations
• Continuous with interlobular septa and perivenous
• High-resolution Cf (HRCT) interstitial space
• I xtends from lung periphery to hila
| O v e r v i e w of Pulmonary Interstitium
Embryology I m a g i n g N o r m a l Pulmonary
• I mbryologic remnant of splanclinoplcuric Interstitium
nieseuchvmal lied
Site ot airway and vessel ingrowth during lung Radiographs
morphogenesis • typically Invisible
• I hin or imperceptible lissural lines demarcate
Anatomy subpleural interstitium
• C o n t i n u u m of loose connective tissue • Visualization of interstitium on radiography should
Extends from pulmonary hila to visceral pleura suggest interstitial lung disease
■ Anchored at hila
■ Under tension by negative visceral pleural HRCT
(intrapleural) pressure • typically invisible
• Occasional visualization of interlobular septa
Microscopic Features I \ picallv located along peripheral pulmonary veins
• Fine reticulin fibers • Imperceptible axial Interstitial network
• Pineelastin fibers •^ Along bronchovascular bundles
• Coarser collagen fibers
• Most prominent around large bronchovascular
structures Imaging of Interstitial Lung Disease
Components of Pulmonary Interstitium Chest Radiography
• Matrix components • 1 imited by spatial resolution and overlapping
• Fibrous network ol collagen a n d ciaslin tillers parenchym.il structures
■ Collagen fibers: Inextensible • Useful for depicting distribution and temporal
■ Blast in fibers: Extensible progression of interstitial abnormalities
• ( cllular c o m p o n e n t s
libroblasts HRCT
Mast cells • General concepts
Tissue macrophages Individual HRCT scans sample lung.it spaced levels
Lymphocytes c Multideteetor HRC T allows volumetric IIKCI of
• Continuous epithelial a n d endothelial basement entire lungs during single breath-hold
membranes • technical factors
form barriers defining outer borders of interstitium Thin c o l l i m a t i o n
■ 1-1.5 mm
Function of Pulmonary Interstitium High-resolution algorithm tor image reconstruction
• Provides lung with structural integrity Full inspiration
• Permits lung deformation during respiration c Optional prone imaging
Optional expiratory imaging
• Utility ol HRCT
| Interstitial Fiber N e t w o r k c Greater sensitivity and specificity t h a n chest
radiography
Three Subdivisions Forming a Continuum Demonstrates gross lung anatomy
• Axial (hroiK l i o a r l c r i a l ) ' Characterizes abnormal findings better than chest
• I'.IK in liym.il ( i n l n i l o h u l a r ) radiography
• Peripheral (subpleural)
Axial (Bronchoarterial)
• Surrounds bronchoarterial bundles Chest Radiography of A b n o r m a l
• Ixtends troni hila to respiratory bronchioles in lung Pulmonary Interstitium
periphery
Linear (Septal) Opacities
Parenchymal (Intralobular) • I hickening of i n t e r l o b u l a r septa
• fine network of very thin connective tissue fibers » Classified by location, extent and orientation as
within alveolar walls Kerlev lines
• Situated between alveolar and capillary basement • Kerley \ lines
membranes Straight linear opacities in upper lung
• Supports structures of secondary pulinonaiv lobule-
 INTERSTITIAL NETWORK
■ 2-ft cm in length • Intralobular interstitial t h i c k e n i n g
■ 1-3 m m in width I ine, reticular mesh-like opacities
Point toward hilum centrally; directed towards lung Often represents earlv f ibrosis
periphery • H o n e y c o m b l u n g (end-stage lung disease)
Extend towards hut not to plcural surface Indicates extensive lung fIbrosis
■ Kcrley B lines I hick-walled, air-filled cvsts
Straight linear opacities predominantly in lower ■ 3 mm to 3 cm
lung ( ysts share walls, occur in several layers In
■ 1.5-2 cm in length subpleural lung
■ 1-2 m m in width Associated with traction
l*crpendlCUlar to and in contact with the pleura bronchiectasis/bronchiolectasis resulting from lung
• Kerle\ C lines fibrosis
Branching linear opacities seen at lung bases ■ Fibrous tissue produces outward traction on
I ine and net-like bronchial walls; resultant irregular bronchial
Represent Kerley B lines seen en lace dilatation
■ Traction bronchiolectasis involves small airways
Peribronchial Cuffing in peripheral lung
• thickening of axial (bronchoarterial) interstitium ■ Associated with reticular opacities, parenchymal
• Seen as apparent bronchial wall thickening when distortion, honeycombing
visualized end-on
• Most apparent in perihilar regions Nodules
• Interstitial nixlules are characteristically small (1-2
Perihilar Haze mm) and well-defined
• Interstitial edema surrounding bronchoarterial • Anatomic distribution may suggest diagnosis
bundles
• Results in blurring of vascular borders
• Best appreciated in comparison to prior radiographs Anatomic Correlates of Specific
Keticular and Nodular Opacities Interstitial Lung Diseases
• Keticular opacities
Multiple intersecting irregular lines Interstitial Pulmonary Edema
■ line: < 3 mm thick • Radiography
■ Medium: 3-10 mm thick Axial interstitium
■ ( oarse: > 10 mm thick ■ Prominence ol bronchovascular bundles
• Nodular opacities ■ Blurring of bronchial and vascular margins
Interstitial nodules ■ Peribronchial cuffing when v isuali/ed end-on
Characteristically small Peripheral interstitium
■ 1-2 m m ■ Prominence and thickening of interlohar fissures
typically well-defined borders ■ Prominent minor fissure on frontal chest
• Reticiilonodular opacities radiograph
Perceived combination ol lines and dots: often ■ \ll fissures prominent on lateral chest radiographs
artifact ual ■ Kerley lines (A and/or B)
Supcrimposition of lines/reticulation may mimic • ( I
nodules Axial interstitium
Superimposition of nodules may mimic reticulation ■ I hickening of bronchovascular bundles
Peripheral interstitium
■ Smooth thickening of interlobular septa
HRCT of Abnormal Pulmonary Lymphangitic Carcinomatosis
Interstitium • Radiographs
\ \ i a l interstitium
Reticular Opacities ■ Smooth and nodular thickening ol
• Multiple intersecting irregular lines with a net-like bronchovascular bundles
appearance ■ Kerley A lines
• Inlcrlobiilar septal t h i c k e n i n g Peripheral interstitium
Smooth ■ Smooth and nodular thickening ol interlohar
■ Pulmonary edema fissures
■ Ivmphangitic carcinomatosis (often nodular) ■ Kerley B lines
Nodular • ( I
■ I ymphangitic carcinomatosis Axial interstitium
■ Sarcoidosis ■ Smooth and nodular thickening of
Irregular bronchovascular bundles
■ I ibrosis ■ Centrilobular peribronchovasculai thickening
■ Associated with architectural distortion a n d ■ Centrilobular nodules
traction bronchiectasis
 INTERSTITIAL NETWORK
Peripheral interstitium
■ Smooth and nodular thickening of interlobular
septa
■ Smooth and nodular thickening of interlobar
tissures
Sarcoidosis
• Radiograph)
\.\ial interstitium
■ Thickening of hronchovascular bundles
■ Reticular and nodular opacities may emanate from
lung hi la
■ Predominant involvement of mid and upper lung
zones
■ Peripheral interstitium
■ Ihkkcning, nodularity of interlobular septa and
interlobar fissures
• C 1
Axial interstitium
■ Small nodules along hronchovascular bundles
■ I hickening of bronchosascular bundles
Peripheral interstitium
■ Small IHKIUICS along interlobular septa
■ Small nodules along interlobar fissures
■ Small subpleural nodules
I n t e r s t i t i a l Fibrosis
• Radiography
■ Peripheral interstitium
■ Relicular opacities
■ Predominantly involve peripheral and basilar
lungs
i Parenchyma! interstitium
■ line basilar relicular opacities
■ Volume loss with progressive lung fibrosis
• (I
Peripheral interstitium
■ Irregular thickening of interlobular septa
■ Irregular thickening of interlobar fissures
■ Irregular interface with mediastinal pleura! surface
Parenchvmal interstitium
■ Intralnhular relicular opacities
■ Associated traction bronchiettasis
 INTERSTITIAL NETWORK
AXIAL & PERIPHERAL INTERSTITIUM

f-'
^

^A ^ k 1
Parenchymal
(intralobular)
Interstltium \ M H

Interstitial sheath
around pulmonary
vein

Peripheral (subpleural) Axial interstltium

Interstltium along bronchovascular
bundle

Graphic shows axial (bronchoarterial) interstltium extending along the bronchovascular structures from the hilum to
the lung periphery. The peripheral (subpleural/tnterlobular septal) interstltium extends along the subpleural region,
including the lnterlobar fissures, and contiguously along Interlobular septa, extending back to the lung hila with the
pulmonary veins and lymphatics. The fine interstitial network of the parenchymal (intralobular) interstltium Is seen
throughout the lung.
 INTERSTITIAL NETWORK
AXIAL, PARENCHYMAL & PERIPHERAL INTERSTITIUM

Peripheral intersanum Axial (bronchoarterial)

along interlobular intersutiuni
septae

Parenchymal
(uUralobular)
inteist* mm

Peripheral (subpleural)
ii terstitlum

— parenchymal (alveolar

■ septa 1) li terrtitium

Alveolar epithelium

Alveolar septal
interstitlum

Alveolar capillary
endothelium

(Top) Graphic shows the parenchymal and peripheral interstitiurn of the secondary pulmonary lobule. The
peripheral interstitlum extends along the subpleural regions and along the interlobular septa with the pulmonary
veins and lymphatics towards the pulmonary hilum. The most distal portions of the axial interstitial sheath are
shown along the bronchovascular structures as they enter secondary pulmonary lobules. The parenchymal
interstitlum forms a meshwork around clusters of alveoli and alveolar sacs. A continuous interstitial fiber network
within the secondary pulmonary lobule extends to the interlobular septa. (Bottom) The parenchymal interstitiurn Is
interposed between the capillary endothelium and the alveolar epithelium and is seen within adjacent alveolar septa.
 INTERSTITIAL NETWORK

Axial
(peril •ToiKtoovasrular)
lntentinum

Bronchiole
Pulm>ii:ti-y artery

Perlphetu (subpleurji)
pulmofTy lnte--' urn

(Top) High-power photon.irrograph (Herr..«toxylinaf.'l F. <m stain) s>iowstKef;<<ec in. tivt t^^ueelcinerrsthat
cuitipo<e the axial (pertbr i\+iovascular) inierstitium sdrrourkfuig the pulmonjTy vessel'' tt»d the airways. (Botiom)
Hlgh-po»\ a photomicrograph (Kematoxylln and Eosfti stainj shi>ws the peripheral (subpleural) pulminsiy
lnterstittum. Fine collagen and elastln fibers occupy the subpleural region and surround subpleuralTOMfeland
lymphatics.
 INTERSTITIAL NETWORK
RADIOGRAPHY OF NORMAL PULMONARY INTERSTITIUM

Normal peripheral
pulmonary vessels

Normal minor fissure

Sharply marginated
vascular borders

Normal pleural surface —

First of two normal chest radiographs of the same patient. PA chest radiograph coned down to the right lung shows
normal pulmonary markings. The pulmonary vascular structures taper normally towards the lung periphery. The
borders of the vascular structures are sharp. The pleural surfaces are imperceptible and the minor fissure is poorly
visualized.
 INTERSTITIAL NETWORK
RADIOGRAPHY OF NORMAL PULMONARY INTERSTITIUM

Normal minor fissure —

— Normal peripheral
pulmonary vessels

Left lateral thest radiograph shows normal vasculature in the lung periphery. The normal minor fissure is visible as a
thin white line. Ill-definition of pulmonary vessels, thickening of the fissures and pleural surfaces, thickening of
bronchovasculai bundles and visualization of intersitial opacities should suggest interstitial lung disease.

11
 INTERSTITIAL NETWORK
ANATOMIC-HRCT CORRELATION

— Artery in cross-section

Lobular artery —

Soptal vein

(Top) Graphic shows the anatomy of the peripheral lung at the level of the secondary pulmonary lobule. Acinar
Structures within the secondary pulmonary lobule are supplied by branching pulmonary arteries and drained by
pulmonary veins and lymphatics. The central vascular structures of the pulmonary lobule and the peripheral vascular
structures within the interlobular septa are highlighted. These are the structures that can \ie resolved with HRCT,
(Bottom) Graphic shows the portions of the underlying anatomy that are typically visible on normal HRCT. Short
segments of tapering arteries and veins may be visualized. Small portions of interlobular septa are occasionally
visualized in normal individuals.
 INTERSTITIAL NETWORK
HRCT OF NORMAL P U L M O N A R Y INTERSTITIUM

Normal intcrlobular
septum

Normal pulmonary
vein

Normal hronchus

Normal
bronchovascular
hundle

Normal left major

fissure

( l o p ) Hirst of two normal axial HRCT images of the same patient show the CT appearance of the interstitium which
is not visible in normal subjects. HRCT through the right upper lobe shows normal vascular and bronchial structures.
Peripheral subpleural linear structures perpendicular to the pleural surface likely represent interlohular septa
containing normal septal veins and their surrounding interstitium. (Bottom) HRCT through the left upper lobe
shows normal vessels, bronchi a n d pleural markings. The left major fissure is partially visualized and manifests as a
thin delicate line that separates the left upper lobe from the left lower lobe. The normal subpleural interstitium is not
visible.
 INTERSTITIAL NETWORK
RADIOGRAPHY OF INTERSTITIAL PULMONARY EDEMA

Normal
bronchovascular
bundle

Well-defined borders of
central pulmonary
vessels

Cardiomcgaly

Mildly thickened —
interlobar fissures

— Bilateral pleura!
effusions

(Top) First of four chest radiographs of a patient with chronic heart failure shows the radiographic appearance of the
abnormal pulmonary interstitium. I'A chest radiograph shows cardiomegaly, an atherosclerotic partially calcified
aorta and a relatively normal pulmonary interstitium. The vascular structures of the lung are normal in caliber and
distribution and their borders are well-defined. A bronchovascular bundle in the right upper lobe exhibits n o
bronchial wall thickening. (Bottom) Lateral chest radiograph shows mild thickening of the interlobar fissures and
bilateral pleural effusions that manifest as blunting of the posterior costodiaphragmatic recesses.
 INTERSTITIAL NETWORK
RADIOGRAPHY OF INTERSTITIAL PULMONARY EDEMA

I'eiibronchial cuffing —

'I hick minor fissure

Kerley B line

Lett pleura! effusion

Kerlev B line —

— Thick interlobar
fissures

(Top) I'A chest radiograph obtained after exacerbation of interstitial pulmonary edema shows engorgement of
pulmonary vascular structures with blurring of vessel margins in the perihilar regions. Note thickening of the minor
fissure and "peribronchial cuffing'' around the bronchovascular bundle seen end-on in the right suprahilar region.
Kerley B lines (septal lines) are demonstrated in the lower lungs, extending inward from and perpendicular to the
pleural surface. Bilateral pleural effusions are larger. (Bottom) I ateral chest radiograph shows engorgement of
pulmonary vessels with blurring of their margins a n d generalized prominence and smooth thickening of interlobar
fissures. Note Kerley B lines (septa! lines) in the retrosternal region.
 INTERSTITIAL NETWORK
CT OF ABNORMAL INTERSTITIUM, INTERSTITIAL EDEMA

Centrilohular vessels

_
Smooth thickening of
interlobular septa

Pericardia! effusion

Thick interlobular
septa

Right pleural effusion —

(Top) First of four images of an unenhanced chest CT (lung window) of a 49 year old man with interstitial edema
and a right pleura) effusion shows characteristic CT findings of thickening of the peripheral (interlobular septal)
interstitium. CT through the right lung apex shows smooth thickening of the interlobular septa outlining the
boundaries of several secondary pulmonary lobules. (Bottom) CT image through the right lower and middle lobes
shows a right pleural effusion and a pericardia! effusion. Smooth septal thickening partially outlines the boundaries
of several secondary pulmonary lobules.
 INTERSTITIAL NETWORK
CT OF ABNORMAL INTERSTIT1UM, INTERSTITIAL EDEMA

Thick interlobulai
septa

Left pleural effusion

Right pleural effusion —

Centrilobular vessels

Thick interlobular —
septa

Right pleural effusion

(lop) Image through the right lung base shows bilateral pleural effusions and relaxation atelectasis of the right lower
lobe. There is smooth thickening of interlobular septa. (Bottom) Image through the right lung base shows prominent
smooth thickening of interlobular septa outlining the peripheral boundaries of an arcade of suhplcural secondary
pulmonary lobules in the inferior aspect of the right lower lobe. Each secondary pulmonary lobule contains a central
dot-like opacity that represents the Iobular pulmonary artery.
 INTERSTITIAL NETWORK
RADIOGRAPHY OF ABNORMAL INTERSTITIUM, LYMPHANGITIC CARCINOMATOSIS

Thick bronchoarterial
bundles

Thick minor fissure — -

Kerley B lines

First of three images of a 46 year old woman with lymphangitic carcinomatosis manifesting with thickening of the
iiiierlobular septa. PA chest radiograph coned down to the right lung shows thickening of the bronchoarterial
bundles and numerous Kerley B lines that course perpendicularly towards the right visceral pleura. Thickening of the
minor fissure reflects involvement of the subpleural interstitium.
 INTERSTITIAL NETWORK
HRCT O F A B N O R M A L I N T E R S T I T I U M , L Y M P H A N C I T I C C A R C I N O M A T O S I S

Smooth & nodular

thickening of
interlobiilar septa

Thickened
bronchoarteriai
bundles

Thickening of
peripheral interstitium

Thickening of axial —
interstitium

(Top) Axial HRCT of the right lung base shows smooth and nodular thickening of the interlobiilar septa outlining
secondary pulmonary lobules. There is also tumor involvement of the axial interstitium that manifests with
thickening of the bronchial walls and hronchoarterial bundles. (Bottom) Axial HRCT of the right lung base shows
thickening of the axial and peripheral interstitial tissues. The axial interstitium is located along bronchoarteriai
bundles. The peripheral interstitium is located in the subpleural region a n d in the interlobiilar septa.
 INTERSTITIAL NETWORK
RADIOGRAPHY OF ABNORMAL INTERSTITIUM, SARCOIDOSIS

— Reticulonodular
opacities

PA chest radiograph of a young man with sarcoidosis coned down to the left lung shows reticulonodular opacities
predominantly involving the mid- and upper lung zones and the central portions of the lung.
 INTERSTITIAL NETWORK
HRCT O F A B N O R M A L INTERSTITIUM, S A R C O I D O S I S

Nodular thickening of
interlobulai st'pta

Subpleural nodules 1 ■

Nodular thickening of
bronchovascular
bundles Thick bronchovascular
bundles

Nodular thickening of — |
bronchovascular
bundle

Thick nodular
bronchovascular
bundle
Nodular thickening of —
interlobular septa

(Top) First of two axial HRCT scans of a patient with sarcoidosis shows nodular thickening of
bronchovascular/bronchoarterial bundles (axial interstitium) and interlobular septa (peripheral interstitium) with
several subpleural nodules (peripheral interstitium). (Bottom) Image through the lower lungs shows nodular
thickening of bronchovascular bundles a n d interlobular septa.
 INTERSTITIAL NETWORK
RADIOGRAPHY OF ABNORMAL INTERSTITIUM, IDIOPATHIC PULMONARY FIBROSIS

Peripheral 6; basal — Peripheral reticular

reticular opacities opacities

Coarse peripheral
reticular opacities

(Top) PA chest radiograph of a patient with idiopathic pulmonary fibrosis (IPI-) shows reticular opacities that
predominantly involve the peripheral and basal aspects of both lungs. (Bottom) PA chest radiograph of a patient
with advanced idiopathic pulmonary fibrosis shows moderate to coarse reticular opacities that predominantly
involve the peripheral and basal aspects of both lungs.
 INTERSTITIAL NETWORK
HRCT OF ABNORMAL INTERSTITIUM, IDIOPATHIC PULMONARY FIBROSIS

Traction bronchicctasis

Honeycomb cyst —1 Irregular pleural

interface

Irregular thickening of -
interlobular septa

Irregular pleural
interface

Intralobular retiiular
opacities

(Top) first of two axial HRCI images of a patient with early idiopathic pulmonary fibrosis shows diflusc involvement
of the peripheral and parenchyma] interstitium. HRCI' through t h e right upper lobe shows irregular thickening of
interlobular septa that results in irregular pleural interfaces. The diagnosis of underlying fibrosis is supported by t h e
presence of traction bronchicctasis and subtle subpleural honeycombing manifesting with tiny subpleural cystic
changes. (Bottom) HRCT through the lower lungs shows irregular thickening of interlobular septa, intralobular
reticular opacities and irregular pleural interfaces. Interstitial fibrosis results in visualization of an abnormal
pulmonary interstitium.
 LUNGS
■ Mediastinal (anterior) and vertebral I posterior)
I Terminology components
Abbreviations ■ Surrounds the hilum
• Right upper lobe ( R l L) ■ Anterior concavitv to accommodate mediastinal
• Middle lobe (MI.) structures
• Right lower lobe (RLL) ■ Right cardiac indentation, predominantly from
right atrium
• I eft upper lobe (LUL)
• left lower lobe (I I I ) ■ I eft cardiac indentation, predominantly from left
ventricle
Definitions ■ Right lung indented by superior and inferior
• Middle lobe: Frequently used to refer to right middle venae cavae. a/ygos vein, esophagus, right
lobe <is there is normally n o left middle lobe brachiotephalit vein
• 1 ingula: Tongue like morphology of Interior aspect of ■ I eft lung indented by aortic arch, descending
lelt upper lobe, equivalent to con trilateral middle lolie aorta, esophagus, left brachfocephalic vein, left
subciavian arterv
• Borders
[Anatomy | Inferior border
■ Separates base from costal surface
General Anatomy Posterior border
• 1 wo lungs, each on either side of t h e mediastinum ■ Separates costal surface from mediastinal surface
• Lath lung lined bv \isceral pleura Anterior border
• Tath lung freely mobile within pleural space with ■ Separates costal surface from mediastinal surface
medial attachments at hilum and pulmonary ligament ■ Right anterior border is vertically oriented
• Right lung ■ Left anterior border exhibits Mt inferior concav itv
I argest or left c a r d i a c n o t c h
■ three lobes
■ Some spatial medial encroachment by adjacent
right mediastinal structures JLobes
Lobes
■ Right upper lobe
Boundaries
- Middle lobe • I obar boundaries defined bv adjacent pleural fissures
■ Right lower lohe • Right major fissure
• I eft lung Separates upper and middle lobes from lower lobe
• Smallest • Minor fissure
■ I wo lobes Separates anterior upper lobe from middle lolie
■ I arger spatial medial encroachment by left • Left major fissure
mediastinal structures Separates upper lobe from lower lobe
• Accessory azygos fissure
Surface Anatomy Gives rise t o anomalous lobe within right upper lobe
• Shape
Each lung resembles a half a c o n e morphologically Internal Structure
• \natomic landmarks of t h e lung • I obar anatomy related to lobar bronchial branches
One apex ancl corresponding pulmonarv arteries that supply the
Due base lobes
I w o surfaces
I hree borders
Right Lung
• Right u p p e r lolx? (right superior lobe)
• Apex
• Middle lobe
Most superior extent of t h e lung
• Right lower lobe (right interior lobe)
■ Level with posteromedial first rib
■ \\iex 3-4 t m above first costal cartilage Left Lung
■ A|K'X 2.5 cm above medial clavicle • I eft u p p e r lobe (left superior lobe)
• Base • I elt lower lobe (lelt inferior lobe)
c oncave scmiluinir morphology adapted to the
shape of adjacent diaphragm Azygos Lobe
■ Deeper concavity in right lung base • Normal variant seen in approximately 0.5% of chest
Slight vertical orientation posteriorlv radiographs
■ Rosterolatcral interior extension into • Reported 2:1 male to female ratio
costodiaphragmatic recesses • I mbryologv
• Surfaces Anomalous development of azygos vein forms
Costal surface accessory azygos fissure
■ Convex morphologv • Imaging
■ Indented bv the ribs \ isualization of azygos fissure
Mediastinal or medial surface
 LUNGS
■ Ihin curvilinear opacity oriented obliquely in
medial right upper lobe
■ terminates in "teardrop" opacity representing the
azygos vein
: Variable size and morphology of azygos lobe and
azvgos vein
typically supplied by apical bronchus or its
branches
[Segments
Internal Structure
• Segmental anatomy related t o segmental bronchial
branches and corresponding pulmonary arteries that
supply the segments
Right Upper Lobe
• Apical segment
• Posterior s e g m e n t
Abuts superior major and posterolateral minor
fissures
Abuts posterolateral costal and posterosuperior
mcdiastinal surfaces
• Anterior segment
Abuts anterior minor fissure
Abuts anterolateral costal and mid anterior
mcdiastinal surfaces
Middle Lobe
• Lateral segment
Abuts inlerolateral major and lateral minor fissures
c .Abuts interior anterolateral costal surface
• Medial s e g m e n t
Abuts inferomedial major and anteromedial minor
fissures
0 Abuts mid anterior costal and inferior anterior
mcdiastinal (right heart border) surfaces
Right Lower Lobe
• Superior s e g m e n t
Abuts superior major fissure
Abuts mid posterolateral costal and mid posterior
mediastinal surfaces
• Medial basal s e g m e n t
Abuts inferomedial major fissure
Units mid interior mediastinal surface
• Anterior basal segment
'. Abuts inferolateral major tissure
Abuts inferior lateral costal surface
• I alciril li.is.il segment
Abuts posterolateral major fissure
Abuts inferior posterolateral costal surface
• Posterior basal s e g m e n t
Abuts inferior posteromedial costal a n d inferior
posterior mediastinal surfaces
Left Upper Lobe
• Apicoposterior segment
1
Abuts superior major fissure
• Anterior segment
■ Abuts anteromedial costal and mid anterior
mediastinal surfaces
• Superior lingular s e g m e n t
Units mid lateral major fissure
□ Abuts inferior anterolateral costal and mid anterior
mediastinal (superior left heart border) surfaces
• Inferior lingular s e g m e n t
Abuts inferior major fissure
Abuts inferior anteromedial costal a n d inferior
anterior mediastinal (inferior left heart border)
surfaces
Left Lower Lobe
• Superior s e g m e n t
Abuts superior major fissure
Abuts mid posteromedial costal and mid posterior
mediastinal surfaces
• Anteromedial basal segment
Abuts inferior major fissure
o Abuts inferior mid lateral costal and mid inferior
mediastinal surfaces
• Lateral basal segment
Abuts inferior posterolateral costal surface
• Posterior basal s e g m e n t
-. Abuts inferior posteromedial costal a n d inferior
posterior mediastinal (descending aorta) surfaces
Anatomy Based Imaging
Abnormalities
General Principles
• Utilization of lobar/segmental anatomy for
localization of disease
■ Use ot o r t h o g o n a l radiographs ro localize lesions
within a lobe or segment
• Determination of v o l u m e loss based on fissural
displacement
• ( I localization of lesions within a lobe or segment
<- Multiplanar reconstructions for accurate localization
with respect to fissures
Preoperative assessment and staging ol patients
with l u n g cancer
■ lesion localization and exclusion of involvement
of adjacent lobes
• Determination of segmental vs. non-segmental
abnormalities on ventilation/perfusion nuclear
scintigraphv
Sign of the Silhouette
• Obscuration of right superior m e d i a s t i n u m
Right u p p e r lobe airspace disease
• Obscuration ot right cardiac b o r d e r
Middle lobe airspace disease
1
Middle lobe medial segment airspace disease
• Obscuration of left cardiac border
i Lingular airspace disease
■ Superior and/or inferior lingular segments
• Obscuration of left superior m e d i a s t i n u m
Left upper lobe airspace disease
• Obscuration ol h e m i d i a p h r a g m
Lower lobe airspace disease
• Obscuration of d e s c e n d i n g a o r t a
I eft lower lobe airspace disease
■ Superior a n d / o r posterior basal segments
 LUNGS
OVERVIEW OF THE LUNGS

¥■
fc Lung apices

■ ■■
J I

Right lung
Mediastinum

*
A Left lung

Chest wall

.9WH - -«• . -' "

Graphic depicts the anatomy of the anterior lungs. The lungs are surrounded by the pleura and the skeletal and soft
tissue structures of the chest wall. The two lungs are located on either side of the mediastinum. Each lung is freely
mobile within its surrounding pleural space and is attached to the mediastinum at the hilum and pulmonary
ligament. The lung apices project above the medial clavicles and anterior first ribs and course towards the roots of
the neck. The right lung has three lobes and is larger than the left lung. The left lung has two lobes.
 LUNGS
SURFACE ANATOMY, ANTERIOR AND POSTERIOR LUNGS

Right apex

Right costal surface

Left anterior border

Cardiac notch, left

anterior border

Right inferior border

Left base

i.

Left apex

nro : posteric

Right costal surface

Left inferior border

(Top) Graphic depicts the surface anatomy of the anterior lungs. The shape of each lung resembles that of a half
cone. The lung surface anatomy is characterized by an apex, a base, two surfaces and three borders. The apices
represent the highest extent of the lungs. The anterior borders separate the anterior costal surfaces from the
medlastinal (medial) surfaces. Note the arcuate morphology of the Inferior aspect of the left anterior border, the
cardiac notch. The costal surfaces are adjacent to the chest wall. The Inferior borders separate the costal surfaces from
the bases. (Bottom) Graphic depicts the posterior lung surfaces. The inferior lung borders separate the costal surfaces
from the lung bases. The posterior borders separate the costal surfaces from the mediastinal (medial) surfaces.
 LUNGS
SURFACE ANATOMY, LATERAL LUNGS

Right apex

Indentation produced
by adjacent right rib

Right costal surface

Right Inferior border

Left apex

Left costal suiface

Left Inferior border

(Top) Graphic depicts the lateral surface anatomy of the right lung. The lateral lung surface forms part of the costal
surface named for the adjacent ribs (and intercostal spaces) which produce obliquely oriented indentations on the
lung parenchyma. The inferior border separates the lateral costal surface from the base. (Bottom) Graphic depicts the
lateral surface anatomy of the left lung. The lateral surface forms part of the costal surface. The inferior border
separates the costal surface from the base.
 LUNGS
SURFACE ANATOMY, MEDIAL LUNGS O
3"
(D

C
CO
Esophagus Indentation

Superior vena cava

indentation

Azygosveln
Indentation
Right anterior border

Right posterior border

Right cardiac
indentation

Right medial surface

Esophagus indentation

Aortic arch indentation

Left anterior border

Descending aorta
Indentation

Left cardiac
indentation

Left lung base

(Top) Graphic depicts the surface a n a t o m y of the medial right lung. The mediastinal surface is concave a n d exhibits
indentations produced by adjacent mediastinal structures, including vessels and organs. The right cardiac
Indentation is produced predominantly by t h e right atrium. The anterior border separates the mediastinal surface
from the costal surface. The right hllum is located centrally o n the mediastinal surface. (Bottom) Graphic depicts the
surface a n a t o m y of t h e medial left lung. The mediastinal surface exhibits indentations produced by adjacent
mediastinal structures. The left cardiac indentation is predominantly produced by t h e left ventricle. The descending
aorta indents the left lower lobe a n d correlates with visualization of t h e retrocardiac descending aorta o n frontal
chest radiographs.
IS
 LUNGS
RADIOGRAPHY, SURFACE ANATOMY OF THE LUNGS

Left lung apex

Right costal surface

Left cardiac
indentation,
Right cardiac —jj mediastinal surface
indentation.
mediastinal surface

Left base

Anterior costal surface

— Posterior costal surfaces

— I ung bases

(Top) First of two normal chest radiographs of the same patient demonstrates the radiographic surface anatomy of
the lungs. PA chest radiograph shows the costal and mediastinal lung surfaces, the lung bases and the apices. Note
the left cardiac indentation on the mediastinal surface produced predominantly by the left ventricle. The right
cardiac indentation on the right medial surface is produced predominantly by the right atrium. (Bottom) Left lateral
chest radiograph demonstrates the anterior and posterior aspects of the costal surfaces and the morphology of the
lung bases. Note the indentations made on the costal surface by the adjacent anterior ribs. The bases exhibit a
convex morphology with a more horizontal orientation anteriorly and a near vertical orientation posteriorly.
 LUNGS
CT, SURFACE ANATOMY OF THE LUNGS

- — Left mediastinal surface

Aortic indentation, left

mediastinal surface
Right costal surface

Cardiac indentation, right -

mediastinal surface Cardiac indentation, left
mediastinal surface

Right costal surface

— Left lung apex

Right costal surface

- 1 — Left lung base

(Top) First of three normal chest CT images (lung window) depicting the CI surface anatomy of the lungs. Axial CT
below the carina demonstrates the undulating morphology of the costal lung surfaces related to indentations
produced by adjacent ribs. The left mediastinal surface is indented by the descending thoracic aorta. (Middle) Axial
CT at the level of the heart demonstrates the surface anatomy of the inferior lungs. The costal surfaces exhibit an
undulating morphology produced by adjacent ribs. Note the larger left cardiac indentation on the mediastinal
surface produced by the left ventricle and the smaller contralateral indentation produced by the right atrium.
(Bottom) HRCT with coronal reconstruction demonstrates the morphology of the apices and the bases. Note the
undulating morphology of the costal surfaces and the superiorly convex morphology of the bases.
 LUNGS
LOBES

Right upper lobe Left upper lobe

Left lower lobe

Right lower lobe

Left upper lobe Right upper lobe

Middle lobe

Left lower lobe

Right lower lobe

(Top) Graphic depicts the anatomy of the anterior lung lobes. The right lung has three lobes and Is larger than the
left. Visceral pleura lines each of the lobes which are compartmentalized by the interlobar fissures. (Bottom) Graphic
depicts the anatomy of the posterior lung lobes. The lobar boundaries are demarcated by the interlobar fissures. Note
the superior extent of the posterior lower lobes.
 LUNGS

(Top) Graphic shows the lateral right lung surface and the location of the three right lung lobes demarcated by the
interlobar (major and minor) fissures. The right upper and middle lobes occupy the anterior right lung. The right
lower lobe occupies the posterior inferior right lung. Note the superior extent of the posterior right lower lobe.
(Bottom) Graphic shows the lateral left lung surface and the location of the two left lung lobes separated by the left
major fissure. The left upper lobe occupies the anterior superior left lung. The left lower lobe occupies the posterior
Inferior left lung. Note the superior extent of the posterior left lower lobe.
 LUNGS
RADIOGRAPHY, LOBES

Right upper lobe -

Right cardiac border — Left cardiac border

Left hemidiaphragm

Upper lobes

Minor fissure —

— Lower lobes

—
Middle lobe and lingula

— Hemidiaphragms

Right lower lobe

Right inferior border —

(Top) lirst of two normal chest radiographs of the same patient illustrating the location of the lung lobes. PA chest
radiograph shows the right and left cardiac borders that abut the middle and left upper lobes respectively. The lower
lobes abut the hemidiaphragms. The relationship of the right upper and middle lobes can be evaluated on
radiography when the minor fissure is visible. (Middle) Left lateral radiograph shows the lower lobes in the posterior
inferior thorax above the posterior hemidiaphragms. The middle lobe and lingula project over the heart. The right
upper lobe is superior to the minor fissure. The right and left upper lobes and the middle lobe are located anterior to
the major fissures. (Bottom) Normal upright abdominal radiograph shows the inferior extent of the posterior lower
lobes with pulmonary vessels visible through the right hemidiaphragm.
 LUNGS
CORONAL & OBLIQUE SAGITTAL CT, LOBES

Right upper lobe -

— Left upper lobe

Right middle lobe-

- Left lower lobe

Right lower lobe -

Right upper lobe

Anterior chest wall

Posterior chest wall

Right middle lobe -

— Right lower lobe

Right base

— Left upper lobe

Left lower lobe -

— Left base

(Top) Normal coronal I1RCT (lung window) demonstrates the five lung lobes and their relationships to adjacent
structures. Visualization of the interlobar fissures allows identification of the boundaries of each lobe. (Middle) First
of two normal oblique coronal chest CT images (lung window) demonstrating the relationship of the lung lobes.
Image of the right lung shows that the right upper lobe forms the right apex and occupies the anterosuperior and
posterosuperior right lung. The middle lobe occupies the mid anterior right lung. The right lower lobe occupies the
posterior right lung and exhibits superior concavity at the base. (Bottom) Image of the left lung shows the
anterosuperior location of the left upper lobe and the superior extent of the left lower lobe. The left lower lobe forms
the concave left lung base.
 LUNGS
AXIAL CT, LOBES

Right upper lobe -

— Left upper lobe

— Left major fissure

— Left lower lobe

Right upper lobe ~

Left upper lobe

Major fissure — - Major fissure

— Left lower lobe

_
Right lower lobe

Right upper lobe

- Left Upper lobe

Minor fissure -

Major fissure —

Left lower lobe

Right lower lobe -

(Top) First of six normal thin section chest CT images (lung window) of the same patient demonstrates the axial
a n a t o m y of the lung lobes. Image through the aortic arch shows that the upper lobes occupy the superior aspects of
the lungs. Visualization of the fissures allows identification of the different lobes. A very small portion of the superior
left lower lobe is anteriorly bound by the major fissure. (Middle) Axial image through the carina demonstrates the
anterior location of the upper lobes a n d the posterior location of the lower lobes. The major fissures manifest as
avascular bands between the lobes. (Bottom) Axial image through the bronchus intermcdius shows portions of the
three right lung lobes. The minor fissure is seen as an avascular band. The lower lobes are located posteriorly, the
upper lobes and middle lobe are located anteriorly.
 LUNGS
AXIAL CT, LOBES

— Portion of minor fissure

Right upper lobe -

Middle lobe - Left upper lobe

Right lower lobe — Left lower lobe

Right middle lobe -

Left upper lobe

Right lower lobe — Left lower lobe

- Lower lobes

(Top) Axial image through the lower lobe bronchi demonstrates that the middle lobe abuts the right cardiac border.
The minor fissure is barely visible as is a tiny portion of the right upper lobe. (Middle) Axial image through the heart
demonstrates its relationship to the middle and left upper lobes. The inferior left upper lobe abuts the left ventricle.
The right middle lobe abuts the right atrium. While the middle lobe and the left upper lobe have a significant
inferior extent, the lower lobes occupy the greatest lung volume at this level. (Bottom) Axial image through the
posterior lung bases demonstrates the retrodiaphragmatic and posteroinferior extent of the lower lobes and highlight
the concave morphology of the lung bases.
 LUNGS
C/5 SEGMENTS OF THE RIGHT LUNG
O
3

Apical segment RUL

a
O

Posterior segment RUL Anterior segment RUL

Lateral segment ML
Medial segment ML

Posterior basal segment

RLL

Apical segment RUL

Posterior segment RUL

Superior segment RLL

Lateral segment ML

Posterior basal segment

RLL Lateral basal segment
RLL

(Top) First of four graphics depicting the segmental anatomy of the right lung. The anterior view shows the three
right upper lobe segments named after their respective segmental bronchi. As the nomenclature would suggest, the
apical, anterior and posterior segments occupy the corresponding regions of the right upper lobe. The anterior
segment of the right upper lobe abuts the minor fissure. The middle lobe has medial and lateral segments. The
medial segment abuts the right atrium. (Bottom) The posterior view shows the posterior segment of the right upper
lobe abutting the posterosuperior major fissure. The superior segment occupies the apex of the right lower lobe. The
basal segments are located inferior to the superior segment. The lateral basal segment of the right lower lobe Is
I located lateral to the posterior basal segment.
144
 LUNGS
SEGMENTS OF THE RIGHT LUNG

Apical segment RUL

Posterior segment RUL

Anterior segment RUL

Superior segment RLL

I
Medial segment ML
Lateral basal segment
RLL

Anterior basal segment Lateral segment ML

I-
RLL

■ Apical segment RUL

r^ ■
Anterior segment RUL
Posterior segment RUL

Superior segment RLL

Medial segment ML Posterior basal segment

RLL
Medial basal segment
RLL

i Lateral basal segment

RLL RLL
^ ^

(Top) Lateral view of the right lung shows the location of the right upper lobe segments (posterior, apical and
anterior) corresponding to their anatomic positions within the lobe. The anterior segment of the right upper lobe
abuts the anterior minor fissure. The medial segment of the middle lobe is located anterior to the lateral segment.
Note the relationship of the anterior basal and lateral basal segments below the superior segment of the lower lobe.
(Bottom) Medial view shows the anatomic location of the right upper lobe segments. The anterior segment abuts the
minor fissure. The posterior segment abuts the superior major fissure. The medial segment of the middle lobe abuts
the right atrium. Note the relationship between the medial and posterior basal segments of the right lower lobe
situated below the superior segment, which abuts the superior major fissure.
 LUNGS
SEGMENTS OF THE LEFT LUNG

Apicoposterlor segment
LUL

Anterior segment I.UL

Superior llngular
segment LUL

Posterior basal segment

LLL Anteromedlal basal
segment LLL

Inferior llngular
segment LUL Lateral basal segment
LLL

Apicoposterlor segment
LUL

Superior segment LLL

Lateral basal segment

LLL Posterior basal segment
LLL

r graphics depleting the segmental anatomy of the left lung. The anterior view shows the four
segments of the left upper lobe. The apicoposterlor segment forms the apex and Is located above the anterior
segment which in turn is located above the ungula. The superior and inferior llngular segments abut the superior and
Inferior aspects of the left cardiac border respectively. Note the anterior and medial location of the anteromedlal
basal segment of the left lower lobe and the posteromedial location of the posterior basal segment. (Bottom) The
posterior view shows the apicoposterlor segment of the left upper lobe above the posterior majorfissure.The superior
segment of the left lower lobe also abuts the posterior major fissure. The posterior basal segment of the left lower
lobe is located medial to the lateral basal segment
 LUNGS
SEGMENTS OF THE LEFT LUNG

- — Aplcoposterior segment
LUL
4k\ k

Anterior segment LUL Superior segment LLL

uU

Superior llngular
segment Lin- Lateral basal segment
LLL

Inferior llngular
segment LUL
Anteromedlal basal
segment LLL

1
^ ^
Aplcoposterior segment
LUL

Superior segment LLL

Anterior segment LUL

Superior llngular
segment LUL
Posterior segment LLL
Inferior llngular
segment LUL

Anteromedlal basal
Lateral basal segment segment LLL
LLL

(Top) Lateral view shows t h a t t h e aplcoposterior a n d anterior segments occupy the corresponding regions of t h e left
upper lobe. The superior llngular segment abuts the mid portion of the left major fissure and a small portion of the
inferior llngular segment abuts the inferior left major fissure. Note the anterior location of the anteromedlal basal
segment of the left lower lobe with respect to the lateral basal segment. The apex of the lower lobe is formed by the
superior segment. (Bottom) Medial view shows the relative locations of the segments of the upper lobe
(aplcoposterior, anterior, superior llngular and inferior llngular). The superior segment of the lower lobe abuts the
superior major Assure and is situated above the basal segments. Note the relationship between the posterior and
anteromedlal basal segments of the lower lobe.
 LUNGS
CT, L U N G S E G M E N T S

Apical segment RUL —

Apicoposterior segment
LUL

Posterior segment RUL

Superior segment LLL

Anterior segment RUL Anterior segment LUL

Lett major fissure

Superior segment KL1. Superior segment LLL

(Top) First of f o u r n o r m a l HRCT images illustrates the general a n a t o m i c locations o f t h e different l u n g segments. CT
segmental a n a t o m y is d e t e r m i n e d using t h e fissural a n d b r o n c h i a l a n a t o m y t o d e t e r m i n e t h e l o c a t i o n of a specific
l u n g segment. Axial image t h r o u g h the aortic arch shows t h e location o f t h e apical a n d posterior r i g h t upper lobe
segments. Ihese are c o m b i n e d i n t o a single apicoposterior segment i n t h e left upper lobe based o n t h e u n d e r l y i n g
b r o n c h i a l anatomy. Visualization o f the left major fissure allows i d e n t i f i c a t i o n o f a small p o r t i o n o f the superior
segment of the left lower lobe. (Bottom) Axial image b e l o w t h e carina demonstrates t h e l o c a t i o n o f the anterior
segments o f the r i g h t a n d left upper lobes. The superior segments o f t h e lower lobes are located posterior t o the
superior aspects o f t h e bilateral m a j o r fissures.
 LUNGS
CT, LUNG SEGMENTS

Medial segment M l —

— Superior lingular
segment LU1.

Lateral segment M L ~~

Superior segment I LI
Superior segment RU —

Inferior lingular
segment I.UI.

Medial basal segment

RU Anteromedial basal
segment 111
Anterior basal segment
RU

Lateral basal segment lateral basal segment

KLL III
Posterior basal segment
Kl.l
Posterior basal segment
III

( l o p ) Axial image t h r o u g h t h e segmental m i d d l e lobe a n d l i n g u l a r b r o n c h i demonstrates t h e relative locations o f the

medial and lateral segments of t h e m i d d l e lobe. The superior lingular segment of the left upper lobe is also s h o w n .
The superior segments o f the right and left lower lohes are located posterior t o t h e superior aspects o f t h e bilateral
major fissures. ( B o t t o m ) Axial image t h r o u g h the basal lower lobe segments demonstrates the relative locations of
the medial, anterior, lateral and posterior basal segments of t h e right lower lobe. The inferior lingular segment of the
left upper lobe is located anterior t o t h e inferior aspect of I he left major fissure. The left lower lobe has three basal
segments designated anteromedial, lateral a n d posterior. Note their relative locations inferred f r o m t h e location of
their respective segmental b r o n c h i .
 LUNGS
PERFUSION SCINTIGRAPHY, LUNGS

Left posk-i KM oblique

Posterior view _ view

Anierior view r Right anterior oblique

view

First of two images from a normal perfusion lung scan shows homogeneous distribution of activity throughout the
pulmonary lobes a n d segments indicating normal lung perfusion. Understanding the segmental anatomy of the
lungs in various projections is crucial for accurate interpretation of pulmonary nuclear scintigraphy. Note the inferior
extent of the lungs o n t h e posterior view. The cardiac notch of the left upper lobe is nicely depicted on the anterior
view. The right anterior oblique view shows the concave morphology of the right base.
 LUNGS
PERFUSION SC1NTIGRAPHY, LUNGS
o
3"
TO

C
CO

Left lateral view — Left anterior oblique

view

Night posterior
Right lateral view — oblique view

Additional views demonstrate homogeneous distribution of activity throughout the lungs indicating normal
pulmonary perfusion and no evidence of thromboenibolic disease. The left lateral view shows relative absence of
activity in the anterior inferior left lung corresponding to the cardiac notch of the left anterior lung border. The right
lateral view shows the concave morphology of the right base. The right posterior oblique view shows the inferior
extent of the posterior right lower lobe.

I
m
 LUNGS
RADIOGRAPHY, AZYGOS LOBE

( l o p ) PA chest radiograph c o n e d - d o w n t o t h e right upper l u n g demonstrates an azygos lobe. The t h i n accessory

azygos fissure terminates i n f e r i o r l y as a teardrop opacity that represents t h e anomalous azygos v e i n . The azygos
fissure divides t h e superior aspect o f the upper lobe a n d demarcates the lateral b o u n d a r y o f t h e anomalous azygos
lobe. ( B o t t o m ) first o f f o u r images o f an a s y m p t o m a t i c y o u n g m a n w i t h a n i n c i d e n t a l l y discovered azygos lobe. PA
chest radiograph c o n e d - d o w n t o the upper lobes demonstrates t h e characteristic m o r p h o l o g y o f t h e accessory azygos
fissure. The azygos lobe i n this example is s l i g h t l y smaller a n d t h e anomalous azygos v e i n is less apparent. There is
great v a r i a b i l i t y in the size a n d c o n f i g u r a t i o n o f the azygos lobe, t h e course of t h e azygos fissure a n d t h e course, size
a n d m o r p h o l o g y of t h e a n o m a l o u s azygos v e i n .
 LUNGS
CT, AZYGOS LOBE
o
CD

c
CO
to

Azygos lolx1
Azygos fissure —

Superior vena cava —

- Trachea
Anomalous azygos arch

- Azygos lobe

Posterior azygos fissure

Superior vena cava

- Trachea

Posterior azygos arch -

(Top) Contrast-enhanced chest CT (lung window) demonstrates the cross-sectional morphology of the azygos lol>e.
Axial image through the superior aspect of the azygos lobe demonstrates the thin accessory azygos fissure that
demarcates the lateral boundary of the azygos lobe which extends behind the trachea. (Middle) Axial image through
the aortic arch demonstrates the anomalous azygos arch that courses within the accessory azygos fissure and
anastomoses anteriorly with the superior vena cava. (Bottom) Axial image through the inferior aortic arch
demonstrates the posterior aspect of the anomalous azygos arch. Note that the azygos fissure is n o longer seen in its
entirety. The medial aspect of the azygos lobe is still evident.

[SI
 LUNGS
RADIOGRAPHY, LOBAR PNEUMONIA

I UL airspace disease

Retrocardiac
descending aorta

— Left hemidiaphragm

LUL airspace disease — Left major fissure

— Normally expanded
lower lot>es

— Lett hemidiaphragm

(Top) Pirst of two chest radiographs of a 42 year old m a n with left upper lobe pneumonia demonstrates complete
opacifitation of the left upper lobe. PA chest radiograph demonstrates obscuration of the left anterior mediastinal
structures. The left hemidiaphragm a n d retrocardiac descending aorta arc visible indicating that the left lower lobe is
not involved. The radiographic findings are consistent with left upper \o\ie airspace disease. (Hottorn) Left lateral
chest radiograph confirms that the consolidation is located in the left upper lobe and involves it in its entirety. The
airspace disease is located anterior to the major fissure. The left lower lobe is normally expanded a n d of normal
opacity. The left hemidiaphragm is not obscured indicating that the left lower lobe is not involved.
 LUNGS
R A D I O G R A P H Y , LOBAR ATELECTASIS
o
3"
a

CO
Obscured RUL bronchus —

F.levatcd minor fissure ■—

Right hilar mass

—
Elevated mine>i fissure

—
1 leterogeneous central mass

Collapsed right upper lobe -

(lop) I-irst of three images of a 72 year old man who presented with hemoptysis. PA chest radiograph demonstrates
right upper lobe volume loss manifesting with elevation of the minor fissure and a central convexity produced by a
right hilar mass. The central mass prevents complete right upper lobe atelectasis and produces the S-sign of Golden.
The right upper lobe bronchus is obscured. (Middle) Left lateral chest radiograph demonstrates a triangular anterior
opacity representing the atelectatic right upper lobe. A portion of the elevated minor fissure is also visible. (Bottom)
Contrast-enhanced chest CT (mediastinal window) shows the atelectatic right upper lobe manifesting as a triangular
anterolateral soft tissue structure. The right upper lobe bronchus (not shown) was obstructed by a heterogeneous
central mass that represented a primary lung cancer. I
155
 LUNGS
R A D I O G R A P H Y , LOBAR ATELECTASIS

Left major fissure

Collapsed 1.1.1

Elevated left —
hemidiaphraRin Non visualization of
portion of left
hemidiaphragm

(Top) first of four images of a 67 year old man who presented with hemoptysis. I'A chest radiograph demonstrates
shift of the midline structures to the left in association with relative hyperlucency of the aerated left lung. An
elongate triangular retrocardiac opacity obscures the distal descending aorta and the medial left hemidiaphragm
localizing the process to the left lower lobe. The triangular morphology of the abnormality and the associated
findings are consistent with left lower lobe atelectasis. (Bottom) Left lateral chest radiograph demonstrates elevation
of the left hemidiaphragm consistent with left lung volume loss. The posterior aspect of the left hemidiaphragm is
obscured by the adjacent atelectatic left lower lobe.
 LUNGS
CT, LOBAR ATELECTASIS

- Left lower lobe

bronchus

Left major fissure

— Central mass

Left major fissure

Atelectatic LI 1. —

(Top) Contrast-enhanced chest CT (lung window) confirms the presence of left lower lobe alelectasis. There is mass
effect on and narrowing of the lumen of the left lower lobe bronchus consistent with an obstructive process. The
atelectatic left lower lobe abuts the descending aorta and obscures its lateral border on the frontal chest radiograph.
The medially displaced left major fissure outlines the border of the atelectatic left lower lobe. Note the relative
hyperlucency of the left upper lobe as compared to the right lung. (Bottom) Unenhanced chest CT (mediastinal
window) demonstrates the soft tissue attenuation of the atelectatic left lower lobe, which abuts the descending aorta.
A heterogeneous central mass representing a bronchogenic carcinoma obstructs the left lower lobe bronchus.
 LUNGS
RADIOGRAPHY, SECMENTAL AIRSPACE DISEASE

Ml. airspace disease

Obscured right cardiac
border

Right hemidiaphragm —

Minor fissure
1,'ninvoJvcd portion of —
ML

MI. airspace disease —

Right hemidiaphragm

(Top) first of four images of a 35 year old man with right middle lobe pneumonia. PA chest radiograph demonstrates
airspace disease in the right lower lung zone. The airspace abnormality obscures the right cardiac border indicating
its right middle lobe anatomic location. (Bottom) Left lateral chest radiograph shows that the process overlies the
heart and confirms its middle lobe location. The consolidation abuts the major fissure posteriorly. A portion of the
middle lobe below the minor fissure is still aerated indicating that the entire middle lube is not affected. The lungs
posterior to the major fissures are well aerated and the hemidiaphragms are visible indicating that the right lower
lobe is not affected.
 LUNGS
CT, SEGMENTAL AIRSPACE DISEASE

Uninvolved medial
segment ML

Lateral segmented
bronchus, Mi-
Medial segmental
bronchus Ml.
Middle lobe
consolidation

Right major fissure

Uninvolved medial
segment Ml.

Airspace disease in
lateral segment of ML

Kight major fissure -

(Top) Contrast-enhanced chest CT (lung window) demonstrates the middle lobe consolidation. Portions of the
medial and lateral segmental middle lobe bronchi are visible. A portion of the medial segment of the middle lobe is
aerated and uninvolved. The posterior boundary of the right middle lobe process is demarcated by the major fissure.
(Bottom) Contrast-enhanced chest CT (mediastinal window) demonstrates the middle lobe consolidation which
affects the lateral segment of the middle lobe in its entirety. The airspace process abuts the right major fissure
posteriorly. A portion of the medial segment of the middle lobe remains uninvolved.
 LUNGS
RADIOGRAPHY, SEGMENTAL AIRSPACE DISEASE

— Inferior lingular
segment airspace
disease

— Left pleura) effusion

Subtle lingular airspace

disease — Anteromedial t\
posterior basal
segmenial opacities

(Top) first of two chest radiographs of a 44 year old w o m a n with multifocal pneumonia. PA chest radiograph
demonstrates airspace disease in the left lower lung zone. The process obscures the inferior left cardiac border
consistent with involvement of the inferior lingular segment of the left upper lobe. There is a small pleural effusion.
(Bottom) Left lateral chest radiograph demonstrates subtle opacity projecting over the heart and confirms left upper
lobe involvement by pneumonia. The increased opacity in the left lower lobe corresponded to subtle involvement of
the anteromedial basal a n d posterior basal segments of the left lower lobe.
 LUNGS
R A D I O G R A P H Y , SECMENTAL AIRSPACE DISEASE

— LLL airspace disease

Airspace disease in
posterior basal segment
III

Crop) First of two radiographs of a 28 year old man with early left lower lobe pneumonia. PA chest radiograpli
demonstrates subtle focal airspace disease located predominantly in the mid portion of the retrodiaphragmatic left
lower lobe. (Bottom) Left lateral chest radiograph demonstrates abnormal opacity located posteriorly and projecting
over a distal thoracic vertebral body. The thoracic vertebrae should appear increasingly lucent when examined in the
cephalocaudad direction on lateral radiographs. Increased density over a distal thoracic vertebra is indicative of lower
lobe airspace disease. Knowledge of the segmental anatomy of the lung and evaluation of orthogonal radiographs
allows localization of the process to the posterior basal segment of the left lower lobe.
 LUNGS
SCINTIGRAPHY, LOBAR & SEGMENTAL ABNORMALITIES

— Normal ventilation

Normal ventilation
Hi I * I

RUL |>erfusion defect

I jugular perfusion — Uiigular/anteroniedial

defect basal perfusion defects

First of two images from a ventilation perfusion lung scintigraphy study of a 56 year old man with advanced prostate
cancer and new onset of dyspnea demonstrate abnormal distribution of activity. Anterior, left lateral and left
posterior oblique ventilation images (top row) demonstrate relatively normal distribution of activity throughout the
lungs. Anterior, left lateral and left posterior oblique perfusion images (bottom row) demonstrate miiltifocal lobar
and segmcntal areas of decreased activity denoting abnormal lung perfusion.
 LUNGS
NUCLEAR SCINTIGRAPHY, 1QBAR & SEGMENTAL ABNORMALITIES

Normal ventilation Normal ventilation

RUI. perfusion defect

RUI. perfusion defect

Abnonnal LLL activity —r '

Additional ventilation perfusion images demonstrate normal pulmonary ventilation on the posterior, right lateral
and right posterior oblique views (top row). Posterior, right lateral and right posterior oblique perfusion images
(bottom row) demonstrate a dominant perfusion defect affecting the right upper lobe and abnormal perfusion
affecting the left lower lobe. The findings are consistent with high probability for pulmonary thromboembolic
disease.
 HILA
jTerminology • Relationships
1 eft m a i n bronchus, located posteriorly in mid
Abbreviations hilum
• American Thoracic Societv (ATS) Left pulmonary arterv, superior to left main
bronchus
Definitions ■ ilvparterial bronchus, main bronchus below left
• l l i l u m : Small point of attachment of a seed to its base pulmonarv artery
or x|i|>|>"rt (plural; hila) I eft superior pulmonarv vein, anterior to left
■ I ung l l i l u m main bronchus and left pulmonarv artery
Point of connection between lung and mediastinum left inferior pulmonary vein in interior hilum
Central area between the mediastinum medially and
the lung laterally through which bronchi, vessels
and other structures course into the lung I Radiography of t h e Hila j
Frontal (PA/AP) Radiography
General Anatomy and Function • Superior right h i l u m
Right ascending pulmonarv arterv itninciis
Anatomy anterior) located medially
• l l i l u m located on central mediastinal lung surface Right superior pulmonary vein located laterally
• Hilar struitures Centrally located apical and anterior segmental
Pulmonary arteries bronchi
Pulmonary veins • Hilar angle
Main bronchi Angle formed by right superior pulmonary vein
lirom hi.il arteries/veins obliquely crossing right descending (interlobar)
Nerves pulmonarv arterv
I vinpli n o d e s • Inferior right h i l u m
lymphatics Right interlobar (descending) pulmonary artery
• Hilar boundaries located lateral to bronchus intermedius
Mediastinal pk'tiral reflections Right inferior pulmonary vein, minimal
■ Inferior extension as pulmonarv ligament contribution to hilar opacity
• Su|»erior left h i l u m
Function ■ Apical pulmonary artery located medially
• Mav play a role in stabilizing the lung Superior pulmonary vein located laterally
■ Pulmonary ligament \nterior and apieoposterior segmental bronchi
i May play a role in stabilizing the lower lolie located centrally
1
Mav accommodate ccphalocaudad motion of hilar ■ Interior left h i l u m
structures during respiration I eft interlobar pulmonary artery lateral to let!
lower lol>e b r o n c h u s
Minimal contribution from letl inferior pulmonary
[Hilar A n a t o m y | vein
• Hilar opacity
Right Hilum Greatest contribution from pulmonarv arteries and
• Structures superior pulmonary veins
Right main bronchus Minimal contribution from bronchial walls, lvmph
< Right pulmonarv artery branches nodes, surrounding tissues
< Right pulmonary veins • Hilar height
Itronchopiilmnnary lvmph ntxles Lett hilum higher than right in 97% ot cases
• Relationships Tqiial hilar height in 3% of cases
Right main bronchus located posteriorly and Right hilum never higher than left in normal
superiorly subjects
■ lparteri.il bronchus, first main branch arises
superiorly and above right pulmonary artery Lateral Radiography
Right pulmonary artery branches, anterior to right • Airwavs
main bronchus Right upper lobe bronchus
Right superior pulmonary vein, anterior to right ■ Superior round lucencv
pulmonary artery brant lies ■ Visible in 50% of cases
Right inferior pulmonary vein, in inferior hilum ■ Circumferential visualization of bronchial walls
suggests abnormal adjacent soft tissue
Left Hilum I eft upper lobe bronchus
• Structures ■ Interior round lucencv
I eft main bronchus ■ Visible in 75% of cases
I elt pulmonarv artery ■ typically circumferential wall visuali/ation.
I elt pulmonarv veins completely surrounded bv vessels
lironchopu 11 nonary l y m p h nodes
 HILA
i I n t e r m e d i a t e stem line Proximal b r o n c h u s intermedius/left u p p e r lobe
■ Vertical thin linear opacity formed by posterior bronchus
walls of right m a i n b r o n c h u s and b r o n c h u s Bronchus intermedius covered anterolaterally by
intermedius horizontal and vertical portions of interlobar artery
■ Normal thickness < 3 m m Kight superior pulmonary vein abuts junction of
■ Visible in 9 5 % of cases horizontal and descending interlobar artery
■ Outlined by eiidoluminal air and reliobroncliial ■ Characteristic "elephant heail-and-trunk"
lung in a/.ygocsophageal recess morphology
■ Courses through posterior/middle third of left Left distal main and upper lobe bronchi
u p p e r lobe b r o n c h u s Left interlobar artery posterior to bronchi
Anterior wall of left lower lobe b r o n c h u s Intennediate/lingular bronchi
■ Merges superiorly with left u p p e r lobe b r o n c h u s Bronchus intermedius
■ Visible in 4 5 % of cases Right interlobar artery lateral to bronchus
' Left retrobronchial line intermedius
■ I ormed by posterior walls of left m a i n b r o n c h u s Proximal lingular upper lobe and left superior
and left lower lobe b r o n c h u s segmental lower lo!>e bronchi
■ Normal thickness < .$ m m Left interlobar artery lateral to bronchial bifurcation
■ Terminates at origin of left lower lobe .superior Middle lobe b r o n c h u s
segmental b r o n c h u s Origin of middle lobe bronchus and superior
■ Shorter and posterior to i n t e r m e d i a t e stem line segmental bronchus (the latter may arise slightly
Vessels superior t o this level)
Right h i l a r vascular opacity o Middle lobe artery lateral to bronchus
■ Anterior to the hilar airways Right interlobar artery lateral to bifurcation of
■ Posteriorly located right a s c e n d i n g and bronchus intermedius into middle and lower lobe
interlobar arteries bronchi
■ Anteriorly located right superior p u l m o n a r y Anteromedial right superior pulmonary vein
vein left interlobar pulmonary artery lateral to left lower
■ Surrounding areolar tissue and lymph nodes lobe truncus basalis
■ Right pulmonary artery is intramediastinal and Basilar lower lobe b r o n c h i / i n f e r i o r p u l m o n a r y
does not form part of hilar vascular opacity veins
t Left hilar vascular opacity Right medial basal segmental bronchus anterior to
■ Left pulmonary artery, forms arcuate opacity inferior pulmonary vein
superior and posterior to left upper lobe o Right anterior, lateral and posterior segmental
bronchus bronchi lateral and posterior to inferior pulmonary
■ Superior aspect of left p u l m o n a r y a r t e r y visible vein
in 9 5 % of cases o Left anleromedial segmental bronchus anterior to
c Inferior hilar w i n d o w inferior pulmonary vein
■ Avasculnr zone in anterior inferior hilum inferior o I clt lateral and posterior segmental bronchi
to lower lobe bronchi |K)slerior to inferior pulmonary vein

[CT of the Hila Hilar Lymph Nodes

Six Characteristic Axial Levels Normal Lymph Nodes
■ Supracarinal trachea • Radiography
Right apical artery medial to apical segmental Typically not apparent
bronchus May be visible when calcified
Right apical vein lateral to apical segmental • C I
bronchus Small soft tissue nodules, may exhibit tat
c left apicoposterior segmental bronchus and artery attenuation centers
Left apical and anterior veins antcromedial t o ■ Optimal visualization on contrast-enhanced
bronchus and arterv studies
• C a r i n a / r i g h t u p p e r lobe b r o n c h u s ■ Most prominent lymph nodes at bifurcations of
Right upper lobe, anterior and posterior segmental right pulmonary artery, middle lobe bronchus, left
bronchi upper lol>e and lingular bronchi
Right ascending artery anterior to main bronchus o Identification of subtle calcification not visible on
Right anterior segmental artery medial to anterior radiographs
segmental bronchus Short axis measurement < 1 cm
Lateral location of right superior pulmonary vein • MR
Left apicoposterior bronchus and artery, lateral to Distinction of lymph nodes from adjacent vessels
left pulmonary aiterv Not sensitive to calcification
Left superior pulmonary vein located antcromedial
to bronchus and arterv
 HILA
• Hilar neoplasm, hronchogenic carcinoma
ATS Lymph Node Stations c. M a v manifest w i t h asymmetric/subtle hilar density
• L y m p h node c l a s s i f i c a t i o n / m a p p i n g o n radiography
• Staging ot l u n g cancer ■ C I ' evaluation tor exclusion of central/hilar mass
• lerminology c C e n t r a l / h i l a r mass w i t h or w i t h o u t b r o n c h i a l
•- N u m b e r relates t o l y m p h node l o c a t i o n (station) obstruction
o Letter denotes l o c a t i o n o f l y m p h node w i t h respect ■ Characteristic o f s q u a m o i i s c e l l c a r c i n o m a
to the m i d l i n c c Hilar/mediastinal l y m p h a d e n o p a t h v w i t h poor
■ K - right visualization of p r i m a r y neoplasm
■ I = left ■ Characteristic o f s m a l l c e l l c a r c i n o m a
• I lil.ir l\ mpli nodes CT i m a g i n g for pre-operative staging
c Considered i n t r a p i i l i u o i i a r y for staging purposes ■ Assessment o f p r i m a r y neoplasm ( I )
Ipsilateral hilar l y m p h node i n v o l v e m e n t i n l u n g ■ Assessment of lymph node involvement (N)
cancer; N I disease • Hilar neoplasm, metastatic disease
o Numeral 10 denotes hilar location *.. Primary l u n g cancer
■ I OK - right hilar lymph nodes c Fxtialhoracic m a l i g n a n c y
■ 101 = left h i l a r l y m p h nodes o Lymphoma
Bilateral Hilar Enlargement, Lymph Nodes
H i l a r Signs • Non-neoplastic l y m p h a d e n o p a t h y
c Sarcoklosis
Hilum Overlay Sign ■ bilateral symmetric hilar lymphadenopathy
• Visualization of hilar structures t h r o u g h medial ■ Associated m e d i a s t i n a l l y m p h a d e n o p a t h y
opacities that overlie the h i l u m o n frontal radiographs (paratradical, aortopulmonary window)
• Indicates that a b n o r m a l i t y is not i n h i l u m / p u l m o n a r y ■ Associated p u l m o n a r y nodules w i t h
artery perilymphatic distribution
o A b n o r m a l i t y anterior or posterior t o the h i l u m • Neoplastic l y m p h a d e n o p a t h y
■ Metastases
Hilar Convergence Sign Lymphoma
• Convergence o f p u l m o n a r y artery branches towards
hilar opacity o n f r o n t a l radiographs Bilateral Hilar Enlargement, Pulmonary
o Radiographic evidence of p u l m o n a r y artery Arteries
enlargement
• Pulmonary arterial h\ pcrtension
c P u l m o n a r y t r u n k w i d t h > 3.0 c m o n CT
o P u l m o n a r y t r u n k diameter greater t h a n diameter of
Imaging of Anatomy Based Hilar adjacent ascending aorta
lAbnormalities Unilateral Hilar Enlargement, Lymph Nodes
Alteration of Hilar Height • Neoplastic L y m p h a d e n o p a t h v
• Typically seen w i t h loss of l u n g v o l u m e o Hronchogenic carcinoma
t Inferior hilar displacement w i t h lower lobe v o l u m e <■■ Metastases
loss I ymphoma
Superior h i l a r displacement w i t h upper lobe v o l u m e
Unilateral Hilar Enlargement, Pulmonary
loss
Artery
Increased Hilar Density • P u l m o n i c stenosis
• Calcification • A s y m p t o m a t i c adults
c ( i r a n u l o m a t o u s disease o Post-stenotic d i l a t a t i o n o f left p u l m o n a r y artery
■ f r e q u e n t f i n d i n g o n radiography related t o d i r e c t i o n o f h i g h velocity |ct of b l o o d
■ focal or m u l t i f o c a l discrete l y m p h node t h r o u g h stenotic valve
calcification: Punctate, irregular, diffuse
■ Association w i t h calcified p u l m o n a r y granulomas Thick Intermediate Stem Line
P n c u m o c o n i o s i s < silicosis c o a l - w o r k e r s • t h i c k n e s s > 3 m m o n lateral radiography
pncumoconiosis) • ltiologies
• May e x h i b i t peripheral (egg-shell) l y m p h node v Interstitial edema
calcification i l l i l a r / p e r i h i l a r mass
■ Association w i t h upper/posterior l u n g zone
p r e d o m i n a n t m u l t i f o c a l p u l m o n a r y silicotic
nodules t h a t may e x h i b i t calcification
o Metastases
■ I y m p h node metastases f r o m bone f o r m i n g or
d y s t r o p h i c neoplasms
■ May be associated w i t h calcified p u l m o n a r y
metastases
 HILA
OVERVIEW OF THE HILA

Right main bronchus Left pulmonary artery

Right pulmonary Left main bronchus

artery
Bronchus Intermedlus

Right pulmonary Left pulmonary veins

veins

Right mediastinal
pieural reflection

Pulmonary ligaments

Graphic shows the normal anatomy of the pulmonary hila. The hila constitute the "roots" of the lungs and are
surrounded by the mediastinal pieural reflections which extend inferiorly as the pulmonary ligaments. The hila are
the site through which airways, vessels and connective tissues travel between the mediastinum and the adjacent
lungs. The illustration shows the central bronchi, pulmonary arteries and pulmonary veins, which are the principal
components of the hila.
 HILA
RIGHT HILUM

Right pulmonary artery

Ascending right
pulmonary artery

Right superior Right main bronchus

pulmonary vein
Right hilar lymph
nodes
Right interlobar
pulmonary artery
Right inferior
pulmonary vein

i
/ ■
4 i

Right pulmonary artery

branches
Right bronchi

Right superior
pulmonary vein
Mediastlnal pleural
reflection

Right inferior
pulmonary vein

Right pulmonary
ligament

(Top) First of two graphics showing the right hilar anatomy. Anterior view shows the pulmonary arteries coursing
along their respective bronchi. The right bronchial morphology is epartenal, with the upper branch above the right
pulmonary artery. The right pulmonary artery has ascending and descending branches. The pulmonary veins follow
a horizontal course relative to that of the arteries. Hilar lymph nodes in the 10R ATS station are shown and are
considered intiapulmonary for the purposes of lung cancer staging. (Bottom) Medial view shows the central location
of the hilum on the mediastinal lung surface and the location of the hilar structures. The upper hilum contains the
superior pulmonary vein, right pulmonary artery and right bronchi (from anterior to posterior). The inferior
puimonary vein is located inferiorly. Normal hilar lymph nodes are depicted in green.
 HILA
LEFT HILUM

tEH T

Left pulmonary artery

Pulmonary trunk z-l Left hllai lymph nodes

Left Interlobar

t
Left superior pulmonary artery
pulmonary vein

Left inferior pulmonary

vein

Left pulmonary artery

Left superior
Left main bronchus pulmonary vein

Mediastinal pleura! Left Inferior pulmonary

reflection vein

Inferior pulmonary
ligament

(Top) First of two graphics illustrating the anatomy of the normal left hilum. Anterior view shows that the left
pulmonary artery courses above the left main bronchus (hyparterlal bronchus). The left interlobar pulmonary artery
courses along the posterolateral aspect of the left lower lobe bronchus. Note the anterior location of the pulmonary
veins. Hilar lymph nodes in the 10L ATS lymph node station are shown in green. (Bottom) Medial view shows the
location of the left hllum on the mid portion of the mediastinal lung surface. The left bronchus is situated
posteriorly within the mid hilum. The pulmonary artery is located above the hyparterial left bronchus. The superior
and Inferior pulmonary veins are located anterior and inferior to the left bronchus respectively.
 HILA
RADIOGRAPHY, NORMAL HILA

Normal left hilum

Normal right hilum

Normal left hilum

Normal right hilum

(Top) First of four normal chest radiographs of different patients demonstrating variations in the radiographic
appearance of the pulmonary hila. PA chest radiograph shows that most of the hilar density visible on radiography is
attributable to the pulmonary arteries and superior pulmonary veins. There is normally a mild asymmetry in hilar
height with the right hilum located slightly lower than the left. This hilar configuration is seen in approximately
97% of normal subjects. (Bottom) Normal PA chest radiograph coned to the hila demonstrates roughly equal hilar
heights. This hilar configuration is seen in approximately 3% of normal subjects.
 HILA
RADIOGRAPHY, NORMAL HILA
o
o
w
■ ■

Normal Lett hilum

Normal right hiluni

Remote left clavicle

fracture

Thoracic vertebra
Normal left hilum

Normal right hilum —

(Top) PA chest radiograph shows mild rotation of the patient to the left. Note that the left hilum may normally
project slightly behind the left cardiac border. The hilar heights are normal with the right hiluni being slightly lower
than the lefl. (Bottom) PA chest radiograph of an asymptomatic adult with thoracic scoliosis and a remote healed
left clavicular fracture. The chest wall deformity results in apparent displacement of the superior mediastinum to the
left of the midline, hilar asymmetry and poor visualization of the right hilum. However, normal hilar height is
preserved with the right hilum being slightly lower than the left.

171
 HILA
RADIOGRAPHY, NORMAL RIGHT HILUM

Ascending right
pulmonary artery
Right superior
pulmonary vein
branches Right upper lobe
bronchus

Right liilar angle —

— Bronchus intermedius

Right interlobar
pulmonary artery

Right inferior
pulmonary vein

First of two coned-down images from a normal 1'A chest radiograph. Coned-down view of the right hilum shows that
the superior hilum is characterized by the ascending right pulmonary artery located medial to the right upper lobe
apical segmental bronchus. The right superior pulmonary vein is oriented obliquely and located lateral to the
bronchus. The right main bronchus bifurcates into the right upper lobe bronchus and the bronchus intermedius. The
right interlobar pulmonary artery is seen in the inferior right hilum and courses along the lateral aspect of the
bronchus intermedius. A branch of the right inferior pulmonary vein exhibits a horizontal course relative to that of
the right lower lobe pulmonary arteries.
 HILA
RADIOGRAPHY, NORMAL LEFT HILUM

Left pulmonary artery — I.eft superior

pulmonary vein

— Left pulmonary artery

Left main bronchus —

— Branches of the left

inferior pulmonary

Coned-down view of the left hilum shows the left pulmonary artery coursing above the left main bronchus. The left
main bronchus is also called the hyparterial bronchus based on its relationship to the left pulmonary artery. Ihe left
superior pulmonary vein courses obliquely towards the left atrium. The left interlobar pulmonary artery courses
along the posterolateral aspect of the left lower lobe bronchus. Branches of the left inferior pulmonary vein follow a
relatively horizontal course when compared to that of the lower lobe pulmonary arteries.
 HILA
GRAPHIC & RADIOGRAPHY, NORMAL HILA
if
o
O
Posterior tracheal wall

Right upper lobe

bronchus

Right hllar vascular Left pulmonary artery

opacity

Intermediate stem line

Left upper lobe
bronchus

Anterior wall of left

lower lobe bronchus

Left pulmonary artery

Left upper lobe

bronchus

■ *Vl

(Top) Graphic illustrates the hilar anatomy seen on a lateral chest radiograph. Two superior parallel gray lines
represent the trachea. Two gray circles (one superior, one inferior) represent the orifices of the right and left upper
lobe bronchi respectively. A gray line drawn from the posterior superior circle intersects the posterior aspect of the
inferior circle and represents the intermediate stem line. The arcuate gray line below the inferior circle represents the
anterior wall of the left lower lobe bronchus. The anterior and posterior blue lines depict the right hilar vascular
opacity and left pulmonary artery respectively. (Bottom) First of four normal lateral chest radiographs of different
patients shows the anterior right hilar vascular opacity and the posterior left pulmonary artery. The left upper lobe
bronchus is seen end-on in the central hilum.
174
 HIIA
RADIOGRAPHY, NORMAL HILA

Trachea —

— Left pulmonary artery

— Intermediate stem line

Right hilar vascular opacity —
— Left upper lobe bronchus

Anterior wall of left lower lobe —

bronchus

Trachea -

Right upper lobe bronchus — Left pulmonary artery

— — Left upper lobe bronchus

Right hilar vascular opacity

Inferior hilar window —

Trachea —

Right hilar vascular opacity - — Left retrobronchial line

— Intermediate stem line

Left upper lobe bronchus

(Top) Left lateral chest radiograph shows the anterior right hilar vascular opacity and the posterior left pulmonary
artery. The left upper lobe bronchus is seen end-on a n d is visible in 7 5 % of normal subjects. The anterior wall of the
left lower lobe bronchus is visible: the right upper lobe bronchus is not. (Middle) Left lateral chest radiograph shows
partial visualization of the right upper lobe bronchus, seen in 5 0 % of normal individuals. Typically the entire
bronchial circumference is not visible. Note the avascular inferior hilar window. (Bottom) Left lateral chest
radiograph shows the intermediate stem line (posterior walls of right main a n d intermediate bronchi), which
normally measures 1.5 t o 3 m m and is visible in 9 5 % of normal subjects. The left retrobronchial line (posterior walls
of left main and proximal lower lobe bronchi) is also visible.
 HILA
AXIAL CT, NORMAL HILA
X

o
O
Right apical segmental bronchus — Left superior pulmonary veins

- Branches of apicoposterior
Right apical segmental artery segmental bronchus

Right anterior segmental bronchus Anterior segmental bronchus

- Apicoposterior segmental
Right posterior segmental vein bronchus

■ Left pulmonary artery

Right upper lobe bronchus -

- Left superior pulmonary vein

branches
Right superior pulmonary vein -
Left apicoposterior segmental
bronchus
Bronchus intermedius ~
Left pulmonary artery

(Top) First of eighteen normal axial CT images (lung and mediastinal window) demonstrates the axial anatomy of
the superior hila. The upper lobe bronchi and vessels form the suprahilar regions. The right apical segmental artery is
medial to the apical segmental bronchus and the vein is lateral to the bronchus. Branches of the apicoposterior
segmental bronchus and their corresponding veins and arteries are noted on the left. (Middle) Axial image shows the
right upper lobe and right anterior segmental bronchi and their relationship to adjacent vessels. The left
apicoposterior and anterior segmental bronchi are anterior to the left pulmonary artery. (Bottom) Axial image
through the bronchus intermedius shows the anterior location of the right superior pulmonary vein. The left
I superior pulmonary vein branches are anteromedial to the apicoposterior segmental bronchus.
170
 HILA
AXIAL CT, NORMAL HILA

Left apual pulmonarv artery

Right superior pulmonary vein branch

Lett superior pulmonary vein

Right apical segments! artery
branches

Right ascending pulmonary artery — Left superior pulmonary veins

Left pulmonary artery

Right upper lolx' bronchus

Right superior pulmonary veins

— Left superior pulmonary veins

Normal right hilar lymph node

— Left pulmonary artery
Right upper lobt! bronchus

(lop) Axial image demonstrates the vascular anatomy of the suprahilar regions. The upper lobe pulmonary vein
branches course medially to join the left superior pulmonary vein. The upper lobe pulmonary arteries are typically
medial to the bronchi (except in the lingula). (Middle) Axial image through the right upper lobe bronchus shows the
ascending right pulmonary artery located anteriorly. The left superior pulmonary veins are located anterior to the left
pulmonary artery. (Bottom) Axial image through the proximal aspect of the right upper lobe bronchus shows
normal right hilar nodal tissue (ATS lymph node station 10R). Hilar lymph nodes are considered intrapulmonary
(Nl) for staging ipsilateral lung cancers. The anterior location of the pulmonary veins is again noted.
 HILA
AXIAL CT, N O R M A L HILA

Right superior pulmonary veins

- Left superior pulmonary vein

Right interiobar pulmonary artery Apicoposterior segmental

bronchus
Bronchus intermedium - Left interiobar pulmonary
artery

Right superior pulmonary veins - I.eft upper lobe bronchus

Right interiobar pulmonary artery

Bronchus intermedius
Left interiobar pulmonary
artery

Left superior pulmonary vein

Right interiobar pulmonary artery Superior lingular bronchus

Left interiobar pulmonary

Bronchus intermedius artery

(Top) Axial image through the bronchus intermedius demonstrates its t h i n posterior wall t h a t forms part of the
intermediate stem line on lateral radiography. The left pulmonary artery courses over the left main bronchus and is
jx>sterior to the apicoposterior segmental bronchus. (Middle) Axial image through the left upper lobe and
intermediate bronchi shows t h e posterolateral location of the left interiobar pulmonary artery with respect to the left
upper lobe bronchus. The proximal right interiobar pulmonary artery a n d right superior pulmonary veins are
anterior to t h e bronchus intermedius. (Bottom) Axial image through t h e superior lingular bronchus shows the
posterolateral left interiobar pulmonary artery. The right superior pulmonary veins a n d interiobar artery exhibit the
characteristic "elephant head-and-trunk" configuration anterior t o the bronchus intermedius.
 HILA
AXIAL CT, N O R M A L HILA

Kight superior pulmonarv veins -

Lett superior pulmonary veins
Horizontal right pulmonary artery -

Left interlobar pulmonary

arterv

—
Kight superior pulmonary veins
— Left superior pulmonary vein

Kight interlobar pulmonary artery -

Left interlobar pulmonary

artery

Right superior pulmonary vein

I eft superior pulmonary vein

Kight interlobar pulmonary artery

Ix'ft interlobar pulmonary

artery

(Top) Axial image through the pulmonary trunk shows the bilateral superior pulmonary - veins located anterior to the
horizontal portion of the right pulmonary artery and anteromedial to the left apicoposterior sogmental bronchus.
The left interlobar pulmonary artery courses posterior to the bronchi. (Middle) Axial image through the left upper
lobe bronchus shows the bilateral superior pulmonary veins located anteriorly. Note the horizontal portion of the
right pulmonary artery and the vertical course of the left interlobar artery behind the left upper lobe bronchus.
(Bottom) Axial image through the bronchus intermedius shows that the right superior pulmonary vein is closely
related to the anterior aspect of the right interlobar artery as the latter curves posteriorly. These Structures form the
"elephant head-ami-trunk" morphology of the right hilum at this level.
 HILA
AXIAL CT, N O R M A L HILA

Middle lobe bronchus —

Right interlobar pulmonary artery

— Left inlerlobar pulmonary
Superior segmental right lower lobe artery
bronchus
Superior segmental left lower
lobe bronchus

Right truncus basalis '

Left truncus basalis
- Basal segmental lett lower lolx-
ISasal segmental right lower lobe pulmonary arteries
pulmonary arteries
Left Inferior pulmonary vein

Right inferior pulmonary vein -

Left inferior pulmonary vein

Right lower lol>e basal segmental

bronchi Ix'ft lower lobe basal segmental
bronchi

(Top) Axial image through the middle lobe bronchus demonstrates the lateral location of the right interlobar
pulmonary artery with respect to the bronchial bifurcation at this level. Note the origins and posterior course of the
bilateral su|x.'rior segmental lower lobe bronchi. (Middle) Axial image through the infrahilar region demonstrates the
bilateral basal trunks of the lower lobe bronchi a n d the posterolateral location of the corresponding lower lobe basal
segmental pulmonary arteries. The left inferior pulmonary vein is medial t o the left basal trunk. (Bottom) Axial
image through the infrahilar region demonstrates the near horizontal course of the bilateral inferior pulmonary
veins. The basal segmental bronchi are located anterior a n d posterior t o the pulmonary veins a n d are accompanied
by their corresponding pulmonary arteries.
 HILA
AXIAL CT, N O R M A L HILA

Middle lobe pulmonary artery -

Right interlobar pulmonary artery

Left interlobar pulmonary
artery-

Left inferior pulmonary vein

Basal segmental left lower lobe

Basal segmental right lower lobe pulmonary arteries
pulmonary arteries

Right inferior pulmonary vein -

Left inferior pulmonary vein

(lop) Axial image at the level of the middle lobe bronchus shows the middle lobe pulmonary artery located lateral to
the bronchus. The vertical course and lateral location of the bilateral interlobar pulmonary arteries are also shown.
(Middle) Axial image through the left inferior pulmonary vein demonstrates the characteristic lateral location of the
pulmonary arteries with respect to their corresponding bronchi in the lower a n d middle lobes. Note the horizontal
course of the left inferior pulmonary vein. (Bottom) Axial image through the bilateral inferior pulmonary veins
demonstrates their horizontal course relative to the more vertical course of the lower lobe arteries. Note that the left
inferior pulmonary vein is located posterior t o the anteromedial basal segmental pulmonary artery but anterior t o
the lateral and posterior basal segmental pulmonary arteries.
 HILA
C O R O N A L CT, N O R M A L HILA

- Left superior pulmonary vein

Right superior pulmonary vein —

Middle lobe bronchus segmental

branches

Right ascending pulmonary artery

- Left pulmonary artery

Right superior pulmonary vein Left superior pulmonary vein

Right descending pulmonary artery

Left atrium

Right main bronchus -

— Left pulmonary artery

Right upper lobe bronchus

Right hilar lymph node

Right descending pulmonary artery —

Left superior pulmonary vein

Left atrium -

(Top) First of twelve normal coronal reconstruction images from a contrast-enhanced chest CT (mediastiiial and lung
window). Image through the anterior hila demonstrates the anterior location of the bilateral superior pulmonary
veins and the medial and lateral segmental middle lobe bronchi seen in cross-section. (Middle) Coronal image
through the horizontal portion of the right pulmonary artery shows its ascending a n d descending branches. The left
superior pulmonary vein is seen in its vertical course into the left atrium. (Bottom) Coronal image through the
carina shows t h e superior location of t h e left pulmonary artery with respect to the right. The right (eparterial) main
bronchus is above the ipsilateral pulmonary artery. Note the normal hilar lymph n o d e at the bifurcation of the right
main bronchus into right upper lobe and intermediate bronchi.
 HILA
C O R O N A L CT, N O R M A L HILA

Left superior pulmonary vein

Right superior pulmonary vein -

—
Middle lobe arteries

Middle lobe bronchi -

Right asi ending pulmonary artery -

Right apical segmental bronchus

Left upper lobe anterior
Right anterior segmental bronchus segmental bronchus

- Linpilar bronchus
Middle lobe bronchus

Right upper lobe bronchus ~ - Left pulmonary artery

Right intcrlobar pulmonary artery

Left superior pulmonary vein
Middle lobe bronchus

(Top) Coronal image through the anterior hila shows the segmental branches (medial and lateral) of the middle lobe
bronchus a n d the anterior location of the bilateral superior pulmonary veins. (Middle) Coronal image? through the
horizontal right pulmonary artery demonstrates the relationship of the right upper lobe arteries and veins to the
airways. The right ascending pulmonary artery is medial t o the apical and anterior segmental bronchi and the right
superior pulmonary vein is located laterally. The middle lobe bronchus and the right a n d left upper lobe anterior
segmental bronchi are seen in cross-section. (Bottom) Coronal image through the right upper lobe bronchus
demonstrates that the right (cparterial) bronchus is situated above the ipsilateral pulmonary artery. Note the superior
location of the left pulmonary artery with respect to the right.
 HILA
CORONAL CT, NORMAL HILA

- Left apical pulmonary artery

Bronchus intermedius -

Right hilar lymph n o d e ■"

Right interlobar pulmonary artery -
Left su|)erior pulmonary vein

Left atrium
Right interior pulmonary vein ■

- Left pulmonary arteiy

Right hilar lymph n o d e

Right interlobar pulmonary artery

- Left main bronchus

Right inferior pulmonary veins —

Lett interlobar pulmonary

Right interlobar pulmonary artery artery

Right interior pulmonary vein Lett interior pulmonary vein

(Top) Coronal image through the bronchus intermedius demonstrates the bilateral pulmonary veins entering the left
atrium. The coronal anatomy of the left suprahilar region is demonstrated. The right interlobar pulmonary artery
courses lateral to the bronchus intermedius. A normal right hilar lymph node is also seen. (Middle) Coronal image
through the mid hila shows the lateral location of the right interlobar pulmonary artery with respect to the bronchus
intermedius. Note the horizontal course of the right inferior pulmonary veins. The left pulmonary artery courses
above the left (hyparterial) bronchus. (Bottom) Coronal image through the posterior hila shows the vertical
orientation of the left interlobar pulmonary artery, seen lateral to the left lower lobe bronchus, and the horizontal
course of the left inferior pulmonary vein into the left atrium.
 HILA
CORONAL CT, NORMAL HILA

Bronchus intermedius - - Left superior pulmonary veins

Left apicoposterior segmental

bronchus
Right interlobar pulmonary artery -
— Left main bronchus

Right inferior pulmonary vein

— Left pulmonary artery

Right interlobar pulmonary artery - — Left main bronchus

Right inferior pulmonary veins —

Left interlobar pulmonary

artery
Right interlobar pulmonary artery Left lower lobe bronchus

Right lower lobe basilar scginental

Left inferior pulmonary vein
bronchi

(Top) Coronal image through the posterior aspect of the carina shows the left pulmonary artery coursing superior t o
the left main (hyparterial) bronchus. Note the bronchial a n a t o m y of the left superior hilum and the relationship of
the airways t o adjacent vessels. The right interlobar artery courses along the lateral aspect of the bronchus
intermedius. (Middle) Coronal image through the posterior hila demonstrates the relationship of the left pulmonary
artery to the left main bronchus and the relationship of the right interlobar artery to the bronchus intermedius. Two
right inferior pulmonary veins enter the left atrium. (Bottom) Coronal image through the posterior hila
demonstrates the left interlobar pulmonary artery coursing vertically along the left lower lobe bronchus and the
relatively horizontal course of the left inferior pulmonary vein.
 HILA
GRAPHIC, SAGITTAL CT & MR, NORMAL RIGHT HILUM

Right pulmonary artery branches - Right bronchi

Right superior pulmonary vein

Right inferior pulmonary vein

Right bronchi

Right pulmonary artery

( - Right hilar lymph node

Right superior pulmonary vein Right inferior pulmonary vein

Right bronchi
Right pulmonary artery

Right superior pulmonary vein

Right interior pulmonary vein

(Top) Graphic demonstrates the relationships of the hilar airways and vessels. The right bronchi are the most
posterior structures in the upper hilum and the superior pulmonary vein the most anterior. The pulmonary artery is
located centrally between the superior pulmonary vein and the bronchi, and the inferior pulmonary vein is located
inferiorly. (Middle) Normal contrast-enhanced chest CT (mcdiastinal window) with sagittal reconstruction through
the right hilum demonstrates the relationship of the airways and vascular structures depicted on the graphic. Hilar
nodal tissue is often identified on thin section chest CT of normal subjects. (Bottom) Sagittal Tl-weighted MR image
through the right hilum shows the anterior and inferior locations of the pulmonary veins and the posterior location
of the airway. The right pulmonary artery Is located in the central hilum.
 HILA
GRAPHIC, SAGITTAL CT & MR, NORMAL LEFT HILUM

Left pulmonary artery

Left superior pulmonary vein -

left main bronchus

Left inferior pulmonary vein

- Left pulmonary artery

Left superior pulmonary vein
- Left main bronchus

Left hilar lymph node -

- Left inferior pulmonary vein

- Left pulmonary artery

- Left main bronchus

left superior pulf nonary vein
- Left inferior pulmonary vein

(Top) Graphic that corresponds to the sagittal CT and MR images shows the normal relationships of the left hilar
vessels to the main bronchus. The pulmonary veins are located anteriorly and inferioriy and the left main bronchus
is located posteriorly. The left pulmonary artery is located superiorly and courses over the left (hyparterial) bronchus.
(Middle) Contrast-enhanced chest CT with sagittal reconstruction (mediastinal window) demonstrates the
appearance of the normal left hilum. The left pulmonary artery courses above the left (hyparterial) bronchus. The
pulmonary veins are located anteriorly and inferioriy within the hilum. The left main bronchus is located posteriorly
within the mid portion of the hilum. Note left hilar lymph nodes. (Bottom) Sagittal Tl-weighted MR image through
the left hilum shows the anatomic relationships shown on the graphic and the CT.
 HILA
AXIAL MR, NORMAL HILA

Left pulmonary artery

Right apical segmental bronchus

Right ascending pulmonary artery - - Left superior pulmonary veins

Right upper lobe bronchus - Left pulmonary artery

Right superior pulmonary vein -

- Lett superior pulmonary vein
Right pulmonary artery -
- Left upper lobe bronchus
■ Left interlobar pulmonary
Bronchus intermedius - artery

(Top) First of three normal axial Tl-weighted MR images demonstrates the left pulmonary artery as it courses over
the (hyparlerial) left bronchus. The right apical segmental bronchus is identified with its corresponding pulmonary
artery. (Middle) Axial image below the carina demonstrates the horizontal portion of the left pulmonary artery and
the anteriorly located left superior pulmonary veins. The right upper lobe bronchus and anteriorly located right
ascending pulmonary artery are seen in the right hilum. (Bottom) Axial image at the level of the bronchus
intermedius shows the horizontal portion of the right pulmonary artery coursing anterior to the bronchus
intermedius and the left interlobar pulmonary artery located posterolateral to the left upper lobe bronchus. Note the
anterior location of the bilateral superior pulmonary veins.
 HILA
C O R O N A L M R , N O R M A L HILA

- Left pulmonary artery

Right ascending pulmonary artery

5 - Left superior pulmonary veins

Right descending pulmonary artery —

- Left atrium

Right upper lobe bronchus - Left pulmonary artery

Left upper lobe bronchus

Right interlobar pulmonary artery —

—
Left lower lobe bronchus

— Left pulmonary artery

Bronchus intermedius - Left main bronchus

- Left Inferior pulmonary- vein

(Top) First of three coronal Tl-weighted MR images through the mid hila shows the horizontal portion of the right
pulmonary artery and its ascending and descending branches. The left superior pulmonary veins are seen coursing
into the left atrium under the left pulmonary artery. (Middle) Coronal image through the carina demonstrates the
relationship of the bilateral pulmonary arteries to their ipsilateral bronchi. The left pulmonary artery courses above
the left main or hyparterial bronchus. The right pulmonary artery is located under the right or eparterial bronchus.
(Bottom) Coronal image through the bronchus intermedius and the posterior left main bronchus demonstrates the
posterior aspect ol Hie left pulmonary artery as it begins to course interiorly to become the interlobar pulmonary
artery. Note the horizontal orientation of the left inferior pulmonary vein.
 HILA
THE HILUM OVERLAY SIGN

Right inrerlohar —
pulmonary artery left intcrlobar
pulmonary artery

Soft tissue mass

Right upper lobe

bronchus i 1 eft pulmonary artery

- Intermediate stem line-

Anterior mediastinal
mass Left upper lobe
bronchus
Right hilar vascular
opacity

(Top) First of two radiographs of a 2 3 year old man with mediastinal T-ccIl lymphoma demonstrates the hilum
overlay sign. PA chest radiograph shows an ovoid mass that projects over the left hilum and mid portion of the left
mediastinal contour. The left interlobar pulmonary artery is visible through the soft tissue mass indicating that the
mass is separate from t h e artery a n d t h e hilum. (Bottom) left lateral chest radiograph demonstrates t h e anterior
mediastinal location of the soft tissue mass. The left pulmonary artery a n d hilar structures appear normal. The right
hilar vascular opacity is noted anterior to the hilar airways. Other normal hilar landmarks such as the bilateral upper
lobe bronchi, the intermediate stem line and the left retrobronchial line are visible.
 HILA
THE HILUM CONVERGENCE SIGN

— Enlarged left
pulmonary artery

Left pulmonary artery

branches

Enlarged right
interlobar pulmonary
artery — I arge pulmonary trunk

Right pulmonary artery

branches

Right upper lobe

bronchus Pulmonary artery
calcification
Fnlargecl pulmonary-
trunk Enlarged left
pulmonary artery

Enlarged right
pulmonary artery

(Top) first of two radiographs of a 45 year old woman with severe pulmonary arterial hypertension due t o
uncorrccted atrial septal defect shows the hilar convergence sign. PA chest radiograph shows cardiomegaly and an
enlarged pulmonary trunk. Enlarged pulmonary arteries converge towards bilateral hilar masses indicating their
vascular etiology. Reproduced with permission from Parker MS, Rosado-de-Christenson MI., Abbott GF. Teaching
Atlas of Chest Imaging. New York: Thieme, 2005. (Bottom) Left lateral chest radiograph shows massive pulmonary
trunk and pulmonary artery enlargement with posterior displacement of the hilar airways. The orifice of the right
upper lobe bronchus is well visualized due t o the surrounding enlarged vessels. Mural pulmonary artery calcification
indicates severe long standing pulmonary arterial hypertension.
 HILA
ABNORMAL HILAR POSITION, VOLUME LOSS

Right apical pleural

thickening

Right upper lobe

airspace disease

Elevated right hilum

Normal left hilum

Right apical pleural

thickening

l:.lcvateil left hilum

Normal right hilum

(Top) PA chest radiograph of an asymptomatic 60 year old man with a remote history of postprimary tuberculosis
demonstrates elevation of the right hilum secondary to right apical fibrosis manifesting with right upper Iol)e
airspace disease and adjacent pleural thickening. The normal right hilum is typically slightly lower than the left.
(Bottom) I'A chest radiograph of a 57 year old man with asymmetric left apical pleural thickening and left upper
lobe fibrosis secondary to prior post primary tuberculosis demonstrates elevation and distortion of the left hilum.
Although the left hilum is typically higher than the right, the asymmetry of hilar height is not normally this
pronounced. The right hilum is of normal size and position.
 HILA
BILATERAL HILAR CALCIFICATION, P N E U M O C O N I O S I S

Left upper lobe fibmsis

Calcified left hilar

lymph nodes

Right upper lobe

bronchus

Calcified left hilar

lymph nodes
Calcified right hilar
lymph nodes

Left upper lobe

bronchus

( l o p ) First of two images of an asymptomatic 64 year old man with silicons. PA chest radiograph demonstrates mild
elevation of the left hilum with associated left suprahilar pulmonary linear opacity secondary t o focal fibrosis. There
are multifocal foci of hilar lymph node calcification secondary to siiicosis. Note multifocal small bilateral calcified
lung nodules related to pulmonary involvement by siiicosis. (Bottom) Left lateral chest radiograph demonstrates
bilateral hilar lymph node calcification. Note exquisite visualization of the entire circumference of the right upper
lobe bronchial orifice which suggests an increase in adjacent soft tissue likely related to adjacent lymph node
enlargement. Mediastinal lymph node calcification is also noted.
 HILA
HILAR CALCIFICATION, REMOTE GRANULOMATOUS INFECTION

— Calcified left hilar

Calcified ri^ht hilar lymph node;.
lympli nodes

Thick Intermediate
stem line

Calcified left hilar

lymph nodes
Calcified right hilar
lymph nodes

(Top) First of four images of a 46 year old man with known remote granulomatous infection and past episodes of
broncholithiasis. PA chest radiograph demonstrates bilateral abnormal hilar density with exuberant bilateral
multifocal calcifications of ovoid and spherical morphology consistent with calcification in bilateral hilar and
mediastinal lymph nodes. There are bilateral small nodular calcified granulomas in the lungs. (Bottom) Left lateral
chest radiograph demonstrates bilateral hilar and mediastinal lymph node calcifications as well as calcified
pulmonary granulomas. There is thickening of the intermediate stem line. Calcified mediastinal granulomas are
noted projecting anterior to the central airways. Note that there are calcified lymph nodes in the inferior hilar
window.
 IIILA
HILAR CALCIFICATION, REMOTE GRANULOMATOUS INFECTION

Kight superior
pulmonary vein

Calcified left hilar

lymph nodes
Calciiicd right hilai
lymph nodes

Thick posterior wall of I eft pulmonary artery

bronchus intermedius

Calcified right hilar

lymph nodes
Calcified left hilar
lymph nodes

Right interlobar Left interlobar

pulmonary artery pulmonary artery

(Top) Contrast-enhanced chest CT (mediastinal window) at the level of the pulmonary trunk demonstrates bilateral
lobular densely calcified hilar nodules representing calcified lymph nodes secondary to remote granulomatous
infection. The posterior wall of the bronchus inteimedius is thick and correlates with the finding seen on t h e lateral
chest radiograph. (Bottom) Contrast-enhanced chest CT (mediastinal window) at t h e level of the left atrium shows
bilateral densely calcified hilar/infrahilar lymph nodes. Calcification in intrathoracic lymph nodes typically relates to
benign processes, usually remote granulomatous infection.
 HILA
T H I C K INTERMEDIATE STEM LINE, B R O N C H O G E N I C C A R C I N O M A

Thick intermediate
stem line

Right major fissure

— Right lower lobe mass

Middle lobe bronchi

Thick posterior wall of

bronchus intermedius

Right lower lobe mass

(Top) First of two images of a 41 year old man with a central right lower lobe squamous cell carcinoma, left lateral
chest radiograph coned-down to the hila demonstrates lobular thickening of the intermediate stem line. Note
inferior displacement and thickening of the major fissure secondary to right lower lobe volume loss and the lobular
right lower lobe mass. (Bottom) Contrast-enhanced chest CT (lung window) demonstrates a large lobular right lower
lobe mass with spiculatcd borders and a pleural tag. The bronchus intermedius is deformed by peri bronchia I and
endoluminal involvement by the neoplasm and adjacent affected intrapulmonary lymph nodes. Note associated
middle and right lower lobe volume loss secondary to bronchial obstruction.
 HILA
UNILATERAL HILAR ENLARGEMENT, B R O N C H O C E N I C CARCINOMA

Right paralratheal mass

I '. II I : i l l I I 1 1
Right hilar enlargement

Encased right pulmonary artery

Lett superior pulmonary vein

I leterogeneous right hilar mass

Lett interlobat pulmonary
artery

lironihus intermedius — lett main bronchus

Righl hilar mass —

- Right main stem bronchus

endoluminal tumor

( l o p ) Hirst o f three images o f a 50 year o l d m a n w h o presented w i t h advanced l u n g cancer metastalic t o the b r a i n .

AP chest radiograph coned t o t h e h i l a demonstrates unilateral right hilar enlargement a n d a right paratracheal mass.
The right upper lobe b r o n c h i a l l u m e n is obscured. ( M i d d l e ) Contrast-enhanced chest CT (medfastinal w i n d o w *
demonstrates a hctcrogeneously e n h a n c i n g right hilar mass that encases, narrows a n d obstructs t h e r i g h t p u l m o n a r y
artery a n d abuts the anterolateral w a l l of the bronchus i n l e r m c d i u s . Hie It'll h i l u i n appears n o r m a l . ( B o t t o m )
Contrast-enhanced chest CT ( l u n g w i n d o w ) shows a large right hilar mass that invades the adjacent m e d i a s t i n u m ,
obstructs t h e right upper lobe bronchus a n d is associated w i t h e n d o l u m i n a l t u m o r in t h e right m a i n bronchus.
Endoscopic biopsy revealed non-small cell l u n g cancer.
 HILA
BILATERAL HILAR ENLARGEMENT, LYMPHADENOPATHY

Right hilar enlargement - Left hilar enlargement

1
ns

Right hilar enlargement Left hilar enlargement

I eft upper lobe bronchus

Soft tissue mass in inferior hilar

window

Right pulmonary artery

I eft upper lobe bronchus

I eft hilar lympliadenopathy

Right hilar lymphadenopathy

I efl iulerlobar pulmonary

Bronchus intcrmcclius arler)

(Top) First of two radiographs of a 38 year old man with sarcoidosis. PA chest radiograph demonstrates bilateral hilar
enlargement secondary to lymphadenopathy. The superior mediastinum is wide consistent with associated right
paratracheal and aorlopulmonary window lymphadenopathy. (Middle) Left lateral chest radiograph demonstrates
bilateral lobular hilar enlargement secondary to lymphadenopathy. Note the abnormal tabular soft tissue in the
inferior hilar window related to lymphadenopathy. (Bottom) Contrast-enhanced chest CT (mediastinal window) of a
32 year old man with sarcoidosis demonstrates marked bilateral hilar and subcarinal lymphadenopathy. The enlarged
lymph nodes encase the vascular structures and airways.
 HILA
BILATERAL HILAR ENLARGEMENT, PULMONARY HYPERTENSION

Enlarged pulmonary
trunk

Enlarged right
pulmonary artery

Enlarged left
pulmonary artery

Enlarged pulmonary
trunk
Enlarged right
pulmonary artery

Rjght pulmonary artery Enlarged left interlobar

pseudodidphragm pulmonary artery

(lop) First of two contrast-enhanced chest CT images (mediastinal window) of a 35 year old woman with primary
pulmonary arterial hyiwrtension. Axial image below the carina demonstrates enlargement of the pulmonary trunk
and the bilateral pulmonary arteries. Pulmonary hypertension should be suspected when the diameter of the
pulmonary trunk is larger than that of the adjacent ascending aorta as in this case. (Bottom) Axial image obtained 10
mm caudally demonstrates an enlarged pulmonary trunk and enlargement of the bilateral pulmonary arteries Note
the linear endoluminal filling defect in the right pulmonary artery which represents a "pseudodiaphragm" secondary
to marked vascular dilatation. This finding may be misinterpreted as imaging evidence of chronic pulmonary
thrornboembolism.
 HILA
UNILATERAL HILAR ENLARGEMENT, PULMONIC STENOSIS

— Enlarged left
pulmonary artery

— Enlarged pulmonary
Normal right hilum — trunk

Enlarged left
Right upper lobe —\ pulmonary artery
bronchus

Intermediate stem line —

Right hilar vascular —

opacity left upper lobe
bronchus

(Top) First of four images of a 49 year old woman with pulmonic stenosis and a heart murmur. I'A chest radiograph
demonstrates asymmetric left hilar enlargement affecting the pulmonary trunk and the left pulmonary artery. The
right hilum exhibits normal height, size and opacity. (Bottom) Left lateral chest radiograph coned-down to the hila
demonstrates unilateral enlargement and lobular morphology of the left pulmonary artery. Poor positioning and
rotation result in an unusual anterior location of the normal intermediate stem line. Note visualization of the
bronchus intermedius and its bifurcation into middle and right lower lobe bronchi. The left upper lobe bronchus is
visualized as is the normal right hilar vascular opacity.
 HILA
UNILATERAL HILAR ENLARGEMENT, P U L M O N I C STENOSIS

Enlarged pulmonary
trunk

Right pulmonary artery — Enlarged left

pulmonary artery

Right pulmonary artery —

Enlarged left proximal
pulmonary artery

I eft interlohar
pulmonary artery

( l o p ) Contrast-enhanced chest CT (mediastinal window) through the carina demonstrates enlargement of the
pulmonary trunk and asymmetric enlargement of the left pulmonary artery. The right pulmonary artery is of normal
size. (Bottom) Contrast-enhanced chest CT (mediastinal window) obtained just below the carina demonstrates
enlargement of the left pulmonary artery. Ihe right pulmonary artery a n d left interlobar pulmonary artery arc-
grossly normal. Patients with pulmonic stenosis are often asymptomatic and exhibit asymmetric enlargement ot the
pulmonary trunk and the left pulmonary artery due to post stenotie dilatation related to the direction of the high
velocity jet of blood that courses through the stenotie valve.
 AIRWAYS
[Terminology
Definitions
• Spurs
E Precise anatomic landmarks of airway origins
>. Thin septum/triangular density along bronchial
edge at points of bifurcation
Nomenclature
System o f Jackson a n d H u b e r (1943)
• Describes segmental lung anatomy
System of Boyden (1961)
• Designates segmental bronchi (Bl
• Followed by a number (e.g.. HI. R2. etc.)
• Numbered sequentially, progressing distally from
trachea
[Overview of Airway Anatomy
Trachea
• See below
Bronchi
• Right main bronchus
• Left main bronchus
Lobar a n d Segmental B r o n c h i
• Right upper lobe bronchus
o Apical segmental bronchus (HI)
o Posterior segmental bronchus (B2)
Anterior segmental bronchus (B3)
• Middle lobe bronchus
lateral segmental bronchus |B4)
Medial segmental bronchus (B.S)
• Right lower lobe bronchus
Superior segmental bronchus (B6)
Basilar segmental bronchi
■ Medial segmental bronchus (B7)
■ Anterior segmental bronchus (B8)
■ lateral segmental bronchus (R9)
■ Posterior segmental bronchus (RIO)
• Left upper lobe bronchus
Apical-posterior segmental bronchus iBl+2)
Anterior segmental bronchus (B3)
■ l.ingular bronchus
■ Superior segmental bronchus (B4)
■ Inferior segmental bronchus (R5)
• Left lower lobe bronchus
o Superior segmental bronchus (B6)
Basilar segmental bronchi
■ Anteromcdial segmental bronchus (R7+8)
■ Lateral segmental bronchus (B9)
■ Posterior segmental bronchus (BIO)
i Trachea
General A n a t o m y
• Midline structure, 10-12 cm in length; intrathoracic
portion 6-9 cm in length
• Extends caudally from inferior aspect of cricoid
cartilage (level of C6 vertebral lx>dy)
• Bifurcates at Carina (level of T5 vertebral body) into
right and left main bronchi
• Diameters
c Coronal 13-25 m m (men): 10-21 m m (women)
o Sagittal 13-27 m m (men); 10-23 m m (women)
Relationships
• Thyroid gland lies on anterior a n d both lateral aspects
of upper trachea, above thoracic inlet
• Lsophagus lies posterior to trachea, interposed
between trachea and vertebral column
• Aorta lies along anterior and left lateral aspect of
trachea
• Rrachiocephalic artery lies along anterior and right
lateral aspect o f trachea
• Aerated lung (right upper lobe) lies adjacent to right
lateral tracheal wall
[Right Bronchial Anatomy
Right M a i n Bronchus
• Origin anterior to esophagus; courses inferolaterall\
posterior t o right pulmonary artery
• Fparterial (i.e.. "situated above an artery"); refers to its
relationship to adjacent right p u l m o n a r y artery
• Relatively short; more vertical than left main
bronchus; more prone to foreign body aspiration
• Divides into right u p p e r lobe b r o n c h u s and
b r o n c h u s interinedius
Right U p p e r Lobe Bronchus
• Origin from lateral aspect of right main bronchus at or
just below carina: more cephalad than left upper lobe
bronchus
• Courses horizontally and laterally (1-2 cm) before
branching
• Posterior wall an important anatomic landmark; in
direct contact with aerated lung (< 3 m m thick)
rhickcned by tumor, lymphadenopathy; prominent
posteromedial azygos vein may mimic thickening
Right Upper Lobe Bronchial Segments
• Apical segmental bronchus
-• First branch of right upper lobe bronchus identified
when scanning in a cephalocaudal direction
Seen as circular lucency in cross section;
superimposed on distal portion of right upper lobe
bronchus
• Posterior and a n t e r i o r segmental bronchi
" Typically horizontal, parallel to axial plane
o Posterior segmental bronchus courses cephalad and
posteriorly; anterior segmental bronchus courses
anteriorly
Bronchus I n t e r m e d i u s
• Origin at level of right upper lobe bronchus
• Courses obliquely (3-4 cm); directly posterior to right
pulmonary artery
• Posterior wall in contact with aerated lung; should be
thin, uniform in thickness (< 3 mm)
 AIRWAYS
Thickening suggests tumor infiltration,
Ivmphadenopalhy, edema
• Branches into m i d d l e loin- and right lower lobe
bronchi
• Obstruction may produce combined volume
Ioss/pneumonitis in middle and right lower lobes
M i d d l e Lobe Bronchus
• Origin from anterolateral wall of b r o n c h u s
i n t c r m e d i u s same level as origin of lower lobe
bronchus; origins separated by a spur
• Courses anterolateral I v, caudally, and obliquely
• Branches into lateral and medial s e g m c n t a l b r o n c h i :
tijiJ.sl in size in 50% of individuals; medial segment
larger than lateral in most other individuals
• 1 atcral segmental bronchus more horizontal;
visualized over a great length
Right Lower Lobe Bronchus
• Superior segmental b r o n c h u s originates posteriorly
from short proximal portion of right lower lobe
bronchus
• Righl lower lobe bronchus continues 5-10 m m as
t r u n c u s basalis; divides into four basilar segmental
bronchi
Medial, anterior, lateral and posterior basilar
segmental b r o n c h i arise on CI in counterclockwise
order
i Supply medial, anterior, lateral and (Kisterior basilar
lung segments, res|M?ctively
' Identified by relative position to each other; course
toward respective lung segments
Left Bronchial Anatomy
Left M a i n Bronchus
• Origin anterior to esophagus; courses inferolaterall)
• llyparterial (i.e., 'situated below an artery"); refers to
its relationship to adjacent left p u l m o n a r y artery
• Longer, more horizontal than right main bronchus;
less prone t o aspiration
• Divides into left upper and left lower lobe b r o n c h i
Left Upper Lobe Bronchus
• Origin from left main bronchus; bifurcates or
trif II n a t e s
• Most commonlv branches into superior and lingular
divisions
Left U p p e r Lobe Bronchial Segments
• Superior portion divides into apicoposterior and
a n t e r i o r segmental b r o n c h i
• Inferior (lingular) portion courses oblk|uelv, interiorly
and anterolaterally; analogous to middle lobe
bronchus
Bifurcates into superior and inferior segmental
bronchi
Left Lower Lobe Bronchus
• Same general branching pattern as righl lower lobe
bronchus
Left Lower Lobe Bronchial Segments
• Superior segmental b r o n c h u s courses posteriorly, at
or near level of lingular bronchus
• left lower lobe bronchus continues as t r u n c u s basalis:
divides into three basilar segmental bronchi
■ Anteromedial, lateral and posterior segmental
b r o n c h i ; arise on CT in clockwise order
• Course toward and supply respective lung segments
| Variants of Bronchial Anatomy
A n o m a l o u s Bronchi
• Arise at lower level than normal in bronchial tree
S u p e r n u m e r a r y Bronchi
• Supply same segment of lung as respective normal
segmental bronchus
Axillary Bronchus
• Supernumerary airway supplying lateral aspect of righl
upper lohe
Accessory Tracheal Bronchus
• Svn.: I'ig bronchus
• Kare; 1-2% prevalence in adults
• Upper lobe bronchus or segmental bronchus; arises
from right lateral tracheal wall
• May be occluded by endotracheal intubation; possible
resultant infection
Accessory Cardiac Bronchus
• Kare supernumerary bronchus: (1.5% prevalence in
adults
• Arises from medial aspect of right main bronchus or
bronchus intermedius
• Courses caudall> toward mediastinum and heart
(hence "cardiac" designation); typically blind-ending
Situs Abnormalities
• Bilateral right-sided airway anatomy; associated with
asplenia, congenital heart disease; rare in adults
• Bilateral lett-sided airway anatomy; isolated finding or
associated with hypogenctic lung syndrome, less
c o m m o n l y with polysplenia
Imaging of the Airways
Radiography
• Tracheal air column visible on I'A and lateral chest
radiography; smooth, parallel intraluminal borders
• Right p a r a t r a c h e a l stripe
I hin line (1-4 m m ) represents right lateral tracheal
wall on l'A chest radiography
Extends from clavicle to arch ot azygos vein in
tracheobronchial angle
Visible in 2/.i ot normal individuals; should be of
uniform thickness
Thickening suggests paratracheal lymphadenopathy
• Bronchoarterial pairs may he visualized in perihilar
region; seen in cross-section on I'A chest radiograph
• Normal bronchi not visualized in mid-to-peripheral
lungs on radiography
 AIRWAYS
CT
■ Imaging optimized by thin-section and/or helical CT,
I IRC I
• Bronchi paired with respective pulmonary arteries as
brnnchoarterial bundle
• Throughout their length, bronchi and accompanying
pulmonarv arteries approximately equal in diameter
• Krone hoarlci ial (11/A) ratio calculated by dividing
internal iluminali diameter of bronchus (B) bv outer
diameter o! adjacent pulmonary artery (A)
li/A ratio in normal individuals ranges from 0.65-0.7
• Expiratory CT/HRCT may reveal air-trapping; evidence
ol small airway disease
• Virtual broiuhoscopv simulates visualisation through
a bronchoscope
I D internal surface rendering ol spiral CT data
' A n a t o m y Based I m a g i n g
[Abnormalities
Tracheal Narrowing
• trachea! stenosis (narrowing of normal diameter by >
10%); trauma is most common benign etiology
- Mav result from endotracheal intubation or
tracheostomv; may cause dyspnea on exertion,
stridor. and wheezing
Ihvroid enlargement related to goiter or neoplasm
may cause tracheal narrowing and/or displacement
Ixfrinsic compression bv vascular anomalies (double
aortic arch, aberrant right subclavian artery,
pulmonary artery sling)
• focal narrowing
1
I'ostintubation stenosis, postintectious stenosis,
neoplasia, systemic diseases (Crohn disease,
sarcoidosis. Ilehcct syndrome)
• Diffuse narrowing
Wegener granulomatosis, relapsing polvchondritis,
tracheobronc hopathia osteochondroplastica,
amyloidosis. papillomatosis, rhinoscleroma
Tracheomalacia
• Abnormal degree of compliance of tracheal wall and
supporting cartilage; flacciditv usually apparent during
forced expiration
Saber Sheath Trachea
• Deformity limited to intrathoracic portion of trachea;
coronal diameter of two-thirds or less than sagittal
diameter at same level
• Common finding in men > 50 years of age; associated
with chronic obstructive pulmonary disease (COI'D);
usually of no clinical significance
Foreign Body Inhalation
• Foreign Ixxlies typically lodge in right or left main
bronchi; less commonly in trachea or lobar bronchi
• Predilection for inhalation into right main bronchus
I.\UL- to its more vertical course
Bronchiettasis
• Chronic, irreversible dilatation of bronchi, usually
associated with inflammation (transient airwaj
dilatation described in pneumonia and atelectasis)
• Diameter of normal bronchi approximately equal to
diameter of accompanying (homologous) pulmonary
artery; bronchoarterial (BA) ratio > 1
• Kcid classification based on gross, bronchographic.
and C. 171 IK( !T appearances
Cylindrical (mild) characterized by relatively
straight, parallel walls (may resemble tram tracks on
radiography/CD; may form signet ring sign on ( I
when imaged in cross-section
Varicose (moderate) appears irregular; foci of
luimn.il constriction alternating with areas of
dilatation; resultant headed bronchial morphology
Cystic/saccular (severe) appears halloon-likc; > I
cm in diameter; reduced number of bronchial
divisions
• (T/HRC I demonstrates dilatation ot bronchi, with or
without bronchial wall thickening
• Mucoid impaction of bronchiectatic airways mav
result in nodular and/or tubular opacities on
radiography and CT; branching tubular opacities ma\
occur
• fraction bronchiectasis refers to airway dilatation
resultant from retractile interstitial fibrosis
Mounier-Kuhn (Tracheobronchomegaly)
• Rare; unknown etiology; dilatation of trachea and
main bronchi; corrugated appearance may result from
mucosal prolapse between adjacent cartilaginous rings
Endoluminal Tumor
• Primary (benign or malignant) and secondary
(metastatic) tumors may narrow, deform and/or
occlude bronchi; with or without distal effects
(atelectasis, pneumonitis, mucoid impaction, lung
abscess)
• Xtclectasis/pneumonitis affecting pulmonan. lobes or
segments should prompt CT assessment of associated
bronchi for tumor detection
• Combined changes (atelcctasis/pneumoiiitis) allccting
middle lobe and right lower lobe suggests involvement
of bronchus intermedius
 AIRWAYS
OVERVIEW OF AIRWAY ANATOMY

H ■ 11

Right main bronchus Left main bronchus

Branching airways
extending Into lung
periphery
9W ?
Bronchus and Its
paired pulmonary
artery

Overview of the airways shows the tracheobronchial tree extending bilaterally from the trachea! bifurcation at the
carina. Lobar and segmental bronchi emanate from the right and left main bronchi as they branch, taper and extend
into the lung penphery. Each airway beyond the lung hila is accompanied by its paired, homologous pulmonary
artery.
 AIRWAYS
ANTERIOR VIEW, SEGMENTAL AIRWAYS

Apical bronchus (RBI)

Aplcoposterior
bronchus (LB1+2)
Posterior bronchus
(RB2)
Anterior bronchus
(LB3)

Anterior bronchus
(RB3)
Lateral bronchus (RB4) Superior lingular
bronchus (LB4)

Medial bronchus Inferior lingular

(RB5) bronchus (LBS)
Anterior basilar
bronchus (RB8) Anteromedial basilar
bronchus (LB7+8)

Lateral basilar Lateral basilar

bronchus (RB9) bronchus (LB9)
Postenor basilar
bronchus (RB10)
Posterior basilar
bronchus (LB10)
Medial basilar
bronchus (RB7)

Graphic of anterior view of tracheobronchial tree depicts color-coded segmental bronchial origins that correspond to
color-coded lung segments (see "Lungs" section).
 AIRWAYS
POSTERIOR VIEW, SEGMENTAL AIRWAYS
n
H i

I i^ (
—I

■
'* .— flJ

■f.

IV

bronchus (LB1+2) Apical bronchus (RBI)

Posterior bronchus
(RB2)
Anterior bronchus
(LB3)

Anterior bronchus
(RIB)
Superior lingular
bronchus (LB4) Lateral bronchus (RB4)
Medial bronchus
(RB5)
Inferior lingular
bronchus (LBS) Anterior basilar
bronchus (RB8)
Anteromedial basilar
bronchus (RB7+8)
Lateral basilar
bronchus (RB9)
Lateral basilar Superior bronchus
bronchus (LB9) (RB6)
Posterior basilar Posterior basilar
bronchus (LB10) \ bronchus (RB10)

Medial basilar
Superior bronchus bronchus (RB7)
(LB6)

Graphic of posterior view of tracheobronchial tree depicts color-coded segmental bronchial origins t h a t correspond
to color-coded lung segments (see "Lungs" section).

1
207
 AIRWAYS
RADIOGRAPHY, CENTRAL AIRWAYS

Trachea

Left main bronchus

Anterior segmental
bronchus
Right main bronchus —
Carina

Trachea, anterior wall — Trachea, posterior wall

— Right upper lobe

bronchus

Left upper lobe

bronchus

(Top) I'A chest radiograph demonstrates the midline tracheal air column. The trachea bifurcates at the carina,
supplying the right main and left main bronchi. The anterior segmental bronchus of the right upper lobe is
frequently visible on PA chest radiographs. (Bottom) I,eft lateral chest radiograph demonstrates the tracheal air
column and the characteristic oval lucencies of the right upper lobe bronchus and left upper lobe bronchus.
 AIRWAYS
CT, CENTRAL AIRWAYS

Apical segmcntal bronchi — Apicoposterlor segmcntal

bronchi

— Trachea

Anterior segmental bronchi

Right upper lobe bronchus -

Posterior segmcntal bronchus, right

upper lobe

Right main bronchus — Carina

— Trachea

— Left main bronchus

Bronchus intermcdius -

Right lower lobe bronchus -

(Top) First of two axial HRCT scans of the central airways demonstrates the trachea as a midline structure with
sharply defined luminal margins. The posterior, membranous tracheal wall bows outward on scans obtained during
full, suspended inspiration. The most cephalad segmental airways imaged in axial sections through the upper lungs
are the apical segmental bronchi on the right and the apicoposterlor segmental bronchi on the left. (Middle) HRCT
at the level of the carina demonstrates the midline carina, the right main bronchus, and the origin of the right upper
lobe bronchus. Note the thin posterior wall of the right main bronchus, a characteristic appearance in normal
individuals. (Bottom) Volumetric HRCT, coronal reformation, demonstrates the relatively vertical course of the right
main bronchus in comparison to the more oblique course of the left main bronchus.
(Top) Graphic of anterior and posterior views of the trachea and right portion of the tracheobronchial tree depicts
color-coded segmental bronchial origins that correspond to color-coded lung segments. (Bottom) Graphic of anterior
and posterior views of the right lung. Lung segments of each lobe are color-coded to correspond to the segmental
bronchial origins depicted in the top graphic.
 AIRWAYS
CT, RIGHT LUNG SEGMENTAL BRONCHI

— Apical segmental bronchus

— Esophagus

— Trachea

Anterior segmental bronchus

Right upper lobe bronchus

Left main bronchus

— Right main bronchus

Posterior segmental bronchus —

Anterior subsegmental bronchi

Anterior segmental bronchus

(Top) First of nine axial HRCT scans demonstrating segmental bronchi of the right lung. The apical segmental
bronchus is characteristically seen in cross-section as a circular lucency. (Middle) Axial HRCT scan at the level of the
carina demonstrates the characteristic horizontal orientation of the anterior and posterior segmental bronchi.
(Bottom) Axial HRCT scan at the level of the right pulmonary artery demonstrates branching of the anterior
segmental bronchus into subsegmental airways that are well visualized by virtue of their horizontal orientation,
parallel to the HRCT scan plane.
 AIRWAYS
CT, RIGHT LUNG SEGMENTAL BRONCHI

Distal left main bronchus

— Bronchus intcrmedius

— Proximal middle lobe bronchus

Spur marking bifurcation of

distal bronchus Intcrmedius

— Superior segmental bronchus,

right lower lobe

Medial segmental bronchus,

middle lobe

Lateral segmental bronchus, middle - Tnincus basalis

lobe

(lop) The bronchus intermedius lies immediately posterior to the right pulmonary artery. Its posterior wall is
characteristically thin and uniform, measuring < 3 mm in thickness. (Middle) At the distal end of the bronchus
intermedius, axial HRCT section demonstrates the distinctive thin septum (spur) demarcating the point of
bifurcation of the bronchus intermedius at the origins of the middle lobe bronchus and the superior segmental
bronchus of the right lower lobe. (Bottom) A more caudal axial HRCf" section demonstrates the horizontal portions
of the medial segmental and lateral segmental bronchi of the middle lobe and the tnincus basalis supplying the right
lower lobe distal to the origin of the superior segmental bronchus.
 AIRWAYS
CT, RIGHT LUNG SEGMENTAL BRONCHI

Anterior segmental basilar

bronchus

— Medial segmental basilar

Lateral segmental basilar bronchus bronchus

— Posterior segmental basilar

bronchus

Anterior segmental basilar

bronchus

— Medial segmental basilar

Lateral segmental basilar bronchus bronchus

— Posterior segmental basilar

bronchus

Anterior segmental basilar

bronchus

Medial segmental basilar

Lateral segmental basilar bronchus bronchus

Posterior segmental basilar

bronchus

(Top) The four basilar segmental bronchi of the right lower lohe originate distal to the truncus hasalis. (Middle) The
medial, anterior, lateral, and posterior basilar segmental bronchi arise in counterclockwise order a n d course toward
their respective lung segment. Each bronchus is accompanied by its paired, homologous, segmental pulmonary
artery. (Bottom) The four basilar segmental bronchi begin to diverge a n d course peripherally within their respective
basilar lung segments.
 AIRWAYS
SEGMENTAL ANATOMY, LEFT LUNG

Anterior
Posterior

Aplcoposterior segment
Apicopostenor segment

Anterior segment

Supenor segment, left

lower lobe

Superior lingular
segment
Inferior lingular Posterior basilar
segment segment
Posterior basilar
segment

Anteromedial basilar Lateral basilar segment

segment Anterior Posterior

(Top) Graphic depicts anterior and posterior views of the trachea and left portion of the tracheobronchial tree.
Segmental airway origins are color-coded to conespond to lung segments. (Bottom) Graphic of anterior and
posterior views of the left lung. Lung segments of each lobe are color-coded to correspond to the segmental bronchial
origins depicted in the top graphic.
 AIRWAYS
CT, LEFT L U N G S E G M E N T A L B R O N C H I
n
n

- Apicoposterior bronchi
—
Trachea

Esophagus —

— Anterior segmental bronchus

—
Right main bronchus
Apicoposterior bronchus

Lett main bronchus —

— Origin ot lingular bronchus

- U-ft upper lobe bronchus

Bronchus intcrmedius —
- Left interlobar pulmonary
artery

( l o p ) First o f n i n e axial HRCT scans d e m o n s t r a t i n g segmcntal b r o n c h i o f t h e left l u n g . The vertically oriented apical
and posterior branches o f t h e apicoposterior bronchus are seen i n cross-section, each adjacent t o its a c c o m p a n y i n g
h o m o l o g o u s p u l m o n a r y artery. ( M i d d l e ) The apicoposterior bronchus is seen i n cross-section, i n c o n t r a d i s t i n c t i o n t o
the h o r i z o n t a l o r i e n t a t i o n a n d l o n g i t u d i n a l display o f the anterior segmental bronchus. The anterior segmental
bronchus is usually easily identified o n axial CT sections because o f its characteristic h o r i z o n t a l course in the same
plane as t h e CT scan. ( B o t t o m ) HRCT scan demonstrates t h e left upper l o o t bronchus. A circular lucency o v e r l y i n g
its distal aspect indicates the o r i g i n o f the lingular bronchus. The lower p o r t i o n of the left upper lobe bronchus is
marginated laterally by the left interlobar p u l m o n a r y artery. I
215
 AIRWAYS
CT, LEFT LUNG SEGMENTAL BRONCHI

- Lingular bronchus
— Left upper lobe bronchus, lower
Bronchus intermedium - portion

— left intcrlohar pulmonary

artery

Bronchus Intermedius — I.ingular bronchus

— Superior segmental bronchus,

left lower lobe

Superior segmental lingular

bronchus
Bronchus intermedius, distal -
portion
Superior segmental bronchus,
left lower lobe

(Top) The lower portion of the left upper lobe bronchus is marginated laterally by the left interlobar pulmonary
artery. The proximal portion of the lingular bronchus courses anterolaterally. (Middle) The lingular bronchus courses
obliquely, inferiorly, and anterolaterally and is analogous to the middle lobe bronchus of the right lung. The origin
of the superior segmental bronchus of the left lower lobe is normally at or near the same level of origin as the
lingular bronchus. (Bottom) More caudally, the superior segmental lingular bronchus courses horizontally within
the left upper lobe, characteristically at or near the same level as the superior segmcntal bronchus of the left lower
lobe.

1\U
 AIRWAYS
CT, LEFT LUNG SEGMENTAL BRONCHI

Superior segmental lingular

bronchus

Truncus basalis, left lower lobe

— Anteromedial segmental basilar

bronchus
— lateral segmental basilar
bronchus

— Posterior segmental basilar

bronchus

— Anteromedial segmental basilar

bronchus

■ Lateral segmental basilar

bronchus
— Posterior segmental basilar
bronchus

(Top) The left lower lobe bronchus continues as the truncus basalis for a short distance before dividing into three
basilar segmental bronchi. (Middle) Distal to the truncus basalis, the anteromedial, lateral, and posterior basilar
segmental bronchi arise in clockwise order. (Bottom) The anteromedial, lateral, and posterior basilar segmental
bronchi diverge and course toward their respective lung segments. Each bronchus is accompanied by its paired,
homologous segmental pulmonary artery.

^
 AIRWAYS
in CORONAL CT, AIRWAY ANATOMY
TO

-c — Anterior segmental bronchus,

Anterior segments! bronchus, right
U left upper lobe
upper lobe

Medial segmental bronchus, middle -

lobe

Anterior segmeiil.il bronchus, right -

Anterior segmental bronchus,
upper lobe
lefi upper lobe

Superior segmental lingular

Medial segmental bronchus, middle - bronchus
lobe

Kight upper lobe bronchus — Left upper lobe bronchm

Lateral segmental bronchus, middle — Inferior lingular segmental

lobe bronchus
Medial segmental bronchus, middle —
lobe — Bronchus intermedius

(Top) First of six coronal CT images of normal bronchi. In this most anterior section, right and left anterior
segmental bronchi and the medial segmental bronchus of the middle lol>e are demonstrated in cross-section, bach
bronchus is adjacent to its paired, homologous pulmonary artery and both are approximately equal in diameter.
(Middle) More posteriorly, in the plane of the right pulmonary artery, the superior segmental lingular bronchus is
demonstrated. The lingular bronchi are analogous to the contralateral middle lobe bronchi. (Bottom) In the plane of
the tracheal carina, the origins of the right upper and left upper lobe bronchi are demonstrated. The origins of the
medial and lateral segmental bronchi of the middle lobe are seen arising beyond the distal end of the bronchus
intermedius.
_'lfl
 AIRWAYS
CORONAL CT, AIRWAY ANATOMY

Apicopostenor segmental
Apical segmental bronchus, right bronchus, left upper lobe
upper lobe

Superior scgmental bronchus, right —

lower lobe
Lateral basilar segmental
Truncus basalis bronchus, left lower lobe

Inferior pulmonary veins

lateral basilar segmental bronchus, —
right lower lobe

— Apicopostenor segmental
bronchi
Posterior segmental bronchus, right —
upper lobe
— Superior segmental bronchus,
left lower lobe
Superior segmeillal bronchus, right "~!
lower Iol>e - Truncus basalis
Posterior basilar segmentdl —r
bronchus, right lower lobe

Superior segmental bronchus, right Superior scgmental bronchus,

lower lobe left lower lobe

— Posterior basilar segmental

bronchus, left lower lobe
Posterior basilar segmental
bronchus, right lower lobe

(Top) 111 the plane of the inferior pulmonary veins, the right truncus basalis and right and left basilar segmental
bronchi are demonstrated. (Middle) In the prevertehral plane, right posterior a n d left apicopostenor bronchi are
demonstrated in the upper lobes and superior segmental bronchi are shown in both lower lobes. (Bottom) The most
posterior section demonstrates superior segmental bronchi and posterior basilar segmental bronchi of both lower
lobes.
 AIRWAYS
VIRTUAL BRONCHOSCOPY

Bronchus intermedius
■-

Right upper lobe bronchus

Right main bronchus Left main bronchus

Superior segniental bronchus, right

lower lobe

Truncus basalis and basilar

segmental bronchi

Bronchus intermedius

■
Medial segmental bronchus, middle
lobe
Soft tissueridgemanifests as
%- . spur on CT

Lateral segmental bronchus, middle Middle lobe bronchus

lobe

Left lower lobe bronchus

Left upper lobe bronchus

^m BrS^

(Top) First of three virtual bronchoscopic images of normal airways. Each image is aligned with the anterior aspect of
the patient at the bottom of the image. The midline carina marks the bifurcation of the distal trachea to form the
right and left main bronchi. (Middle) In the distal aspect of the bronchus Intermedius, a ridge of soft tissue
demarcates the origins of the lower lobe bronchus (above) and the middle lobe bronchus (below) and manifests on
CT as a thin septum (spur). (Bottom) The left main bronchus bifurcates to form the left upper lobe bronchus and left
lower lobe bronchus.
 AIRWAYS
BRONCHOARTERIAL RATIO

B A

Major fissure

Broncho-arterial pair
Broncho-arterial pair

Segmental pulmonary veins

Broncho-arterial pairs

Segmental pulmonary vein

Broncho-arterial pairs

(Top) Graphic demonstrates the broncho-arterial ratio (B/A), determined by dividing the inner luminai diameter of
an airway by the outer diameter of its accompanying (homologous) pulmonary artery. The B/A ratio In normal
individuals ranges from 0.65-0.7. (Middle) CT of right lower lobe demonstrates broncho-arterial pairs, each
comprised of a bronchus and its adjacent (homologous) pulmonary artery seen in cross-section. (Bottom) CT of the
right lower lobe demonstrates broncho-arterial pairs seen longitudinally.
 AIRWAYS
RADIOGRAPHY, BRONCHIECTASIS

Parallel linear opacities (tram-track -

pattern)
- Parallel linear opacities
(tram-track pattern)

Linear, curvilinear and ring-shaped ■

opacities

Minor fissure, displaced superiorly - Bronchiectasis

Bronchiectasis -

Bronchiectasis with mucoid

impaction

( l o p ) PA chest radiograph of a patient with cystic fibrosis demonstrates extensive changes of bronchiectasis
manifesting as parallel linear opacities emanating from b o t h hila and curvilinear and ring shaped opacities. (Middle)
Coned down PA chest radiograph demonstrates bronchiectasis and loss of volume in the right upper lobe. Subtle
bronchiectasis in the superior segment of the right lower lobe manifests as parallel linear opacities emanating from
the hilum (tram-track pattern). (Bottom) Coned down PA chest radiograph demonstrates mucoid impaction within
bronchieclatic airways in the left upper lobe, manifesting as tubular opacities emanating from the hilum.
 AIRWAYS
CT, BRONCHIECTASIS

Mutoid inij>aitioii forming

nodular opacities
Signet ring pattern ot
bronchicctasis

lironchiectasis with airway wall

thickening

Atdi'ilatii middle lobe

Small parenchymal nodules

Ilronclui'iiasis

Bronchicctasis and retractile

scarring, right lower lobe

traction broiiiliiectasis — -

■— Traction brniichiecMsis
l-nd-stage (honeycomb) lung

( l o p ) Chest CT (lung window) of a patient with a history of recurrent pneumonia demonstrates scattered areas of
bronchiectasis in the lung bases, manifested by dilated airways and airway wall thickening. Small nodular opacities
represent mucoid impaction of bronchicctatic airways. (Middle) Chest c I" (lung window) of the right lower lung
demonstrates bronchiectasis within an atelectatic middle lobe a n d focal bronchiectasis in the anteromedial aspect of
the right lower lobe. Small nodular opacities arc noted in the lung periphery. This combination of features is
suggestive ot atypical mycobacterial infection. Kronchoscopic cultures yielded Mycobacterium avium intracellulare
(MAI). (Itottom) I IK( rr (lung window) of the right lower lolie demonstrates traction bronchiectasis within areas of
interstitial fibrosis and honeycomb (end-stage) lung.
 AIRWAYS
TRACHEAL NARROWING

- Narrowing of trachea! lumen;

tracheomalacia

Air in esophagus —

Normal trachea, alxwe the thoracic —

Inlet
Saljcr sheath deformity within
the thorax

Thyroid goiter
Narrowed and displaced
trachea

(Top) Chest CT (bone window) demonstrates tracheomalacia at the level of a previous percutaneous trachcostomy
complicated by fracture of tracheal cartilaginous rings. (Middle) Chest CT (lung window) demonstrates saber sheath
tracheal deformity of the intrathoracic portion of the trachea (right). The extrathoracic trachea (left) is normal in size
and configuration. (Bottom) Contrast-enhanced chest CT (mediastinal window) shows a moderately large thyroid
goiter that narrows the trachea at the thoracic inlet and displaces it to the left of midline.
 AIRWAYS
BRONCHIAL ANOMALIES, TRACHEAL BRONCHUS

— Trachea

Trachea! bronchus

Right and left main bronchi

— Trachea

— Tracheal bronchus

(. anna

Origin of accessory tracheal

bronchus

(Top) Hirst of three Images of a patient with an incidentally discovered tracheal bronchus. 3D rendered C" I image of
the central airways and adjacent upper lungs demonstrates the accessory tracheal bronchus arising from the right
lateral aspect of the trachea. (Middle) Contrast-enhanced chest ( J ilung window) demonstrates an accessory
tracheal bronchus arising from the right lateral wall ot the trachea a n d supplying adjacent lung parenchyma in the
right upper lobe. (Bottom) Virtual bronchoscopic image demonstrates the origin of the accessory tracheal bronchus
arising from the right lateral tracheal wall. The anterior tracheal wall is at the bottom of the virtual bronchoscopic
image.
 AIRWAYS
ENDOBRONCHIAL TUMORS

— Adenoeaiiinoina obstructing
Superior lingular bronchus

Left main bronchus - Atelectatk left upper lobe

Carina —

Lung cancer occluding left upper -

lobe bronchus

- Mucoid impaction within

obstructed, dilated bronchi

Lung cancer obstructing left lower —

lobe bronc hus

(Top) l-irst o f three cases. Chest CT ( l u n g w i n d o w ) demonstrates e n d o b r o n c h i a l o b s t r u c t i o n o f the superior lingular

bronchus by a p r i m a r y adenocarcinoma of the l u n g . Presumed collateral v e n t i l a t i o n of p a r e n c h y m a distal t o the
p o i n t o l o b s t r u c t i o n prevents d e v e l o p m e n t o f atelectasis or other distal effects o f e n d o b r o n c h i a l o b s t r u c t i o n .
( M i d d l e ) Contrast-enhanced chest CT (mediastinal w i n d o w ) demonstrates t o t a l occlusion of the left upper lobe
bronchus b y a p r i m a r y l u n g cancer (squamous cell carcinoma) w i t h resultant atelectasis o f t h e left upper lobe. Lack
o f air bronchograms w i t h i n a n atelectatk lobe suggests the presence of p r o x i m a l airway o b s t r u c t i o n . (Bottom)
Composite o f t w o CT images of the left lower lobe ( l u n g w i n d o w ) demonstrates e n d o b r o n c h i a l t u m o r o b s t r u c t i n g
the left lower bronchus a n d associated distal m u c o i d i m p a c t i o n w i t h i n distended b r o n c h i .
 AIRWAYS

I _•

Thickening and Irregularity, right

main bronchus

.*A
Thickened posterior wall, right Narrowing and irregularity of
main bronchus left main bronchus

kw
Trachea! nanowlng

V
Narrowing and Irregularity of
Narrowing and Irregularity of right left main bronchus
main bronchus

Narrowing and Irregularity of right Narrowing and irregularity of

main bronchus left main bronchus

(Top) First of three images of a patient with Wegener granulomatosis involving the central airways. Chest CT
(mediastinal window) at the level of the carlna demonstrates thickening of airway walls with involvement of right
and left main bronchi and the carina. (Middle) 3D CT rendering of the central airways demonstrates narrowing and
irregularity of the distal trachea and the right and left main bronchi. (Bottom) Virtual bronchoscoplc image of the
carina and right and left main bronchi demonstrates narrowing and irregularity of the central airways.
 PULMONARY VESSELS
| Pulmonary Arteries
Function
• Conduit of de-oxygenated blood to capillary-alveolar
interface
Pulmonary Trunk
• Arises from right ventricular outflow tract; anterior
and to the left of ascending aorta
• Postcrosuperior course toward the left and posterior to
ascending aorta
• Contained in p e r i c a r d i u m
Common serous pericardia! sheath contains
proximal pulmonary trunk and ascending aorta
Right Pulmonary Artery and Branches
• Right pulmonary artery
longer and larger than lelt pulmonary artcrv
Horizontal intramcdiastinal course
Relationships
■ Posterior to aseendiiig aorta, superior \ena cava
and right superior pulmonary vein
Branches
■ \scending trunk or truncus anterior, supplies
right upper lobe
■ Descending trunk or interlobar pulmonary
artery, supplies middle and right lower lobes
■ Peripheral branches located medial to bronchi in
upper lobes and lateral to bronchi in middle and
lower lobes
Left Pulmonary Artery and Branches
• I elt pulmonary artery
Shorter and smaller than right pulmonary artery
Slightly posterior to right pulmonary artery
Courses superior to left main bronchus
• Branches
■ Short ascending branch, supplies left upper lobe
■ Descending or interlobar pulmonary artery,
supplies left lower lobe and lingula
■ Peripheral pulmonary arteries located medial to
bronchi in anterior and apicoposterior segments
of left upper lobe and lateral to bronchi in lingula
and lower lobe
| Pulmonary Veins
Function
• Conduit of oxygenated blood from capillary-alveolar
interface to left heart chambers
Embryologic Anatomy
• I eft atrium partially derived from primitive common
pulmonary vein
• Atrial expansion with incorporation of primitive
common pulmonary vein into atrial chamber
• Two pairs of sujicrior and inferior pulmonary veins
with frequent variations in number
■ 70% ol population has four pulmonary veins
Undcrincorporation of pulmonary veins into atrium
■ More common on the left
■ Common trunk for superior and inferior
pulmonary veins in 12-25% of subjects
Ovenncorporation ot pulmonary veins into atrium
resulting in supernumerary/accessory veins
■ More common on the right
Frequent variations in central anastomosis ot
middle lobe pulmonary vein
■ Middle lobe pulmonary vein draining into right
superior pulmonary vein in 53-69% of normal
subjects
■ Middle IOIK- pulmonary vein draining directly
into left atrium in 17-23% of normal subjects
■ Middle lobe pulmonary vein draining into
interior pulmonary vein in 3-8% of normal
subjects
Above data per tihayc B et al: Percutaneous ablation
for atrial fibrillation: the role ot cross-sectional
imaging. Radiodraphics. 23:S19-S33, 2(M).I
• Clinical significance
Identification of normal anatomic variants
< Pre-ablatiou imaging of patients with atrial
fibrillation due to cctopic arrhvthmogcnii l<Ki
General Anatomy
• Pulmonary veins course along peripheral aspects of
subsegments. segments and lobes
• Superior pulmonary veins exhibit an oblique course
into left atrium
• Inferior pulmonary veins exhibit an oblique course
into left atrium
• Right pulmonary veins
Superior p u l m o n a r y vein
■ Drains up|>er and middle lobes
Inferior pulmonary vein
■ Drains lower lnlie
• Left pulmonary veins
.Superior pulmonary vein
■ Drains up|H'r and lower div isions of upper lobe
Inferior pulmonary vein
■ Drains lower lolie
N o m e n c l a t u r e of Pulmonary Arteries
and Veins
General Concepts
• Boyden nomenclature of trachcobronchial tree (see
" Virways" section)
• Jackson and MIIIRT svstematization of seginental lung
anatomy (See "lungs" section)
• Right (10; left (I)
• Arteries (A); veins (V)
• Numerical descriptor, analogous to bronchial
nomenclature (see "Airways" section)
• typical branching pattern
c 10 segmental pulmonarv arteries, second order
branches
c 20 subsegmental pulmonary arteries, third order
branches
c Subsegmental pulmonary arteries, fourth order
branches: dichotouioiis division of segmental
arteries
Subsequent dichotomous divisions into lilth and
sixth order branches
 PULMONARY VESSELS
• Nomenclature thai follows is based on: Remy-Jardin
M: Cl Angiography of the Chest. Philadelphia,
I ippincott Williams & Wilkins, 2(X)I
Right Upper Lobe Pulmonary Arteries
• Ascending t r u n k (truncus anterior)
Apical segmental artery; RA1
■ Posteriorly located apical and anterior
subsegmental branches
Anterior segmental artery; RA2
■ I aterally located posterior and anterior
subsegmental branches
• Posterior .segmental artery; RA.i
o Originates from interlobar pulmonary artery
Laterally located apical and posterior subsegmental
branches
Middle Lobe Pulmonary Arteries
• Origin from right interlobar p u l m o n a r y artery
: May arise as a single vessel
May arise as two distinct vessels
Origin slightly superior to origin of right lower lone
sii|x.'rior segmental artery
• Lateral s e g m e n t a l artery; RA4
Posterior and anterior subsegmental branches
• Medial segmental artery; RA5
Superior and interior subsegmental branches
Right Lower Lobe Pulmonary Arteries
• Lower lobe p u l m o n a r y artery
Continuation of interlobar pulmonary artery distal
to origin of middle lobe arteries
'.' Superior segmental artery; RA6
■ Posterior origin
■ Combined medial/superior and lateral
subsegmental branches
■' C o m m o n basal artery
■ Gives rise to basal segmental arteries
a Medial basal segmental artery; RA7
■ Anterolateral a n d anteromedial subsegmental
branches
■ Anterior basal segmental artery; KAR
■ Lateral and basal subsegmental branches
I ateral basal segmental artery; RA9
■ 1 ateral and basal subsegmental branches
■' Posterior basal segmental artery; RA10
■ I ateroba.sal and mediobasal subsegmental
branches
Left Upper Lobe Pulmonary Arteries
• Greater number of separate subsegmental branches
• Upper division
Independent origin ot apical and posterior
segmental arteries, unlike bronchial divisions
i Apical segmental artery; LAI
Anterior segmental artery; 1A2
■ lateral and anterior subsegmental arteries
•3 Posterior s e g m e n t a l artery; LA.?
• Lower division
1
Single lingular artery gives rise to two segmental
arteries
o Superior lingular segmental artery; I.A4
■ Posterior and anterior subsegmental branches
Inferior lingular segmental artery; I A5
■ Superior a n d inferior subsegmental branches
Left Lower Lobe Pulmonary Arteries
• Superior s e g m e n t a l artery; I A6
Posterior origin, superior to that of lingular artery
Superomedial and lateral subsegmental branches
• Anteromedial basal s e g m e n t a l artery; LA7+8
o Anterior, medial, lateral anil basal subsegmental
branches
• I ateral basal s e g m e n t a l artery; 1 A9
Lateral and basal subsegmental branches
• Posterior basal s e g m e n t a l artery; LA 10
I ateral and basal subsegmental branches
Right Upper Lobe Pulmonary Veins
• Apical s e g m e n t a l vein; RV1
Apical and anterior subsegmental tributaries
• Anterior s e g m e n t a l vein; RV2
Interior and superior tributaries
• Posterior s e g m e n t a l vein; RV3
• RV1, RV2 and RV.i join to form a large vein anterior t o
interlobar pulmonary artery
Middle Lobe Pulmonary Veins
• I ateral segmental vein; RV4
• Medial segmental vein: RV5
• form c o m m o n trunk that courses below middle lobe
bronchus and joins superior p u l m o n a r y vein
Right Lower Lobe Pulmonary Veins
• Superior segmental vein; RV6
Drains into inferior pulmonary vein
• Medial basal s e g m e n t a l vein; RV7
• Anterior basal s e g m e n t a l vein; RV8
• Lateral basal segmental vein; RV9
• Posterior basal segmental vein; RV10
• C o m m o n basal vein draining basal segments
Left Upper Lobe Pulmonary Veins
• Upper Division
Apicoposterior segmental vein: LVl+3
Anterior segmental vein: 1V2
• Lower Division
Superior lingular segmental vein; LV4
Inferior lingular segmental vein; I V5
Left Lower Lobe Pulmonary Veins
• Su|>erior s e g m e n t a l vein; IV6
• Anteromedial basal segmental vein; IV7+8
• I ateral basal segmental vein; LV9
• Posterior basal segmental vein; IV10
Imaging of Pulmonary Arteries
Radiography
• Pulmonary trunk
Prominent in normal children, adolescents, young
adults
• Right i n t e r l o b a r p u l m o n a r y artery
I ateral to bronchus iutermedius on frontal
radiographs
Normal transverse measurements
■ 15 m m in w o m e n ; 16 m m in m e n
 PULMONARY VESSELS
Imaging
Angiography ■ N o d u l a r opacity w i t h feeding a n d d r a i n i n g
• Assessment of endoluminal integrity and luminal size vessels
• Visualization of branching patterns and ilistal arterial ■ Single or multiple
tree (including capillary bed) ■ Arteriography tor exclusion ol multitocal disease
• Visualization of abnormal vascular connections a n d embolothcrapy
CT • Hepatopulmonary syndrome
o Acquired pulmonary arteriovenous malformations
• Pulmonary trunk
in patients with end-stage liver disease
> Normal transverse diameter of up to 28.6 mm (24.2
mm ± 2.2) i Characterized by hepatic dysfunction, hypoxemia
and pulmonary vascular dilatation
Measured in scan p l a n e of bifurcation on axial
images, perpendicular to vascular long axis < Imaging
• Inlerlobar pulmonary artery ■ Dilated peripheral lower lobe pulmonary vessels
extending to the pleura
o Normal transverse diameter of u p lo 16.8 m m (13 ±
■ Direct visualization of abnormal arteriovenous
1.9 m m )
connections
Anomalous Pulmonary Venous Drainage
Pulmonary Lymphatics • Partial a n o m a l o u s p u l m o n a r y v e n o u s drainage, left
u p p e r lobe
Anatomy
o Imaging
• Pulmonary lymphatic channels ■ 1 eft upper lobe venous drainage to a n o m a l o u s
• Pulmonary lymph nodes vertical vein coursing along left superior
( Peripheral i n t r a p u l i u o n a r y mediastinum and draining into left
< Suhsegmcntal: station 14 b r a c h i o c e p h a l i c vein
■ Scgmcntal; station 13 ■ Absence of normal left superior pulmonary vein at
I obur; station 12 hilum
Interlobar; station 11 • Scimitar s y n d r o m e (congenital venolobar
• ISronchopulmonary (hilar) lymph nodes syndrome)
llilar; station 10 ' Partial anomalous right lung pulmonary venous
Imaging drainage into inferior vena cava, hepatic or portal
• Normal pulmonary lymphatic channels not visible on veins
imaging studies \sso( iared with right p u l m o n a r y hy]M>plasia,
• Normal intrapulmonary lymph nodes visible on CT bronchopulmonary malformations, systemic arterial
( Elongate subpleural small pulmonary nodules; supply to right lung
intrapulmonary lymph nodes ' Imaging
o Normal sized lymph nodes at bronchial bifurcations ■ Visualization of abnormal vein with scimitar
shape
■ Identification of site of venous drainage
Anatomic-Imaging Correlations ■ Evaluation of associated anomalies
P u l m o n a r y Vein Varix
Pulmonary Venous Hypertension
• Congenital or acquired e n l a r g e m e n t of central
• Vascular equalization (mean pulmonary venous
p u l m o n a r y vein o r veins
pressure; 13-15 m m Hg)
• Associated with chronic elevation of left atrial
■ Larliest radiographic manifestation; equal size of
pressures
upper and lower lobe vessels
• Imaging
• Vascular redistribution (mean pulmonary venous 1
pressure; 15-18 m m Ilg) Nodular opacity on radiography corresponds to
enlarged pulmonary vein on CT
< I 'pper lobe vessels more dilated than lower lol)e
vessels Pulmonary Thromboembolic Disease
Pulmonary Arterial Hypertension • C o m m o n disease with significant morbidity/mortality
• Symptomatic patients; post-operativc/bed-ridden,
• Me.in p u l m o n a r y a r t e r y pressure > 25 m m Hg at
patients with malignant neoplasms
rest; > 30 m m I Ig d u r i n g exercise
• Imaging of acute thromboembolic disease
• Imaging
o Acute dilatation of pulmonary trunk as sign of
i Enlarged pulmonary trunk, diameter > 2.8 cm
pulmonary arterial hypertension
Arteriovenous Malformations i Visualization of partial/complete filling defects
• Congenital pulmonary arteriovenous malformation within contrast opacified pulmonary arteries
o Direct communication between pulmonary • Imaging of chronic thromboembolic disease
artery(ies) and vein(s) without intervening capillary findings of pulmonary arterial hypertensioii
bed ■ Partial/complete filling defects in vascular lumen
o Hereditary hemorrhagic telangiectasia with eccentric l o c a t i o n a n d irregular borders
(Rendu-Osler-Weber syndrome) Recanalization/calcification of emboli
 PULMONARY VESSELS

Right ascending Left pulmonary artery

pulmonary artery

Right descending
pulmonary artery

r Left descending
pulmonary artery

Pulmonary trunk
Left pulmonary veins

I
Graphic depicts the anatomy and relationships of the pulmonary vessels. The pulmonary arteries (In blue)
accompany the bronchi and carry deoxygenated blood to the capillary-alveolar Interface. The pulmonary veins travel
along the periphery of the pulmonary units (secondary pulmonary lobules, pulmonary segments and pulmonary
lobes) and carry oxygenated blood from the alveolar capillaries to the left-sided circulation. Pulmonary lymphatics
(not shown) course along the vascular structures and the tracheobronchial tree and are focaliy organized Into lymph
nodes in the lungs, along the airways and in the hila. The bronchopulmonary and hilar lymph nodes are considered
intrapulmonary lymph nodes for the purpose of lung cancer staging.
 PULMONARY VESSELS
RADIOGRAPHY, NORMAL PULMONARY VESSELS

I .eft superior
pulmonary vein
Right superior
pulmonary vein
— Pulmonary trunk
— I .eft interlobar
Right interlobar pulmonary artery
pulmonary artery

— Peripheral pulmonary
vessels

Right hilar vascular —

opacity
— Left pulmonary artery
Pulmonary trunk —

Peripheral pulmonary
vessels

(Top) First of two normal chest radiographs illustrating the radiographic appearance of the normal pulmonary
vessels. PA chest radiograph demonstrates that the pulmonary arteries provide the greatest contribution to the hilar
opacities. The bilateral interlobar (descending) pulmonary arteries are typically well visualized. Normal peripheral
pulmonary vessels are also seen. The pulmonary arteries undergo dichotomous branching and are least perceptible in
the subpleural lung periphery. The superior pulmonary veins are seen in the suprahilar central lungs. The pulmonary
lymphatics are not visible on normal radiographs. (Bottom) Left lateral chest radiograph shows the normal
pulmonary vessels. The pulmonary trunk is barely apparent. The right hilar vascular opacity is produced by
pulmonary veins and arteries. The left pulmonary artery is visible in most normal subjects.
 PULMONARY VESSELS
RADIOGRAPHY, NORMAL PULMONARY VESSELS
n
:r
a;
</>
■ ■

c_
3
o
Left superior
pulmonary vein

Prominent pulmonary
trunk

Right interlobar
pulmonary artery

I-eft pulmonary artery

Right superior
pulmonary vein

Concave pulmonary
trunk

Right interlobar
pulmonary artery

(Top) First of two normal chest radiographs demonstrating the variable appearance of the pulmonary trunk. PA chest
radiograph of a 23 year old woman shows a prominent pulmonary trunk. The pulmonary trunk may be prominent in
chest radiographs of children, adolescents and young adults. (Bottom) PA chest radiograph of a 15 year old boy
demonstrates the normal medially concave pulmonary trunk configuration typically seen in adult patients.

I
Ml
 PULMONARY VESSELS
ANATOMY OF W E PULMONARY ARTERIES AND VEINS

Right ascending
pulmonary artery

Right descending
pulmonary artery Pulmonary trunk

Middle lobe pulmonary Right superior

artery pulmonary vein

Right Inferior
pulmonary vein

Left pulmonary artery

Pulmonary trunk

Left superior Left interlobar

pulmonary vein pulmonary artery

Left inferior pulmonary

vein

(Top) First of two graphics depicting the anatomy of the pulmonary vessels. Anterior view of the right pulmonary
vasculature shows the right pulmonary artery arising from the pulmonary trunk and bifurcating into ascending and
descending branches. Pulmonary arteries generally course medial to the bronchi in the right upper lobe and lateral to
the bronchi in the middle and lower lobes. The right superior pulmonary vein courses anterior to the bronchi and
pulmonary artery. The right inferior pulmonary vein courses posterior to the bronchi in the inferior portion of the
hilum. (Bottom) Anterior view of the left pulmonary vessels shows the left pulmonary arteries coursing along the
bronchi. The left pulmonary artery courses over the ipsilateral main bronchus. The pulmonary veins course anterior
to the bronchi Note bronchopulmonary and hilar lymph nodes (in green).
 PULMONARY VESSELS
ANGIOGRAPHY, NORMAL PULMONARY ARTERIES

Right ascending
pulmonary artery

R i g h t ill v. , i iiiil;;
pulmonary artery
Right pulmonary artery

Left pulmonary artery

Lett ascending
pulmonary artery

Left descending
pulmonary artery

(Top) First of two images from a normal pulmonary arteriogram. Right pulmonary arteriogram shows an
endovascular catheter that courses from the inferior vena cava through the right atrium, right ventricle, pulmonary
trunk and right pulmonary artery to terminate in the proximal right descending (interlobar) pulmonary artery. Note
the superior course of the right ascending pulmonary artery, the arcuate course of the interlobar pulmonary artery
and the horizontal course of the proximal right pulmonary artery. (Bottom) Left pulmonary arteriogram shows the
endovascular catheter coursing from the right atrium through the right ventricle and pulmonary trunk to terminate
in the interlobar left pulmonary artery. The left pulmonary artery is shorter and smaller than the right and courses
over the left main bronchus.
 PULMONARY VESSELS
-i£! AXIAL CT, NORMAL CENTRAL PULMONARY ARTERIES & VEINS
Oi
in
<L>
>

c
c Pulmonary trunk
E Right ascending pulmonary artery -

••
l/l
a; — Left pulmonarv artery
J=
U

— Pulmonary trunk
Right superior pulmonary veins -
I .eft superior pulmonary vein

Right descending pulmonary artery -

Right pulmonary artery ■ Left intcrlobar pulmonary
artery

- Pulmonary trunk

Right superior pulmonary veins -

— Left superior pulmonary vein

Right descending pulmonary artery -

left descending pulmonary

artery

(Top) First of six normal contrast-enhanced axial CT images (mediastinal window) through the central pulmonary
vessels. Image through the left pulmonary artery shows that it is located superior to the right pulmonary artery and
courses posteriorly over the left main bronchus. Note the right ascending (truncus anterior) pulmonary arlery.
(Middle) Image through the pulmonary trunk shows its posterior course and relationship to the ascending aorta. The
lett pulmonary artery courses over the left main (hyparterial) bronchus continuing as the interlobar artery. Note the
horizontal course of the proximal right pulmonary artery behind the ascending aorta and superior vena cava.
(Bottom) Image through the proximal pulmonary trunk shows that it is the most anteriorly located vascular
I structure at this level. Note the anterior location of the bilateral superior pulmonary veins at the hila.
236
 PULMONARY VESSELS
AXIAL CT, NORMAL CENTRAL PULMONARY ARTERIES & VEINS
n
3"
rD
»
- Right ventricular outflow track
c_
3
o
Right superior pulmonary vein Left atrial appendage

<
— Left superior pulmonary vein ft
Right inlerlobar pulmonary artery —
Left inlerlobar pulmonary 2.
artery

Left atrium
- Lett Interior pulmonary vein

Right lower lobe basilar segmcntal

pulmonary arteries Left lower lobe basilar
segmcntal pulmonary arteries

Right inferior pulmonary vein

— Left inferior pulmonary vein

Left lower lobe basilar

segmcntal pulmonary' arteries

(Top) Image through the superior aspect of the left atrium demonstrates the constant relationship between the left
superior pulmonary vein and the left atrial appendage. The right superior pulmonary vein is located anterior to the
bronchus intermedius. The bilateral interlobar pulmonary arteries are located posterolateral to the bronchi. (Middle)
Image through the mid portion of the left atrium shows the left inferior pulmonary vein and the bilateral basilar
segmcntal pulmonary arteries which follow a relatively vertical course with res|>ect to the pulmonary veins. (Bottom)
Image through the inferior left atrium demonstrates the normal right inferior pulmonary vein and the more distal
basilar segmental lower lobe pulmonary arteries. This patient has four separate central pulmonary veins.

2 57
 PULMONARY VESSELS
ANGIOGRAPHY, NORMAL PULMONARY VEINS

Right superior
pulmonary vein Pulmonary artery
catheter

Middle lobe pulmonary

vein

Left atrium

Right inferior
pulmonary vein

Pulmonary artery
catheter

Left atrium I eft superior

pulmonary vein

Left interior pulmonary

vein

(Top) first of two images from a normal pulmonary arterlogram showing the normal anatomy of the pulmonary
veins. Venous phase of a right pulmonary arteriogram shows Ihe catheter tip within the right interlobar pulmonary
artery. The delayed image shows the morphology of the pulmonary veins as they enter the left atrium. In this case,
the middle lobe pulmonary vein drains into the right inferior pulmonary vein. The right superior pulmonary vein is
not well opacified. (Bottom) Venous phase of normal left pulmonary arteriogram demonstrates the pulmonary veins
draining into the left atrium. The arterial catheter travels through the right atrium, right ventricle, pulmonary trunk
and left pulmonary artery to terminate in the interlobar artery. Ihe normal left superior pulmonary vein is well
opacified. The left inferior pulmonary vein is less clearly visualized.
 PULMONARY VESSELS
CORONAL CT, NORMAL VARIANTS OF PULMONARY VENOUS ANATOMY

Aortic arch

— Left pulmonary artery

Middle lobe pulmonary vein — — Lett superior pulmonary vein

Lett atrium
Right inferior pulmonary vein —

Aortic arch

Azygos arch -

Right intcrlobar pulmonary artery

Right superior pulmonary vein

Middle lobe pulmonary vein

Left atrium
Right lower lobe pulmonary vein

Single left pulmonary vein

Left atrium

(Top) First of three contrast-enhanced chest CT images (mediastinal window) of different patients illustrating
variations in the normal anatomy of the central pulmonary veins. Oblique coronal reconstruction demonstrates the
middle lobe pulmonary vein draining into the right inferior pulmonary vein. (Middle) Composite image of two
oblique coronal sections through the right side of the left atrium demonstrates a supernumerary right pulmonary
vein. The middle lobe pulmonary vein drains directly into the lift atrium between the ostia of the superior and
inferior pulmonary veins. Supernumerary pulmonary veins are more common on the right and result from
overincorporation during embryogenesis. (Bottom) Coronal image through the posterior left atrium shows that the
superior and inferior left pulmonary veins have a single trunk, the result of underincorporation.
 PULMONARY VESSELS
J£: C O R O N A L CT. CENTRAL P U L M O N A R Y ARTERIFS & VEINS

>

c
o
_E
Q_
— Pulmonary trunk
</>

Right superior pulmonary vein Left superior pulmonary vein

Right pulmonary artery - Left atrial appendage

Right ascending pulmonary artery — I eft pulmonary artery

Right descending pulmonary artery - — Left superior pulmonary vein

Right superior pulmonary vein -

Left atrium

(Top) First of six normal contrast-enhanced chest CT images (mediastinal window) shows the normal anatomy of the
pulmonary vessels. The pulmonary tmnk courses posteriorly and to the left of the ascending aorta and is seen in
cross-section. (Middle) Image through the right pulmonary artery shows its horizontal intramediastinal course. Note
the constant relationship of the left superior pulmonary vein and the left atrial appendage. The bilateral superior
pulmonary veins course obliquely into the left atrium and are anteriorly located stnicturcs. (Bottom) Image through
the left atrium shows the bifurcation of the right pulmonary artery into ascending and descending branches and
shows the proximal left pulmonary artery.
 PULMONARY VESSELS
C O R O N A L CT, C E N T R A L P U L M O N A R Y ARTERIES & V E I N S

Left pulmonary artery

Lefl main (hyparterial)

Right descending pulmonary artery - bronchus
- Left superior pulmonary vein

Left apical pulmonarv artery

l*tt interlobar pulmonary

artorv
Right interlobar pulmonary artery —

Left interlobar pulmonary

artwy
Right interlobar pulmonary artery —

Left inferior pulmonary vein

Right inferior pulmonary vein

( l o p ) Image t h r o u g h the m i d p o r t i o n o f the left a t r i u m shows that t h e loft p u l m o n a r y artery is higher t h a n the r i g h t
a n d courses over the ipsilateral left m a i n (hyparterial) bronchus. The lateral aspect o f t h e h o r i z o n t a l p o r t i o n of t h e
right p u l m o n a r y artery is also s h o w n . ( M i d d l e ) Image t h r o u g h t h e carina shows t h e bilateral interlobar p u l m o n a r y
arteries. Note the left apical p u l m o n a r y artery arising as a branch o f t h e distal left p u l m o n a r y artery. ( B o t t o m )
Coronal image t h r o u g h the posterior aspect o f the left a t r i u m shows the bilateral i n f e r i o r p u l m o n a r y veins entering
the posterior left a t r i u m . The bilateral interlobar p u l m o n a r y arteries a n d their relative vertical course w i t h respect t o
the p u l m o n a r y veins are also s h o w n .
 PULMONARY VESSELS
SAGITTAL MR, NORMAL CENTRAL PULMONARY ARTERIES & VEINS

— Left pulmonary artery

— Left pulmonary veins

Pulmonary trunk -

Left main bronchus

Right ventricle —

A s c e n d i n g aorta

Right pulmonary artery

Left atrium

Right atrium

(Top) Hirst of three normal sagittal II MK images through the central pulmonary vessels showing the normal
vascular relationships in this imaging plane. Image obtained to the left of midline shows the left superior and inferior
pulmonary veins located anterior t o the left main bronchus. Note that the left pulmonary artery courses over the left
main (hyparterial) bronchus. (Middle) Image through the aorlic arch demonstrates that the pulmonary trunk arises
from the right ventricular outflow track and courses posteriorly and to the left prior t o bifurcating into right and left
pulmonary arteries. (Bottom) Image obtained to the right of midline shows a portion of the ascending aorta a n d the
horizontal course of the right pulmonary artery. The pulmonary trunk is located anterior and t o the left of the
ascending aorta.
 PULMONARY VESSELS
AXIAL CT, NORMAL RIGHT SEGMENTAL PULMONARY ARTERIES
n
n

C_
3
RUI. apical segmental pulmonary o
artery. RA1

Tributaries of right superior

pulmonary vein RUL apical segmental bronchus s
en
LAI

RUI. apical segmental pulmonary

arlery, RAI
RUL anterior segmental pulmonary
artery, RA2

Rigtit upper lobe bronchus

RUL posterior segmental
pulmonary artery, RAJ

Right ascending pulmonary arlery

RUI posterior segmental vein, RV3

RUI. posterior segmental Right main bronchus

pulmonary artery, RA3
- Right upper lobe bronchus

(Top) First of nine axial contrast-enhanced chest CT images (lung window) through the right lung showing the
normal anatomy of the segmental pulmonary arteries. Image obtained above the carina shows the right apical
segmental pulmonary artery (RAI) located medial to the right upper lobe (RUL) apical segmental bronchus.
Tributaries of the right superior pulmonary vein are located lateral to the bronchus. (Middle) Image through the
right upper lobe bronchus shows the apical segmental (RAI) and anterior segmental (RA2) pulmonary arteries.
Tributaries of the right superior pulmonary vein are seen lateral to the bronchi. (Bottom) linage through the right
upper lobe anterior segmental bronchus shows the right ascending pulmonary artery. Ihe right posterior segmental
pulmonary artery (RA.i) typically arises from the right interlobar pulmonary artery. I
243
 PULMONARY VESSELS
AXIAL CT, NORMAL RIGHT SEGMENTAL PULMONARY ARTERIES

CD
>

ro
Right superior pulmonary vein
C
o
Right inlerlobar pulmonary artery
E
=3
Q-
•• RI.l. superior segmental pulmonary
■ * —

</> artery, RA6

<D Bronchus intermedius
-c
U

Middle lobe pulmonary artery -

RI.l superior segmental pulmonary

artery, RA6 — Bronchus intermedius

Middle lolw piilnionar>' artery -

Right lower lobe pulmonary artery -

— KLL superior segmental

bronchus

(Top) Image through the bronchus intermedius shows the origin of the right lower lobe (RLL) superior segmental
pulmonary artery (RA6) arising from the right inlerlobar pulmonary artery. Although it is difficult to resolve, the
right superior pulmonary vein is located immediately anterior t o the right pulmonary artery at this level. (Middle)
Image through the proximal middle lobe pulmonary artery shows the inferior aspect of the right lower lobe superior
segmental pulmonary artery (RA6). This vessel typically arises just superior t o its corresponding segmental bronchus.
The middle lobe (ML) pulmonary artery arises as a single trunk from the right interlobar pulmonary artery. (Bottom)
Image through the origin of the right lower lobe superior segmenial bronchus shows the middle lobe pulmonary
1 artery prior to its bifurcation and the right lower lobe pulmonary artery.
244
 PULMONARY VESSELS
AXIAL CT, NORMAL RIGHT SEGMENTAL PULMONARY ARTERIES
n
3"
rc
••
MI medial segmental pulmonary C_
artery, RAS 3
Middle lobe bronchus c
Ml lateral segmental pulmonary
artery, RA4 -<
<
Right lower IOIK pulmonary artery fn
1/1
— Right lower lobe Iruiuus basalis cr>

ML pulmonary vein. RV4+S —r

Ml medial segmental pulmonary

artery, RAS

Right lower lobe tmntus basalis

Ml lateral segmental pulmonary
artery, RA4

Rl.l basal segmental pulmonary

arteries

Rl.l. anterior basal segmental

pulmonary artery, RAH

Rl I. lateral basal segmental

pulmonary artery, RA9
Rl.l. medial basal segmental
RI.L posterior basal segmental pulmonary artery, RA7
pulmonary artery, RAIO

( l o p ) Image through the origin of the middle lobe bronchus shows the bifurcation of the middle lobe pulmonary
artery into lateral (RA4) and medial (RAS) segmental pulmonary arteries. The right lower lobe pulmonarv artery is the
caudal continuation of the intcrlobar pulmonary artery after the take off of the middle lobe pulmonary artery.
(Middle) Image through the truncus basalis shows the middle lobe segmental pulmonary arteries and the right lower
lobe basal segmental artery branches. The middle lobe pulmonary vein (RV4+5) courses inferomedially to drain into
the right superior pulmonary vein. (Bottom) Image through the basal segmental bronchi shows the right lower lobe
basal segmental pulmonary arteries located lateral to the corresponding bronchi. These are the medial (RA7), anterior
(RA8), lateral (RA9) a n d posterior (RAIO) basal segmental pulmonary arteries. I
245
 PULMONARY VESSELS
AXIAL CT, NORMAL LEFT SEGMENTAL PULMONARY ARTERIES

I L'l apical segmental

pulmonary artery, l.Al
LUI. anterior segmental
pulmonary artery, I.A2

LUL posterior segmental

pulmonary artery, LAS

I.UL anterior segmental

bronchus

— LUI apicoposterior segmental

bronchus

Left pulmonary artery

- Left superior pulmonary vein

— Left apicoposterior segmental
bronchus

Loft i MI.i bronchus " Left interlobur pulmonary

artery

LUI superior segmental

pulmonary artery, LA6

(Top) First of nine axial contrast-enhanced chest CT images (lung window) showing the normal anatomy of the left
segmental pulmonary arteries. Image through the carina shows the bifurcation of I.A1+3 into medially located apical
(LAI) and laterally located posterior segmental pulmonary arteries. I he left upper lobe (LUL) anterior segmental
pulmonary artery (LA2) is also demonstrated. (Middle) Image through the left upper lobe anterior segmental
bronchus shows the left pulmonary artery coursing over t h e left main (hyparterial) bronchus. (Bottom) Image
through the left main bronchus shows the origin of the left lower lobe superior segmental pulmonary artery (LA6)
from the interlobar artery. The anteriorly located left superior pulmonary vein is also demonstrated.
 PULMONARY VESSELS
AXIAL CT, NORMAL LEFT SECMENTAL PULMONARY ARTERIES
n

C_
3
c
Lefl upper lobe bronchus

LUL superior lingular

segmental pulmonary artery, <
1.A4 o
Left main bronchus Left interlobar pulmonary ro_
artery
to
Branches of I.I I. superior
segmental pulmonary artery

LUL superior lingular bronchus

— Lett interlobar pulmonary

artery

— LUL sii|K'rior lingular

segmental vein. I.V4
— LUL inferior lingular segmental
bronchus
— LUL inferior lingular segmental
pulmonary artery, LAS
1.1.1 superior segmental bronchus -
- Left lower lobe pulmonary
artery

(Top) Image through the left upper lobe bronchus shows the origin of the superior lingular segmental pulmonary
artery (I.A4) from the interlobar pulmonary artery. This artery is typically seen superior t o its accompanying
segmental bronchus. Branches of the left lower lobe superior segmental pulmonary artery are also demonstrated.
(Middle) Image through the left upper lobe superior lingular segmental bronchus demonstrates the posterolateral
location of the lefl interlobar pulmonary artery. (Rottom) Image through the superior aspect of the left lower lobe
superior segmental bronchus shows the proximal left upper lobe inferior lingular segmental pulmonary artery (LA5)
coursing lateral to its corresponding bronchus. The left upper lobe superior lingular vein courses medial to the
bronchus.
247
 PULMONARY VESSELS
J£ AXIAL CT, NORMAL LEFT SEGMENTAL PULMONARY ARTERIES

IS
>
TO
C
o
E
— I.UI. inferior lingular segmental
pulmonary artery, I.A5
(D Left lower lobe pulmonary
U LLL superior segmental bronchus - artery

I.UL inferior lingular segmental

pulmonary artery, LAS

LLL medial basal segmental

pulmonary anery, LA7

LLL anterior basal segmental

pulmonary artery, LAS
I.I.L posterior basal segmental - LLL lateral basal segmental
pulmonary artery, LA 10 pulmonary artery, LA9

LLL medial basal segmental

pulmonary artery, I.A7

I.I.L anterior basal segmental

pulmonary artery, LAS
I LL posterior basal segmental -
pulmonary artery, LA10 LLL lateral basal segmental
pulmonary artery. I A9

(Top) linage through the left lower lobe (I.I.L) superior segmental bronchus shows ihe course of the left upper lobe
inferior lingular segmental pulmonary artery (LAS) lateral to the corresponding segmental bronchus. (Middle) Image
through the proximal left lower lobe basal segmental bronchi shows the anteriorly located left lower lobe medial
(LA7) and lateral (I.A8) basal segmenlal pulmonary arteries. These vessels typically arise from a common trunk
(I.A7+8). The left lower lobe lateral (I.A9) and posterior (LA10) segmental pulmonary arteries are also shown.
(Bottom) Image through the left lower lobe basilar segmental bronchi shows the basilar segmental pulmonary
arteries. These are (clockwise from anterior to posterior) the left lower lobe medial (LA7), anterior (LAS), lateral (LA9)
I and posterior (LA 10) basal segmental pulmonary arteries.
248
 PULMONARY VESSELS
GRAPHIC & CT, NORMAL INTRAPULMONARY LYMPH NODES n
3"
ft!
1/1
r*
"C
C
3
Pulmonary lymphatics o

<
</>
Hilar lymph nodes JL
Intrapulmonary lymph
node

Bronchopulmonary
lymph nodes

Intrapulmonary lymph
node

Minor fissure

i
Major fissure

(Top) Graphic depicts the normal anatomy of the pulmonary lymphatic vessels. These small structures are not visible
on normal imaging studies. They course centripetally towards the hilum and form aggregates of lymphold tissue or
lymph nodes. These typically occur at bronchial bifurcations. The bronchopulmonary lymph nodes and hilar lymph
nodes are considered intrapulmonary for the purpose of lung cancer staging. (Bottom) Normal high-resolution chest
CT shows a peripheral subpleural ovoid soft tissue nodule along the minor fissure. With increasing utilization of thin
section multJdetector chest CT, small pulmonary nodules are often identified. Many nodules under 4 mm in size
relate to benign conditions such as remote granuloniatous infection. Ovoid elongate small subpleural nodules likely
represent intrapulmonary lymph nodes. 1
24«)
 PULMONARY VESSELS
CT, PULMONARY LYMPH NODES

Normal pulmonary lymph node -

Granulomatous pulmonary lymph -

nodes
— Normal sized calcified
pulmonary lymph node

Normal pulmonary lymph node -

(Top) Normal axial contrast-enhanced chest CT (mediastinal window) demonstrates non-enhancing soft tissue
adjacent to the basilar segmental right lower lobe pulmonary arteries near the bronchovascular sheath representing a
normal pulmonary lymph node. (Middle) Axial contrast-enhanced chest CT of a patient with remote granulomatous
infection demonstrates granulomatous calcification in normal-sized pulmonary lymph nodes. These lymph nodes are
easily identified by virtue of their complete calcification. Note their intimate relationship to the structures in the
bronchovascular sheath. (Bottom) Normal coronal contrast-enhanced chest CT (mediastinal window) demonstrates
non-enhancing soft tissue representing a normal pulmonary lymph node located at a bronchial bifurcation.
 PULMONARY VESSELS
VASCULAR REDISTRIBUTION; PULMONARY VENOUS HYPERTENSION

I
"0
3
o
Wide vascular pedicle

1/1

Vascular redistribution
Indistinct hilar angle

Cardiomegaly

Normal vascular
pedicle

Normal upper lobe

pulmonary vessels
Improved visualization
of hilar angle

Normal heart size

(Top) hirst of two images of a 52 year old man who developed dyspnea after an autologous bone marrow transplant.
PA chest radiograph demonstrates redistribution of pulmonary vascular flow to the upper king zones and
indistinctness of the hilar angle. There is cardiomegaly and a wide vascular pedicle. The findings indicate the
presence of pulmonary venous hypertension. (Bottom) Follow-up PA chest radiograph demonstrates resolution of
vascular redistribution, visualization of distinct vascular margins, visualization of the hilar angle, a normal vascular
pedicle and resolution of previously demonstrated cardiomegaly. Note the right internal jugular catheter tip in the
right atrium.

251
 PULMONARY VESSELS
ABNORMAL VASCULAR CONNECTIONS, ARTERIOVENOUS MALFORMATION
%
tSi
•SI
AV malformation —
Draining vein
ro Feeding artery
C
c
E
Endovascular coil -

cu

u
Small AV malformation -

Feeding artery -
AV malformation -
— Right pulmonary artery
Draining vein -

— AV malformation

Feeding artery -

AV malformation

Draining vein

(Top) Composite axial nonenhanced chest CT (lung window) of a 58 year old man with hereditary hemorrhagic
telangiectasia and multifocal pulmonary arteriovenous (AV) malformations shows metallic material within the
lumen of a previously embolized lesion and at least two additional AV malformations. (Middle) 1 irst of two images
of a 37 year old woman with hereditary hemorrhagit telangiectasia. Right pulmonary arteriogram shows at least two
pulmonary AV malformations. Angiography is j>erformed for identification of multifocal lesions and for evaluation
prior to embolotherapy. (Bottom) Selective injection from a pulmonary arteriogram into the feeding artery of an AV
malformation shows the smaller feeding artery and the larger draining vein. AV malformations provide direct
I communication between the pulmonary arterial and venous systems without an intervening capillary bed.
252
 PULMONARY VESSELS
ABNORMAI VASCULAR CONNECTIONS, HEPATOPULMONARY SYNDROME
n
3"
^r .^^fl ^r **

3
3
<
1/1

Pleiiral based AV malformation

— Dilated right lower lobe vessels

Dilated intcrlobar pulmonary artery

Pulmonary vein

AV malformations

— Right pulmonary artery

Left interlobar pulmonary artery Right interlobar pulmonary

artery

Subpleural AV malformations - Dilated peripheral pulmonary

arteries

(Top) First of three contrast-enhanced chest CT images of a 48 year old man with end-stage liver disease and
hepatopulmonary syndrome. Axial image through the right lung base shows markedly dilated right lower lobe
pulmonary arteries and veins and pleural based acquired AV communications. Note visualization of subpleural
enlarged vascular structures. (Middle) Coronal image demonstrates marked enlargement of the right pulmonary
arteries and veins. Peripheral AV malformations or communications are visualized in the right lung base. (Bottom)
Coronal posterior volume rendered CT image through the thorax shows the large size of the pulmonary arteries,
particularly the bilateral lower lobe pulmonary arteries. The interlobar pulmonary arteries are also enlarged.
Subpleural AV communications and dilated peripheral pulmonary vessels are also noted. I
2 S3
 PULMONARY VESSELS
A B N O R M A L VASCULAR C O N N E C T I O N S , PARTIAL A N O M A L O U S P U L M O N A R Y V E N O U S RETURN

— Anomalous vertical vein

- Anomalous left upper lone

wins

- Anomalous vertical vein

Left brachloccphaiic vein —

I — Anomalous vertical vein

Meiiiastinal lymph nodes

(Top) First of three contrast-enhanced axial chest CT images miediastinal w i n d o w ) of a 6.i year o l d m a n w i t h partial
anomalous p u l m o n a r y venous r e t u r n o f t h e left upper lobe. A n o m a l o u s left upper l o i n ; p u l m o n a r y veins drain i n t o
an anomalous vein i n t h e left superior m e d i a s t i n u m . ( M i d d l e ) Image t h r o u g h the superior aspect o f the aortic arch
demonstrates t h e a n o m a l o u s vertical v e i n coursing along t h e left lateral aspect o f t h e aortic arch. ( B o t t o m ) Axial
image at the level of t h e left brachiocephalic vein demonstrates its anastomosis w i t h t h e a n o m a l o u s vertical v e i n .
Mediastinal l y m p h a d e n o p a t h y is also n o t e d i n the right paratracheal region. Patients w i t h this a n o m a l y e x h i b i t
absence o f t h e n o r m a l superior p u l m o n a r y vein i n t h e left h i l u m (not s h o w n ) .
 PULMONARY VESSELS
A B N O R M A L VASCULAR C O N N E C T I O N S , SCIMITAR S Y N D R O M E
n
(T>
in
r*
• w

-o
c_
3
o
DJ
I lypoplastic right kiny -

<
(/I

If*

Dextrcxardia

Scimitar vein —US

-~ Bovine pattern of
branching

Right pulmonarv artery -"

Scimitar vein —

(fop) PA chest radiograph of a woman with congenital venolobar (scimitar) syndrome shows mild rotation to the
right. There is dextrocardia related to right pulmonary hypoplasia. An arcuate right-sided vascular structure
represents the anomalous scimitar vein that drains into the inferior vena rava. (Bottom) Magnetic resonance
angiography of another patient with congenital venolobar syndrome demonstrates a right aortic arch with bovine
pattern of great vessel branching. An anomalous arcuate (scimitar) vein drains portions of the right lung and
anastomoses with the inferior vena cava. Patients with scimitar syndrome may be asymptomatic or may have
symptoms related to congenital heart disease. The syndrome may be associated with right pulmonary hypoplasia,
systemic blood supply to the right lung and anomalies of the tracheobronchial tree. I
25"5
 PULMONARY VESSELS
J£ PULMONARY VEIN ENLARGEMENT, PULMONARY VARIX

Hi
>

C
c
E
13
••
■ * - >

</>
Q)
-C
U

Ovoid pulmonary —
nodule

Pulmonary vanx —

Paramcdiastinal
ground glass opacity

(Top) first of two images of a patient with a right pulmonary varix. lateral chest radiograph shows an ovoid soft
tissue nodule that projects over the left atrium and the anatomic location of the pulmonary veins. The lesion was
poorly visualized on PA chest radiograph (not shown). (Bottom) Unenhanced chest CT (lung window) shows that
the pulmonary nodule seen on radiography represented an enlarged right inferior pulmonary vein. There is also
heterogeneous attenuation of the surrounding lung parenchyma with high attenuation in the paramediastinal
aspects of the lung. Pulmonary varices can be congenital or acquired lesions. Acquired varices are often related to
elevated left atrial pressures a n d are typically found incidentally on radiography. Images courtesy of Jerry Speckman,
MD, University of Florida, Gainesville, Florida.
_>»f>
 PULMONARY VESSELS
P U L M O N A R Y ARTERY ENLARGEMENT, P U L M O N A R Y ARTERIAL HYPERTENSION
n
=r
rt>
ri-
••
- Measurement of the pulmonary -a
trunk
c_
3
o
u
<

GL

— Enlarged pulmonary trunk

— Massively enlarged pulmonary

trunk

Enlarged right pulmonary artery

Enlarged left pulmonary artery

(Top) N o r m a l contrast-enhanced axial gated chest I I' image (mediastinal w i n d o w ) shows the m e t h o d o f
measurement of the p u l m o n a r y t r u n k (blue line) o n CT, p e r f o r m e d perpendicular t o t h e vascular l o n g axis at the
b i f u r c a t i o n . The n o r m a l size of the p u l m o n a r y t r u n k is u p t o 28.6 n u n . ( M i d d l e ) First o f t w o axial contrast-enhanced
chest CT images (mediastinal w i n d o w ) t h r o u g h t h e p u l m o n a r y trunks of t w o different patients. CT o f a 74 year o l d
w o m a n w i t h p u l m o n a r y arterial hypertension a n d m u l t i p l e p r i o r episodes of p u l m o n a r y t h r o m b o e m b o l i c disease
demonstrates enlargement o f the p u l m o n a r y t r u n k measuring 5.7 c m . ( B o t t o m ) CT o f a 51 year o l d w o m a n w i t h
severe p u l m o n a r y hypertension shows massive enlargement o f the p u l m o n a r y arteries. T h e p u l m o n a r y t r u n k
measures 7.4 c m a n d the p u l m o n a r y artery pressure was 56 m m Hg.
 PULMONARY VESSELS
J£ ARTERIAL FILLING D E F E C T S ; ACUTE P U L M O N A R Y T H R O M B O E M B O L I C DISEASE
0)
o
>
- Pulmonary trunk
ro
C
o
E
=3

a. Acute pulmonary emboli ■ - Acute pulmonary emboli

- Pulmonary trunk

_
Acute pulmonary embolus
- Acute pulmonary embolus

Acute pulmonary emboli

- Acute pulmonary embolus

(Top) First of three images from a CT pulmonary angiogram (mediastinal window) of a 67 year old woman with
acute pulmonary thromboembolic disease. Axial image shows pulmonary emboli within the left and the proximal
left interlobar pulmonary arteries. A large pulmonary embolus is also noted within a n enlarged right ascending
pulmonary artery. (Middle) Axial image through the pulmonary trunk shows low attenuation filling defects
surrounded by endovascular contrast within the right pulmonary artery and the left interlobar pulmonary artery.
(Bottom) Oblique coronal image through the left pulmonary artery shows endoluminal centrally located emboli in
the left pulmonary artery and in branches of the left upper lobe anterior segmental artery.
 PULMONARY VESSELS
ARTERIAL FILLING DEFECTS; CHRONIC PULMONARY THROMBOEMBOLIC DISEASE

I
-a
c_
— Pulmonary trunk 3
o
Chronic pulmonary embolus -
<
Enlarged left pulmonary artery
CL

Chronic pulmonary embolus

Left pulmonary artery-

Peripheral irregular pulmonary

embolus

Enlarged lett interlobar

pulmonary artery

(Top) First of three axial images from a contrast-enhanced chest CT (mediastinal window) of a 2(J year old man with
pulmonary arterial hypertension (pulmonary artery pressure of 51 mm Hg). Image through the pulmonary trunk
shows diffuse pulmonary artery enlargement. The pulmonary mink measured .'i.5 cm. Note chronic pulmonary
embolus in the right pulmonary artery. (Middle) Image obtained below the carina shows eccentric soft tissue in the
right pulmonary artery and enlargement of the left interlobar pulmonary artery. (Bottom) Axial image through the
root of the aorta shows the posterior eccentric soft tissue filling defect in the right pulmonary artery that extends
into the proximal right interlobar artery. The irregular contour of the soft tissue filling defect is consistent with
known chronic pulmonary embolus. The left interlobar pulmonary artery is enlarged. I
2'.9
 PULMONARY VESSELS
P U L M O N A R Y E M B O L I S M , F O R E I G N MATERIALS
Site ot catheter fracture — r
O
>
Proximal Iraclurcd central catheter
rc
C
o
_E - Proximal as|H.xt of fractured
13 catheter fragment
Distal fragment of fractured
catheter

- Portion of catheter within

proximal right pulmonary
artery
Distal as|H'ct of catheter fragment —

Right pulmonary artery

Middle lobe pulmonary artery —

Proximal catheter Iragment
Distal catheter fragment

(Top) First of three images of a 44 year old man with a fractured right subclavian central catheter which cmboli/ed to
the middle lobe pulmonary artery. PA chest radiograph coned-down to the right lung shows the site of catheter
fracture and the embolizcd catheter fragment within the middle lobe pulmonary artery. The proximal aspect of the
fractured fragment is in the intramediastinal (hori?ontal) right pulmonary artery. (Middle) Coned-down lateral chest
radiograph demonstrates the fractured catheter fragment projecting over the right hilar vascular opacity and within
the proximal right pulmonary artery. (Bottom) Right pulmonary arteriogram performed prior to catheter retrieval
shows the location of the catheter fragment with its proximal portion in the right pulmonary artery and its distal
I portion in the middle lobe pulmonary artery.
260
 PULMONARY VESSELS
PULMONARY EMBOLISM, FOREIGN MATERIALS
o
zr
IT)
c/>
•r-t-•
c_
3
c

<

I Lmbolit vertebroplasty
material

Vertebroplasties

L in hi'In. vertebroplasty
material

Embnlic vertebroplasty
material

Embolic vertebroplasty
material

(Top) Kirst of two images of a 77 year old woman with metastatic breast cancer and prior multirocal thoracic
vertebroplasty. PA chest radiograph coned-down to the left lung demonstrates multiple linear branching high
density lesions in the bilateral lungs that follow the course of the peripheral pulmonary arteries. (Bottom)
Composite of contrast-enhanced abdominal CT images through the lung bases (lung window) demonstrates
endovascular vertebroplasty material manifesting as foci of high attenuation that fill the lumens of distal pulmonary
arteries. bmboli7ation of vertebroplasty material during the procedure resulted in high density foreign material
lodged in the lumens of various peripheral pulmonary arteries.

?C>1
 PLEURA
I General Anatomy and Function
General anatomy
• Parietal pleura
• Visceral pleura
• Fissures
i- Interlobar fissures
■ Right major fissure
■ Minor fissure
■ 1 eft major fissure
o Accessory fissures
■ Azygos fissure
■ Left minor fissure
■ Superior accessory fissure
■ Inferior accessory fissure
Pleural Structure
» Continuous surface epithelium a n d underlying
connective tissue
• Visceral pleura adheres to pulmonary surfaces
• Parietal pleura a continuation of visceral pleura; lines
corresponding half of thoracic wall, covers ipsilateral
diaphragm and ipsilateral mediastinal surface
• Visceral and parietal pleurae form right and left
pleural cavities; potential spaces containing a small
amount of serous pleural fluid
• Combined thickness of visceral and parietal pleurae
and fluid-containing pleural space is < 0.5 m m
Function
• Visceral pleura directly apposeS and slides freely over
parietal pleura during respiration
• During inspiration, muscles of respiration and
diaphragm increase intrathoracic volume; create
negative pressure within pleural space and lung
c Resultant lung expansion causes reduction in
intra-alveolar pressure; prompts conduction of air
through upper respiratory tract and airways into
alveoli
Pleural Space
• Potential space; normally contains 2-10 m l of lluid
• fluid p r o d u c t i o n cap.it its. 100 m l /hr; fluid
a b s o r p t i o n capacity. 300 ml / h r
• fluid flux normally from parietal pleura capillaries
t o pleural space; absorbed by microscopic stomata in
parietal pleura
[Parietal Pleura
Nomenclature
• Covers nonparenchyinal surtaces; lorms lining of
thoracic cavities
• Costal portion extends along ribs a n d intercostal
spaces; d i a p h r a g m a t i c portion covers the diaphragm;
mediastinal portion covers the mediastinum
Blood Supply and Drainage
• Supply from adjacent chest wall (intercostal, internal
mammary, diaphragmatic arteries)
• Drainage to bronchial veins (diaphragmatic pleural
drainage to interior vena cava and brachiocephalic
trunk)
Innervation
• Intercostal nerves (costal and peripheral
diaphragmatic pleura) and p h r e n i c nerves
(mediastinal and central diaphragmatic pleura)
• Irritation of costal or peripheral diaphragmatic pleura
refers pain a l o n g intercostal nerves to thoracic o r
a b d o m i n a l wall
• Irritation of mediastinal or central diaphragmatic
pleura refers pain t o lower neck a n d s h o u l d e r
Histology
• Single layer of parietal mesotheli.il cells over loose,
fat-containing areolar c o n n e c t i v e tissue; bounded
externally by endothoracic fascia
[Visceral Pleura |
Layers
• Mesotheli.il layer, t h i n c o n n e c t i v e tissue layer, chief
layer of c o n n e c t i v e tissue, vascular layer, limiting
l u n g m e m b r a n e (connected to chief layer by collagen
and elastic fibers)
c Histology reveals single layer of flat mesothelial cells
separated by basal lamina from underlying lamina
propria of loose connective tissue
Blood Supply and Drainage
■ Supply by systemic b r o n c h i a l vessels, drainage by
p u l m o n a r y a n d b r o n c h i a l veins
• l y m p h a t i c drainage to deep pulmonary plexus within
interlobar and peribronchial spaces toward hilum
Innervation
• Visceral afferent nerves traveling along bronchial
vessels; lacks pain fibers
[Pleural Reflections ~]
Pulmonary Ligament
• formed by mediastinal pleura extending inferiorly, as
a double layer, below the hilum isee 'llila" section)
Costodiaphragmatic Recesses
• Pleura extends caudally bevond inferior lung border
• Costal and diaphragmatic pleura separated by narrow
slit, the costodiaphragmatic recess
• Extends approximately 5 cm below interior border of
the lung during quiet inspiration; caudal extent at
12th rib posteromedially
Interlobar Fissures
General Concepts
• C o m p l e t e fissures extend from the lung surface to the
hilum
• I n c o m p l e t e fissures fail t o extend to the hilum; allow
p a r e n c h y m a l c o m m u n i c a t i o n anil collateral airdritl
between adjacent lobes
i frequency 12.5-73% (major fissures); 60-90%
( m i n o r fissure); m o r e frequent o n right t h a n left
 PLEURA
Major (Oblique) Fissures
• Originate posteriorly, near level of TS vertebral lx>dy:
lei! major fissure originates near T4 in 7 5 % of
individuals
• Terminate along anterior diaphragmatic pleural
surface. 3-4 cm posterior to anterior chest wall
• Right major fissure separates right u p p e r lobe ami
m i d d l e lolie from right lower lobe
• I ell major fissure separates left u p p e r lobe trom left
lower lobe
• ( hange in contour from u p p e r portion (concave
a n t e r i o r aspect) m lower portion (convex a n t e r i o r
aspect); termed pro|>eller-Iike morphology
Minor (Horizontal) Fissure
• Separates superior aspect of m i d d l e lobe from right
u p p e r lolie: i n c o m p l e t e in > 8 0 % of individuals
| Accessory Fissures
General Concept*
• ("lofts of varying depth in outer surface of lung; occur
in 22-32% of individuals
Azygos Fissure
• Right sided: results from failure of normal migration
of azygos vein to tratheobronthial angle
• luvaginaled visceral and parietal pleura form fissure
(four layers of pleura) in medial aspect of right lung
apex (sec "I iings" section)
Left Minor Fissure
• Separates lingula from remainder of left upper lolic;
frequents of 8-18% but rarely detected on I'A chest
radiographs (frequency of 1.6%)
Superior Accessory Fissure
• Sepaiates superior segment of lower lolx> from basal
segments; horizontal or oblique in orientation
Inferior Accessory Fissure
• Incompletely separates medial basal s e g m e n t from
rest of basal segments of lower lobe: right m o r e
c o m m o n t h a n left
• frequency ot 5-10% o n chest radiographs. 16-21% of
chest ( I' studies, and .10-50% of a n a t o m i c
specimens
[imaging
Radiography
• Major fissures
Not normallv seen on I'A chest radiographs
Portions of major fissures typically visible on lateral
chest radiographs: identified by continuity with
respective hemidiaphragm
• Minor fissure
Visible in 50-80% ot I'A chest r a d i o g r a p h s as a
horizontal linear opacity at or near anterior 4lb rib;
variable t o n t o u r
Contacts lateral chest wall near axillary portion of
right 6th rib; ends medialls at interlobar pulmonary
artery; never crosses hilar vessels
( ui ves genilv downward in anterior and lateral
portions
\ / y g o s fissure
I bin, < urvilinear opacity coursing from right lung
apex toward hilum; characteristic tear-drop
configuration of inferior e n d (azygos vein)
Lett m i n o r fissure
I'hin linear opacity, m o r e c c p h a l a d a n d o b l i q u e
t h a n m i n o r fissure
Superior accessory fissure
( Projected below and medial to minor fissure on PA
chest radiograph
Inferior accessory fissure
1 hin linear opacity extending obliquely Irom medial
hemidiaphragm toward hilum on I'A chest
radiograph; occasionally seen on lateral chest
radiograph
CT
• Normal pleura not imaged by (T/1IR( I
• Intercostal stripe
I'hin, linear opacity (1-2 m m thick) in normal
individuals; overlies intercostal spaces; connects
inner aspects ot ribs
Produced bv two layers of pleura, extrapleural fat,
endothoracic fascia, a n d innermost intercostal
muscle (see "Chest Wall" section)
Disappears on inner aspect of ribs (innermost
intercostal muscle absent); may be mimicked b>
intercostal veins in paravertebral region
• Major fissures
I bin linear opacities; curvilinear in upper and lower
thorax (concave and convex anterior aspects,
respectively); may api>ear as thin bands of
ground-glass opacity when oblique to axial plane
• Minor fissure
1
Variable appearance; thin, curv ilinear opacit):
ground-glass opacity; area devoid of vessels (roughly
triangular)
Ultrasound
• Differentiation of solid pleural masses Irom fluid;
assessment ot cchogcnicity and morphology (may
change shape with respiration) of fluid collections,
visualization of cchogenic line of visceral pleura
• Anechoic effusions usually transudative (see below);
echoic effusions with septations typically exudative
1 (see below)
Imaging Anatomic Correlations
Pleural Effusion
• ( ategorized as t r a n s u d a t e s or exudates; based on
composition of fluid obtained by thoracentesis:
determined bv I ight's criteria
rransudates not associated with pleural disease;
systemic a b n o r m a l i t i e s (cardiac failure, pericardial
disease, cirrhosis, pregnancy, hypoalbuminemia,
overhvdration, renal failure)
 PLEURA
Fxiidatcs indicate presence of pleural disease
(pneumonia, empvema, tuberculosis, neoplasm,
pulmonary embolism, collagen vascular disease)
• Radiography
Blunt costophreiiic angle (focal opacification,
meniscus-shaped upper border)
■ \'\ detection ol at least 200 ml. in lateral
costophreiiic angle; lateral detection of at least
75 m l in |H»sterior costophreiiic a n g l e
■ Lateral decubitus radiograph detection ot > 10 m l
Small to moderate effusions manifest as opacities
with meniscus-shaped up|>er borders: lateral aspect
more cephalad than medial portion; obscure
d i a p h r a g m if > 500 m l ; large effusions may opacity
hemithorax, displace mediastinum, invert
diaphragm
Supine radiography: Increased density of affected
hemithorax, veil like opacity, apical cap, thickening
of paravcrtebral stripe
S u b p u l n i o n i c effusion: Accumulation ot fluid in
suhpulmonic pleural space
■ 1 aii ia! displacement of d o m e or |>eak of
pscudcxliaphragm on PA radiograph
■ Flattening, elevation ot undersurface ol posterior
lung on lateral radiograph; flattening of interior
lung contour anterior to major fissure; sharp
fissural downward angulation (resembles profile of
Rock of Gibraltar)
■ 1 ett suhpulmonic ettusion > 2 cm distance
between lung base and superior border of gastric
air bubble
I'seiidotiiinor
* Interlobar pleural lluid; most associated with
c a r d i a c d e c o m p e n s a t i o n : typical after treatment
of heart failure; spontaneous resolution
■ Focal elliptical/lenticular opacity within interlobar
fissure; m i n o r fissure most c o m m o n l y affected
■ Peripheral margins of opacity tvpicalls taper as
t h e ; merge with affected lissure
I.oculation associated with exudative pleuial
effusion; limited In pleural adhesions
■ fixed, non-mobile mass-like opacity; typically
elliptical or lenticular
■ Tvpicalls sharply defined on chest radiographs
when surface is tangential (parallel) to X-ray
beam; ill-defined when imaged en face
I mpyema
■ Infected pleural cfiusion; association with
pneumonia; loculation (see above)
■ Air-fluid levels within loculated effusion suggest
enipyenia with broiu Implenral fistula
• ( I
-> Not useful for distinguishing transudate from
exudate; most effusions near water attenuation on
CM (20-40 HU) regardless ol cause; range from 0 HI'
to tOO.HU
Small effusions initially in |*>sterior
coslodiaphragmalic recess; maintain
concavc/meniscoid anterior margin
I arge effusions track anteriorly and cephalad; may
extend into fissures
Enipyenia: Floptical or lenticular fluid collection;
often Ixiunded by .smooth, uniform thick visceral
and parietal pleurae ("split pleura" sign)
■ 'I luck pleura may e n h a n c e with contrast; air-fluid
levels within pleural effusion suggest
broncbopleur.il fistula
■ Nondependent location, sharp demarcation from
adjacent lung, compression/displacement of
adjacent lung and vessels
• Ultrasound
Anechoic effusions mav be t r a n s u d a t i s e or
exudative
Sepiations suggestive exudative ettusion
Pneumolhorax
• Air or gas within pleural space; spontaneous
(associated with blebs, bullae); primary (no underlying
lung disease) or secondary (underlying lung disease)
• Radiographic features vary with degree of volume loss,
presenie of tension (pleural pressure exceeds alveolar
pressure), and patient position
• rhin linear opacity represents outer margin ot visceral
pleura; separated from parietal pleura and chest wall
by lucent space devoid of pulmonarv \essels; findings
at lung apex in upright patient
• I ucency extending into costodiaplir.igmatit sulcus in
supine patients (deep sulcus sign)
Pleural Thickening
• Focal thickening
Pleural plaques occur 15-20 years after asbestos
exposure: focal collections of acellular collagen on
parietal pleura (costal, diaphragmatic and
mediastiual pleura)
■ Imaging, discontinuous areas of pleural
thickening, predominantly along oth-Hth ribs, on
parietal pleura at domes of diaphragms, along
inediastin.il pleura; spare apices and coslophrenic
sulci; non-calcified or calcified
I o c a l i / c d fibrous tumor, solitary lenticular, round,
or lobulated neoplasm: benign (80%) or malignant
Hronciiogi'iiic c a r c i n o m a mav focalh invade
pleura or produce diffuse pleural thickening
• Diffuse thickening ma> be benign tfibrothoras) or
malignant (metastases. mesothelioma. lymphoma.
invasive thyninma)
Pleural Calcification
• Focal (pleural plaques) or diffuse (fibrothoiax, healed
hemotlioraM
 PLEURA
OVERVIEW OF PLEURAL ANATOMY

Caudal extent of lung Caudal extent of lung

Caudal extent of Caudal extent of

pleura pleura

Graphic shows the anatomy of the pleura. The visceral pleura covers the pulmonary surfaces. The parietal pleura
covers the non-pulmonary surfaces within the thoracic cavity and extends more caudally than the lungs. The inferior
reflection of parietal pleura extends within the costophrenic sulci to the level of the upper kidneys.

JMfe\
 PLEURA
CORONAL SECTION, ANATOMY OF PLEURAL REFLECTIONS

Parietal pleura
V Parietal pleura

Visceral pleura visceral pleura

Incomplete minor
fissure
\ Costal pie

Right major fissure

Left major fissure

Caudal extent of lung

Costodiaphragmatic Caudal extent of lung

Costodiaphragmatic

Pleural reflection Pleural reflection

Diaphragmatic pleura
Diaphragmatic pleura

Mediastinal pleura Mediastinal pleura

Graphic shows the extensive distribution of the pleura as visualized in the coronal plane. Visceral pleura covers the
surfaces of both lungs and forms interlobar fissures that may be complete or incomplete in their extension to the
hila. Parietal pleura lines both thoracic cavities and may be designated by its location as costal, diaphragmatic or
mediastinal pleurae. Inferiorly, the parietal pleura extends deeply into the costodiaphragmatic recesses where costal
and diaphragmatic pleura are in apposition.
 PLEURA
SAGITTAL SECTION, ANATOMY OF PLEURAL REFLECTIONS

Parietal pleura
I Visceral pleura

Costal pleura

Left major Assure

Anterior recess

Caudal extent of lung

Anterior pleura! Posterior

reflection
costodiaphragmatic
recess
Posterior pleural
reflection
Diaphragmatic pleura ■ IB L

i H ^H

Graphic shows the extent of parietal and visceral pleura as visualized in the sagittal plane in the left mid-clavicular
zone. The posterior pleural reflection in the costodiaphragmatic recess extends caudally to the level of the 12th nb.
 PLEURA
ANATOMY OF PLEURAL FISSURES

Azygos fissure

Left minor fissure

Minor fissure
ir \

■ MiM.

Superior accessory Superior accessory

fissure fissure
Inferior accessory 1
fissure S. 1
Left major fissure
Right major fissure

Left minor fissure

Minor fissure

Right major fissure

Superior accessory
fissure

Superior accessory
fissure

(Top) Graphic shows standard Lnterlobar fissures as solid lines and the most common accessory fissures as dashed
lines. (Bottom) The minor fissure is typically slightly convex superiorly and its anterior aspect courses Inferioriy.
 PLEURA
R A D I O G R A P H Y & CT, N O R M A L PLEURA

Minor lissure -

Ribs

Intercostal stripe -

( l o p ) N o r m a l I'A chest radiograph shows a subtle t h i n , curvilinear opacity o v e r l y i n g the posterolateral aspect of the
r i g h t 7 t h r i b representing t h e n o r m a l m i n o r fissure. T h e m a j o r fissures are n o t visualized. ( B o t t o m )
Contrast-enhanced chest CT (mcdiastinal w i n d o w ) shows t h e intercostal stripe m a n i f e s t i n g as a t h i n , linear opacity
(1-2 m m ) along t h e inner m a r g i n o f t h e intercostal spaces. The stripe appears t o connect the i n n e r aspects of the ribs
and is produced by t w o layers of pleura, extrapleural fat, endothoracic fascia, a n d i n n e r m o s t intercostal muscle. The
stripe is not s h o w n o n the inner aspect of the ribs because the i n n e r m o s t intercostal muscle is absent at that location.
The stripe becomes more apparent i n the paravertebral region, particularly i n obese i n d i v i d u a l s .
 PLEURA
CT, STANDARD FISSURES

Upper major fissures, concave

anteriorly

Mid portion ot right major fissure — Mid portion of left major

fissure

lower major fissures, concave

posteriorly

(Top) first of three axial chest CT images (lung window) demonstrates the right and left major fissures in the upjwr
thorax manifesting as thin curvilinear structures with concave anterior aspects. (Middle) In their mid-portions, near
the hilar levels, both major fissures arc nearly straight in configuration. (Bottom) In the lower thorax, the contour of
the major fissures has changed and the anterior aspects of both major fissures are convex. This shift in configuration
along the vertical axis of the major fissure has been described as a "propeller-like" morphology. Alterations of this
normal shift in configuration may occur with atelectasis.
 PLEURA
RADIOGRAPHY, MINOR FISSURE

Minor fissure

Mid portion of minor fissure

Anterior aspct I of minor fissure Posterior aspect of minor

fissure

— Minor fissure

(lop) First of three coned-down chest radiographs showing the anatomy of the minor fissure. On the PA chest
radiograph the fissure manifests as a thin linear opacity extending across the mid-right hemithorax. originating near
the axillary portion of right 6th rib and ending medially at the interlobar artery. Note that the linear opacity never
crosses hilar vessels. (Middle) On the lateral view, the anterior and posterior portions of the minor fissure curve
gently downward in characteristic fashion. (Bottom) PA chest radiograph shows the fissure manifesting as two
adjacent and roughly parallel linear opacities. Because of its curving configuration, the minor fissure often manifests
as a double-line on frontal radiographs, produced by the X-ray beam encountering tangential c o m p o n e n t s of the
fissure at two locations along its course.
 PLEURA
CT, M I N O R FISSURE

( urvilinear ground-glass band

Curvilinear opacity —

Avascular zone

(Top) First of three chest CT images (lung window) of three normal individuals showing the variable appearance of
the minor fissure on axial CT sections. In this example, the fissure manifests as a curvilinear band of ground-glass
opacity. (Middle) The minor fissure may also manifest as a discrete curvilinear opacity. Note the incomplete minor
fissure that allows parenchymal communication and collateral air drift between the right upper and middle lobes.
(Bottom) In many individuals, the minor fissure may manifest as a zone of relative avascularity that is often roughly
triangular in morphology.
 PLEURA
CORONAL CT, STANDARD FISSURES

Right upper lobe —

— Left upper lobe

Minor fissure

Right 6th rib

— Left major fissure

Middle lobe —

Right major fissure J

Right lower lobe —

Left lower lobe

Right upper lobe - I eft upper lobe

Minor fissure

— Left major fissure

Right major fissure —

5 — left lower lobe

(Top) First of four coronal chest CT images (lung window) showing the normal coronal fissural anatomy. In this
most anterior section, the minor fissure is seen originating near the axillary portion of right 6th rib. The major
fissures are slightly oblique in orientation. (Bottom) At the hilar level, the minor fissure terminates medially at the
right intcrlobar artery and separates the right upper lobe from the middle lobe. The right major fissure separates the
right lower from the right upper and middle lobes; the left major fissure separates the left upper and left lower lobes.
 PLEURA
CORONAL CT, STANDARD FISSURES

Right upper lobe Left upper lobe

Minor fissure —

Left major fissure

Middle lobe — I

Right major fissure -

Right lower lobe - Left lower lobe

T5 vertebral body T4 vertebral body

Right upper lobe

Left upper lobe

Right major fissure - Left major fissure

Right lower lobe —

I .eft lower lobe

(Top) In the coronal plane of the aorta, the medial aspect of the minor fissure intersects the major fissure
posterolateral to the right hilum. (Bottom) The right major fissure originates posteriorly at the level of the T5
vertebral body; the left major fissure originates at the level of the T4 vertebral body. The middle lobe is n o longer
visualized in this posterior coronal plane.
 PLEURA
ANATOMY, CT & RADIOGRAPHY, INCOMPLETE FISSURES

Visceral pleuralreflectionforms
Incomplete right major fissure incomplete fissure

Incomplete left major fissure

Incomplete right major fissure

Complete left major fissure

Incompletefissuremanifests as
sharp interface

Moderate-sized pleural effusion

(Top) Graphic shows bilateral incomplete major fissures that extend inward from the lung surface but fall to reach
the hila. Visceral pleura reflects upon itself at the medial termination of each incomplete fissure. (Middle) Axial
HRCT (lung window) shows an incomplete right major fissure and a complete left major fissure. The incomplete
fissures allow parenchyma! communication between the right upper and right lower lobes. (Bottom) PA chest
radiograph shows an incomplete right major fissure. A moderate sized pleural effusion extends into the right major
fissure and produces a sharp interface where the visceral pleura reflects upon itself to form the medial termination of
the incomplete fissure.
 PLEURA
ANATOMY & RADIOGRAPHY, AZYGOS FISSURE

Normal azygos vein in

tracheobronchlal angle

Azygosfissure(4 layers of pleura)

Azygos vein in azygos Assure

Azygos fissure

Right paratracheal stripe

Azygos vein terminates azygos

fissure (tear-drop)

(Top) First of two graphics shows the result of normal migration of the primitive posterior cardinal vein to the
tracheobronchlal angle to form the azygos vein. (Middle) Early migration of azygos vein coursing inferiorly from the
lung apex results in formation of an azygos fissure, composed of four layers of pleura. (Bottom) PA chest radiograph
coned-down to the right upper lung shows an azygos fissure manifesting as a curvilinear opacity extending
inferomedlally from the right lung apex. The teardrop-shaped opacity at the inferior aspect of the fissure represents
the azygos vein. Lung parenchyma medial to the fissure ("azygos lobe") shares communication and collateral drift
with adjacent parenchyma in the right upper lobe.
 PLEURA
RADIOGRAPHY & CT, INFERIOR ACCESSORY FISSURES

Interior accessory —
fissure

— Right major fissure

Inferior accessory
fissure

(Top) I'A chest radiograph toned-down to the right lower hemithorax shows an inferior accessory fissure manifesting
as a thin linear opacity extending obliquely from the medial aspect of the hemidiaphragm toward the hilum.
(Bottom) Composite of two adjacent chest CT images (lung window) of the right lung base demonstrates an inferior
accessory fissure manifesting as a gently curving linear opacity separating the medial basal segment from the
remainder of the basal segments of the right lower lobe.
 PLEURA
R A D I O G R A P H Y , ACCESSORY FISSURES

Displaced minor fissure

Displaced superior
accessory fissure

Left minor fissure

Minor fissure
(incomplete)

(Top) PA chest radiograph shows right upper lobe atelectasis resulting from a central obstructing squamous cell
carcinoma. The minor fissure manifests as a sharp interface between the airless right upper lobe superiorly a n d the
aerated lung interiorly. Ihe superior accessory fissure is displaced superolaterally and mimics the normal appearance
of a non-displaced minor fissure. The right hemidiaphragm is elevated, an indirect sign of right upper lobe
atelectasis. (Bottom) Coronal HRCT (lung window) shows an incomplete minor fissure on the right and a left minor
fissure. The left minor fissure separates the lingula from t h e remainder of t h e left upper lobe.
 PLEURA
R A D I O G R A P H Y & CT, P N E U M O T H O R A X

Right apical
pneumothorax

Visceral pleura, right

upper lobe

Right pneumothorax
Left pneumothorax

Bleb at right lung

surface
Bulla Pneumothorax in left
major fissure
Pneumothorax in
major fissure

l'aravcrtebral extension
of pneumothorax

(Top) PA chest radiograph shows air in t h e r i g h t apical pleural space ( p n e u m o t h o r a x ) m a n i f e s t i n g as a b n o r m a l

lucency peripheral t o t h e visceral pleural surface of t h e r i g h t upper lobe. (Bottom) Chest CT ( l u n g w i n d o w ) shows
bilateral pneumothoraces f o l l o w i n g t r a u m a , m a n i f e s t i n g as a b n o r m a l air a t t e n u a t i o n w i t h i n t h e bilateral pleural
spaces. The right p n e u m o t h o r a x extends i n t o t h e right m a j o r fissure a n d along the paravertebral pleural space. A
superficial bleb a n d adjacent bulla are also demonstrated. The left p n e u m o t h o r a x extends i n t o t h e lateral aspect o f
t h e left m a j o r fissure a n d a l o n g t h e anterior pleural space.
 PLEURA
AZYGOS FISSURE, PNEUMOTHORAX & PI.EURAL EFFUSION

Pncumothorax in
azygos fissure Azygos "IOIK-"

Azygos vein at interior

aspect of azygos fissure
Lateral margin of
azygos fissure

Loculated fluid in
azygos fissure

Loculated pleural —
effusion

(Top) PA chest radiograph coned-down to the right upper lung shows a pneumothorax extending within an azygos
fissure a n d separating the medial and lateral portions of the fissure. (Bottom) PA chest radiograph of a patient with
malignant pleural effusion shows a loculated pleural effusion along the lateral right hemithora.x and within an
azygos fissure. The expanded fissure roughly maintains its characteristic configuration with a tear-drop morphology
of its inferior termination.
 PLEURA
RADIOGRAPHY, PLEURAL EFFUSION

Obscuration of right
Blunt posterior recess
coAtodiaphragmalic

Meniscus-shaped upper —
bonier of plcural
cl'liision

— Moderate-sized plcural
cftusion obscures the
diaphragm

( l o p ) Composite of I'A and Literal radiographs shows a small right plcural effusion manifesting on the PA radiograph
as blunting of the right costodiaphragmatic recess. On the lateral radiograph the effusion manifests as ha?y opacity
obscuring the right posterior costodiaphragmatic recess. (Bottom) PA chest radiograph of a 57-year old man with
right lower lobe pneumonia shows a small-to-moderale plcural effusion manifesting as a dense opacity with a
meniscus-shaped upper border that obscures the right diaphragm (> 500 m l ) . The lateral aspect of the opacitv is
more cephalad (ban its medial portion.
 PLEURA
RADIOGRAPHY, PSEUDOTUMOR

Pseudotunior
(lnferomcdial margin)

Incomplete border

Pseudotumor in right
major fissure (anterior
border)
Pseudotumor in right
major tissure (posterior
border)
Right major tissure —

Left hemidiaphragm -

Right hemidiaphragm

Blunt left posterior

costodiaphragmatic
recess

(Top) first ot two chest radiographs of a patient recently treated for heart failure. PA chest radiograph shows a focal
opacity in the right mid-hemithorax that has both well-defined and ill-defined (incomplete) borders, suggesting an
extraparenchymal lesion. (Bottom) lateral radiograph shows the lenticular shape of the same opacity. The anterior
and posterior borders of the opacity taper and form obtuse margins as they merge with the involved right major
fissure. Following further diuresis and treatment of the patient's underlying cardiac failure, the opacity
("pseudotumor") resolved completely.
 PLEURA
RADIOGRAPHY & CT, PLEURAL EFFUSION

Left pleura) effusion

Pleural fluid in major fissure

Left pleural effusion

— Pleural fluid in left major

fissure

— Pleural effusions

(lop) Iirst of three images of a patient with a left pleural effusion, PA chest radiograph shows a small-to-modcrate
left pleural effusion manifesting as a hazy opacity that obscures the ipsilateral diaphragm. (Middle) Axial
contrast-enhanced chest CT (mediastinal window) shows that the effusion layers posteriorly in the dependent aspect
of the left pleural space. The fluid collection has a concave/meniscoid anterior margin and extends into the adjacent
major fissure. (Bottom) Coronal contrast-enhanced chest CT (mediastinal window) shows the left pleural effusion
extending across the left liemidiaphragm and along the paravcrtcbral pleural space. The effusion also extends into
the major fissure superiorly.
 PLEURA
RADIOGRAPHY & CT, LOCULATED PLEURAL EFFUSION

— Well-defined margins of
loculated plenral effusion

Loculated pleural effusion

Relaxation atelertasis of left upper Loculated pleural effusion

and lift lower lobes

(lop) First of three images of a patient with a loculated pleural effusion. PA chest radiograph shows a dense
lenticular opacity extending along the lateral aspect of the left hemithorax. The opacity appeared fixed and
nonmobile on lateral decubitus radiographs (not shown). (Middle) Coronal contrast-enhanced chest CT (mediastinal
window; first of two images) shows the characteristic lenticular morphology' of a loculated pleural effusion. (Bottom)
Coronal contrast-enhanced chest CT (mediastinal window; last of two images) shows extension of the loculated fluid
along the hemidiaphragm and relaxation atelectasis of the left upper and left lower lobes.
 PLEURA
RADIOGRAPHY, CT & ULTRASOUND, EMPYEMA & BRONCHOPLEURAL FISTULA

Air-fluid level —-■ Air-fluid levels

Loculated pleural effusion

Multiple septations within

loculated pleural effusion

Thick visceral pleura

Thick parietal pleura

Empyema and bronchopleural
fistula

(Top) First of three images of a patient with right empyema a n d bronchopleural fistula. I'A chest radiograph shows a
loculated right pleural effusion with associated air-fluid levels indicating bronchopleural fistula. (Middle) Ultrasound
reveals multiple septations within the loculatcd fluid collection suggesting an exudative pleural effusion. (Bottom)
Unenhanced chest CT (mediastinal window) shows a loculated fluid collection in the posterior aspect of the right
hemilhorax. Small pockets of air within the fluid collection are consistent with a bronchopleural fistula and multiple
internal septations. Thoracentesis confirmed empyema. Smoothly thickened parietal and visceral pleurae diverge to
surround the empyema and form the "split pleura" sign.
 PLEURA
CT, EMPYEMA

"Split pleura' encloses

abnormal fluid
collection
Thick visceral pleura

Thick parietal pleura —

—
Kmpyema necessitatis
l.ii. ulaicd left pleural -
effusion

(Top) Contrast-enhanced chest CT (mediastinal window) of a 66 year old man with empyema demonstrates the "split
pleura" sign associated with a loculated fluid collection in the posterolateral aspect of the right inferior pleural space.
Enhancing smoothly thickened visceral and parietal pleurae "split" to enclose the abnormal fluid collection.
(Bottom) Chest CT (mediastinal window) of a 32 year old woman with empyema necessitatis shows a loculated left
pleural effusion a n d pockets of fluid in the subcutaneous tissues of the adjacent chest wall.
 PLEURA
RADIOGRAPHY, PLEURAL PLAQUES

l'lciiral plaque —
Pleural plaque

Pleural plaque

Pleura 1 plaque <

— Pleural plaque

Pleural plaques —

— Pleural plaque

(Top) hirst of two images of a patient with a documented history of asbestos exposure twenty years prior to this
radiographic examination. PA chest radiograph shows multiple ill-defined partially calcified plaque-like opacities
overlying the 5th to 9th ribs and extending along the diaphragmatic pleurae. Some of the opacities appear to have
incomplete borders. A dense vertical band of calcified pleural plaque is also shown extending along the right
paravertebral region. (Bottom) Lateral chest radiograph demonstrates similar but less apparent opacities overlying
the lungs and extending along the diaphragmatic pleurae.
 PLEURA
CT, P L E U R A L P L A Q U E S

Pleural plaque
i — Pleural plaque

Pleural plaque
Pleural plaque

- Pleural plaque

Pleural plaque

—
Pleural plaques
Pleural plaques

Diaphragmatic pleural plaques Diaphragmatic pleural plaques

Pleural plaque

(Top) I-irst of three axial chest CT images (mediastinal window) shows multifocal, discontinuous areas of plaque-like
pleural thickening, some of which are partially calcified. Several plaques appear to extend along the inner aspect of
the rihs manifesting as thickening of the costal parietal pleura. (Middle) Chest CT through the heart shows similar
multifocal areas of pleural thickening that appear partially calcified and extend along the costal a n d mediastinal
pleurae. (Bottom) Chest CT through the lung bases shows calcified plcural plaques along the diaphragmatic pleurae
bilaterally.
 PLEURA
RADIOGRAPHY & CT, PLEURAL THICKENING & CALCIFICATION

— Pieural thickening and

calcification

— Pieural calcification

Pieural thickening

(Top) PA chest radiograph of a 64 year old man with a previous history of left empyema shows marked pieural
thickening and calcification along the lower half of the left hemithorax. (Bottom) Chest C f (lung window) shows
loss of volume in the left hemithorax and extensive pieural thickening and calcification extending along the lateral
and posterior aspects of the hemithorax. The bands of pieural calcification are separated from the inner aspect of the
adjacent ribs by a prominent band of pieural thickening, a distinguishing feature from calcified pieural plaques.
 PLEURA
RADIOGRAPHY, FIBROTHORAX
n
rts

c
55
Pleural calcification —

Pleural calcification

Pleural calcification

(Top) PA chest radiograph shows an extensive band of continuous pleural thickening and calcification extending
along the right apical pleura and along the right lateral pleural surface. The mediastinal and diaphragmatic pleurae
appear spared. (Bottom) Lateral chest radiograph shows the pleural thickening and calcification extending along the
apical and posterior aspects of the left hemithorax.

I
29 I
 PLEURA
MORPHOLOGY & CT, PLEURAL MASSES

3 r->- <y
Mass with obtuse
margins

Parenchymal mass
invading pleura

Fusiform mass in
fissure

Asymmetric mass with

obtuse and acute
margins
Piaque-like thickening

Pleural mass with

Incomplete borders

Pleural mass with

obtuse margins

4
Incomplete borders

(Top) Graphic shows the variable shapes and configurations of pleural masses, including those produced by
loculation of pleural fluid. Pleural masses along fissures may be fusiform, while those occurring along peripheral
pleural surfaces may be symmetrically or asymmetrically lenticular with obtuse or acute angles at their interface with
the adjacent pleura. Parenchymal lesions may invade adjacent pleura. (Bottom) Composite of PA and lateral
coned-down chest radiographs and axial CT (lung window) through the same region shows the characteristic
lentiform shape of a pleural mass with obtuse margins at the interface of the mass with adjacent pleura. As X-ray
beams pass through a mass of this shape, they produce orthogonal radiographic Images that often manifest as
opacities that appear to have incomplete borders.
 PLEURA
R A D I O G R A P H Y & CT, LOCALIZED FIBROUS T U M O R

Localized fibrous tumor with

incomplete Inferior border

Lobulated Ux'alizcd fibrous tumor

- Tapered pcnterkir margin along
axi> of major fissure

Heterogeneous pleural mass

Sharply defined posterior margin

conforms to major fissure

(Top) First of three images of a 65 year o l d m a n w i t h a localized fibrous t u m o r o f t h e pleura that was discovered
incidentally o n chest radiography. The t u m o r originated w i t h i n the inferior aspect o f t h e right major fissure. PA
chest radiograph shows the t u m o r m a n i f e s t i n g as a lohulated soft-tissue mass w i t h a well-defined superior border a n d
an i n c o m p l e t e l y visualized inferolateral border. ( M i d d l e ) I ateral radiograph shows the pleural t u m o r manifesting as
a lobulated mass in the right major fissure. The posterior aspect ot the t u m o r tapers a n d extends along t h e plane o f
the fissure. In this projection, the t u m o r borders are more u n i f o r m l y visualized. ( B o t t o m ) Chest CT (mediastinal
w i n d o w ) shows a lobulated heterogeneous pleural mass i n t h e right major fissure.
 PLEURA
R A D I O G R A P H Y & CT, P L E U R A I MFTASTASES

— Multiple uodulat pleural masses

Multiple nodular pleural masses

I'lcural fluid or mass -

i Pleural metastascs

Pleural metastasis in major fissure

Pleural metastascs

- Pleural masses along

mediastinai pleura

Circumferential pleural masses

( l o p ) PA chest radiograph shows multiple lobulated pleural opacities that appear t o circumferentially involve the
right hemithorax and extend along the mediastinai pleural surface. (Middle) Composite of serial CT images (lung
window) shows early formation of pleural metastascs (left) growing along the peripheral pleural surface a n d within
the major fissure and progression of pleural metastascs six m o n t h s later (right). Circumferential growth pattern and
extensive involvement of mediastinai pleura are consistent with malignant pleural thickening. Additional features of
malignancy include nodular growth pattern and pleural thickening > 1 cm. (Bottom) Chest CI" (mediastinai
window) shows extensive nodular pleural metastases > 1 cm in thickness, circumferential in distribution, and
involving the mediastinai pleura.
 PLEURA
RADIOGRAPHY & CT, MESOTHELIOMA

Calcified pleural plaques - — Mediastinal invasion by tumor

Circumferential nodular pleural

masses

Extension of tumor into left

major fissure

Calcified pleural plaque

— Malignant pleural thickening

—
f Pleural plaque

Pleural effusion —

— Mesothelioma extending into

costodiaphragmatic recess

(Top) Chest CT shows circumferential nodular pleural masses that extend into the left major fissure and invade the
anterior mediastinal fat. Video-assisted thoracoscopic biopsy revealed mesothelioma. Note calcified pleural plaques,
indicating prior exposure to asbestos. (Middle) First of two chest CT images of a 77 year old m a n with history of
asbestos exposure. Axial CT image shows right pleural effusion and postcroinediat pleural thickening. Note small
calcified pleura! plaque o n the right diaphragmatic pleura. (Bottom) Coronal chest CT demonstrates pleural
thickening extending into the right lateral costodiaphragmatic recess and associated pleural effusion. Subtle pleural
plaque is demonstrated along the right mediastinal pleura. Video-assisted thoracoscopic biopsy revealed
mesothelioma.
 MEDIASTINUM
Description of anatomic abnormalities
General Anatomy | c lassitication of disease processes based o n location
Mediastinum Differential diagnosis of mediastinal masses
• Space between lungs and pleura! surfaces • Mediastinal compartments
• l : roni sternum anteriorly t o thoracic vertebrae i- A n a t o m i c m e d i a s t i n a l c o m p a r t m e n t s
posteriorly Surgical m e d i a s t i n a l c o m part m e n Is
I rom thoracic inlet sui>eriorly to diaphragm Kadiologic m e d i a s t i n a l c o m p a r t m e n t s
interiorly Anatomic Mediastinal Compartments
• Does not include paraverlehral regions • Superior m e d i a s t i n u m
r
Structures Mediastinal contents superior to a transverse plane
• Organs extending from sternal angle t o 14-T5 disk
Ihvmus ■ rrom inanubrium sternum anteriorly t o T l - T 4
Heart (see "Heart" section) vertebral bodies posteriorly
• \eroiligestive tract Contents
trachea and central airvwivs (see " \ i r w a y s ■ I hymns
section) ■ Aortic arch
I s o p h a g u s (see "Fsophagus" section I ■ Right brachiocephalic, left c o m m o n carotid
• Vessels (seeSystemic Vessels and P u l m o n a r y Vessels) left siibclaviaii arteries
Systemic arteries ■ Superior v e n a cava
■ thoracic aorta ■ I elt superior intercostal, right a n d left
■ thoracic aortic branches br.ichiocephalic veins
Systemic veins ■ Superior trachea
■ Venae cavae ■ Superior e s o p h a g u s
■ Azygos and hemiazvgos veins ■ Phrenic, vagus, left recurrent larwigeal nerves
Central pulmonary arteries a n d \ e i n s ■ Superior aspect of thoracic d u c t
• Lymphatics, thoracic duct, Ivmph nodes ■ 1 \ m p h nodes
• Nerves • Inlenor mediastinum
Vagus nerves (X) three compartments l>ciow superior mediastinum
■ Right vagus nerve courses interiorly along lateral ■ Nnterior m e d i a s t i n u m
trachea, behind hilum and along lateral esophagus ■ Middle mediastinum
with branches to esophagus, cardiac a n d ■ Posterior m e d i a s t i n u m
pulmonary plexi Anterior m e d i a s t i n u m
■ I eft vagus n e r v e courses interiorly along lateral ■ l-rom sternum anteriorly t o pericardium
aortic arch, behind hilum and along lateral posteriorly
esophagus with branches to esophagus, cardiac ■ inferior t h y m u s
and pulmonarv plexi ■ t a t nerves, l y m p h nodes, vessels
■ Left recurrent laryngeal nerve, branch of leit Middle m e d i a s t i n u m
vagus n e r v e ai lateral aortic arch, courses under ■ Round h\ fibrous p e r i c a r d i u m
aortic arch, continues superiorly in a groove ■ Heart
between t h e trachea a n d esophagus towards t h e ■ Central systemic and p u l m o n a r v vessels
neck to supplv the larynx ■ Nerves, vessels
Phrenic nerves Posterior m e d i a s t i n u m
■ Right p h r e n i c nerve is lateral to vagus nerve. ■ from fibrous pericardium anteriorly to thoracic
courses along lateral aspect of right vertebral bodies posteriorly
brachiocephalic vein, continues anterior to hilum ■ Inferior e s o p h a g u s
along lateral pericardium ■ Descending a o r t a
■ 1 eft p h r e n i c n e r v e is lateral to vagus nerve a n d ■ Portions of azygos system
proximal left brachiocephalic Vein, courses along ■ t h o r a c i c duct, Is m p h n o d e s
lateral proximal aortic arch, continues anterior t o ■ S y m p a t h e t i c trunks, nerves
hilum along lateral pericardium Radiologic Mediastinal C o m p a r t m e n t s
• Mesenchymal tissues • Mediastinal c o m p a r t m e n t s , lelson classification
Pericardium (sec ' P e r i c a r d i u m " section) Rased on left lateral chest r a d i o g r a p h
Mcdinsiinal fat Includes p a r a s e r t e b r a l region
Anterior m e d i a s t i n u m
1 ■ Structures anterior to continuous line dravsn along
Mediaslinal Compartments anterior trachea and posterior heart
General Concepts Middle m e d i a s t i n u m
■ Structures anterior to imaginary line connecting
• No true mediastinal compartments
points located I cm behind anterior margins of
No defined tissue planes compartmentalize the
thoracic vertebrae, a n d posterior to anterior
mediastinum
mediastinum
• 1 stablishment of arbitrars mediastinal compartments
Posterior m e d i a s t i n u m
 MEDIASTINUM
■ Structures posterior to middle mediastinum
Mediastinal compartments, frascr, Mtiller, Colman,
Pare classification
Rased on left lateral chest radiograph
I ocalization of lesions as predominantly w i t h i n a
compartment
■ Addresses multicompartment abnormalities
: Anterior mediastinum
■ Identical to anterior mediastinum of Felson
i Middle-posterior mediastinum
■ I'osterior to anterior mediastinum, anterior to
thoracic vertebrae
Paravertebral regions, not in mediastinum proper
Mediastinal compartments, Heitzman classification
Thoracic inlet
■ Cervicothoracic junction
■ Immediately above and below transverse plane
through tirst rib
Anterior mediastinum
■ I rom thoracic inlet superiorly to diaphragm
inferiorly
■ Anterior to heart, ascending aorta, superior vena
cava
Areas posterior to the anterior mediastinum
■ Supra-aortic area, above aortic arch
■ Infra-aortic area, below aortic arch
■ Supra-azygos area, above azvgos arch
■ Infra-azygos area, below azygos arch
Imaging of the Mediastinum
Radiography of the Mediastinum
• frontal radiographs
Kight mediastinal contours from cephalad to caudad
■ Superior vena cava interface, right atrium,
inferior vena cava
i left mediastinum from cephalad to caudad
■ I.eft subclavian artery interface, aortic arch,
pulmonary trunk, left atrial appendage, left
ventricle
• lateral radiography
Anterior contours from cephalad to caudad
■ Right ventricle, pulmonary trunk, ascending
aorta
i Posterior contours from cephalad to caudad
■ Aortic arch, proximal descending aorta, left
atrium, left ventricle, inferior vena cava
CT/MR of the Mediastinum
• Identification and characterization of vascular
structures, organs, lymph nodes, and abnormal tissues
I Mediastinal Lines, Stripes & Spaces
Mediastinal Lines
• Anterior junction line
o Contact between anterior lungs just posterior to the
sternum; imaging of four plcural layers
t Radiography
■ I hin line or stripe, oblique course from lower
manubrium sternum and inferiorly to the left
• Posterior junction line (or stripe)
Contact between posterior lungs behind esophagus
and anterior To vertebrae; imaging of four plcural
layers
Mediastinal Stripes
• Right paratracheal stripe
' Contact between right lung and right tracheal wall
above azygos arch
Up to 4 mm thick on radiographs of normal subjects
• I eft paratracheal stripe/interface
< Contact between left lung and lett tracheal wall and
intervening tissues
' Thin soft tissue stripe
• I'aravertebral stripes
Contact between lower lobes nni\ paravertebral
skeleton and soft tissues
Mediastinal Spaces & Recesses
• Pret radical space
Triangular morphology
\ntcrolateral to trachea
■ Bound by aortic arch medially, mediastinal pleura
laterally, superior vena cava anteriorly, trachea
posteriorly
Contains fat, prelracheal lymph nodes
• Prevascular space
Triangular morphology
Anterior to aorta and superior vena cava
■ Bound by mediastinal pleurae bilaterally, sternum
anteriorly, great vessels posteriorly
Contains thymus, Ivmph nodes, fat
• Aortopulmonary window
left mediastinum lateral to trachea
■ Bound by trachea medially, mediastinal pleura
laterally, aortic arch superiorly, left pulmonary
artery interiorly
i Contains lymph nodes, fat, recurrent laryngeal
nerve, ligamentum arteriosum
• Subcarinal space
Immediately below carina
■ Round by main bronchi laterally, carina
superiorly, left atrium inferiorly
Contains lat and lymph nodes
• Azygocsophageal recess (see "Systemic Vessels")
Portion of right mediastinum below tracheal carina
■ Contains azygos vein, esophagus
< Makes contact with medial right lung
< Concave laterally, may be convex in normal subjects
with prominent azygos veins
• Retrocrural space
>■ Medial to bilateral diaphragmatic cnira
Adjacent to descending aorta and paravertebral
region
• Paravertebral space
Not always considered anatomically part of
mediastinum
' Incorporated into mediastinal compartments by
seveial classifications
| Thymus
Anatomy
• Rilolied encapsulated organ
 MEDIASTINUM
• Closely related to anterior great \essels and
pericardium
• \ge-related changes
Involution after puberty
ratty infiltration after age of 4(1 years
Imaging
• Not visible radiographically in normal adults
• Prominent in normal infants and children
o I hy mic sail sign, morphologic appearance of
nautical sail (5%Of infants)
I hymic wave sign, indentations of normal thymus
hv anterior ribs
• Cl
< (Quadrilateral morphology in i n f i n i t y and
childhood
■ triangular morphology in late childhood and
adulthood
I.it replacement beginning at 25 years, usuallv
complete hv age 40 years
Size
■ Children s 5 years; average thickness 1.4 t i n
■ Patients < 20 vears; maximum thickness 1.8 cm
■ Patients > 20 years; maximum thickness 1.3 cm
Mediastinal Lymph Nodes
Rouviere Anatomic Classification
• Parietal, outside parietal pleura, drain chest wall
Intern.il mammarv, diaphragmatic, paracardiac,
intercostal
• Visceral, within mediastinum or hila
Anterior mediastinal, paratracheal, paraesophageal
Intrapulmonarv, bronchopulmonary.
trai 'heohronchial
W e b b and Miggins Classification
• Rased on common usage and visualization on
cross-sectional imaging according to Webb WR,
Higgins CB. thoracic Imaging. Pulmonary and
Cardiovascular Radiology. Philadelphia: l.ippincott
Williams & Wilkins, 2005
• Anterior l y m p h nudes
Internal mammary, parasternal locations
Prevascular, anterior to aorta/great vessels
Paracardiac icardiophrenic angle), anterior or
lateral to heart
• Iraeheobronchial
Paratracheal. anterior/lateral to trachea
i Aortopiilmoniiry, aorlopulmonary window,
drainage ot lelt upper lobe
a Pcribroiuhial
Subcarinal. between proximal main bronchi inferior
to carina
• Posterior
Paraesophageal and inferior pulmonary ligament,
near esophagus and descending aorta
Intercostal and pa r.i vertebra I, paraveriebral regions
at intercostal spaces
■ Retrotrural, posterior to crura
AJCC/UICC Lymph N o d e Stations
• Fourteen lymph node stations (numbered I-14I
J Mediastinal Ivmph ncxlcs. N2 descriptor in lung
cancer staging (nine lymph node stations)
i Ililar and intrapulmonary lymph nodes, N l
descriptor in lung cancer staging
• R & I designations with respect to midline
• Superior mediastinal h m p h nodes (1. 2, J, 4)
highest mediastinal. station I: above horizontal
line at upper left brachiocephalic vein
t'pper paratracheal. station 2, above horizontal
line tangential to upper aortic arch and below
station 1
Prevascular and retrotrachcal. station .<
1 ower paratracheal, station 4
■ Right paratracheal lymph nodes below
horizontal margin of upper aortic arch and alxive
Superior aspect of right main bronchus
■ l eft lower paratracheal lymph nodes to left ol
trachea between lctt main bronchus at upper
margin of left upper lobe bronchus and medial to
ligamentum arteriosum
• \ o r t i c Ivmph nodes (stations 5. 6)
Subaortic or aortopuhtUHiarv. station 5; lateral to
ligamentum arteriosum, aorta or left pulmonary
artery
Para-aortic (ascending aortic or phrenic), station
6; anterior and lateral to ascending aorta/arch or
brachiocephalic artery lx'low upper aortic arch
• Inferior mediastinal l y m p h nodes >stations 7, 8. 9)
Nubcarinal. station 7: interior to tracheal carina
Paraesophageal, station 8; adjacent to esophagus
Pulmonary ligament, station 9; within pulmonary
ligament, along posterior wall ot lower aspect of
interior pulmonary vein
Imaging of Mediastinal Lymph Nodes
• Round, ovoid discrete soft tissue, may exhibit fat
attenuation center
• Normal short axis measurement ol <. 1.0 cm and <, 1.5
cm in subcarinal region
• I-'nlargcd lymph nodes may exhibit round/ovoid
morphologv or mav exhibit nodal coalescence with
diffuse infiltrative mediastinal soft tissue
Anatomy-Imaging Correlations
Pneumomediastinum
• Air in mediastinum, mav occur spontaneously;
elevated lung pressure with airway rupture, traumatic
instrumentation
Mediastinal Enlargemenl
■ Focal masses
Primary neoplasms, benign and malignant
Congenital cysts, typically unilocular and
subcarinal
Vascular lesions, vascular enhancement, continuitv
with vascular lumen
Glandular enlargement, enlargemenl ol
thymus/thvroid
I Urinations, visualization of abdominal fat/organs
• Diffuse mediastinal enlargement
I y mphadenopathy related to malignant neoplasia
I ipomatosis
 MEDIASTINUM
OVERVIEW OF THE MEDIASTINUM

■ IT

Superior vena cava

1 Aortic arch

%&■
Pulmonary trunk

ir ■*
Thymus

Heart & pericardium

Diaphragm

Graphic demonstrates the location of the mediastinum with respect to the other structures and tissues of the chest.
The mediastinum is the space between the pleural spaces and lungs and contains the heart, pericardium, thymus,
aerodigestJve tract and the central aspects of the thoracic great vessels. The mediastinum extends from the thoracic
inlet superiorly to the diaphragm Interiorly and from the sternum anteriorly to the thoracic vertebrae posteriorly.
 MEDIASTINUM
CORONAL & SAGITTAL MEDIASTINAL ANATOMY

Proximal aortic arch

Pulmonary trunk
Superior vena cava

Uftlung

Diaphragm

Thoracic inlet
Trachea

Thymus
Thoracic vertebrae

Heart & pericardium

Sternum
Esophagus

Diaphragm

^ y,
(Top) First of four graphics depicting the general anatomy of the mediastinum. Graphic depicting the coronal
anatomy of the mid portion of the mediastinum shows that It contains the heart (seen in cross-section) and portions
of the great vessels. The mediastinum Is located centrally within the chest between the lungs and pleural surfaces.
The Inferior boundary of the mediastinum is the diaphragm. The mediastinum extends superiorly to the thoracic
inlet. (Bottom) Graphic depicts a sagittal view of the mediastinum which extends from the sternum anteriorly to the
thoracic vertebral bodies posteriorly and from the thoracic inlet superiorly to the diaphragm Interiorly. The
mediastinum contains the heart, thymus, portions of the aerodigestive tract and the great vessels of the thorax.
Medlastinal fat Is also present In variable quantities.
 MEDIASTINUM
ANATOMY, MEDIASTINAL NERVES

Right vagus nerve

Right phrenic nerve

Right vagus nerve

Right phrenic nerve

Esophagus

Left phrenic nerve Left vagus nerve

Left vagus nerve

Left vagus nerve

Left phrenic nerve

Left )ugular vein

Left recurrent laryngeal nerve

Aortic arch Left vagus nerve

Left recurrent laryngeal nerve

(Top) First of three graphics depicting the anatomy of the nerves of the mediastinum. The right vagus nerve courses
along the lateral trachea, and continues Inferiorly posterior to the hilum and along the lateral esophagus. The right
phrenic nerve courses lateral to the light brachiocephalic vein and continues inferiorly anterior to the hilum and
along the pericardium. It enters the abdomen with the inferior vena cava. (Middle) The left vagus nerve courses
along the lateral aorta and continues Inferiorly posterior to the hilum along the lateral esophagus. The left phrenic
nerve courses anterior to the hilum and along the pericardium and pierces the diaphragm to enter the abdomen.
(Bottom) The left recurrent laryngeal nerve, a branch of the left vagus nerve, follows an arcuate course under the
aortic arch and continues superiorly along the trachea to supply the larynx.
 MEDIASTINUM
ANATOMIC MEDIASTINAL COMPARTMENTS

Mediastinum

Right paravertebral

Superior mediastinum
(green)

Anterior mediastinum
(yellow)

Posterior mediastinum
(blue)

Middle mediastinum
(red)

(Top) First of two graphics depicting the anatomic medlastlnal compartments. The cross-sectional anatomy of the
mediastinum proper at the level of the arch is illustrated and highlighted by showing it in color. By definition, the
mediastinum is the space between the pleural surfaces and the lungs bound anteriorly by the sternum and posteriorly
by the vertebrae. Thus, the paravertebral regions are not Included in the anatomic mediastinum although they are
often included in classifications used by imagers and clinicians. (Bottom) Graphic depicts the anatomic medlastlnal
compartments. The superior mediastinum lies above a line drawn from the stemomanubrial junction to the T4-S
intervertebral disk. The inferior mediastinum contains anterior and posterior compartments in front and behind the
heart and pericardium, and a middle compartment bound by the fibrous pericardium.
 MEDIASTINUM
RADIOGRAPHIC MEDIASTINAL COMPARTMENTS, FELSON

* , •. - • '■

Anterior mediastinum

Posterior mediastinum

Middle mediastinum

' - - <~«>J r- *
Middle mediastinum
(red)

Anterior mediastinum
(yellow)
t\ Posterior mediastinum
(blue)
*W

; >

+3A
Middle mediastinum
(red)

(Top) Left lateral chest radiograph illustrates the Felson classification of the mediastinal compartments. The anterior
mediastinum is located anterior to a vertically oriented line drawn along the anterior trachea and continued along
the posterior aspect of the heart. The posterior mediastinum is located behind a line drawn connecting points
located 1 cm posterior to the anterior margins of the thoracic vertebral bodies. The middle mediastinum is located
between the anterior and posterior compartments. This classification uses three compartments, includes the
paravertebral regions and places the heart in the anterior compartment. (Bottom) Graphic illustrates the location of
anatomic structures according to the Felson classification. The mediastinal compartments are illustrated with
different colors. The posterior mediastinum includes the paravertebral region.
 MEDIASTINUM
RADIOGRAPHIC MEDIASTINAL COMPARTMENTS, FRASER ET AL

*i

Anterior mediastinum

Paravertebral region

Middle-posterior
mediastinum
1

Anterior mediastinum
(yellow)

Paravertebral region
(blue)

Middle-posterior
mediastinum (red)

(Top) Left lateral chest radiograph showing the Fraser, Miiller, Colman and Pare classification of the mediastinal
compartments. Lesions are classified as being located predominantly within one of the compartments allowing for
localization of large multicompartment lesions. The anterior mediastinum is identical to that of the Felson
classification. The middle and posterior compartments are combined and placed between the anterior mediastinum
and the paravertebral region. (Bottom) Graphic shows the anatomic structures of the mediastinum as they relate to
the mediastinal compartments of Fraser, Miiller, Colman and Pare. These authors specifically separate the
paravertebral region from the traditional mediastinal compartments. It should be noted that these classifications use
imaginary boundaries as there are no tissue planes that compartmentalize the mediastinum.
 MEDIASTINUM
R A D I O G R A P H Y & C O R O N A L CT, N O R M A L M E D I A S T I N U M

— Aortic arch
Superior vena cava —

— Pulmonary trunk

— Left atrial appendage

Right atrium
Left ventricle

Inferior vena cava

— Aortic arch

Superior vena cava —

— Pulmonary trunk

Left atrial appendage

Right atrium —
— Left ventricle

Clop) First of four normal images showing the structures that form the radiographic mediastinal contours. On PA
chest radiography, the right mediastinal contour (from superior to inferior) is formed by the superior vena cava, right
atrium and inferior vena cava. The right atrium forms most of the right inferior mediastinal contour. The left
mediastinal contour is formed (from superior to inferior) by the aortic arch, pulmonary trunk, left atrial appendage
and left ventricle. The left ventricle forms most of the left inferior mediastinal contour. (Bottom) Contrast-enhanced
coronal chest CT (mediastinal window) shows the anatomic structures that contribute to the mediastinal contours.
The superior vena cava and right atrium form the right mediastinal contour. The aortic arch, pulmonary trunk, left
atrial appendage and left ventricle form the left mediastinal contour.
 MEDIASTINUM
R A D I O G R A P H Y & C O R O N A L CT, N O R M A L MEDIASTINUM
n
</>

Aortic arch
I
Q.
CJ'
in
^—
13"
C
3
Pulmonary trunk

I elt atrium

Right ventricle —
I eft ventricle

— Inferior vena cava

Proximal aortic arch ~

— Distal aortic arch

Pulmonary trunk —

Left atrium

Hight ventricle — I.eii ventricle

(Top) The anterior c o n t o u r o f the m e d i a s t i n u m o n t h e left lateral chest radiograph ( f r o m i n f e r i o r t o superior) is

f o r m e d by the right ventricle and p u l m o n a r y t r u n k . A p o r t i o n of t h e p r o x i m a l ascending aorta may be evident
siiperiorlv. The posterior c o n t o u r ( f r o m superior t o inferior) is f o r m e d by the aortic arch, left a t r i u m , left ventricle
and inferior vena cava. ( B o t t o m ) Sagittal contrast-enhanced chest (IT (mediastinal w i n d o w ) shows t h e anatomic-
correlates of the mediastinal c o n t o u r s seen o n lateral radiography. The anterior c o n t o u r is f o r m e d (from inferior t o
superior) by the right ventricle, p u l m o n a r y t r u n k a n d p r o x i m a l aortic arch. Hie posterior c o n t o u r (from superior t o
inferior) is f o r m e d by the distal aortic arch, t h e left a t r i u m and t h e left ventricle.

507
 MEDIASTINUM
RADIOGRAPHY & CT, ANTERIOR JUNCTION LINE

Anterior junction line

Azygoesopbagcal recess

Anterior junction line

—
Anterior junction line

(Top) First of three images illustrating the normal anterior junction line. TA chest radiograph shows the anterior
junction line formed by the apposition of the anterior lungs. The line is formed by four layers of pleura, projects over
the mediastinum and courses from superior to inferior from the inferior aspect of the manubrium sternum towards
the left. (Middle) Contrast-enhanced chest CT (lung window) shows the cross-sectional anatomy of the anterior
junction line. The line is formed by contact between the right and left lungs anterior to the mediastinum, (liottom)
Coronal chest CT (mediastinal window) shows the anterior junction line. Note the superior widening of the tine
(anterior triangle) formed by divergence of the pulmonary surfaces.
 MEDIASTINUM
R A D I O G R A P H Y & CT, POSTERIOR J U N C T I O N LINE/STRIPE

— Posterior junction line

Azygoesophageal recess

Kight lower lobe airspace disease —I

- Posterior junction line

Posterior junction line

(Top) l-irst of three images illustrating the n o r m a l posterior j u n c t i o n l i n e or stripe. PA chest radiograph shows t h e
typical appearance ot the posterior j u n c t i o n line w h i c h represents the posterior apposition o f trie l u n g surfaces in t h e
m i d l i n e . The line terminates i n t e r i o r l y at t h e superior aspect of t h e aortic arch or m i d p o r t i o n ol t h e azygos arch
Note right lower lobe airspace disease related t o p n e u m o n i a . ( M i d d l e ) Axial chest CT ( l u n g w i n d o w ) shows the
posterior p u l m o n a r y apposition that results in the posterior j u n c t i o n l i n e or stripe f o r m e d by four pleural layers a n d
i n t e r v e n i n g mediastinal fat. ( B o t t o m ) C o r o n a l chest CT ( l u n g w i n d o w ) shows the apposition o f the posterior r i g h t
and left lungs anterior to the vertebrae f o r m i n g t h e posterior j u n c t i o n line. Note t h a t t h e posterior j u n c t i o n l i n e
terminates at t h e level of the aortic arch.
 MEDIASTINUM
R A D I O G R A P H Y & CT, R I G H T & LEFT P A R A T R A C H E A L STRIPES
■

Left paratracheal stripe

(tight paratrachcal siripr —

Suixrior vena cava interface —

Azygos arch

Kight paratrat-lii-iil stripe

—
Left paratrachral stripe

Right paratracheal stripe —

( l o p ) lirst of three images s h o w i n g t h e paratrachcal stripes. The right paratracheal stripe is a t h i n soft tissue line that
follows t h e outer c o n t o u r o f t h e right i n t r a t h o r a c i c trachea a n d terminates at the azygos a r c h . The left paratracheal
stripe is o f variable thickness a n d o f t e n includes a p o r t i o n o f the left subclavian artery a n d mediastinai fat. ( M i d d l e )
Contrast-enhanced axial chest CT ( l u n g w i n d o w ) demonstrates t h e a n a t o m i c correlate o f t h e r i g h t paratracheal stripe
f o r m e d as t h e r i g h t upper lobe comes in contact w i t h t h e lateral tracheal w a l l . It is f o r m e d b y t w o pleural layers, the
tracheal wall a n d i n t e r v e n i n g fat. The left paratracheal stripe is also seen. ( B o t t o m ) C o r o n a l contrast-enhanced chesl
C.I ( l u n g w i n d o w ) shows contact o f t h e right upper lobe w i t h t h e lateral w a l l o f t h e trachea t o f o r m t h e right
paratracheal stripe.
 MEDIASTINUM
RADIOGRAPHY, PARAVERTEBRAL STRIPES

Right paravertebral
stripe
Left paravertebral stripe

I eft para-aortic
interface

Right paravcrtebral —
stripe

Left paravertebral stripe

(Top) 1 irst of two images demonstrating the anatomy of the paravertebral stripes. PA chest radiograph shows that the
left paravertebral stripe is distinct from the left para-aortic interface. It represents the apposition of the posterior lung
against the paravertebral region. A portion of the right paravertebral stripe is also visualized. (Bottom)
Contrast-enhanced coronal chest CT (lung window) shows the bilateral paravertebral stripes. They represent the
points of contact between the posterior lungs and the paravertebral soft tissues.
 MEDIASTINUM
AXIAL ANATOMY OF THE MEDIASTINUM

in Anterior (unction line

Prevascular space
Thymus

Pretracheal space
Of

Prevascular space
Thymus

Subcarinal lymph node

Subcarinal space

Right ventricle
Right atrium

Left ventricle

Esophagus
Left atrium
Azygoesophageal recess

Azygos vein
Paravertebral region

(Top) First of three graphics demonstrating the cross-sectional anatomy of the mediastinum and the different
medlastinal spaces. Illustration of the mediastinum at the level of the aortic arch shows the anatomic correlate of the
anterior (unction line, the apposition of the anterior lungs in front of the mediastinum. It also shows the prevascular
space occupied by the thymus and mediastinal fat. The pretracheal space Is anterior to the trachea, posterior to the
superior vena cava and to the left of the aortic arch. (Middle) Illustration of the mediastinum at the bifurcation of
the pulmonary trunk shows the prevascular space, which contains fat and thymus and the subcarinal space which
contains fat and lymph nodes. (Bottom) Illustration of the mediastinum at the level of the heart shows the
azygoesophagealrecessand the paravertebral regions.
i\l
 MEDIASTINUM
AXIAL CT & RADIOGRAPHY, NORMAL MEDIASTINUM

Prevascular space
Normal thymus —

Pretracheal space "•

- Trachea

Posterior junction line Esophagus

Prevascular space

Sii|x*rior vena cava

Normal lymph node Aortopulmonary window

Azygos arch
- Descending aorta

Aortic arch

- Aortopulmonary window

Left pulmonary artery

(Top; First of two axial contrast-enhanced chest CT images (mediastinal window) showing the normal mediastinal
spaces. The prevascular space contains fat and thymic tissue and is anterior to the great vessels. The adult normal
thymus may manifest with strands of soft tissue amid mediastinal fat. The pretracheal space is anterior to the trachea
and contains fat and lymph nodes. (Middle) Axial image through the azygos arch demonstrates the prevascular
space anterior to the ascending aorta and the aortopulmonary window. Prevascular soft tissue strands likely relate to
residual thymus. Pretracheal small nodular soft tissue foci likely represent normal mediastinal lymph nodes.
(Bottom) Coned-down normal PA chest radiograph demonstrates the aortopulmonary window located hetween the
inferior aspect of the aortic arch and the left pulmonary artery.
 MEDIASTINUM
A X I A L CT, N O R M A L M E D I A S T I N U M

— Prevascular space

Normal right hilar lymph node -

Subcarinal spate — Esophagus

Azygos vein

Azygoesophageal recess
Esophagus

Azygos vein

— Paravertcbral region

Esophagus

— Descending aorta

Left paravertebral region

Right paravertcbral region Peripheral nerve

(Top) First of three normal axial contrast-enhanced chest CT images (mediastinal window) demonstrating the
normal appearance of the mediastinum. Image through ihe pulmonary trunk shows the normal subcarinal space
located immediately below the trachcal bifurcation. Soft tissue within the prevascular space represents normal
thymus. (Middle) Axial image through the heart demonstrates the normal appearance of t h e azygoesophageal recess.
The azygoesophageal recess is the interface produced by the contact of the right lower lobe with the retrocardiac
mediastinum. The paravertebral regions are also demonstrated and normally contain paravertcbral fat. (Hot torn)
Axial image through the interior thorax demonstrates the normal paravertebral regions that contain fat and lymph
nodes. The peripheral nerves and sympathetic chain are also located in t h e paravertebral regions.
 MEDIASTINUM
CT, N O R M A L M E D I A S T I N U M
n
=r
m
■ •

o
Q.
5'
u'
— su|H'rinr aortk recess a
Ascending aorta -
3

— Aortopulmonary
Pulmonary artery — lymph node

— Ligamentum
arteriosum
Lower paratracheal -
lymph in■<!.■■-.

Descending aorta

Aortic arch

Aortopulmonary
Aortic arch — window
Calcified ligaimnturr.
arteriosum
Calcified ligamentum ■
arteriosum Pulmonary artery

Pulmonary artery

( l o p ) First o l t w o images of a n o r m a l C l p u l m o n a r y angiogram (mediastinal w i n d o w ) demonstrates the l i g a m e n t u m

arteriosum. Composite o f t w o axial images t h r o u g h t h e a o r t o p u l m o n a r y w i n d o w shows t h e l i g a m e n t u m arteriosum
manifesting as a linear calcification that courses f r o m the p r o x i m a l descending aorta t o t h e superior aspect o f the
p u l m o n a r y artery. The l i g a m e n t u m arteriosum is the r e m n a n t o l the ductus arteriosus w h i c h is patent d u r i n g fetal
life. Note f l u i d in the anterior p o r t i o n o f the superior aortic pericardia! recess. N o r m a l l y m p h nodes a n d fat are also
noted i n t h e a o r t o p u l m o n a r y w i n d o w . ( B o t t o m ) Composite of bilateral o b l i q u e coronal images t h r o u g h the
l i g a m e n t u m arteriosum demonstrate its a n a t o m i c location w i t h i n the a o r t o p u l m o n a r y w i n d o w coursing between the
inferior aspect of the aortic arch a n d the superior aspect o f the p u l m o n a r y artery.
$15
 MEDIASTINUM
CORONAL CT, NORMAL MEDIASTINUM

— Left subclavian artery

Aortic arch

Aortopulmonary
Right pulmonary artery — window

— Pulmonary trunk

Proximal descending
aorta
Carina —
I .eft pulmonary artery

Subcarinal space —

— Left atrium

(Top) First of two normal contrast-enhanced coronal chest CT images (mediaslinal window) demonstrating the
anatomy of the mediaslinal spaces. Image through the right pulmonary artery shows the anatomy of the
aortopulmonary window situated between the inferior aspect of the aortic arch and the superior aspect of the
pulmonary trunk and central pulmonary arteries. The aortopulmonary window normally contains fat and lymph
nodes. (Bottom) Image through the carina demonstrates the anatomy of the subcarinal space, situated between the
carina superiorly and the left atrium inferiorly. It typically contains mediastinal fat and lymph nodes.
 MEDIASTINUM
CORONAL MR, NORMAL MEDIASTINUM

- Aortic arch

— Aortopulmonary window
Superior vena cava -

l'ulmonary trunk

Right pulmonary artery -

r — Aortic arch
Trachea ■

— Aortopulmonary window

Right pulmonary artery -

— Left pulmonary artery

Left atrium ■

Aortic arch

Tracheal carina

eft pulmonary artery

Subcarinal space

■ Left atrium

(Top) First of three Tl-weighted coronal MR images through the mediastinum demonstrating the normal mediastinal
spaces. Image through the right pulmonary artery demonstrates the aortopulmonary window located between the
aortic arch superiorly and the pulmonary trunk and central pulmonary arteries infcriorly. The aortopulmonary
window is filled with high signal intensity fat. (Middle) Image through the distal trachea demonstrates the posterior
aspect of the aortopulmonary window. Small foci of intermediate signal intensity within the high signal mediastinal
fat likely relate to normal mediastinal lymph nodes. (Bottom) Image through the carina demonstrates the normal
subcarinal space located between the tracheal bifurcation superiorly and the left atrium inferiorly.
 MEDIASTINUM
THYMUS

Thymus ■*-^2

\
Sternum

Ascending aorta

Thymus

Pulmonary trunk

O?--

(Top) First of two graphics depicting the anatomy of the normal thymus. Illustration of the anterior surface of the
thymus shows that it is a bilobed organ with a central isthmus. It Is composed of multiple lobules covered by a thin
capsule. The thymus is located immediately anterior to the superior aspect of the pericardium and the origins of the
great vessels. (Bottom) Graphic illustrating the left lateral surface of the thymus shows its location in the prevascular
anterior mediastinum. The posterior surface of the thymus is intimately related to the anterior superior aspect of the
pericardium and the central great vessels. The thymus is located in the anterior mediastinum and is posterior to the
sternum.
 MEDIASTINUM
R A D I O G R A P H Y & CT, N O R M A L PEDIATRIC T H Y M U S
n
re

I
Thymic sail sif;n
c
3

Thymic wave sign

— Normal thymus
Superior vena cava

Aortic arch

(Top) First of two chest radiographs of normal infants demonstrate variations in the appearance of the normal
pediatnc thymus. AP chest radiograph of a 10 m o n t h old infant illustrates the sail sign. The left thymic lobe
manifests as a triangular opacity that mimics the morphology of a nautical sail. (Middle) AP chest radiograph of a 2
month old infant shows a prominent normal thymus that exhibits the thymic wave sign. The anterior ribs indent
the soft prominent left thymic lobe producing an undulating wave-like contour. (Bottom) Contrast-enhanced chest
CT (mediastinal window) of an 8 m o n t h old child demonstrates the appearance of t h e normal pediatric thymus. The
anterior mediastinum is filled by homogeneous thymic soft tissue. The lateral borders of the thymus extend beyond
those of the thoracic great vessels and result in a wide superior mediastinum on radiography. I
319
 MEDIASTINUM
G R A P H I C & CT, T H Y M I C M E A S U R E M E N T

long axis of thymic

lobe
Width of thymic lobe —

1 ong axis of thymic

lobe

[ — Width of thymic IOIK-

Enlarged left thvmic

lobe

(Top) Ciraphic illustrates the method for measuring the thymus. The width or thickness of the thymus (I) is
measured perpendicular to the long axis (W) of each lohe. (Bottom) Contrast-enhanced chest CT (mediastinal
window) through the thymus of a 22 year old woman with right upper lobe pneumonia shows thymic enlargement
manifesting with a laterally convex enlarged left thymic lobe. Note prominent vascular structures within the thymus.
The black line indicates the width or thickness of the left thymic lobe.
 MEDIASTINUM
AXIAL CT, NORMAL THYMUS

— Prominent normal thymus

Normal thyinus

— Normal thymus

f l o p ) First of three axial contrast-enhanced chest CT images (mediastinal window) show the normal thymus in
patients of various ages. Image through the thymus of a 15 year old boy demonstrates a triangular soft tissue
structure in the prevascular anterior mediastinum. Although the right thymic lobe has a laterally convex margin, the
width of the thymic lobes were within normal limits for age. (Middle) Image through the thymus of a 20 year old
woman shows a straight lateral contour of the right lobe and a mildly convex lateral contour of the left lobe. Fatty
infiltration of the thymus is evident manitesting with heterogeneous attenuation in the prevascular space. (Bottom)
Image through the thymus of a 22 year old woman shows that the thymus is small with straight lateral borders and
small amounts of linear soft tissue within the mediastinal fat.
 MEDIASTINUM
ANATOMY OF MEDIASTINAL LYMPH NODES

Right brachiocephalic
artery Aortic arch

Pulmonary trunk

Azygos arch *

12, 13,

3, 14L Pulmonary ligament

Esophagus

Station 3P lymph node fj

0
Recurrent laryngeal
nerve
* * I
Station 3A lymph node
it
Pulmonary ligament

Ascending aorta

Pulmonary trunk

(Top) First of two graphics Illustrating the regional lymph node classification for staging lung cancer according to the
American Joint Committee on Cancer (AJCC) and the Union Internationale Contre le Cancer (UICC). Numbers refer
to lymph node stations and L and R are used to indicate their location with respect to the midline. The following
nine mediastinal lymph node stations are shown: 1) highest mediastinal; 2) upper paratracheai; 4) lower
paratracheai; 5) subaortic (aortopulmonary); 6) para-aortic; 7) subcarlnal; 8) paiaesophageal; 9) pulmonary ligament.
Lymph nodes in stations 10-14 are considered intrapulmonary. (Bottom) Graphic illustrates mediastinal lymph node
stations 3 and 5. Station 3 denotes prevascular (3A) and retrotracheal (3P) lymph nodes. Station 5 denotes subaortic
(aortopulmonary window) lymph nodes.
 MEDIASTINUM
CT, M E D I A S T I N A L L Y M P H N O D E S

Station 1R lymph node - Station II lymph node

— Station .<P lymph node

Station 3P lymph node -

- Left brachiocephalic vein

Station 3A prevascular Ivmph node —

- Station 3A lymph node

Station 2R lymph node

— Station 3P Ivmph node

Station M' lymph node

Superior vena cava - - Station 6 lymph nodes

— Aortic arch
Station 4R lymph nodes

(Top) first o f n i n e contrast-enhanced chest CT images (mediastinal w i n d o w ) of a 5b year o l d m a n w i t h n o n - H o d g k i n

l y m p h o m a shows diffuse l y m p h a d e n o p a t h y . Axial image t h r o u g h t h e superior m e d i a s t i n u m a l x w e the left
brachiocephalic v e i n demonstrates p r o m i n e n t highest mediastinal (station 1) l y m p h nodes. There is also an enlarged
right retrotracheal (3P) a n d a p r o m i n e n t left retrotracheal (31') l y m p h node. ( M i d d l e ) Axial image t h r o u g h the m i d
left brachiocephalic v e i n demonstrates enlargement o f right upper paratracbeal (station 2) l y m p h nodes as well as
p r o m i n e n t retrotracheal ( 3 D l y m p h nodes. There are also p r o m i n e n t prevascular (station 3A) l y m p h nodes. ( B o t t o m )
Axial image t h r o u g h the superior aspect o f the aortic arch demonstrates enlarged lower paratracheal (station 4R)
l y m p h nodes a n d p r o m i n e n t para-aortic (station 6) l y m p h nodes.
 MEDIASTINUM
CT, MEDIAST1NAL LYMPH N O D E S

Proximal aortic arch - Left internal mammary lymph

node

Station 6 lymph nodes

Station 4R lymph node

Station 41 lymph node

Ascending aorta -

Station 4R lymph nodes Station 5 HiiXKHtiC lymph

nodes

Station 41 lymph node

—
Descending aorta

Ascending aorta — Pulmonary trunk

Station 7 lymph nodes —

(Top) Axial image through the inferior aspect of the aortic arch demonstrates enlargement of right and left lower
I MI.ill ii heal (station 4) lymph nodes as well as prominent para-aortic (station 6) lymph nodes. There is mild
enlargement of a left internal m a m m a r y lymph node. (Middle) Axial image below the aortic arch demonstrates
bilateral station 4 lower paratracheal lymphadenopathy. Station 5 siibaortic (aortopulmonary window)
lymphadenopathy is noted lateral t o the expected location of the pulmonary ligament. (Ilottom) Axial image
obtained below the carina demonstrates abnormal soft tissue in the subcarinal region related to coalescent station 7
subcarinal lymphadenopathy.
 MEDIASTINUM
CT, MEDIASTINAL LYMPH N O D E S

- Station VI. lymph node

Station 8R lymph node -

— Lett para-aortic lymph node

— Left paravci Ichral lymph nodes

Right paraiardiac Ivmph node —

High! para-aortic lymph node —

— Left para-aortic lymph node
Right paravertebral lymph nodes -
Left paravcrtchral lymph nodes

Upper alxlominal
lymphadenopathy

Right diaphragmatic cms

Left diaphragmatic cms

Right retrocrural lymph node -

— Left retroc rural lvmph node

(Top) Axial image through the inferior as|)ect of the left atrium demonstrates a prominent left pulmonary ligament
(station 91.) lymph node adjacent to the left inferior pulmonary vein. There is also enlargement of a right
paraesophageal (station KR) lymph node, a left para-aortic and several left paravertebral lymph nodes. (Middle) Axial
image through the heart demonstrates lymphadenopathy surrounding the descending aorta. There is also
lymphadenopathy in the bilateral paravertebral regions. Note the prominent right paracardiac lymph node in the
right eardiophrenic angle. (Bottom) Axial image through the posterior lung bases shows lymphadenopathy in the
bilateral retrocrural regions. There is also splenomegaly and upper abdominal lymphadenopathy.
 MEDIASTINUM
PNEUMOMEDIASTINUM

Subcutaneous air

Pneumomediastinum —

— I'neumornediastinum

Pneumomediastinum —

Pneumomediastinum —

(Top) First of two images of a 19 year old man with a spontaneous pneumomediastinum and right pneumothorax
shows air surrounding the heart and upper mediastinal structures. The PA chest radiograph shows subcutaneous air
in Ihe soft tissues of the neck and right axilla. The mediastinum communicates with the neck through the thoracic-
inlet as there are no defined tissue planes that compartmentalize the mediastinum. (Bottom) Left lateral chest
radiograph demonstrates air in the anterior mediastinum outlining the anterior aspect of the heart and the great
vessels. Spontaneous pneumomediastinum may result from an abrupt increase in intrapulnionary pressure and may
occur in association with conditions such as asthma and obstructive lung disease. It may also occur as a complication
of thoracic instrumentation.
 MEDIASTINUM
FOCAL M E D I A S T I N A L ENLARGEMENT, M A L I G N A N T NEOPLASIA

Right upper lobe mass

A
Thick right paratracheal stripe

Station 4R lymph nodes -

Cavitary primary lung cancer -

— Aortic arch

Mediastinal nodal coalescence

— Pulmonary trunk

Station 10R lymph nodes

— Descending aorta

(Top) First of three images of a 67 year old m a n with advanced lung cancer. PA chest radiograph shows a right upper
lobe mass and ipsilateral right mediastinal lymphadenopathy manifesting with lobular thickening of the right
paratracheal stripe. (Middle) Contrast-enhanced chest CT (mediastinal window) through the aortic arch
demonstrates a cavitary mass in the right upper lobe and right lower paratracheal (station 4R) lymphadenopathy.
There is nodal coalescence a n d apparent extranodal neoplasm infiltrating the mediastinum a n d encasing the trachea.
(Bottom) Axial image through the pulmonary trunk demonstrates the locally invasive mediastinal neoplasm
encasing and nearly obstructing the superior vena cava and the right pulmonary artery. There is involvement of the
right hilar (station 10R) lymph nodes.
 MEDIASTINUM
DIFFUSE MEDIASTINAL ENLARGEMENT, MALIGNANT NEOPLASIA

— Station 6
lyinpliadenopathy

Station 4R lymph node —

Station 3A
lymphadenopathy
— I eft brachiocephalic
vein

Station 2R
lymphadenopathy

(Top) First of two images of different patients with diffuse mediastinal malignant lymphadenopathy exhibiting two
different patterns of lymph node involvement. Contrast-enhanced chest CT (mediastinal window) through the aortic
arch of a 62 year old woman with non-Hodgkin Iymphoma demonstrates multiple discrete ovoid and rounded
enlarged mediastinal lymph nodes in the para-aortic (station 6) and right lower paratracheal (station 4H) regions.
(Rottom) Axial contrast-enhanced chest CT tmediastinal window) of a 20 year old man with Hodgkin Iymphoma
demonstrates diffuse mediastinal lymphadenopathy. Discrete lymph nodes are not visible. A diffuse infiltrative
mediastinal soft tissue mass encases the left brachiocephalic vein and represents nodal coalescence. Involvement of
at least two separate lymph node stations (2R and 3A) should suggest lymphadenopathy.
 MEDIASTINUM
DIFFUSF M F O I A S T I N A l ENLARGEMENT, LIPOMATOSIS
n

3"

Wide superior mediastinum - Wide superior mediastinum

O
&/
i—t-

5"
c
3

- Prevasculor space

Pretrachcal space —

I'revascular space

Pretrachcal space —

(Top) First of three images of a 41 year old man with mediastinal enlargement secondary to mediastinal lipomatnsis.
l'A chest radiograph demonstrates diffuse bilateral mediastinal enlargement particularly affecting the superior
mediastinum. (Middle) Nonenhanced chest CT (mediastinal window) demonstrates that the mediastinal
enlargement is secondary to diffuse mediastinal fat deposition. Fat expands the lateral contours of the mediastinum
and surrounds the vascular structures, trachea a n d esophagus without evidence of obstruction. (Bottom)
Unenhanced chest CT (mediastinal window) through the aortic arch demonstrates diffuse mediastinal fat deposition.
Mediastinal lipomatosis is the accumulation of unencapsulatcd non-neoplastic mediastinal fat and may result from
obesity, or endogenous/exogenous hypercortisolism. I
 MEDIASTINUM
FOCAL MEDIASTINAL ENLARGEMENT, PRIMARY THYM1C NEOPLASM

Right anterior mediastinal mass

Right anterior mediastinal mass -

Right anterior mediastinal mass —I

(lop) First of three images of an asymptomatic 63 year old man with an incidentally discovered thymoma. PA chest
radiograph demonstrates a local contour ahnormality of the right inferior mediastinum obscuring the right cardiac
border. (Middle) Left lateral chest radiograph demonstrates the anterior location of the mass which projects over the
heart anterior to the posterior cardiac border in the radiographic anterior mediastinal compartment. (Bottom; Axial
contrast-enhanced chest CT (mediastinal window) demonstrates an ovoid right anterior mediastinal soft tissue mass.
A tissue plane is seen between the lesion and the adjacent vascular structures. Based on the demographic
information, the focal unilateral nature of the lesion and the absence of lymphadenopathy, thymoma is the most
likely diagnosis and was confirmed at surgery.
 MEDIASTINUM
FOCAL MEDIASTINAL ENLARGEMENT, CONGENITAL LESION

Bronchus intermedius

Right subcarinal mass

- Mass effect on anterior trachea

Mediastinal mass

Superior vena cava

Right pulmonary artery

Cyst wall
_
Bronchus interniedius

Subcarinal cystic mass

(Top) First of three images of a 29 year old man with a bronchogenic cyst. PA chest radiograph demonstrates a soft
tissue mass in the subcarinal region that produces mass effect tin the medial aspect of the bronchus intermedius.
(Middle) Left lateral chest radiograph demonstrates mass effect on the anterior aspect of the distal trachea. The mass
extends into the anterior and middle-posterior radiographic mediastinal compartments. (ISottom)
Contrast-enhanced chest CJ (mediastinal window) demonstrates a large thin-walled cystic subcarinal mass which
produces mass effect on the bronchus interniedius and the right pulmonary artery. The location and morphology of
the lesion and its homogeneous non-enhancing water attenuation content are most consistent with congenital
foregut cyst (in this case a bronchogenic cyst) confirmed at surgery.
 MEDIASTINUM
F O C A L M E D I A S T I N A L ENLARGEMENT, G l A N D U I A R ENLARGEMENT

Cervical tracheal deviation

Trachea! deviation

Mediastinal goiter

Trachea

Trachea -
Esophagus —
Mediastinal goiter

(Top) lirst of three images of a 70 year old man with a mediastinal goiter. PA chest radiograph demonstrates a left
cervical soft tissue mass that extends inferiorly into the mediastinum. The lesion produces deviation of the trachea to
the right above and below the thoracic inlet. (Middle) Unenhanced chest CT (mediastinal window) through the
superior mediastinum demonstrates a polylobular soft tissue mass that deviates the trachea to the right and is
continuous with the left lobe of the thyroid gland. (Bottom) Unenhanced chest CT (mediastinal window)
demonstrates the intramediastinal extension of the cervical lesion which displaces the trachea and the esophagus to
the left. The lesion exhibits a slightly higher attenuation than that of the adjacent soft tissues and vascular structures
and subtle punctate calcifications.
 MEDIASTINUM
FOCAI MEDIASTINAI. ENLARGEMENT, HERNIATION
3"

*•

ft
9-
~+
=3'
c
3
Right anterior mediastinai mass

Right anterior mediastinai mass

Morgagni hernia
Morgagni hernia

—
Right anterior diaphragmatic defect

( l o p ) first o f three images of an a s y m p t o m a t i c 59 year o l d w o m a n w i t h a M o r g a g n i hernia. PA chest radiograph

demonstrates a right cardiophrenic angle anterior mediastinai mass w i t h a well-defined r o u n d e d superior contour.
The mass obscures the riglit cardiac border. ( M i d d l e ) Left lateral chest radiograph shows that t h e lesion projects over
the heart a n d is located in t h e r a d i o g r a p h i c a n t e r i o r m e d i a s t i n u m . ( B o t t o m ) C o m p o s i t e image f r o m a
contrast-enhanced chest C I (mediastinai w i n d o w ) w i t h coronal (left) a n d sagittal (right) reconstructions shows that
the lesion represents h e r n i a t i o i i of o m e n t a l fat t h r o u g h a diaphragmatic defect. The f i n d i n g s arc consistent w i t h the
diagnosis o f M o r g a g n i hernia.

333
 SYSTEMIC VESSELS
■ Connects pulmonary artery to aortic arch during
General Anatomy and Function embrvonic/fetal circulation allowing hlcxxl to
Anatomy bypass lungs in utero; closes after birth
• Systemic arteries Branches
I horacic aorta ■ Itnichioccphalic a r t e r y
Brachioccphalic t r u n k (artery) ■ I eft c o m m o n carotid a r t e r y
■ Right c o m m o n carotid artery ■ Left siibclasian a r t e r y
■ Right sulKlavian a r t e r y (gives rise to right • Descending a o r t a
vertebral artery) Descends on lett of midline
I elt c o m m o n carotid artery Lxits thorn* through aortic hiatus posterior to
I ett subclavian artery diaphragm
■ 1 efl vertebral artery Branches
• Systemic veins ■ Bronchial arteries, variable number, supply right
Right b r a c h i o c c p h a l i c vein ,UH\ left main bronchi
I ett b r a c h i o c c p h a l i c vein ■ Posterior intercostal arteries
A/vgos system ■ Pericardia), esophageal, mediastinal. superior
■ \ / v g o s vein phrenic and subcostal branches
■ H e m i a / y g o s vein Brachiocephalic Artery
■ Accessory h e m i a / y g o s \ e i n • Relationships
Superior vena c a \ a First b r a n c h of aortic a r c h
Inferior \ c i i a t a v a Origin posterior to manubrium a n d lett
• Lymphatic vessels brachiocephalic vein, anterior to trachea
I horacic duct Ascends along right side ol trachea toward right
sternoclavicular joint where it bifurcates
Function
• Systemic arteries • Branches
Conduit a n d delivery of oxygenated blood from left Right c o m m o n carotid a r t e r y
heart to tissues ■ Supplies right head and neck
Right subcl.isiiin artery
• Systemic veins
( onduit a n d delivery of deoxygenated blood from ■ Supplies right upper extremity and upper thorax
tissues to right heart ■ Gises rise to right vertebral a r t e r y
Thyroid ima artery
■ Supplies thyroid gland
| Systemic Arteries Left Common Carotid Artery
• Relationships
Thoracic Aorta
i Second b r a n c h of aortic a r c h
• Anatomic divisions
i Origin posterior to niaiuibrium sternum posterior
■ Ascending a o r t a
and to the lett of brachiocephalic trunk
Aortic arch Ascends anteiior to left subclavian artery
- Descending a o r t a Courses anterior and to the left of trachea
• Ascending aorta
Originates at aortic orifice from left ventricle left Subclavian Artery
Origin a n d proximal aspect within p e r i c a r d i u m • Relationships
Courses atitcrosuperiorlv and to the right I bird branch of aortic arch
Branches \sceruts lateral to left aspect of trachea and lett
■ C o r o n a r y arteries c o m m o n carotid artery
Relationships Gives rise to left vertebral artery
■ Central location with respect t o other vascular
struitures
■ Anterior to left atrium, posterior to right ventricle [Systemic Veins
■ Medial to right atrium a n d left ventricle
• Aortic arch Azygos System
Relationships • Drains posierior chcst/alwiomiual walls and
■ Ascends anterior to right pulmonary artery a n d mediastinum
trachea) carina • Ma> drain lower body in cases of inferior vena cava
■ Apex on left side of distal trachea obstruction
■ Descends posterior to left liiluin ■ A/ygos v ein
I i g a m e n t u m arteriosum Potential collateral pathway between superior and
■ Remnant of cluctus arteriosus connecting inferior s e n a e caxae in cases of venous obstruction
superior aspect of p u l m o n a r y t r u n k to interior Drains posterior chest a n d abdominal walls
aspect ol aortic arch \scends on right side of anterior 1 1 2 to 15 vertebral
bodies
 SYSTEMIC VESSELS n
\rchcs anteriorly at l 4 o \ e r right m<iin b r o n c h u s left pericardiacophrenic vein re
to drain into posterior aspect of superior vena cava • Courses along left side of aortic arch • ■

Tributaries I atcral to left vagus nerve en

■ Posterior intercostal veins; including right Medial to left p h r e n i c nerve -<
superior intercostal \ e i n formed by second, third • Drains into left brachiocephalic vein *—»
(D
and fourth intercostal veins • May connect with accessory hemiazvgos vein 3
■ H c m i a / y g o s and accessory h c m i a / y g o s veins n
■ Mediastinal, esophagcal. pcricardial and right
bronchial veins [Thoracic Lymphatics <
• Hemiazygos vein i^
Ascends oil left side of anterior T12 to T 9 vertebral Thoracic Duct
re.
bodies • I argest lymphatic channel
• Posterior to thoracic aorta as far as 19 • Origin from cisterna chyli
Crosses to the right to join azygos vein • Ascends into thorax through aortic hiatus
Tributaries • Crosses to the lett at the 14, IS or To vertebral Ixxlies
■ Interior four or live lett posterior intercostal veins • Drains near union of left internal jugular and
■ Tsophagcal and mediastinal veins subclavian veins: m.iv drain into left subciav ian
• \ccessory hemiazygos vein vein
IX'scends on lelt side of anterior 14 to TK vertebral • Tributaries
bodies Mav receive left jugular and lelt subclavian l y m p h
Frequently connects t o azygos, hemiazygos and trunks
left supciior intercostal veins Upper intercostal lvmph trunks, posterior
mediastinal lvmph nodes
Venae Cavae • Relationships
• Su|K*rior v e n a cuva Courses along anterior aspects of 112 to 16 vertebral
I ormed b\ anastomosis of right and left bodies
hrachinccphalic veins
Distal portion partially invested by pericardium Lymphatic Trunks
Drains into the right a t r i u m • I'lilmonarv lymphatics drain into iiitrapulinonarv
Tributaries (trat lu'obroiu hial) and m e d i a s t i n a l l y m p h nodes
■ Vzygos vein • I llerent lymphatic channels arise from lymph nodes,
• Inferior vena cava anastomose With other thoracic lymphatics
Courses through diaphragm to drain into right • Right broiu houiediaslinal l y m p h t r u n k
a t r i u m ; partially invested bv p e r i c a r d i u m Drains right lung, left lower lobe and mediastinum
• I ell bronc hnincdiastiii.il l y m p h t r u n k
Brachiocephalic Veins Drains left u p p e r lolie and mediastinum
• Right brachiocephalic vein
lormed by anastomosis of right subclavi.m and
right jugular veins Radiography of the Great Vessels
Origin posterior lo medial right clavicle
Vertical course to superior vena cava PA Chest Radiograph
Tributaries • Superior v e n a cava interface
■ Vertebral vein Right superior m e d i a s t i n u m
■ first posterior intercostal vein Visualization of lateral border of superior vena cava
■ Internal thoracic vein above azygos a r c h and below thoracic inlet as it
■ Inferior thyroid and thyinic veins abuts mediastinal surface of right u p p e r lobe
• 1 elt brachiocephalic vein • \zygos a r c h
lormed by anastomosis ol left subclavian and left Right superior mediastinum
jugular veins Ovoid opacity at right tracheohroiichial angle
Origin posterior to medial left clavicle Normal width of u p to lO m m
Crosses midline, courses to the right to anastomose • I eft subclavian artery interlace
with lett brachiocephalic vein and form superior I eft superior m e d i a s t i n u m
vena cava Visualization of lateral border ol It-It sulKlavian
Tributaries artery above aortic a r c h as it abuts mediastinal
■ Vertebral vein surface ol left upper lobe
■ left sii|K'rior intercostal vein • Vascular pedicle
■ Interior thyroid vein Width ot great vessels arising from the heart
■ Internal thoracic vein Measured from vertical line drawn from where
■ l l n m i c and pcricardial veins superior v e n a cava interface crosses right main
bronchus to point where left subclavian artery
Left Superior Intercostal Vein arises from aortic arch
• Tributaries ■ Normal width of u p to 58 m m
l u s t t w o or three left intercostal veins • \ o r t i c a r c h interface
1 eft bronchial veins I eft superior m e d i a s t i n u m
 SYSTEMIC VESSELS
local outward convexity <it left trdchcobronchi.il
angle with mass effect on distal left tnicheal wall
• I eft superior intercostal vein (aortic nipple)
I elt superior mediastinum
Rounded or triangular bulge of aortic arch contour:
seen in < 5% of normal subjects
• I eft para-aortic interface
I i l l mid and inferior mediastinum
0 Visualisation of lateral wall of descending aorta
from aortic arch to diaphragm as it abuts left
incdidstinal lung suiface
Lateral Chest Radiograph
• Ascending .tori.i
May IK' visible in superior aspect ot mediastinum on
patients with aortic ectasia
• Proximal descending aorta
Visible in most indi\ iduals posterior to distal trachea
• Inferior vena cava
Convex, straight or concave interlace posleroinlerior
to left ventricle
[ C J / M R ^ t theCreat Vessels
Supra-Aortic Mediastinum
• Great veins anterior and lateral to great arteries
• Great arteries (aortic branches) surround anterolateral
trachea
• Brachioccphalic veins
Right hrachiocephaiic vein, shorter, vertical course
Lett hrachiocephaiic vein, longer than right,
horizontal or oblique course
• Brachioccphalic artery
Anterior to trachea, right of midline
• I eft common carotid artery
Posterior and to the left of brachioccphalic artery
Smallest great arterv at this level
• I eft sulKlavian artery
Postcrolatcral or lateral to trachea
Aortic Arch Level
• Aortic arch
Proximal arch is anterior and to right of trachea
Courses posteriorly and to the left
i Posterior arch is anterolateral to vertebral Ixxlas
1
Proximal ascending aorta; average diameter of 3.6
cm (2.4-4.7 c m range)
3 Ascending aorta proximal to arch; average diameter
of 3.5 cm (1.6-3.7 cm range)
• Superior vena cava
Otfoid or round morphology
1
( ourses verticallv anterior and to right of trachea
• Pericarinal and subcarinal region
• A/ygos arch
■ Courses anteriorly at right tracheobronchial
angle
■ Drains into posterior aspect of superior vena cava
A/ygos vein
■ Courses vertically along right anterolateral
vertebral bodies
<. Ilcmia/ygns vein
■ Courses verticallv along left anterolateral vertebral
bodies posterior to descending aorta
Descending aorta
■ Courses along posterolateral aspect of the spine
■ Mid descending aorta, 2.5 cm diameter (1.6-3.7
cm range)
■ Distal descending aorta. 2.4 cm diameter
(1.4-3.3 cm range)
Anatomy-Based Imaging
Abnormalities
Aortic Arch Anomalies
• Itovine arch
Left c o m m o n carotid artery originating from
hrachiocephaiic artery
Most common great vessel anomaly, seen in up to
20% of population
• AlxTmnt right suhclav ian artery
Seen in 0.4-2.3% of population, typically
asymptomatic but mav produce dvspnea/dvsphagia
I ast aortic branch arising distal to left suhclav ian
artery coursing cephalad, posteriorly and to the
right, usually behind trachea and esophagus
Diverticulum of Kommerell. local dilatation of
proximal aberrant suhclav ian arterv. seen in 60*%
ot cases
• \noinalous left vertebral artery
Direct origin from aortic arch, seen in 10% of
population
■ Kight aortic arch
Seen in 0.141.2% ot population
Mirror image great vessel branching associated with
congenital heart disease
Non-mirror image great vessel branching, associated
with aberrant left subclavian artery
• Double aortic arch
i> Seen in 0.05-0.3% of population, usually svmptoins
of stridor/dvsphagia, mav l>e asymptomatic
Most common complete vascular ring
Right arch gives ofl right subclavian and right
common carotid arteries
■ Larger, extends more superior!) and posteriorly
than left arch
■ Left arch gives off left common carotid and left
subclavian arteries
Venous Anomalies
• Persistent left superior \L-mi cava
c Seen in 1-3% of population, usually asymptomatic
Arises Irom anastomosis of left sulKlavian and left
jugular veins
■ Typically drains into coronary sinus
■ May coexist with a right superior vena cava,
rxcasional venous connection between the two
superior venae cavac
■ Vertical course, anomalous vessel anterior to
normal left superior pulmonary vein
• Vygos continuation ol interior vena ca\a
■ Infrahepatic interruption of interior \vn,\ cava with
a/vgos continuation
I nlarged azygos vein, mav mimic
1\ mphadenopathy
Association with situs ambiguous ipolysplcniai
 SYSTEMIC VESSELS
OVERVIEW OF THE THORACIC SYSTEMIC VESSELS

ft

Brachiocephalic artery
'
Left common carotid
artery

te
Left subclavlan artery

Right brachiocephalic — Left brachiocephalic

vein vein
\

Superior vena cava

Thoradc aorta

■
Graphic depicts the anatomy of the principal systemic great vessels of the thorax and their relationship to the other
thoracic structures. The vena cava transports de-oxygenated blood to the right heart chambers, which in turn deliver
it to the alveolar-capillary interface via the pulmonary arteries. The superior vena cava is formed by the anastomosis
of the bilateral brachiocephalic veins. The thoracic aorta transports oxygenated blood from the left heart chambers to
the body. The three main branches of the thoradc aorta, the brachiocephalic, left common carotid and left
subclavian arteries, supply the upper extremities, the orax and the head and neck.
 SYSTEMIC VESSELS
ANATOMY OF THE THORACIC SYSTEMIC VESSELS

Left biachlocephalic
Right brachlocephallc vein
vein Aortic arch

•§
Superior vena cava
Ascending aorta

J
Inferior vena cava

Left common carotid

artery

Brachlocephallc artery
Left subdavian artery
Right brachlocephallc
vein
Proximal descending
aorta
Superior vena cava

^M

Inferior vena cava

(Top) First of two graphics illustrating the anatomy of the systemic great vessels and their relationship to the heart
and the pulmonary vessels. Anterior view shows the superior vena cava formed by the anastomosis of the right and
left brachiocephalic veins, which are located anterior to the branches of the aortic arch. The venae cavae drain into
the right atrium. The proximal aorta is located centrally with respect to the surrounding vascular structures. Its
ascending portion courses superiorly. The aortic arch gives off the brachiocephalic, left common carotid and left
subclavian arteries in sequence. (Bottom) Graphic shows a posterior view of the great vessels. The superior and
inferior vena cavae course into the right atrium. The branches of the aortic arch are located behind the anteriorly
located great veins.
 SYSTEMIC VESSELS
ANATOMY OF THE THORACIC AORTA & SYSTEMIC ARTERIES
n
rt>
r-+

Right common carotid 3.

artery n
<
Left common carotid rt>
in
Right subclavian artery 1/1
artery

Right internal Left subclavian artery

mammary artery
Aortic arch
Brachiocephalic artery

Ascending aorta

Descending aorta

Left intercostal arteries

Diaphragm

' Aortic hiatus

Right diaphragmatic

Graphic shows the anatomy of the thoracic aorta and its branches. The aorta has three major portions: ascending
aorta, aortic arch and descending aorta. The ascending aorta courses superiorly and toward the left. The aortic arch
curves over the left tiacheobronchial angle. The first branch of the aortic arch is the brachiocephalic artery followed
by the left common carotid and left subclavian arteries. These vessels supply the upper thorax, upper extremities and
the head and neck. The brachiocephalic artery gives rise to the right common carotid and right subclavian arteries.
The subclavian arteries give rise to the bilateral inter il mammary arteries that supply the anterior chest wall and to
bilateral vertebral arteries.
 SYSTEMIC VESSELS
ANATOMY OF THE THORACIC SYSTEMIC VEINS
ID
IS)

>
y ■:-
^
E
■*—>
V)
>-
to Right jugular vein Left jugular vein
+-'
t/>

c Right subclavian vein Left subclavian vein

_c
U
Left superior
intercostal vein

Accessory hemiazygos
vein

Graphic shows the anatomy of the thoracic systemic veins. The superior vena cava is formed by the anastomosis of
the right and left brachiocephalic veins which in turn are formed by the anastomosis of the jugular and subclavian
veins. The chest wall is drained by intercostal veins that course along the undersurfaces of the ribs and drain into the
azygos vein on the right and the hemiazygos and accessory hemiazygos veins on the left. Venous anastomoses
connect the azygos and hemiazygos veins. The first three left intercostal veins drain into the left superior intercostal
vein that courses along the lateral aspect of the aortic arch to drain into the posterior aspect of the left
brachiocephalic vein. The right superior intercostal vein, shown posterior to the superior vena cava and right
I brachiocephalic vein, receives the second third and fourth right intercostal veins.
540
 n
=r
<n
v>
!-*■

ir>
i —

re
3
n
<
in
ui
O

(Top) First of two graphics showing the anatomy of the azygos and hemiazygos venous systems. Illustration of the
right medfcistinal su-face shows the intercostal veins draining into the azygos vein. The azygos arch courses over the
right mam bronchus to drain into the posterior aspect of the superior vena cava. The right superior Intercostal vein is
also shown. (Bottom) Illustration of the left mediastinal surface shows the Intercostal veins draining into accesv>ry
hemiazygos and hemiazygos veins that communicate wi'h the azygos vein through venous anastomoses. The left
superior intercostal vein receives bjbutades from the first three intercostal veins and courses along the lateral aspect
of the aortic arch to drain into the left brachiocephalic vein. The left superior intercostal vein may be promineut in
patients with venous obstruction and collateral flow. I
341
 SYSTEMIC VESSELS
J2 R A D I O G R A P H Y , N O R M A L SYSTEMIC VESSEL INTERFACES
CJ
en
>s>
O
>
u
E Left subclavian artery
tri interface

Aortic arch interlace

Superior vena cava

a interface

Azygos arch -

I elt para-aortic
interface

Proximal descending
thoracic aorta

— Inferior vena cava

interface

(lop) First of two normal chest radiographs of a middle-aged patient demonstrating the radiographic anatomy of the
systemic great vessels. I'A chest radiograph shows mild tortuosity of the thoracic aorta and a prominent aortic arch.
The left subclavian artery interface is produced by contact with the adjacent mediastinal surface of the left upper
lobe. The superior vena cava interface results from contact with the mediastinal surface of the right upper lobe. The
left para-aortic interface is produced by contact between the left lateral descending aorta and the mediastinal surface
of the left lung. (Bottom) Left lateral chest radiograph demonstrates the proximal aspect of the descending aorta and
the inferior vena cava interface.

Ul
 SYSTEMIC VESSELS
RADIOGRAPHY, NORMAL SYSTEMIC VESSEL INTERFACES
n
3-

•<
1/1
Left suhclavian artery interface rc

n
- Aortic arch interface
— en
Superior vena cava interface 1/1

2.
Mass effect of aortic arch on left
distal trachea Left para-aortic interlace

— Measurement of vascular
pedicle

Aortic arch
Azygos arch -

- Left para-aortic interface

A/ygoesuphageal recess

(lup) Coned-down I'A chest radiograph shows the superior vena cava interlace a n d the aortic arch interface in the
right and left superior mediastinum respectively. The left suhclavian artery interface is seen in the left superior
mediastinum where the vessel ahuts the left mediastinal lung surface. (Middle) Coned-down I'A chest radiograph
illustrates the method for measuring the vascular pedicle, measured from a vertical line from where the superior vena
cava interface crosses the right main bronchus to the point where the left suhclavian artery arises from the aortic
arch. (Bottom) PA chest radiograph shows the left para-aortic interface that results from contact of the vessel with
the mediastinal surface of t h e left lung. The azygoesophageal recess results from contact of the medial right lung with
the right retrocardiac mediastinum near the azygos vein and esophagus. I
 SYSTEMIC VESSELS
AXIAl CT, SYSTEMIC VESSELS

Right brachiocephalic vein -

Left brachiocephalic vein
Left common carotid artery
Brachiocephalic artery
Left si :1K. lavian artery

Left brachiocephalic vein

Right brachiocephalic vein -
I eft common carotid arterv
Brachiocephalic artery —
— Ix'ft subclavian artery

Left brachiocephalic vein

Right brachiocephalic vein
Left common carotid artery
Brachiocephalic artery
Left subclavian artery

— Proximal descending aorta

flop) l-irst of nine axial contrast-enhanced chest CT images (mediastinal window) demonstrating the anatomy of the
systemic great vessels. Image through the medial clavicles shows the bilateral brachiocephalic veins located anterior
to the brachiocephalic, left common carotid and left subclavian arteries. (Middle) Image through the manubrium
sternum shows the anteriorly located brachiocephalic veins. Note the oblique course of the left brachiocephalic vein
compared to the vertical course of the right. The systemic arteries are located posterior to the veins. (Bottom) Image
through the horizontal portion of the left brachiocephalic vein demonstrates its course towards the right
brachiocephalic vein. The superior aspect of the aortic arch and the origins of its branches are also visualized.
 SYSTEMIC VESSELS
AXIAL CT, SYSTEMIC VESSELS
n
t/>

in
— Lett hrachiocephalic vein -<
1/1
Right hrachiocephalic vein <T>
3
n"
— Aortic arch <
en

Right superior intercostal vein *L

en

Superior vena cava -

Aortic arch

Azygos arch

P r o x i m a l descending aorta

- Ascending aorta
Superior vena cava

— Descending aorta

(Top) Image through the aortic arch demonstrates the anastomosis of the left and right hrachiocephalic veins to
form the superior vena cava. The right superior intercostal vein is seen just anterior to an upper thoracic vertebral
body to the right of midline. (Middle) Image through the mid aortic arch demonstrates the superior vena cava
abutting the right upper lobe and the azygos arch which courses above the right main bronchus. The aortic arch
courses over the left main bronchus. (Bottom) Image through the inferior portion of the aortic arch demonstrates
the a/ygos arch which courses over the right main bronchus to drain into the posterior aspect of the superior vena
cava. The ascending and descending aortas leading t o and from the aortic arch respectively are also seen.
I
J4S
 SYSTEMIC VESSELS
AXIAL CT, SYSTEMIC VESSELS

— Right ventricular outflow tract

Right atrium —
— Ascending aorta
Superior, vena cava -

Azygocsnphageal recess —
Descending aorta

Azygos vein - — llemiazygos vein

Right atrium -

Left ventricle
Inferior vena cava

Azygos vein -
Hcmiazygos vein

Inferior vena cava —

- Descending aorta
Azygos vein -
- Hcmiazygos vein

- Left Intercostal vein

(Top) Image through the superior aspect of the heart demonstrates the central location of the ascending aorta with
respect to the great vessels and cardiac chambers. The distal superior vena cava is seen draining into the right atrium.
The azygos and hcmiazygos veins are located posterior to the descending aorta on the anterior aspects of the
vertebral bodies. (Middle) Image through the mid portion of the heart shows the inferior vena cava draining into the
right atrium. The azygos and hcmiazygos veins are seen posterior and lateral to the descending aorta. (Bottom) Axial
image through the inferior aspect of the heart shows the inferior vena cava. Bilateral intercostal veins drain into the
azygos and hcmiazygos veins.
 SYSTEMIC VESSELS
C O R O N A L CT, SYSTEMIC VESSELS

Brachiocephalic artery
I eft brachiocephalic vein

Right brachiocephalic vein Aortic arch

Superior vena cava -

Ascending aorta

— Lell brachiocephalic vein

Right brachiocephalic vein —■
— I.cll common carotid artery

— Aortic arch
Superior vena cava -

1 eft subclavian artery

Aortic arch
Azygosarch -

_
Inferior vena cava

(Top) First of six coronal contrast-enhanced chest C.Y Images (mediastinaJ window) showing the anatomy of the
thoracic systemic vessels. Image through the anterior great vessels shows the anterior location of the brachiocephalic
veins which anastomose to form the superior vena cava. The ascending aorta is located centrally. The aortic arch is
partially visualized as is its first branch, the brachiocephalic artery. (Middle) Image through the mid superior vena
cava shows the anatomic correlate of the superior vena cava interface seen on radiography, produced by contact of
the vessel with the adjacent right lung. The left c o m m o n carotid artery courses superiorly and to the left of the
trachea. (Bottom) Image through the posterior arch shows the anatomic correlate of the aortic arch and left
subclavian artery interfaces. The a/ygos arch and the inferior vena cava are also seen.
 SYSTEMIC VESSELS
J£ C O R O N A L CT, SYSTEMIC VESSELS
CD
Left common carotid artery
Of
> — Left suhclavian artery

Aortic arch

I Azygos arch -

I
Intrahcpntic inferior vena cava

— Aortic" arch
Right intercostal arteries

Azygoesophageal recess —

- Descending aorta

- Proximal descending aorta

Right Intercostal arteries —

Distal descending aorta

(Top) Image through the carina demonstrates the dorsal aspect of the aortic arch which contacts the adjacent left
lung to form the aortic arch interface. The azygos arch is located at the right tracheobronchial angle. The distal left
common carotid and subclavian arteries are also imaged. (Middle) Image through the anterior aspect of the
descending aorta shows several right intercostal arteries. The course of the unopacificd azygos vein is also seen. The
azygoesophageal recess seen on radiography results from contact of the right lung with the right retrocardiac
mediastinum. It may exhibit a gentle lateral convexity as illustrated in this image. (Bottom) Image through the
posterior aspect of the descending aorta demonstrates the anatomic correlate of the left para-aortic interface that
results from contact of the vessel with the left mediastinal lung surface.
 SYSTEMIC VESSELS
C O R O N A L , S A G I T T A L & V O L U M E R E N D E R E D CT, S Y S T E M I C V E I N S
n
Azygos arch -

en

Azygos vein —
Accessory hemiazygos vein
n
— Anastomoses with azygos vein
<
1/1

—
Hemiazygos vein

Azygos vein

— Azygos arch

Superior vena cava -

Azygos vein

Inferior vena cava

Azygos arch

Descending aorta
Azygos vein

Hemiazygos vein
Anastomosis between azygos &
hemiazygos veins

(Top) First of three contrast-enhanced chest CT images (mediastinal w i n d o w ) d e m o n s t r a t i n g the a n a t o m y of t h e

systemic veins o f t h e t h o r a x . C o r o n a l image t h r o u g h t h e a/ygos vein demonstrates a p o r t i o n of t h e azygos arch a n d
the course o f the azygos vein i n the right m e d i a s t i n u m . The accessory hemiazygos a n d hemiazygos veins are also
seen. Note anastomoses of t h e azygos v e i n w i t h the hemiazygos and accessory hemiazygos veins. ( M i d d l e ) Sagittal
image t h r o u g h the azygos vein shows t h e azygos arch d r a i n i n g i n t o t h e dorsal aspect of the superior vena cava. The
superior a n d inferior venae cavae are seen d r a i n i n g i n t o the right a t r i u m . ( B o t t o m ) V o l u m e rendered coronal image
t h r o u g h t h e azygos v e i n shows its vertical course i n t h e r i g h t m e d i a s t i n u m a n d a p o r t i o n o f t h e azygos arch. T h e
hemiazygos vein is partially obscured by the descending aorta. I
149
 SYSTEMIC VESSELS
SAGITTAL MR, THORACIC AORTA & BRANCHES

J.
in
1/1

> - Bracliiocephalic artcrv

u Lelt brachiocephalic vein ■"
Ascending aorta

I
U

— Left common carotid artery

left bracliiocephalic vein

Aortic arch —

Intercostal vessels

Descending aorla

Left brachiocephalic vein -

Left subclavian arterv
Aortic arch -

Descending aorta

(lop) first of three sagittal Tl-weighted magnetic resonance images through the aorta and its branches demonstrates
the normal anatomy of these vessels. The distal ascending aorta and proximal arch are imaged as is the origin of the
brachiocephalic artery. Note the anterior location and horizontal course of the left brachiocephalic vein imaged in
cross-section. (Middle) Image through the mid aortic arch demonstrates the origin and course of the left common
carotid artery, the second branch of the aortic arch. The descending thoracic aorta and some of its intercostal
branches are seen. (Bottom) Image through the distal aspect of the aortic arch demonstrates the origin of the left
subclavian artery, the last branch of the aortic arch. The descending aorta is also visualized.

i50
 SYSTEMIC VESSELS
C O R O N A L & SAGITTAL M R , A Z Y G O S VEIN
n
(V
••
~<
O
3
n"
— Aortic arch
<
A/.vgos arch en
s.
Right main bronchus

Azygos vein —

— Descending aorta

Superior vena cava ~ Azygos arch

Inferior vena cava

lntrahepatic interior
vena cava

( l o p ) first of two II-weighted MR images of the chest shows the arches of the azygos vein and the aorta. Note the
Oblique vertical course of the azygos vein in the right rctrocardiac mediastinum and the anatomic basis for the
morphology of the azygocsophageal recess seen on radiography. The azygos arch courses o\er the right main
bronchus. I he distal descending aorta is also seen. (Bottom) Sagittal image through the azygos arch demonstrates its
course over the right hilum to drain into the posterior aspect of the superior vena cava. The lntrahepatic and
intrathoracic portions of the inferior vena cava are also seen.

r»i
 SYSTEMIC VESSELS
-S2 RADIOGRAPHY & CT, LEFT SUPERIOR INTERCOSTAL VEIN (AORTIC NIPPLE)
<D

a
y
E
a
t?>
>^
CO

0)
— Aortic nipple
U

I lorizontal portion of
left brachiocephalir
vein

Right brachiocephalic
vein

Left superior intercostal

vein

Right superior
intercostal vein Accessory hemiazygos
vein

(Top) Coned-down normal PA chest radiograph demonstrates a small nodular bulge of the superolateral aspect of the
aortic arch interface that corresponds to the left superior intercostal vein as it courses lateral and slightly superior to
the aortic arch. This structure, also known as the aortic nipple based on its morphology, is seen in 5% of normal
subjects. (Bottom) Contrast-enhanced chest CT (mediastinal window) of another patient demonstrates the anatomic
basis for visualization of the so-called aortic nipple on radiography. The left superior intercostal vein courses along or
slightly superior to the left lateral aspect of the aortic arch and may manifest as a contour irregularity of the aortic
arch on radiography. The left superior intercostal vein receives the first three or four intercostal veins and usually
I anastomoses with the accessory hemiazygos vein.
152
 SYSTEMIC VESSELS
AORTOGRAPHY
n
IT

4?
l i f t c o m m o n carotid
artery
3
■ Left suhclavian artery
o
%
Distal aortic arch in
Brachiocephalic artery

Proximal aortic arch

Ascending aorta

— Descending aorta

Right c o m m o n carotid
artery Left common carotid
artery

Right suhclavian artery ■ — f l

— Left suhclavian artery

Right internal
mammary artery
Aortic arch

Brachiocephalic artery

(Top) Oblique thoracic aorlogram demonstrates the anatomy of the aortic arch and its branches. Contrast was
injected into the distal ascending aorta. The aortic arch and its branches are opacified. The first branch is the
brachiocephalic artery, followed by the left common carotid and left siibclavian arteries. The irregular contour of the
descending aorta and the luminal narrowing of the left siibclavian artery were secondary to atherosclerosis. (Bottom)
Oblique thoracic aortogram demonstrates the normal branching pattern of the aortic arch. The first branch is the
brachiocephalic artery which gives rise to the right siibclavian and right common carotid arteries. The left common
carotid and left suhclavian arteries are the second and third aortic branches res|)ectively. The right internal mammary
artery, a branch of the right suhclavian artery is also visualized.
 SYSTEMIC VESSELS
GRAPHIC & CORONAL CT, BRONCHIAL ARTERIES

Third right intercostal

artery

Right bronchial artery Descending aorta

Left superior bronchial

artery

Left inferior bronchial

artery

Aortic arch

Right Intercostal artery

Descending aorta

Bronchial artery

(Top) Graphic depicts a common variation of the anatomy of the bronchial arteries. In this illustration, the right
bronchial artery arises from the third right intercostal artery and supplies the wall of the right main bronchus.
Superior and Inferior left bronchial arteries arise from the descending thoracic aorta and supply the wall of the left
main bronchus. (Bottom) Contrast-enhanced chest CT (mediastlnal window) of a 46 year old man with abdominal
arterial thrombosis (not shown) demonstrates partial visualization of the bronchial arteries. Coronal image obtained
posterior to the tracheal carina demonstrates several small branches of the descending thoracic aorta. One of the
branches courses anteriorly to supply the right main bronchus. A right intercostal artery is also shown.
 SYSTEMIC VESSELS
ANATOMIC VARIANTS OF THE BRONCHIAL ARTERIES
n

3
n'
<
^ Left superior bronchial artery
1/1

Left bronchial arteries

Common trunk for left & right

Right bronchial artery bronchial arteries

Right bronchial artery

Left bronchial artery

Right bronchial artery

Right subclavlan artery

Right bronchial artery

- * Supernumerary bronchial
arteries

Right bronchial artery

Common trunk for right and

left bronchial arteries

(Top) First of three graphics illustrating anatomic variations of the bronchial arteries. In this illustration the left
superior bronchial artery supplies the left main bronchus. The left inferior bronchial artery also supplies the left main
bronchus but gives off a right bronchial artery that supplies the right main bronchus. (Middle) Graphic shows single
bronchial arteries arising from the descending aorta to supply the right and left main bronchi. (Bottom) Graphic
shows several supernumerary bronchial arteries supplying the right and left main bronchi. There is also an inferior
bronchial artery with branches to the right and left main bronchi and a right bronchial artery originating from the
right subclavian artery.

ir>5
 SYSTEMIC VESSELS
ANATOMY OF THE THORACIC LYMPHATICS
m
Distal thoracic duct

Superior vena cava

Thoracic duct

Thoracic duct

Inferior vena cava

Cistema chyli

N
Distal thoracic duct
Right subclavlan
lymphatic trunk

Right Left
bronchomedlastinal bronchomedlastinal
lymphatic trunk lymphatic trunk

' /

(Top) First of two graphics depicting the anatomy of the thoracic lymphatics. The thoracic duct arises from the
cistema chyli located at the level of the L2 vertebra. It courses superiorly and to the left of midline along the anterior
aspect of the spine to drain near the anastomosis of the left internal jugular and subclavlan veins. (Bottom) Graphic
depicts the lymphatic drainage of the thorax. The right bronchomedlastinal lymphatic trunk Joins with the right
subclavian and jugular trunks as the right lymphatic duct which drains into the proximal aspect of the right
brachiocephalic vein. The thoracic duct drains into the posterior aspect of the junction of the left internal jugular
and subclavlan veins. The left bronchomediastinal lymphatic trunk drains into the left brachiocephalic vein.
 SYSTEMIC VESSELS
LYMPHANGIOGRAPHY, THORACIC DUCT n
3"
n

~<.
i/>
i—*■
<T>
3
n
<
o_
in

— Distal thorack duel

— Lymph node &

lymphatic channels

— Proximal thoracic duct

Frontal image from a lymphangiogram shows the proximal aspect of the thoracic duct. The variations in the caliber
of the thoracic duct relate t o valves within the duct lumen. The thoracic duct arises from the cisterna chyli (not
shown) and courses vertically and superiorly t o the left of midline anterior to t h e thoracic vertebrae. There is
opacification of a lymph n o d e a n d surrounding small lymphatic channels. Courtesy of Jud Gurney, MD, University
of Nebraska Medical Center, Omaha, Nebraska.

I
r
3 >7
 SYSTEMIC VESSELS
-£ LYMPHANGIOCRAPHY, THORACIC DUCT
IT>
in
O)
>

E
£

01
.n Thoracic duct
U proximal to left
brachiocephalic vein

— Distal thoracic duct

Mid portion of —
thoracic duct

Frontal image from a lymphangiogram demonstrates the distal aspect of the thoracic duct. The thoracic duct drains
into the dorsal aspect of the proximal left brachiocephalic vein as shown. Courtesy of Jud Gurney, MD, University of
Nebraska Medical Center, Omaha, Nebraska.

I
358
 SYSTEMIC VESSELS
AXIAl & CORONAL CT, THORACIC DUCT & CISTERNA CHYLI

— Thoracic duct
lisophagus

Azygos vein Descending aorta

Primary lung cancer

Azygos vein

Thoracic duel —
Descending aorta

Cisterna chyli

— Cisterna chyli tributaries

— Hepatic metastases

Normal cisterna chyli -

— Enlarged cisterna chyli

(Top) Contrast-enhanced chest CT (mediastinal window) shows the normal thoracic duct manifesting as a tiny "dot''
between the azygos vein and the descending aorta. Courtesy of Elizabeth Moore, MD, University of California-Davis.
(Middle) Coronal contrast-enhanced chest CT (mediastinal window) of a patient with primary lung cancer shows the
normal thoracic duct arising from the cisterna chyli and coursing superiorly in the mediastinum. Courtesy of
Elizabeth Moore, MD, University of California-Davis. (Bottom) Composite contrast-enhanced chest CT images
(mediastinal window) showing the normal and abnormal appearances of the cisterna chyli. The abnormal cisterna
chyli (right image) is enlarged secondary to obstruction related to malignancy. The normal cisterna chyli is seen in
the left image. Courtesy of Elizabeth Mc.x>re, MD, University of California-Davis.
 SYSTEMIC VESSELS
AORTIC ENLARGEMENT, TORTUOSITY

Aortic arch

I eft para-aortic
interface
Enlarged ascending
aorta

- trachea
Aortic arch

Ascending aorta —
— Descending aorta

( l o p ) Hirst of t w o images o f a 63 year o l d m a n w i t h h y p e r t e n s i o n demonstrates a n a b n o r m a l ectatic and tortuous

atherosclerotic aorta. I'A chest radiograph shows that t h e ascending aorta is enlarged a n d produces a laterally convex
interface in the right mediastinal contour. The left para-aortic interface also e x h i b i t s a laterally convex m o r p h o l o g y .
( B o t t o m ) Left lateral chest radiograph shows a significant p o r t i o n of t h e dilated tortuous thoracic aorta. W i t h
increasing aortic d i l a t a t i o n a n d tortuosity, there is visualization o f a greater l e n g t h o f t h e vessel o n chest
radiography.
 SYSTEMIC VESSELS
AORTIC ENLARGEMENT, ASCENDING AORTA

Aortic arch

Enlarged ascending — |
Left para-aortic
aorta
interface

Aortic a n h

Distal ascending aorta

Proximal ascending -
aorta Descending aorta

(Top) hirst o f t w o images of a 28 year o l d w o m a n w i t h M a r f a n s y n d r o m e w i t h an enlarged ascending aorta secondary

t o medial degeneration ot the aorta. I'A chest radiograph demonstrates an enlarged ascending aorta that produces a
laterally convex interface in t h e m i d p o r t i o n o f t h e r i g h t mediastinal border. There is also p r o m i n e n c e a n d ectasia o f
t h e aortic arch a n d the descending aorta. ( B o t t o m ) Lefi lateral chest radiograph demonstrates a n a r r o w AP chest
diameter a n d marked enlargement of the ascending aorta, w h i c h is visualized almost i n its entirety. Significant
portions of the aortic arch a n d the descending aorta are also visible.
 SYSTEMIC VESSELS
Ji? B O V I N E A R C H , A O R T O C R A P H Y & CT
O

>
Left common carotid artery
E
a;

S Brachiocephalic artery
Left subclavian artery

Origin of left common carotid

artery

Brachiocephalic artery

Brachiocephalicartery - Left common carotid artery

Origin of left common carotid Left subclavian artery

artery

Aortic arch -
— Origin ot brachiocephalic Js left
common carotid arteries
left subclavian artery

(Top) Oblique aortogram of a 59 year old patient demonstrates a c o m m o n aortic arch anomaly, the bovine arch. In
this anomaly the left c o m m o n carotid artery arises from the proximal aspect of the brachiocephalic artery. The left
subclavian artery arises independently from the aortic arch. (Middle) First of two composite axial contrast enhanced
chest CT images (mcdiastinal window) of a 25 year old patient with tuberculosis a n d a bovine arch. The left c o m m o n
carotid artery arises from the brachiocephalic artery. The left subclavian artery arises independently from the aortic
arch. (Hotlom i Images through the superior aspect of the aortic arch demonstrate that the brachiocephalic and left
c o m m o n carotid arteries originate from a c o m m o n trunk that arises from the aortic arch. The left subclavian artery
I arises from the aortic arch independently.
 SYSTEMIC VESSELS
ANOMALOUS LEFT VERTEBRAL ARTERY n
T

Left brachiocephalic vein - - Brachiocephalic artery

l/l
- left common carotid artery rS
Right brachiocephalic vein -
- Anomalous left vertebral artery
n
- I*ft subciavian artery
in

Left brachiocephalic vein

- Left common carotid artery

Right brachiocephalic vein
■ Anomalous left vertebral artery
Brachiocephalic artery-
- Left subciavian arterv

Left common carotid artery —

- Left subciavian artery

Brachiocephalic artery
- Anomalous left vertebral artery
Aortic arch

(Top) First o f three contrast-enhanced chest CT images (mediastinal w i n d o w ) d e m o n s t r a t i n g the imaging appearance
o f the anomalous left vertebral artery, w h i c h arises directly f r o m t h e aortic arch. The left vertebral artery t y p i c a l l y
arises f r o m t h e left subciavian artery. Axial image t h r o u g h t h e origins o f t h e aortic arch blanches shows four separate
vessels i n c l u d i n g an anomalous left vertebral artery located between the left c o m m o n carotid a n d the left subciavian
arteries. ( M i d d l e ) Axial image o b t a i n e d above the aortic arch shows four aortic branches i n c l u d i n g t h e anomalous
left vertebral artery. ( B o t t o m ) O b l i q u e coronal reconstruction t h r o u g h t h e aortic arch shows f o u r aortic branches;
t h e brachiocephalic, left c o m m o n carotid, anomalous left vertebral a n d left subciavian arteries.

JOl
 SYSTEMIC VESSELS
1/1 ABERRANT RIGHT SUBCLAVIAN ARTERY
CD
1/1
i/>

>

"E
Esophagus w.^.
4—
^ ^ ^ jT
I/) Trarhpa
1 1 ci%_i l e d
>-
c/>
l/l
^H '. Aberrant right
O) subclavian artery
-C
u
NV ^ ^ ^
Right common carotid —
artery l1 **-
Left subciavlan artery
"
•
mm * Left common carotid
artery
Ascending aorta

Right common carotid

artery Left common carotid
artery
Right subclavian artery

Left subclavian artery

Origin of aberrant right

subclavian artery
Common trunk for
bilateral carotid arteries

Ascending aorta

(Top) Graphic depicts the anatomy of the aberrant right subclavian artery, which arises as the last branch of the
aortic arch. The anomalous vessel courses obliquely and typically behind the esophagus and trachea to supply the
right upper extremity. Mass effect on the esophagus and trachea may result in symptoms. (Bottom) Oblique
aortogram demonstrates an aberrant right subclavian artery arising as a fourth branch from the aortic arch. The
superior and oblique course of the vessel towards the right upper extremity is also demonstrated. Note that the first
branch of the aortic arch Is an anomalous common trunk for the right and left common carotid arteries.
1
%4
 SYSTEMIC VESSELS
ABERRANT RIGHT SUBCLAVIAN ARTERY
n
3"
rt>
ft
— Trachea

3
o
Esophagi^
<
Aberrant right subclavian artery —
in

- Aberrant right subclavian artery

Right common carotid artery

Left common carotid artery

Trachea —
Left subclavian artery
Esophagus
Esophagus
Alierrant right subclavian artery Aberrant right subclavian artery

- Right common carotid artery

Left common carotid artery

Esophagus
— Aortic arch
Proximal aberrant right subclavian
artery
Origin of aberrant right
subclavian artery

( l o p ) hirst of three composite axial contrast-enhanced chest CT images (mediastinal window) demonstrates the axial
anatomy of the aberrant right subclavian artery. Images through the superior mediastinum demonstrate the
abnormal posterolateral location of the distal aspect of the aberrant right subclavian artery. (Middle) Images through
the superior mediastinum demonstrate the course of the aberrant right subclavian artery behind the trachea and
esophagus. (Bottom) Images through the aortic arch demonstrate the anomalous right subclavian artery which arises
as the last branch of the aortic arch and courses behind the trachea and esophagus to reach the right upper
extremity. Dilatation of the origin of this vessel is known as the diverticulum of Kommerell.

.165
 SYSTEMIC VESSELS
J£ ARCH ANOMALIES, RIGHT AORTIC ARCH
CD
ir.
2>
<D
>U
Right aortic arch —

IS)

Right para-aortic interlace -

Azygos arch -

Descending aorta

(lop) First of three images of an asymptomatic 49 year old woman with an incidentally discovered right aortic arch.
The aortic arch indents the lateral wall of the distal right trachea. The aorta descends on the right side producing a
right para-aortic interface. (Middle) Axial contrast-enhanced chest CT (mediastinal window) demonstrates the right
sided location of the proximal descending aorta. Note that the azygos vein courses along the lateral aspect of the
descending aorta to drain into the superior vena cava. (Bottom) Coronal contrast-enhanced chest CT (mediastinal
window) demonstrates the right sided arch producing mass effect on the right distal trachea. The azygos arch and the
right sided descending thoracic aorta are also demonstrated.
 SYSTEMIC VESSELS
ARCH ANOMALIES, DOUBLE AORTIC ARCH
n
a>
t/1
Left brachiocephalic vein - ••
~<
«-t-

Right brachiocephalic vein Left aortic arch

3
n
<
Q
<s>
Right aortic arch Fsophagus f2_

- Left aortic arch

Right aortic arch

Right subclavian and common - — Left subclavian and common

carotid arteries carotid arteries

Right aortic arch — - Left aortic arch

- Ascending aorta

(Top) first of three contrast-enhanced chest CT images (mediastinal window) of a 50 year old w o m a n with a double
aortic arch who presented with chest pain. Axial image through the superior aspect of the left aortic arch shows that
the right aortic arch is higher and larger than the left arch. This anomaly produces a complete vascular ring, and
affected patients may present with stridor. (Middle) Axial image through the mid portion of the left aortic arch
demonstrates the vascular ring that surrounds the trachea and esophagus and produces mild narrowing of the
trachea. (Bottom) Volume rendered coronal CT image demonstrates the larger right aortic arch and the smaller left
aortic arch. Note that each arch gives off separate c o m m o n carotid and subclavian arteries.

$f»7
 SYSTEMIC VESSELS
PERSISTENT LEFT SUPERIOR VENA CAVA, NORMAL RIGHT SUPERIOR VENA CAVA

Left superior vena cava

interface
Right sujierior vena cava interlace

I -eft para-aortic interface

Right superior vena cava -

Persistent left superior vena
cava

Left superior intercostal vein

— Left superior vena cava

Right superior vena cava

Right atrium

Inferior vena cava

(Top) First of three images of a 48 year old m a n with persistent left superior vena cava a n d normal right superior
vena cava. PA chest radiograph shows a normal right superior vena cava interface and an unusual left superior
mediastinal contour formed by a persistent left superior vena cava. The aortic arch interface is obscured but the left
para-aortic interface is demonstrated. (Middle) Contrast-enhanced chest CT (mediastinal window) through the aortic
arch shows the right and left superior venae cavae in cross-section. The left superior intercostal vein drains into the
left superior vena cava. (Bottom) Coronal contrast-enhanced chest CT (mediastinal window) shows the anatomic
correlate of the superior mediastinal interfaces seen on radiography formed by the bilateral superior venae cavae as
they contact the mediastinal lung surfaces.
 SYSTEMIC VESSELS
PERSISTENT LEFT SUPERIOR VENA CAVA, HYPOPLASTIC RIGHT SUPERIOR VENA CAVA
n
Horizontal anterior bridging vein 3"
n
V>
*<
t/i
Persistent left superior vena ?5
Right MI| ■■■-. KM vena cava — cava 3
n
<
CO
en
fD_
en

Lett superior intercostal vein

Ascending aorta -

Small right superior vena cava —

Persistent left superior vena

cava

left superior pulmonary vein

Azygos vein
— Descending aorta

Azygos vein - Knlarged coronary sinus

- Descending aorta

(Top) First of three axial contrast-enhanced chest CT images (mediastinal window) of a 45 year old man with
persistent left superior vena cava and a hypoplastic right superior vena cava. Composite of two images through the
superior mediastinum demonstrates the bilateral superior vena cavae (the right smaller than the left) connected by a
bridging vein analogous to the left brachiocephalic vein. The left superior intercostal vein drains into the left
superior vena cava. (Middle) Image through the pulmonary trunk shows a small right superior vena cava. The left
superior vena cava characteristically courses inferiorly and anterior t o the left superior pulmonary vein to drain into
the coronary sinus. (Bottom) Axial image through the heart demonstrates an enlarged coronary sinus produced by
the increased blood flow contributed by the persistent left superior vena cava. I
 SYSTEMIC VESSELS
J£ PERSISTENT LEFT SUPERIOR VENA CAVA, ABSENT RIGHT SUPERIOR VENA CAVA
0)

E
to
>- — Central line in persistent left
CO superior vena tava

Catheter in horizontal right

brachincephalic vein
Persistent left superior vena
cava

Ascending aorta —
C atheter in persistent left
superior vena cava

Descending aorta

Hemiazygos vein

(lop) First of three images of a 51 year old woman undergoing treatment for leukemia who had an incidentally
found persistent left superior vena cava. I'A chest radiograph demonstrates a right internal jugular central catheter tip
terminating in a left paramediastinal location instead of following the expected course into a right sided superior
vena tava. (Middle) Unenhanced chest CT (mediastinal window) through the superior mediastinum demonstrates
the endovascular catheter coursing within a horizontal anterior venous structure that anastomoses with a persistent
left superior vena cava. (Bottom) Unenhanced chest CT (mediastinal window) through the pulmonary trunk
demonstrates a catheter within a i>ersistent left superior vena cava. The right superior vena cava was absent. A
I prominent hemiazygos vein is seen, but a normal right sided azygos vein was not identified.
{70
 SYSTEMIC VESSELS
AZYGOS CONTINUATION OF INFERIOR VENA CAVA

Aortic arch

Enlarged azygos arch

i : n large v. azygos vein lX->ct ruling aorta

Kight pleural effusion Lett pleural effusion

Enlarged suprahepatic inferior vena

cava
Descending aorta
Enlarged azygos vein

Kight pleural effusion Left pleural effusion

(Top) Hirst of three axial contrast-enhanced chest CT images (mediastinal window) of a 63 year old m a n with azygos
continuation of t h e inferior vena cava. Image through the aortic arch demonstrates an enlarged azygos arch. Bilateral
pleural effusions are also present. (Middle) Image through the root of the aorta demonstrates bilateral pleural
effusions and a prominent azygos vein. (Bottom) Image through the inferior hemithorax demonstrates enlargement
of the azygos vein and the suprahepatic |>ortion of the inferior vena cava. In this anomaly, the intrahepatic portion
of the inferior vena cava is hypoplastic and the hepatic veins drain via the suprahepatic inferior vena cava. This
anomaly is associated with situs ambiguous a n d congenital heart disease. The enlarged azygos arch may mimic
lymphadenopathy on radiography.
 SYSTEMIC VESSELS

Right superior vena cava -

Enlarged left superior

intercostal vein

— Left atrtal ap|)cnddge

— Persistent left superior vena

cava

- Left su|K'rior pulmonary vein

Descending aorta —
— Hemiazygos vein

(Top) First of six axial contrast-enhanced chest CT images (mediastinal window) of a 32 year old m a n with situs
ambiguous, persistent left superior vena cava a n d hemiazygos continuation of the inferior vena cava. Image through
the aortic arch demonstrates a persistent left superior vena cava. A right superior vena cava is also present. (Middle)
Image through the pulmonary trunk demonstrates an enlarged horizontal left venous structure that likely represents
an enlarged left superior intercostal vein that drains into the persistent left superior vena cava. (Bottom) Image
through the left atrial appendage shows the persistent left superior vena cava coursing anterior to the left superior
pulmonary vein to drain into the coronary sinus. The enlarged hemiazygos vein courses parallel to the descending
aorta.
 SYSTEMIC VESSELS
HEMIAZYGOS CONTINUATION OF LEFT INFERIOR VENA CAVA, SITUS AMBIGUOUS

Enlarged coronary sinus

Descending aorta —

- Enlarged hemiazygos vein

Descending aorta

Hemiazygos vein

Right sided spleen —

Horizontal liver -

Right renal vein

Left inferior vena cava

(Top) Image through the inferior pulmonary veins demonstrates enlargement of the coronary sinus. An enlarged
hemiazygos vein is located posterior to the descending aorta. (Middle) Image through the inferior aspect of the
thorax demonstrates findings consistent with situs ambiguous. The spleen is on the right side. The enlarged
hemiazygos vein is located posterior to the descending aorta. (Bottom) Image through the upper abdomen
demonstrates a horizontal liver and the right renal vein draining into a left sided inferior vena cava. In patients with
this anomaly, alxlominal blood reaches the right atrium by flowing from the left inferior vena cava into a dilated
hemiazygos vein. The blood then flows into the left superior intercostal vein to reach a persistent left superior vena
cava and finally into the coronary sinus to reach the right atrium.
 HEART
[General Anatomy and Function Apex
• I aces anteriorly, inferiorlv, ami lo the left
Anatomy • Structures: Inferolateral left ventricle
• l ardiac chambers
Right a t r i u m , right ventricle, left a t r i u m . It-It Anterior Surface
ventricle • Faces anteriorly
• Cardiac valves » Structures: Right ventricle portions of right a t r i u m
Iricuspid, piilmoiiii mitral, aortic and left ventricle
• Cardiac structure
Ipicardiiini: Serous visceral pericardium Diaphragmatic Surface
Myocardium: Specialized cardiac muscle that forms • I aces interiorly
atrial and ventricular walls • Rests o n diaphragm
I lulocardiiim: I hin layer of cells that lines internal • Structures: Left ventricle, portion of right ventricle
Surfaces ol cardiac chambers, participates in cardiac
Left Pulmonary Surface
contraction
• Paces left lung
Function • Structures: Left ventricle, portion of left atrium
• Pump action Right Pulmonary Surface
Delivery o f d e - o \ y g e n a t e d blood t o
• I aces right lung
capillary -alveolar interface
• Structure: Right a t r i u m
Delivery of o x y g e n a t e d blood to tissues
• Cardiac conduction system
Siiio.itri.il (S.\) n o d e
■ Cardiac pacemaker; atrial contraction
■ Superior end of crista tcrniinalis at superior v e n a
Cardiac Borders (Margins) 3
Upper Border
c a \ a orifice
• Not well appreciated on imaging
\ t r i o v e n t r i c u l a r nocU
■ In atrioventricular septum, near coronary sinus Inferior (Acute) Border
orifice, close to attachment of sept«il cusp of • I ilge between a n t e r i o r and d i a p h r a g m a t i c surfaces
tricuspid valve • Structures: Right ventricle portion of lei I ventricle
■ Receives impulse generated at sino-atrial node,
propagates it to ventricles, produces ventricular Obtuse (Left) Border
contraction • Between a n t e r i o r and left piilmoiiarv surfaces
Alriosciilricular b u n d l e • Curved morphology
■ Continuation of atrioventricular node along • l-rom left atrial a p p e n d a g e lo apex
interventricular septum, divides into right and left • Structures: Left ventricle, portion of left atrial
bundle branches appendage
Right b u n d l e b r a n c h
■ Continues along right side of intersentricular
Right Border
septum to reach subendocardial Purkinje fibers • Confusing terminology
I eft b u n d l e b r a n c h • \nalogous to right p u l m o n a n surface
■ Continues along left side of interventricular
septum to apex to reach subendocardial Purkinje
fibers t Cardiac Suici
General Features
■ Heart divided into chambers
Cardiac Shape a n d O r i e n t a t i o n • Internal cardiac partitions demarcate chamber
Shape boundaries
• Pyramidal • Suici: Lxtcrnal grooves related lo internal partitions

Orientation Coronary Sulcus (Atrioventricular Sulcus)

• Position analogous to pyramid on its side • Surrounds heart, separates atria from ventricles
• Apex oriented anteriorly, interiorly, to the left • Structures: Right coronary/circumflex branch ot left
coronary arteries, small cardiac vein, coronary sinus
Anterior/Posterior Interventricular Suici
Cardiac Surfaces • Separate sentricles
Posterior Surface tBase) • I n t e r i o r i n t e r v e n t r i c u l a r sulcus
Anterior heart surface
• Quadrilateral shape
Structures: Anterior intenentricular (descending)
• I aces posteriorly
arterv, great cardiac vein
• Structures: l e f t a t r i u m , small portion of right a t r i u m ,
• Posterior i n t e r v e n t r i c u l a r sulcus
central great veins Diaphragmatic heart surface
 HEART „n
' Structures: Posterior interventricular (descending) • Structures in
artery, middle cardiac vein Posterior or inflow portion: Smooth walls, receives
Anterior and posterior interventricular sulci p u l m o n a r y veins
continuous interiorly to left of apex c Anterior or outflow p o r t i o n : Continuous with left
atrial a p p e n d a g e , lined b\ p e c t i n a t e muscles
< Interatrial s e p t u m 3
, Cardiac Chambers ■ Contains valve of foramen ovale, prevents blood
from passing from left atrium to right atrium
Right Atrium ■ Valve of f o r a m e n ovale may provide passage
• Forms right cardiac border and portion of a n t e r i o r between atria during cardiac instrumentation
surface
• Receives de-oxygenated blood through Left Ventricle
SiijHrior vena cava: Superior posterior right atrium • Contributions to anterior, d i a p h r a g m a t i c , left
Interior vena cava: Inferior posterior right arrium p u l m o n a r y cardiac surfaces, forms a p e x
C o r o n a r y sinus: Inferior posterior right atrium • lliickcst myocardium
• Blood exits through atrioventricular tricuspid valve • Structures
• Structures Fine, delicate trabeculae c a r n e a e
c
Compartmentalized by external sulcus lerminalis Papillary muscles larger than in right ventricle
cordis ■ Anterior papillary muscle
■ From right of superior vena cava to right of ■ Posterior papillary muscle
inferior vena cava Interventricular s e p t u m
0 Compartmentalized by internal crista terminal!* ■ t h i c k muscular p o r t i o n forms major part ot
■ Smooth ridge, begins at roof of atrium anterior to septum
superior vena cava orifice, extends to anterior lip ■ M e m b r a n o u s portion
of inferior vena cava orifice
Sinus of venae cavae, posterior to crista lerminalis
- Right a t r i u m proper Cardiac Skeleton
■ Anterior to crista terminals
■ Wall covered bv ridges called p e c t i n a t e muscles Anatomy
■ Right atrial a p p e n d a g e (auricle) • Amiuliis fibrosus: Four fibrous rings between atria
■ i Vascular orifices and ventricles
■ Orifice of superior v e n a cava, orifices a n d i Points of origin of atrial (superior) and ventricular
valves of inferior v e n a c a v a a n d c o r o n a r y s i n u s (inferior) myocardium
lntcratri.il s e p t u m Maintains integrity ol orifices
■ Fossia ovalis: Depression in septum above orifice Traversed by a t r i o v e n t r i c u l a r b u n d l e
Ot inferior vena cava • Surrounds atrioventricular valves and
■ l.itnbus fossa ovalis: Margin of fossa ovalis aortic/pulmonary trunk orifices
■ Fossa ovalis marks location of primitive f o r a m e n • Interconnecting fibrous tissue
1
ovale, which allows oxygenated blood to enter Right fibrous trigone: Between aoitic and right
left atrium and bypass lungs in utero atrioventricular rings
Left fibrous trigone: Between aortic and left
Right Ventricle atrioventricular rings
• Forms a n t e r i o r cardiac surface and small portion ol
d i a p h r a g m a t i c surface
• Structures Cardiac Valves
( o n u s arteriosus: Smooth walled rigiit ventricular
infundibulum or outflow tract Tricuspid Valve
■ Right ventricular inflow tract lined by traljcculac • I'hree cusps attached to fibrous ring
cariieac, form ridges and bridges Anterior, septal, posterior
1 • Anatomy of right atrioventricular valve
■ Papillary muscles are trabeculae cariieac attached
to ventricular surface and c h o r d a e tendincac, Cusps continuous with each other at their basis
connect c h o r d a e t e n d i n c a c to tree edges of commissures
tricuspid valve Free margins attached to c h o r d a e t e n d i n e a e
■ Anterior papillary muscle: largest, arises from C h o r d a e t e n d i n e a e from two papillary muscles
anterior ventricular wall attach to each cusp
■ Posterior papillary muscle: Some chordae
tendineae arise directly from ventricular wall
Pulmonk Valve
■ Septal papillary muscle: Most inconsistent • Three semilunar cusps
Septomarginal trabec ula or m o d e r a t o r h a n d I eft, right, a n t e r i o r
■ Forms bridge between lower interventricular • Anatomy of semilunar cusps
Free edges project into lumen ot pulmonarv trunk
s e p t u m a n d base of a n t e r i o r papillary muscle
forming sinuses
Left Atrium liach cusp has thick central focus, n o d u l e ol
• Forms base or posterior cardiac surface semiliuiar c u s p

•
 HEART
o [ a d i cusp has thin lateral portion, Inutile of
scniiltuiar c u s p
Milral Valve
• Two CUSpS attached to fibrous ring
Anterior, (josterior
• Anatomy of left atrioventricular valve
2 Cusps continuous with each other at commissures,
c h o r d a e t e n d i n e a e attach papillary muscles to free
borders of cusps
Aortic Valve
• Three semi lunar cusps
Right, left, posterior (iioncoronary)
• Three sinuses
Right coronary artery originates from right sinus
l.ell coronary artery originates from left sinus
Noncoronary sinus
Imaging the Heart
Radiography
• Analysis of cardiac borders and surfaces
i Right cardiac b o r d e r Right a t r i u m
■ I.eft cardiac border Left atrial a p p e n d a g e a n d left
ventricle
i Anterior cardiac surface: Right ventricle
• Posterior cardiac surface: Left a t r i u m and left
ventricle
• Variations in cardiac morphology
Infancy: P r o m i n e n t c a r d i o t h y m i c silhouette
C h i l d h o o d , adolescence and y o u n g adulthood:
P r o m i n e n t p u l m o n a r y t r u n k (see " P u l m o n a r y
Vessels" section)
A d u l t h o o d : Progressive left ventricular
configuration with dominant left sided structures
and concavity of upper left cardiac border
• Analysis ot cardiac size
( a r d i o t h o r a t i c ratio
■ Maximum transverse cardiac diameter to
transverse thoracic diameter ^ 0.55
■ Influenced by rotation, lung volume, projection
< Analysis of individual chamber enlargement
• Analysis of abnormal cardiac density/calcification
CT/MR Anatomy
• Right a t r i u m
Right atrial a p p e n d a g e (trabcculated) anterior and
superior to right ventricle
< Crista teriuiualis: Vertical ridge in right atrium
extending from superior t o inferior venae cavae
■ I eft a t r i u m
< Most superior and posterior cardiac chamber
I eft atrial a p p e n d a g e (trabcculated) anterior a n d
superior to left ventricle
i Smooth muscle ridge at junction of left atrial
a p p e n d a g e and central left superior p u l m o n a r y
vein
• Interatrial s e p t u m
Thin structure, difficult identification on CT;
increased visibility with fat deposition
» Fat spares fossa ovalis and may allow its
identification
• Right ventricle
Most anterior cardiac chamber, anterior heart
surface
Heavy trabeculations, thin wall
■ Moderator b a n d : Connects anterior papillary
muscle t o interventricular septum near right
ventricular apex, contains righl bundle branch
Anterior, posterior, scptal papillary muscles
• I eft ventricle
Posterior and diaphragmatic cardiac surfaces
o Thicker than right ventricle, less tralM'iularcd
o Anterior and posterior papillary muscles
• Interventricular s e p t u m
Thicker than interatrial septum
• Valves
c Imaging in longitudinal and perpendicular planes
" Contrast-enhanced CI" and bright blood cardiac
MR, thin low attenuation/signal structures
0 Assessment ot function, morphology, calcification
CT/MR
• Assessment of cardiac chambers, valves, myocardium
Size, morphology, wall thickness, calcification,
function
• Short axis view
■ Cross-section through short axis of left ventricular
cavity and bodies of papillary muscles
• Two c h a m b e r view
Display of left atrial and ventricular chambers,
evaluation of m i t r a l deft atrioventricular) valve
• Four c h a m b e r view
i Display of tour cardiac chambers and
atrioventricular valves
Anatomy-Based Cardiac and Valvular
Abnormalities
Situs Abnormalities
• Indirect analysis of atrial morphology by evaluation of
tiacheobronchial tree
• Association with abnormal cardiac position and
congenital heart disease
Cardiomegaly and Chamber Enlargement
• Increased cardiothoracic ratio
• Analysis of spit ifii chamber enlargement
Myotardial Calcification
• Sequelae of myotardial infarction
• May be associated with ventricular aneurysm
Annular and Valvular Calcification
• Mitral a u m i l t i s calcification: Involvement of mitral
valve ring, C- o r J-shaped m o r p h o l o g y on
radiography
• Valvular calcification
c Aortic stenosis: C o n g e n i t a l (bicuspid or
bicommissural valve), d e g e n e r a t i v e (tibrocalcific),
r h e u m a t i c heart disease
1
Mitral stenosis: R h e u m a t i c h e a r t disease
 OVERVIEW OF THE HEART

Ascending aorta
Pulmonary trunk
v
Superior vena cava

Left atrial appendage

Right atrium

Right ventricle
V Left ventricle

Diaphragm

Graphic illustrates the location of the heart with respect to the rest of the structures and organs in the thorax. The
heart is surrounded by the pericardium and has a pyramidal shape with its apex oriented inferiorly and towards the
left side. The cardiac base faces posteriorly. The four heart chambers connect with the great pulmonary and systemic
vessels. The heart receives blood from the systemic and pulmonary circulations via the systemic and pulmonary
veins respectively. The blood is then pumped into the pulmonary circulation for delivery to the capillary-alveolar
interface and into the systemic circulation for delivery to the tissues and organs of the body.
 HEART
ANATOMY OF HEART SURFACES, MARGINS & SULCI

Obtuse (left) cardiac

border

Anterior
Coronary sulcus interventricular sulcus

Anterior cardiac
surface

Inferior cardiac border

First of three graphics depicting t h e surface a n a t o m y of the heart. The heart has a pyramidal shape with a base a n d
an apex. It has anterior, diaphragmatic, posterior and right and left pulmonary surfaces. The anterior surface is
formed by the right and left ventricles with small contributions from the right atrium and left atrial appendage. The
obtuse (left) cardiac border separates the anterior and left pulmonary surfaces. The Inferior (acute) cardiac border
separates the anterior and diaphragmatic surfaces. External suld correspond to Internal partitions that divide the
heart into chambers. There are anterior and posterior interventricular suld and a coronary sulcus. The coronary
sulcus is circumferential and separates the atria from the ventricles. The anterior and posterior interventricular suld
separate the ventricles.
 ANATOMY OF HEART SURFACES, MARGINS & SULC1
n

cu

Superior vena cava

Left atrium

Right pulmonary veins

Left pulmonary veins

Right atrium

Coronary sulcus

Infenor vena cava

Coronary sulcus

Posterior
interventricular sulcus
Left ventricle

Right ventricle

Inferior heart border

CTop) Graphic shows the posterior heart surface or base of the heart, which is formed by the left atrium, a small
portion of the right atrium, the paired superior and inferior pulmonary veins and the superior and inferior venae
cavae which fix the heart base to the pericardium. The coronary sulcus Is seen at the junction of the left atrium and
ventricle. (Bottom) Graphic shows the diaphragmatic heart surface which is formed by the right and left ventricles
and is separated from the heart base by the coronary (atrioventricular) sulcus which runs along the atrioventncular
groove. The inferior (acute) cardiac border separates the diaphragmatic from the anterior heart surfaces. The posterior
interventricular sulcus marks the location of the interventricular septum.
I
.179
 HEART
t: RADIOGRAPHY OF THE HEART

X
in

Obtuse cardiac border

Right cardiac border —5

Apex

Heart base
Anterior heart surface —

(lop) lirst of two normal chest radiographs illustrating the surface anatomy of the heart. PA chest radiograph shows
the right and obtuse (or left) cardiac borders. The diaphragmatic cardiac surface is not visible radiographically. The
right cardiac border is formed by the right atrium and is analogous to the right pulmonary cardiac surface. The left or
obtuse cardiac border is formed by the left ventricle and a small portion of the left atrium, the left atrial appendage.
(Bottom) Left lateral chest radiograph shows the anterior and posterior cardiac surfaces. The anterior surface is
formed by the right ventricle. The base of the heart or posterior surface is formed by the left atrium.

380
 HEART
CT O F HEART SURFACES, B O R D E R S & SULCI
n
CD

I
a.

Right cardiac border — — Obtuse (left) cardiac

border

Coronary sulcus —

Apex
Diaphragmatic cardiac —
surface

— Heart base (left atrium)

Anterior cardiac surface —

— Coronary sulcus

Diaphragmatic cardiac
surface

(Top) First of two normal contrast-enhanced chest CT images (mediastinal window) demonstrating the cardiac
surfaces, borders and sulci. Coronal image through the aortic valve shows the right and obtuse (left) cardiac borders
The right cardiac border is analogous to the right pulmonary cardiac surface. The diaphragmatic cardiac surface is
also visible. Fat is present in the coronary sulcus which demarcates the boundary between the atria and ventricles.
(Bottom) Sagittal image demonstrates the base of the heart formed primarily by the left atrium, the diaphragmatic
cardiac surface formed by the left and right ventricles and the anterior cardiac surface formed by the right ventricle.
A portion of the coronary sulcus is also seen.

Uil
 HEART
ANATOMY OF ANTERIOR HEART SURFACE & RIGHT ATRIUM

Superior vena cava

I I Right a trial appendage

Right atrium

Right ventricle

Inferior vena cava

Right atrial appendage

Orifice of superior vena

cava
Fossa ovalis
Crista terminalls

Tricuspld valve

Pectinate muscles

Valve of inferior vena Valve of coronary sinus

cava

(Top) First of three graphics demonstrating the anatomy of the right cardiac chambers. Illustration of the anterior
surface of the heart shows that it is predominantly formed by the right ventricle and portions of the right atrium and
left ventricle. The right atrial appendage is also shown. (Bottom) Illustration of the interior of the right atrium shows
trabeculated (pectinate muscles) and smooth regions separated by the crista terminalls. The posterior smooth portion
receives the venae cavae (sinus of the venae cavae) and the coronary sinus. The anterior trabeculated portion Is
known as the right atrium proper. The interatrial septum contains the fossa ovalis, which marks the location of the
embryonic foramen ovale.
 HEART
ANATOMY OF RIGHT VENTRICLE

Pulmonic valve

Right ventricular
outflow tract

Tricuspid valve

Anterior papillary
muscle

Moderator band

Trabeculae cameae

t
Illustration of the Interior of the right ventricle shows trabeculated and smooth areas. The proximal (inflow portion)
right ventricle is characterized by the trabeculae cameae. Some of these form papillary muscles, which attach to the
free edges of the tricuspid (right atrioventiicular) valve cusps via chordae tendineae. There are anterior, septal and
posterior papillary muscles. A thick trabecula carnea connects the interventricular septum to the anterior papillary
muscle and is known as the moderator band or septomarginal trabecula. The right ventricular outflow tract leads to
the pulmonic valve and is characterized by its smooth walls.
 HEART
CT, RIGHT HEART CHAMBERS

- Right ventricular outflow tract

Right atrial appendage —

Superior vena cava

Right airial appendage- — Right ventricle

Orifice of superior vena cava -

Coronary sulcus —
Right ventricle

Right atrium proper —

Crista terminalis

Sinus of the venae cavae —

flop) Hirst of six normal contrast-enhanced cardiac gated axial CT images (mediastinal window) showing the
anatomy of the right heart chambers. Image through the junction of the superior vena cava and right atrium shows
the anteriorly oriented triangular right atrial appendage. (Middle) Image through the upper heart shows the orifice
of the superior vena cava as it enters the right atrium. The right atrium is located anterior and to the right of the left
atrium and the ascending aorta. The right ventricle is located anterior and to the left of the ascending aorta.
(Bottom) Image through the upper heart demonstrates the superior aspects of the right atrium and ventricle. These
chambers are separated by the coronary sulcus. The crista terminalis courses between the orilices of the venae cavae
and separates the atrium proper from the sinus of the venae cavae.
 HEART
CT, RIGHT HEART CHAMBERS
n
fD
— Right ventricle CT

Coronary sulcus
I
— Interventricular septum
P
Right atrium proper 3

Crista terminalis

Sinus of t h e venae cavae

Trabeculae carneac - Moderator band

Coronary sulcus -

Crista terminalis -

Right ventricular myocardium - - Right ventricle

Valves of the inferior vena cava & —

coronary sinus

Orifice of inferior vena cava - — Coronary sinus

(Top) Image through the mid heart shows the mid portions of the right atrium and ventricle. The chambers are
separated by the coronary sulcus. The crista terminalis is seen along the posterolateral right atrial wall. (Middle)
Image through the inferior heart shows the trabeculae carneac that characterize the internal surface of the wall of the
right ventricle. The septoinarginal trabecula or moderator band courses from the inferior interventricular septum to
the base of the anterior papillary muscle. (Bottom) Image through the inferior aspect of the heart shows the
junctions of the inferior vena cava and coronary sinus with the right atrium. Note the fine trabeculations of the right
ventricular myocardium produced by the trabeculae carneac. The right ventricular myocardium is very thin when
compared to that of the left ventricle. I
ins
ANATOMY OF POSTERIOR HEART SURFACE & LEFT ATRIUM

Left atrlal appendage

Right pulmonary veins

Left pulmonary veins

Right atrium

Left atrium

»%3

Left atrlal appendage

Right superior
pulmonary vein

Valve of foramen ovale

Mitral valve
Left atrium

(Top) Fust of three graphics illustrating the anatomy of the left cardiac chambers. Posterior view of the heart shows
the heart base formed predominantly by the left atrium and a small portion of the right atrium. The left atrium
receives the paired superior and Inferior pulmonary veins. (Bottom) Graphic shows the internal anatomy of the left
atrium, which has smooth and trabeculated inner surfaces. The left atrlal appendage Is characterized by its
trabeculated inner surface produced by the pectinate muscles. The valve of the fossa ovalis is noted on the interatrial
septum and prevents passage of blood between the atria.
 HEART
CT, LEFT HEART CHAMBERS
O
I
• ■

u
— Left atrial appendage
Right superior pulmonary vein —
lxrft superior pulmonary vein

Right superior pulmonary vein — I .eft atrial appendage

Left atrium Ridge at junction of atrial

appendage & pulmonary vein

Right superior pulmonary vein —

- Lett atrial appendage

(lop) first of six contrast-enhanced axial chest CT images (mediastinal window) illustrate the anatomy of the left
heart chambers. Image through the superior aspect of the left atrium demonstrates the relationship between the left
atrial appendage and the left superior pulmonary vein and the smooth or nodular ridge at the junction of these two
structures. (Middle) Image through the right superior pulmonary vein demonstrates the trabeculated appearance of
the left atrial appendage produced by the pectinate muscles in contrast to the smooth internal wall of the left atrium
proper. (Bottom) Image through the mid portion of the left atrium demonstrates the inferior aspect of the left atrial
appendage and the mid portion of the right su|)erior pulmonary vein.

$88
 HEART
CT, LEFT HEART CHAMBERS

Left ventricular outflow trad - — Left ventricular myocardium

— Mitral valve
—
Right inferior pulmonary vein
Left inferior pulmonary vein
Left atrium -

Right ventricular myocardium -

Intervcntricular septum

Trabeculae carneae

Left ventricular myocardium

Inferior vena cava -

Right ventricular myocardium

Left ventricular myocardium

Inferior vena cava

(Top) Image through the superior aspect of the left ventricle demonstrates the thickness of the normal left
ventricular wall. The trabeculae carneae produce an irregular cndoluminal ventricular surface. Note the smooth
appearance of the left ventricular outflow tract. (Middle) Image through the mid portion of the ventricles
demonstrates internal filling defects produced by the trabeculae carneae. Compare the thickness of the left
ventricular myocardium to that of the normal thinner right ventricular myocardium. (Bottom) Image through the
inferior heart demonstrates the inferior portion of the left ventricle and the trabeculated appearance of its lumen.
Note the trabeculated appearance of the right ventricular chamber.
 HEART
CORONAL CT, NORMAL HEART

Right ventricular outflow tract

Left ventricle
Trabeculae carneae —

—
Right ventricle

Pulmonary trunk

Right atrial appendage -

Right atrium
- Left ventricle
Coronary sulcus

Right ventricle

Superior vena cava —

Aortic valve

- Left ventricular outflow tract

Right atrium
Papillary muscle

Coronary sulcus

—
Right ventricle

(Top) First of six coronal contrast-enhanced chest CT images (mediastinal window) through the heart demonstrates
t h e anteriorly located trabeculated right ventricle leading to the superiorly located and relatively smooth right
ventricular outflow tract. The left ventricle forms the left cardiac border. (Middle) Image through the pulmonary
trunk demonstrates the right atrial appendage. The right ventricle is anterior a n d t o the left of the right atrium. The
left ventricle forms the left heart border and has a thicker wall t h a n that of the right ventricle. (Bottom) Image
through the aortic arch shows the smooth internal wall of the left ventricular outflow tract compared to the
trabeculated inner surface of left ventricle proper. The coronary sulcus separates the right atrium and right ventricle.
The right atrium forms the right heart border on radiography.
 HEART
CORONAL CT, NORMAL HEART

Superior vena cava - Left atrial appendage

Right atrium -
- Papillary muscle

Inferior vena cava - - Left ventricle

_
Right ventricle

— Left superior pulmonary vein

Right superior pulmonary vein — Left atrial appendage

Left atrium

Inferior vena cava — I eft ventricle

— Lelt interior pulmonary vein

Right inferior pulmonary vein —

Left atrium

(Top) Image through the posterior aspect of the right atrium shows its junction with the superior and inferior venae
cavae. The left atrial appendage is sujxfrior to the left ventricle and forms a portion of the obtuse (left) cardiac border.
A prominent papillary muscle is outlined by contrast within the left ventricle. (Middle) Image through the mid
portion of the left atrium shows its junction with the bilateral superior pulmonary veins. Note the close relationship
between the left superior pulmonary vein and the left atrial appendage. (Bottom) Image through the posterior aspect
of the left atrium shows the bilateral inferior pulmonary veins coursing obliquely into the left atrium.
 HEART
SAGITTAL CT, N O R M A L HEART

Left ventricle
Right ventricle ~
Papillary muscle

Pulmonary trunk -

— Left pulmonary veins

Rulmonic valve -
Right ventricular outflow tract -
» i— Left atrium

m — Coronary sulcus

Right ventricle -
— Left ventricle

Aortic valve —

— t.ett atrium
—
Left ventricular outflow tract

- Coronary sulcus

Right ventricle —
Left ventricle

(Top) First of six sagittal contrast-enhanced chest CT images (mediastinal window) showing the sagittal anatomy of
the heart. The images are presented from left to right. The left ventricle has a thicker myocardium when compared to
the right and exhibits well-defined papillary muscles. The right ventricle forms the anterior cardiac surface. (Middle)
Image through the right ventricular outflow tract shows the anterior location of the right ventricle and the
posterosuperior course of t h e right ventricular outflow tract and pulmonary trunk. The left ventricle is posterior to
the right ventricle. The left atrium is superior to t h e left ventricle a n d is separated from it by the coronary sulcus. The
left pulmonary veins are seen entering the left atrium. (Bottom) Image through the mid heart shows the central
location of the left ventricular outflow tract and ascending aorta.
 HEART
SAGITTAL CT, NORMAL HEART
n
3"
■ ■

n
3
Aortic valve
Left atrium

Right ventricle —

Ascending aorta —

— Left atrium

Right dtrium

Inferior vena cava

Superior vena cava ~

Right inferior pulmonary vein

Coronary sulcus
Right atrium

— Interior vena cava

Coronary sukus

(lop) Image through the aortic valve shows the anatomic location of the right ventricle, which forms the anterior
cardiac surface and contributes to the diaphragmatic cardiac surface. The left atrium forms the posterior surface or
base of the heart. (Middle) Image through the right heart chambers shows the posterior location of the right atrium
with respect to the right ventricle and its connection with the inferior vena cava. (Bottom) Image through the right
side of the heart shows the connection of the venae cavae with the right atrium. The right ventricle is located
anteriorly and separated from the right atrium by the coronary sulcus.

!<M
 HEART
A X I A L CT, R I G H T A T R I U M

I
Right ventricle -

u
Right atrium -

Fatty Infiltration ol interatrial -

septum

fossa ovalis -

Right ventricle

Right iitrium

fossa ovalis -

tatty infiltration < >l interatrial

septum

Right atrium —

fatly infiltration of the interatrial

septum

Left atrium

(Top) l-irst o f three axial CT images t h r o u g h the r i g h t a t r i u m d e m o n s t r a t i n g various degrees o f fatty i n f i l t r a t i o n o f

the interatrial septum N o n e n h a n c e d chest C T (mediastinal w i n d o w ) demonstrates m i l d f a t t y i n f i l t r a t i o n o f t h e
interatrial septum that spares t h e fossa ovalis a n d allows its localization i n t h e axial plane. This appearance may
m i m i c an atrial septal defect. ( M i d d l e ) Contrast-enhanced chest CT (mediastinal w i n d o w ) shows fatty i n f i l t r a t i o n o f
t h e interatrial septum that spares t h e fossa ovalis w h i c h manifests as focal t h i n n i n g o f t h e interatrial septum.
( B o t t o m ) Contrast-enhanced chest CT (mediastinal w i n d o w ) demonstrates p r o m i n e n t fatty i n f i l t r a t i o n of t h e
interatrial septum. I n this case, t h e area o f fat replacement is mass-like a n d produces mass effect o n t h e l u m e n o f t h e
I adjacent right a t r i u m .
I'M
 HEART
CT, LEFT A T R I U M
n
zr
o
(/>
••
as
BJ
2.

Left atrial appendage

Irfl atrium —

Left superior
pulmonary vein

Left superior
Normal soft tissue ridge ~ pulmonary vein

Left atrial appendage

Right superior —
pulmonary vein

Left atrium —

- Left ventricle

(Top) First of two images demonstrating the nodular appearance of the ridge at the junction of the left atrium and
left superior pulmonary vein adjacent to the left atrial appendage. Axial image through the superior aspect of the left
atrium demonstrates the constant relationship between the left superior pulmonary vein and the adjacent left alrial
appendage. The left atrial appendage is always anterior and inferior to the left superior pulmonary vein. Note the
nodular soft tissue ridge that protrudes into the left atrial lumen which should not be confused with thrombus or
neoplasia. (Bottom) Coronal image through the left atrial appendage demonstrates the normal soft tissue ridge that
occurs at the junction ol the left atrium with the left superior pulmonary vein adjacent to the left atrial appendage.

39 r i
 HEART
CT, S H O R T AXIS V I E W

Right ventricular outflow tract

Lett ventricle

Right ventricle

- Posterior interventricular sulcus

- Papillary muscle

Right ventricle Left ventricle

Interventricular septum

— Left ventricle

— Trabeculae carneae
Right ventricle

(Top) First of three contrast-enhanced cardiac gated short axis CT images (mediastinal window) showing the
ventricular chambers. The right ventricle is located anteriorly and has a t h i n wall. The right ventricular outflow tract
courses superiorly and posteriorly to give off the pulmonary trunk. The left ventricle is posterior a n d has a thicker
myocardium than the right ventricle. The two chambers are separated by the interventricular sulcus. (Middle) Image
through the mid heart shows the a n a t o m y of the left ventricular chamber. The papillary muscles manifest as filling
defects within the contrast filled left ventricular lumen. (Bottom) Image obtained just medial t o the left apex
demonstrates trabeculations in b o t h ventricular chambers produced by trabeculae carneae. The right ventricle forms
the anterior heart surface.
 HEART
CT, T W O CHAMBER VIEW
n

1 — Left atrial appendage 5-

I .eft superior
pulmonary vein

Left ventricular
myocardium

Lett atrium —

Coronarv sulcus Lett ventricle

Left atrial appendage —

Anterior mitral valve
leaflet

Left atrium —

— Left ventricle
Coronary sulcus

— Papillary muscle

( l o p ) first of two two-chamber contrast-enhanced gated cardiac CT images (mediastinal window) showing the
anatomy of the left ventricle and left atrium. Note the intimate relationship of the left superior pulmonary vein and
the left atrial appendage with an intervening nodular soft tissue ridge. The left atrial appendage exhibits a
trabeculated internal surface produced by the pectinate muscles. The left ventricle, the thickness of its wall and its
papillary muscles are well visualized. (Bottom) Image through the mitral valve obtained during systole demonstrates
coaptation of the thin anterior and posterior valve cusps. The papillary muscles manifest as rounded filling defects
within the contrast filled left ventricular chamber.

$97
 HEART
CT, F O U R C H A M B E R V I E W

High! ventricle — Interventricular sulcus

— Apex

Coronary sulcus —

— Papillary muscle

Right atrium —

— Left ventricle

Left atrium —

Right ventricle
Interventricular sulcus

" " Apex

Coronary sulcus

Right atrium
— Mitral valve leaflets

left atrium — Coronary sulcus

( T o p ) First o f t w o contrast-enhanced gated f o u r c h a m b e r cardiac C T images (mediastinal w i n d o w ) d e m o n s t r a t i n g t h e

a n a t o m y o f the heart. This v i e w allows simultaneous e v a l u a t i o n of the f o u r cardiac chambers. The right chambers are
projected anterolateral t o t h e left heart chambers and are less opacified w i t h contrast. The m i t r a l valve leaflets
manifest as t h i n linear soft tissue structures between t h e left a t r i u m a n d left ventricle. ( B o t t o m ) Four-chamber gated
cardiac CT image demonstrates the n o r m a l m i t r a l valve. The f o u r cardiac chambers a n d the coronary a n d
interventricular sulci are d e m o n s t r a t e d . The i n t e r v e n t r i c u l a r sulcus is located s l i g h t l y t o the right o f the cardiac apex.
 HEART
CORONAL M R , N O R M A L HEART

— Right ventricular outflow tract

Right ventricle

Pulmonary trunk

Ascending aorta

Left ventricle

Right atrium --
- Apex

Diaphragmatic cardiac surface

— Left superior pulmonary vein

Right superior pulmonary vein -

Left Mrium
— Left ventricle

-
Interior vena cava

(Top) First o f three coronal IT -weighted magnetic resonance images o f t h e chest s h o w i n g the a n a t o m y of t h e heart.
Image t h r o u g h t h e anterior heart demonstrates t h e trabeculatcd wall of the right ventricle. 1 he right ventricular
o u t f l o w tract is o r i e n t e d posterosuperiorly. ( M i d d l e ) Image t h r o u g h the m i d p o r t i o n o f t h e heart shows the centrally
located aortic root. The right a t r i u m forms t h e right cardiac border. The left ventricle f o r m s the left or obtuse cardiac
border. Note t h e t h i c k left ventricular m y o c a r d i u m . The diaphragmatic cardiac surface is also visualized. ( I t o t t o m )
Image t h r o u g h the posterior aspect of t h e heart shows the lett a t r i u m a n d a p o r t i o n o f t h e posterior left ventricle.
The bilateral superior p u l m o n a r y veins are also imaged as is the posterior aspect o f t h e suprahepatic i n f e r i o r vena
cava
 HEART
SAGITTAL MR, NORMAL HEART
o
I
Cf)
CD
-C
U Papillary muscle

— Left ventricle
Right ventricle -

— Central left pulmonary veins

Right ventricular outflow tract

— Ix'ft atrium
Right ventricle — — Coronary sulcus

i— Left ventricle
Diaphragmatic cardiac surface —

Aortic root -

Left atrium
Right atrium

Right ventricle —i i
Left ventricle

—
Interventricular sulcus

(Top) First of five sagittal Tl -weighted magnetic resonance images of the chest showing the anatomy of the heart.
The images are presented trom left to right Image through the ventricles demonstrates their trabeculatcd internal
surfaces. Note the thickness of the left ventricular myocardium relative to that of the right. (Middle) Image through
the pulmonary outflow tract shows the anterior location of the right ventricle, which forms the anterior cardiac
surface. The left atrium is located posterior and superior to the left ventricle and forms the base of the heart. The
right ventricle forms the anterior heart surface. The right and left ventricles form the diaphragmatic cardiac surface.
(Bottom) Image though the root of the aorta shows its central location with respect to the vessels and the heart
I chambers and the anatomic relationship of the right and left atria.
4(K)
 HEART
SAGITTAL MR, NORMAL HEART
n
3"
O
X
CD
Oi
3

Ascending aorta - — Right pulmonary artery

lx:ft atrium

Right ventricle — Right atrium

— Orifice of inferior vena

cava

Right pulmonary artery

Superior vena cava

- Left atrium

Right atrium

Right ventricle —

Interior vena cava

Coronary sulcus —

(Top) Image through the ascending aorta demonstrates the posterior location of the atria with respect to the
anteriorly located trabecuiated right ventricle. The proximal ascending aorta and its root are located in the center of
the heart. (Bottom) Image through the right atrium demonstrates its posterosuperior and posteroinferior
connections with the superior and inferior venae cavac respectively. There i.s visualization of a small portion of the
anteriorly located right ventricle. The posteriorly located left atrium, which forms a large portion of the base of the
heart is also visualized. The coronary sulcus is located between the atria and ventricles.

401
 HEART
ANATOMY OF CARDIAC SKELETON & HEART VALVES

Fibrous ring of

■
pulmonic valve

Fibrous ring of aortic

valve
Left fibrous trlgone

Fibrous ring of left

atrioventiiculai Fibrous ring of right
(mitral) valve atrioventricular
(tricuspld) valve

Right fibrous trlgone

Graphic demonstrates the anatomy of the cardiac skeleton located between the atria and ventricles. The cardiac
skeleton consists of thick fibrous connective tissue and provides support for the valve orifices and the areas of
attachment for the valve cusps. In this illustration, the atria have been "removed" to expose the cardiac skeleton and
heart valves seen from above. The four fibrous rings that surround the valves are known as the annulusftbrosus.The
right fibrous trlgone Is the connective tissue bridge between the aortic valve and right atrioventricular (tricuspld)
valve rings. The left fibrous trigone is the connective tissue bridge between the aortic valve and the left
atrioventricular (mitral) valve rings. The yellow dot represents the atrioventricular bundle seen in cross-section as it
courses caudally from the atria to the ventricles.
 HEART
RADIOGRAPHY, PROSTHETIC AORTIC & MITRAL VALVES

Stemotumy wires —

— Aortic valve prosthesis

Mitral valve prosthesis

_
Stemotomy wires

Aortic valve prosthesis —

Left atrium
Mitral valve prosthesis —

— Left ventricle

(Top) l-irst of two images of a 56 year old woman status post-aortic and mitral valve replacement for rheumatic heart
disease. I'A chest radiograph shows the close relationship of the aortic and mitral valves and post-surgical changes.
The aortic valve prosthesis is located in the center of the heart and is oriented along the long axis of the ascending
aorta. The mitral valve prosthesis is located more inferiorly and its orifice exhihits a more horizontal orientation.
(Bottom) Left lateral chest radiograph shows the aortic valve prosthesis in the center of the heart and the more
posteriorly located mitral valve prosthesis oriented along the long axis of the left atrioventricular orifice. The close
relationship of these two prosthetic valves is consistent with the fact that they share a common fibrous annulus and
the left fibrous trigone.
 HEART
ANATOMY & CT, ATRIOVENTRICULAR VALVE

Left atrium
Attachment to
atrioventricular ring

Papillary muscle

Left ventricular
myocardium

Left ventricle

Anterior mitral valve Papillary muscle

cusp
Chordae tendineae

Posterior mitral valve

cusp
Left atrium

(Top) Graphic shows the anatomy of the anterior mitral valve cusp. The valve cusp is flat and has a broad
attachment to the fibrous atrioventricular valve ring. The free edge of the valve is attached to the tips of two sets of
papillary muscles by chordae tendineae. The mitral and tricuspid valves share this morphology, but the former has
two cusps and the latter has three. The valve opens during ventricular filling and its cusps protrude into the left
ventricle. During ventricular systole the cusps are forced closed and are prevented from protruding into the left
atrium by the chordae tendineae and papillary muscle contraction. (Bottom) Normal contrast-enhanced axial cardiac
CT (mediastinal window) shows the mitral valve during ventricular tilling. The valve cusps protrude into the
ventricular lumen and are attached to the papillary muscles by thin chordae tendineae.
 ANATOMY & CT, SEMILUNAR VALVES

Lunule of the
semllunar cusp

Fibrous valve ring

Nodule of the
semllunar cusp

Valve sinuses
Valve free edges

Aortic valve, right Nodule of the

coronary sinus semllunar cusp

Aortic valve, Aortic valve, left

noncoronary sinus coronary sinus

(Top) Graphic illustrates the anatomy of the semllunar valves, the pulmonic and aortic valves. These valves are
tricuspld (three cusps) and have free edges without tendinous attachments to the ventricle. The free cusp edges
project into the vessel lumen during valve closure forming sinuses. Retrograde blood flow after ventricular
contraction forces the valves shut. Antegrade blood flow during ventricular systole forces the valve open. The
superior free edge of the valve cusp exhibits a central focus of nodular thickening, the nodule of the semllunar cusp
and a thin lateral free edge, the lunule of the semllunar cusp. (Bottom) Axial contrast-enhanced gated cardiac CT
(mediastinal window) shows the morphology of the aortic valve during ventricular filling. Thickened foci in the
central aspects of the cusp free edges represent the nodules of the semllunar cusps.
 HEART
ANATOMY OF TRICUSPID & PULMONIC VALVES
CD
I

Pulmonic valve, right

cusp Pulmonic valve,
anterior cusp

Pulmonic valve, left

Chordae tendlneae cusp

Tncuspid valve, septal

cusp

Septal papillary
muscle
Tricuspld valve,
anterior cusp Valve commissure

Posterior papillary
muscle

Anterior papillary Tricuspid valve,

muscle posterior cusp

Graphic illustrates the internal anatomy of the right ventricle and the anatomy of the right heart valves. The right
atrioventricular valve is the tricuspld valve. It has three cusps that are attached to the fibrous valve ring and are
continuous with each other at the valve commissures. The cusps are named according to their positions; anterior,
septal and posterior. The free edges of the valves attach to chordae tendineae that in turn attach to the tips of
papillary muscles that are also named according to their location. The pulmonic valve is a tricuspld semilunar valve
located just distal to the right ventricular outflow tract. The free edges of the valve project into the pulmonary trunk
forming sinuses and coapt at the nodules of the semilunar cusps. There are left, right and anterior pulmonic valve
I cusps.
•106
 HEART
CT, RICHT HEART VALVES
n
3"
••
I
rs
Right ventricle —
3-

Tricuspid valve, —
anterior cusp

Tricuspid valve, septal

cusp
Right atrium —

Sinuses <>t pulmonic "~

valve

Right ventricular —
outflow tract

Right ventricle —

( l o p ) First o f t w o contrast-enhanced chest CT images (mediastinal w i n d o w ) d e m o n s t r a t i n g the a n a t o m y a n d

location of t h e right heart valves. The n o r m a l valves are t h i n and are difficult t o visualize o n c o n v e n t i o n a l CT.
Cardiac gated axial CT image shows t h e tricuspid valve imaged d u r i n g ventricular systole. The coapted septal a n d
anterior valve cusps manifest as t h i n soft tissue linear opacities w i t h i n the contrast filled right heart chambers.
(Bottom) Sagittal image t h r o u g h the p u l m o n a r y t r u n k shows the a n a t o m y a n d location o f the p u l m o n i c valve. The
p u l m o n i c valve is tricuspid a n d is located at the a|x.'x o f the right ventricular o u t f l o w tract. This image is obtained
during ventricular filling (diastole) and shows two of the three valve cusps coapted within the vessel lumen. The free
valve edges protrude into the vascular lumen and form sinuses. I
40;
ANATOMY OF LEFT HEART VALVES

Ascending aorta

Aortic valve, left

coronary cusp
Aortic valve,
noncoronary cusp
Mitral valve, anterior
Aortic valve, right cusp
coronary cusp

Valvular commissure

Mitral valve, posterior

cusp

— Chordae tendineae

I Papillary muscles

Graphic depicts the close relationship between the aortic and mitral valves. These valves are supported by fibrous
valve rings connected by the left fibrous trigone. Thus, the anterior cusp of the mitral valve is closely related to the
left coronary cusp of the aortic valve. The aortic valve right coronary, left coronary and non-coronary cusps are
shown. The semllunar cusps form sinuses during valve closure which occurs by adaptation of the free cusp edges.
Each valve has a fibrous nodule on the central portion of its free edge called the nodulus arantii. The mitral valve
cusps are continuous along the left atrioventricular fibrous valve ring and are connected at the valve cusp
commissures. The free edges of the mitral valve cusps attach to the anterior and posterior papillary muscles via
chordae tendineae.
 HEART
ANATOMY & CT, LEFT HEART VALVES

Aortic valve, left coronary cusp

Mitral valve, anterior cusp

Left atrium
Left ventricle

Aortic valve, left coronary sinus

Left coronary artery

Mitral valve, anterior cusp

Right ventricle
Mitral valve, posterior cusp

Left ventricle

Left ventricle
Left ventricular outflow tract

Left sinus of Valsalva

i
Mitral valve, posterior cusp
Mitral valve, anterior cusp

Left atrium

(Top) Graphic illustrates a three chamber view of the heart and the relationship between the mitral and aortic valves.
The fibrous rings that support these valves share a common fibrous bridge called the left fibrous trigone. The fibrous
bridge forms a connection between the anterior cusp of the mitral valve and the left coronary cusp of the aortic
valve. (Middle) First of two contrast-enhanced gated cardiac CT images (mediastinal window) demonstrating the
anatomic relationship between the aortic and mitral valves. The left coronary cusp of the aortic valve shares a
common fibrous attachment with the anterior cusp of the mitral valve. (Bottom) Four chamber image demonstrates
the close relationship between the anterior cusp of the mitral valve and the left coronary cusp of the aortic valve. The
left coronary cusp is only partially visualized on this image.
 HEART
CT, MITRAL VALVE

— Lett ventricle

Mitral valve, anterior

cusp

— Mitral valve, |x>sterior

cusp

left atrium —

— Mitral valve, anterior

cusp
—
Left atrium

Mitral valve, posterior Left ventricle

cusp

— Papillary muscle

(lop) Contrast-enhanced four chamber gated cardiac <'. I (mediastinal window) demonstrates the anatomy of the
mitral valve. The anterior and posterior valve cusps manifest as thin linear structures that extend across the
atrioventricular orifice. While the traheculated left ventricular wall is visihle, the chordae tendineae are not
visualized. (Bottom) ( ontrast-enhanced two chamber gated cardiac ( T (mediastinal window) demonstrates the
anterior and posterior leaflets of the mitral valve at the atrioventricular orifice. The posterior papillary muscle is also
demonstrated.
 HEART
CT, AORTIC VALVE
n
ru
I/)

Ascending aorta — I
O
3-
Left coronary aortic valve cusp
Non-coronary aortic valve cusp

Papillary muscle

Left ventricular outflow tract -

— Left ventricle

Right coronary sinus -

Non-coronary sinus — — Left coronary sinus

—
Left atrium

Left ventricular hypertrophy

DiIdted ascending aorta —
Abnormal aortic valve cusps

Left atrium -

(Top) First of two gated contrast-enhanced cardiac CT images (mediastinal window) demonstrating the
cross-sectional imaging appearance of the aortic valve. Coronal image shows the aortic valve cusps in coaptation. The
valve cusps manifest as thin curvilinear soft tissue structures located at the apex of the left ventricular outflow tract.
The sinuses of Valsalva are visible during diastole and are located above the valve cusps. (Middle) Axial image
through the aortic valve in coaptation shows right coronary, left coronary and non-coronary sinuses of Valsalva
bound by the aortic wall and the corresponding valve cusps. (Bottom) Axial image through a bicuspid or
bicommissural aortic valve shows partial visualization of abnormal valve cusps. The valve was stenotic, and there was
associated dilatation of the ascending aorta and left ventricular hypertrophy. I
411
 HEART
MR, VALVE FUNCTION
a
I
in
OJ Right ventricle
U Tricuspid valve —

Right atrium —
Left ventricle

Posterior mitral valve

cusp
Left atrium

Right pleural effusion

Right ventricle
Tricuspid valve

Right atrium — Left ventricle

— Mitral valve

Left atrium —

Right pleural effusion

(Top) First of four gated cardiac white blood magnetic resonance images through the heart demonstrating the
function of the heart valves. Four chamber view obtained during ventricular systole shows that the atrioventricular
valve cusps are coapted or closed allowing blood to be pumped in an antegrade direction into the pulmonary and
systemic arteries by the contracting myocardium without regurgitation or retrograde flow into the atria. (Bottom)
Four chamber view obtained during diastole demonstrates that the cusps of the atrioventricular valves are o p e n
allowing blood to flow in an antegrade direction from the atria t o fill the bilateral ventricles. The papillary muscles
where the chordae tendineae attach are also visualized. There are small bilateral pleural effusions, larger on the right.

412
 HEART
MR, VALVE FUNCTION

Right ventricle

Left ventricle
Ascending aorta —
— Papillary muscle

Loft atrium —

— Posterior mitral valve

cusp

— Moderator band, right

ventricle

Aortic valve —

Left atrium — Papillary muscles, leit

ventricle

Posterior miiral valve

cusp

(Top) First of two gated white blood cardiac magnetic resonance images demonstrating the function of the mitral
and aortic: valves. Three chamber view image obtained during ventricular systole demonstrates that the aortic valve
cusps are n o t visible at the aortic root distal t o t h e right ventricular outflow tract indicating that the aortic valve is
open to allow antegrade flow of blood into the aorta. The mitral valve cusps are closed or coapted to prevent
regurgitation of ventricular blood into the left atrium. (Bottom) Three chamber view obtained during diastole shows
that the mitral valve cusps are open to allow blood t o flow into the left ventricle. The aortic valve cusps are closed
preventing retrograde flow of blood from the aorta. The papillary muscles of the left ventricle and moderator band of
the right ventricle are also visualized.
 HEART
R A D I O G R A P H Y , N O R M A L HEART

Aortic artli

Cardiac apex

- Prominent aortic arch

Prominent concavity in
upper left heart border

Increased convexity of
ajX'.v

left para-aortic
interface

(Top) first of two normal chest radiographs demonstrating the variability of the cardiac configuration with
advancing age. PA chest radiograph of a 15 year old boy demonstrates a normal heart configuration for this age
group. Patients of this age may also exhibit a prominent pulmonarv trunk (see "Pulmonary Vessels" section). The
aortic arch is small and the descending aorta is poorly visualized. (Bottom) PA chest radiograph of an asymptomatic
55 year old woman shows that the heart exhibits a left ventricular configuration in which the left sided structures
produce the dominant radiographic findings. The pulmonary trunk is not apparent. The aortic arch is prominent,
and there is a concavity in the mid left or obtuse cardiac border. The left heart lx>rder has increased convexity. The
descending aorta is visible throughout its length.
 HEART
ABNORMAL SITUS
n
a-
re
n:
3

Right aortk arch I eft eparterial

bionchus

Right descending aorta

Right cardiac apex

Right gastric l)ulible —

I ell aortic arch

Right 11\ | vi!ui u l

bronchus

Lett descendinn aorta

Right cardiac apex

Right gastric bubble

(Top) PA chest radiograph of a 25 year old man with situs inversus demonstrates dextrocardia. The aortic arch,
descending aorta and gastric bubble are located on the right. The diagnosis of situs inversus is supported by the
presence of left eparterial and right hypartcrial bronchi. Abnormal situs relates to abnormalities of atrial morphology.
The most accurate radiographic indicator of atrial morphology is the configuration of the central tracheobronehial
tree. (Bottom) PA chest radiograph of a 45 year old woman with situs ambiguous. The cardiac apex and gastric
bubble are located on the right side. The aortic arch and descending aorta are located on the left side. Bilateral
hyparterial bronchi are present, consistent with pulysplcnia or bilateral left sidedness. Bilateral chest wall round
curvilinear calcifications represent partially calcified breast implants. I
4IS
 HEART
CARDIOMEGALY

Width of hean

- Width of inferioi
thorax

I j

— Cardiomcgaly

Post surgical changes

(Top) Normal PA chest radiograph demonstrates the method for measuring the cardiothoracic ratio. The
cardiothoracic ratio is the ratio of the width of the cardiac silhouette at its widest point to the width of the inferior
thorax between the inner maigins of the lateral ribs. The normal cardiothoracic ratio is 0.5S or less, indicating that
the heart is typically a little over half as wide as the inferior thorax. (Bottom) I'A chest radiograph of a 52 year old
woman with cardiomyopathy demonstrates an abnormal cardiothoracic ratio consistent with cardiomcgaly. There
are post-surgical changes in the left upper quadrant.
 HEART
LEFT A T R I A L E N L A R G E M E N T
n

Elevated left main

bronchus

Cardiomegaly

Double contour of
enlarged left atrium

Left ventricular
myoeardial
calcification

—
Sternal wires

Left upper lobe

bronchus

— Enlarged left atrium

Left ventricular —
myoeardial
calcification

( l o p ) l-irst of two images of a 42 year old man with left atrial enlargement secondary to mitral stenosis. I'A chest
radiograph demonstrates cardiomegaly and left atrial enlargement. The latter produces a double contour
superimposed on the right atrium, elevation of the left main bronchus and splaying of the Carina. There are
post-surgical changes of stcrnotomy and findings of left ventricular calcification likely related to remote myoeardial
infarction. There is vascular redistribution consistent with pulmonary venous hypertension, (llottom) Left lateral
chest radiograph demonstrates the enlarged left atrium which is easily differentiated from the left ventricle, as the
latter exhibits dense mural calcification. There is posterior displacement of the left upper lobe bronchus by the
enlarged left atrium. Findings of prior stcrnotomy are also noted. I
417
 HEART
t LEFT V E N T R I C U L A R A N E U R Y S M
a
I
■ ■
in
0)
U

Coronary artery —
calcification

Calcified left
Ventrkiilar aneurysii)

Left ventricular
aneurysm

Left ventricular
thrombus

— Lett lower lobe

iitelectasis

Right pleural effusion — I eft pleural effusion

(Top) I eft lateral chest radiograph of a 49 year old man with coronary artery disease and a dual lead
pacer/defihrillator demonstrates coronary artery calcification and an arcuate calcification projecting over the
posterior inferior left ventricular wall consistent with a left ventricular aneurysm secondary to prior myocardial
infarction. (Bottom) Contrast-enhanced chest CT (mediastinal window) of a 57 year old man with prior myocardial
infarction and a left ventricular aneurysm shows that the heart is enlarged. The aneurysm manifests as focal thinning
and outpouching of the anterior apical left ventricular myocardium with abnormal soft tissue attenuation content
consistent with thrombus. There are bilateral small pleural effusions and left lower lobe relaxation atelectasis.

41«
 HEART
M I T R A L A N N U L U S CALCIFICATION

(.nroiwry artery
calcification

Calcified mitral
annulus

Coronary artery
calcification

— Calcified mitral
annulus

(Top) first of two images of a 72 year old man with calcification of the mitral annulus. PA chest radiograph
demonstrates a thick arcuate calcification projecting over the inferior asjx?ct of the left heart in the region of the
mitral valve ring. (Bottom) Left lateral chest radiograph demonstrates ttie C-shaped calcification projecting between
the left atrium and left ventricle in the region of the mitral valve. The calcification conforms to the periphery of the
mitral valve orifice. Calcification of the mitral annulus typically affects elderly patients, particularly women, who are
often asymptomatic. Affected patients may develop valvular insufficiency or arrhythmias. Ihe calcified mitral
annulus typically manifests with dense C- or J-shaped calcification projecting over the expected location of the
mitral valve ring. Note evidence of coronary artery calcification.
 HEART
VALVE DISEASE, AORTIC STENOSIS
0)
I
*5
</>
<U

Central line tip in right atrium

Amorphous calcification

Central line

—
Aortic valve calcification

Thick interventricular septum

Dense aortic valve calcification -

Central catheter in right atrium — - Thick lelt ventricular

myocardium

(Top) First of three images of an 81 year old m a n with calcific aortic stenosis. PA chest radiograph coned-down t o the
heart demonstrates a left ventricular cardiac configuration and a subtle focus of calcification projecting over the
central portion of the heart in the expected location of the aortic valve. A right internal jugular central line
terminates in the right atrium. (Middle) Left lateral chest radiograph coned-down to the heart demonstrates dense
calcification in the expected location of the aortic valve. The morphology of the calcification suggests involvement
of the valve cusps. (Bottom) (lomposite image of a contrast-enhanced chest CT (mediastinal window) shows dense
calcification of the aortic valve cusps consistent with calcific aortic stenosis. Note associated thickening of the left
I ventricular myocardium consistent with left ventricular hypertrophy.
420
 HEART
VALVE DISEASE, MITRAL STENOSIS
n
rr

I
a.
— Enlarged left atrial appendage

Right pleural effusion

— ( alcified stenotic mitral valve

Right lower lobe airspace disease -

Right pleural effusion ■

— Coronary artery calcification

Left atrial appendage

Left atrial thrombus

— Atherosclerotic aorta
Right pleural effusion

(Top) First of three images of a 72 year old woman with mitral stenosis. PA chest radiograph demonstrates
cardiomegaly and a focal convexity of the superior left cardiac border representing enlargement of the left atrial
appendage. The aorta is tortuous a n d atherosclerotic. There is a moderate right pleural effusion a n d mild interstitial
edema. (Middle) Unenhanced chest CT (rnediastinal window) through the left atrium demonstrates dense mitral
valve calcification indicative of mitral stenosis. There is a right pleural effusion and right lower lobe airspace disease.
(Bottom) Contrast-enhanced chest CT (rnediastinal window) through the left atrium demonstrates filling defects
within the atrial lumen that extend into an enlarged left atrial appendage and are consistent with atrial thrombi.
Atherosclerosis and bilateral pleural effusions are also present. I
421
 CORONARY ARTERIES AND CARDIAC VEINS
■ May arise from proximal LCX
Terminology ■ Supplies sinoatrial node
Abbreviations ' Anterior branches to free wall of right ventricle
• Left anterior descending artery (1 AD) c Acute m a r g i n a l a r t e r y
• I eft circumllex artery (LCX) ■ Arises at junction of mid and distal RCA
• Posterior descending artery (PDA) ■ Supplies free wall of right ventricle
• Right coronary artery (RCA) PDA
• Posterolaleral artery (PI.A) ■ terminal branch of RCA
• Sii|>erior vena cava (SVC) ■ Runs in posterior interventricular groove
■ Can extend around apex t o supply anterior
Definitions interventricular septum, it LAD is small
• Coronary sulcus: Atrioventricular groove PLA
■ Terminal branch of RCA
Coronary Veins
Imaging Anatomy • Accompany coronary arteries and their branches
Coronary Arteries • C o r o n a r y sinus
• Right and left coronary arteries, each arises from i- Most veins of the heart drain into the coronary
corresponding aortic coronary sinus (of Valsalva) sinus
• Coronary arterv branches generally considered end c Wide venous channel in posterior part of coronary
arteries sulcus; ends in right atrium
- Myocardial segments predominately supplied by c Great cardiac vein (left c o r o n a r y vein)
segmental coronary artery branches accompanies LAD
' Potential to develop collateral circulation c Small c a r d i a c vein (right c o r o n a r y vein)
• Coronary artery d o m i n a n c e accompanies acute marginal artery
>- Determined by artcry(ies) supplying PDA and I'l A c M i d d l e cardiac vein accompanies PDA
■ Right d o m i n a n t : RCA supplies both arteries (- Posterior vein of left ventricle
85%) Oblique vein of left a t r i u m
■ I eft dominant: LCX supplies both arteries (- ■ Remnant of embryonic left SVC
7.5%) ■ ( a n persist as left SVC
■ Co-dominant: RCA supplies PDA and LCX • Other cardiac veins do not end in coronary sinus;
supplies PLA(- 7.5%) drain directly in right atrium
• I.eft m a i n c o r o n a r y artery Anterior cardiac veins
Passes leftward, posterior t o pulmonary trunk and c Smallest cardiac veins
bifurcates into LAD and LCX
c Occasionally, trifurcates into LAD, LCX and ranuis
intermedius Analomy-Based Imaging Issues
■ Rainus i n t e r m e d i u s : Course similar to 1st
diagonal branch of I AD to anterior left ventricle
Imaging Recommendations
o May be absent: I AD and ICX arise separately from • Catheter angiography remains gold standard for
coronary artery imaging
left coronary sinus
! Main advantage is ability t o perform coronary
• LAD
interventions if arterial stenosis is detected
o Runs in anterior interventricular groove (sulcus) and
terminates near cardiac apex • CT coronary angiography is gaining popularity as an
excellent non-invasive technique for coronary artery-
■ Diagonal b r a n c h e s to anterior free wall of left
imaging
ventricle (numbered as they arise from LAD)
" Septal b r a n c h e s to anterior interventricular c High sensitivity, specificity, accuracy and negative
septum (numbered as they arise from I AD) predictive value for coronary artery disease
c Specially suited for coronary artery anomalies
• LCX
o Runs in left coronary sulcus ■ Multiplanar capabilities
■ O b t u s e m a r g i n a l b r a n c h e s to lateral left ventricle • Myocardial segmentation
a Standard 17 segments model has hcen adopted for
(numbered as they arise from ICX)
left ventricular wall
• RCA
■ Used to assess myocardial perfusion, left
u Runs rightward posterior to pulmonary trunk, then
ventricular function and coronary anatomy
downward in right coronary sulcus, toward posterior
interventricular septum • Coronary artery anomalies
( ' o n u s artery o - 1% of coronary angiograms
■ First branch of RCA o Types of coronary artery anomalies
■ May have separate origin directly from right ■ High takeoff
coronary sinus ■ Multiple ostia
■ Supplies pulmonary outflow tract ■ Single coronary artery
Sinus n o d e a r t e r y
■ Origin from opposite or noncoronary sinus
■ Origin from pulmonary artery
■ Arises from proximal RCA in 60% of individuals
 CORONARY ARTERIES AND CARDIAC VEINS
ANTERIOR VIEW OF THE CORONARY ARTERIES
n
3"

n
o
o
Co

>
o
a>'
in
Co

Q_

n
CJ
n
<
Pulmonary artery
Left main coronary
artery

Sinus node artery

Obtuse marginal
branch of LCX

Septal perforator
branch of LAD

Diagonal branch of
LAD

Acute marginal artery

Graphic illustrates branches of the coronary arteries. The left main coronary artery divides into the LAD and the
LCX. The LAD runs in the anterior interventricular groove and gives off septal perforator branches to the
interventricular septum and diagonal branches to the free wall of the left ventricle. The LCX gives off obtuse
marginal branches to the lateral wall of the left ventricle. The RCA runs In the right coronary sulcus and gives off the
conus artery, sinus node artery (in 60% of the population), anterior branches to the free wall of the right ventricle
and the acute marginal artery. It then curves around the Inferior cardiac border and divides into the PDA and
posterolateral ventricular artery (in a right dominant coronary circulation).
I
An
 CORONARY ARTERIES AND CARDIAC VEINS
POSTERIOR VIEW OF THE CORONARY ARTERIES

uV

■-v.

Obtuse marginal
artery

Posterolateral artery

Acute marginal artery

3«3 '£•-> ■ ■
^JB

I*

■VJ
'*. -

Illustration of the coronary artery anatomy, viewed from the posterior aspect of the heart, in a right dominant
coronary circulation. The RCA runs in the right coronary sulcus and divides Into two terminal branches: PDA and
posterolateral artery. The PDA runs in the posterior interventricular groove. The LCX is seen along the left cardiac
border and ends as an obtuse marginal branch. The coronary circulation is classified as right dominant if the RCA
supplies the PDA and at least one branch of the posterolateral artery. It is classified as left dominant if the LCX
supplies both arteries (PDA, PLA). It is co-dominant if the RCA supplies the PDA and the LCX supplies the
posterolateral branch(es).
^m _
 C O R O N A R Y ARTERIES A N D C A R D I A C V E I N S

n
o
o
=3
-<
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ro
-n
n>"
01

n
EL
n
<
z>

1. Basal anterior 10. Mid inferior

2. Basal anteroseptal
3. Basal inferoseptal
4. Basal inferior
5. Basal inferolateral
6. Basal anterolateral
7. Mid anterior
8. Mid anteroseptal
9. Mid inferoseptal
11. Mid inferolateral
12. Mid anterolateral
13. Apical anterior
14. Apical septal
15. Apical inferior
16. Apical lateral
17. Apex

Standardized, 17 myocardial segments were adopted by the Cardiac Imaging Committee of the Council on Clinical
Cardiology of the American Heart Association, for tomographic imaging of the left ventricle. The names for the
myocardial segments define the location relative to both the long and short axis of the left ventricle. Basal,
mid-cavity and apical designations localize the segments along the long axis of the left ventricle. With regard to the
circumferential location on the bull's-eye view, the basal (segments 1-6) and mid-cavity (segments 7-12) sections are
divided into 6 segments of 60° each. The apical section (segments 13-16) is divided into 4 segments of 90° each. The
cardiac apex is segment 17. The attachment of the right ventricular wall to the left ventricle is used to separate the
septum from the left ventricular anterior and inferior free walls. I
42 S
 CORONARY ARTERIES AND CARDIAC VEINS
CORONARY ARTERY TERRITORIES

Graphic illustrations of the left ventricular myocardial segments and the distribution of coronary blood flow to these
segments. Segmentation of left ventricular myocardium is used to assess myocardial perfusion, left ventricular
function and coronary anatomy. Myocardial perfusion and function can be assessed using nuclear medidne cardiac
SPECT and cardiac MR.
 n
CD

n
c
o
CJ

>
r—¥

o
13
Q.

n
n
<

The first three images are short axis CECT views of the left ventricular wall at the basal, mid and apical levels. The
fourth image is a vertical long axis image, obtained from the same data set, reformatted to show the apex. Different
colors are assigned to show the vascular territories of the coronary arteries. The LAD supplies the anterior septum, the
anterior wall, and in most cases, the apex. On a short axis image, It usually supplies from 9 to 1 o'clock at the basal
and mid ventricular levels. The LCX supplies the lateral wall, usually from 2 to 4 o'clock . The RCA supplies the
inferior wall segments and the posterior septum, usually from 5 to 8 o'clock. It should be emphasized, however, that
great variation in the distribution of coronary blood flow is observed in clinical practice.
I
427
 CORONARY ARTERIES A N D CARDIAC VEINS
in CATHETER CORONARY ANCIOCRAPHY
c
'CJ
— LAD
>
LAD
u
Left main coronary artery
U
"D
C LCX
(V
in
Obtuse marginal artery

I
<
Obtuse marginal artery
TO
C

o
2
u LCX
1/5
cu
x:
U
Obtuse marginal artery
LAD

Diagonal branch ot LAD

Left main coronary artery LAD

LCX

Obtuse marginal branch of LCX

Septal perforator branches of
LAD

Obtuse marginal branch of LCX

(lop) First of four images of the left coronary circulation obtained during catheter angiography in a 48 year old
patient who presented with chest pain. Because of the overlap between the branches of the coronary arteries,
multiple radiographic projections are obtained to show different segments in greater detail. The first image is a LAO
caudal view showing the bifurcation of the left main coronary artery into the LAU and ICX. The LAD is
foreshortened on this projection, while the LCX with its obtuse marginal branches is well seen. (Middle) LAO cranial
projection shows the IAD and iLs diagonal branch. It is difficult to separate the LCX and its obtuse marginal
branches on this projection. (Bottom) RAO caudal view shows the origin of the LAD and LCX from the left main
coronary artery. The diagonal branch of LAD is projecting over the LAD. Note the septal perforator branches of LAD.
 CORONARY ARTERIES AND CARDIAC VEINS
CATHETER CORONARY ANGIOGRAPHY
n
=r
re
</>
■ •

n
Diagonal branch of LAD o
Obtuse marginal branches of ICX 3
>
3.
Q
LAD

CJ
13
Q-
n
-n
Q.
CJ'
n
<
Sinus n<*1e artery ft).

RCA

Acute marginal artery -

Posterolateral branch of R< A

PDA

Sinus node artery Conus artery

RCA

Acute marginal artery Posterolateral branch of RCA

PDA

(Top) RAO cranial projection separates (he LAD f r o m its diagonal b r a n c h . The LCX is not well seen, but its obtuse
marginal branches arc well delineated. ( M i d d l e ) l i r s t o f t w o images o b t a i n e d d u r i n g i n j e c t i o n o f t h e RCA. L A O
cranial v i e w shows t h e branches of the RCA a n d its b i f u r c a t i o n i n t o the PDA a n d t h e posterolateral artery. The acute
marginal artery is superimposed o n the RCA o n this p r o j e c t i o n . ( B o t t o m ) RAO cranial projection shows t h e branches
of the RCA. "ITic conus artery is usually t h e first b r a n c h a n d supplies the p u l m o n a r y o u t f l o w tract. The acute marginal
artery is separated o n this projection f r o m t h e RCA.

42c)
 CORONARY ARTERIES AND CARDIAC VEINS
3D VOLUME RENDERED IMAGES OF THE CORONARY ARTERIES

Location of pulmonary trunk

Diagonal branch of LAD

Ascending aorta
Left main coronary artery

-•--Li--:
Descending aorta

Left coronary sinus

Left main coronary artery

- ^.

Posterolateral artery branch

I^^P
Right coronary sinus

b T
Right atrium

flop) First of three volume rendered images of the coronary arteries. In this image viewed from above (pulmonary
trunk digitally removed), the origins of the coronary arteries are shown. The right coronary artery arises from the
right coronary sinus. The short left main coronary artery arises from the left coronary sinus and divides into the LAD,
which runs in the anterior interventricular groove, and the LCX, which runs in the left coronary sulcus. (Middle)
Posterior oblique volume rendered image shows the RCA and LCX forming a circle as each runs in its respective
coronary sulcus. (Bottom) A frontal oblique image shows the origin of the RCA from the right coronary sinus. The
RCA passes to the right of the pulmonary artery (removed during image post processing) to reach the right coronary
sulcus (atrioventricular groove).
 CORONARY ARTERIES AND CARDIAC VEINS
RIGHT DOMINANT CORONARY CIRCULATION

Second diagonal branch of LAD

Location of pulmonary trunk

First diagonal branch of LAD

Acute marginal artery
Conus artery

fil
Location of right atria]
appendage
Ascending aorta
Left main coronary artery

Conus artery

Right ventricle free wall

Left ventricle

Right ventricle

Right atrium

Posterolateral artery Left ventricle

(Top) The first of three volume rendered images in a patient with nght dominant coronary circulation shows the
conus artery, usually the 1st branch of the RCA, which supplies the pulmonary outflow tract. The acute marginal
artery arises at the junction between the mid and distal parts of the RCA and supplies the anterior wall of the right
ventricle. (Middle) Frontal image shows the conus and acute marginal arteries. During Its course in the coronary
sulcus, the RCA also gives off multiple branches to the right ventncular free wall. (Bottom) Axial image through the
base of the heart shows the two terminal branches of the RCA In a right dominant coronary circulation (85% of
population). The posterolateral artery supplies the posterolateral wall of the left ventncle, while the PDA diverges to
run in the posterior interventricular groove.
 CORONARY ARTERIES AND CARDIAC VEINS
LEFT DOMINANT CORONARY CIRCULATION

>
Ascending aorta
Pulmonary trunk

u
-c
c
TO

,0; Conus artery

CD

<

c
O
i_
o
U
Left main coronary artery
o
_c
U
Obtuse rT...ir#inal branch of LCX
Diagonal branch of LAD

Diagonal branch of LAD

Posterior interventrlcuiar
groove

Cardiac apex

Right coronary suicus

(Top) First of three volume rendered images in a patient with left dominant coronary circulation. Frontal oblique
image shows a common origin of the RCA and conus artery from the the right coronary sinus. The RCA is small and
ends before reaching the posterior interventrlcuiar septum. (Middle) Frontal oblique image shows the branches of
the left coronary artery. The LAD is large and wraps around the cardiac apex. The LCX is also large and runs in the
left coronary suicus to reach the posterior interventrlcuiar groove. (Bottom) A diaphragmatic view of the heart shows
the LAD wrapping around to supply the cardiac apex and anterior portion of interventricular septum. The LCX
supplies a small PDA. Note the absence of the RCA In the right coronary suicus.
I
4)2
 CORONARY ARTERIES AND CARDIAC VEINS
MAXIMUM INTENSITY PROJECTION (MIP) OF CORONARY ARTERIES

Right ventricle -

RCA -

— I.AD
Right atrium -
— LCX

Left atrium

Mural calcification

Aorta - LAD

Left coronary sinus -

r— LCX

Mural calcification

Aorta — LAI)

(Top) First of three maximum intensity projection (MIP) images depicting the origins of both coronary arteries. The
RCA arises from the right coronary sinus, passes t o the right behind the pulmonary outflow tract, to reach the right
coronary sulcus. The short stem left main coronary artery divides into the IAD and LCX (Middle) Axial oblique MIP
image of the left coronary system, in another patient with mild coronary artery disease, shows the I.AD in the
anterior inierventricular groove and the LCX in the left coronary sulcus. Note the mild calcification of the LAD. The
obliquity of the plane of reconstruction makes the left coronary sinus appear aneurysmal and masks the left coronary
artery origin, (bottom) Coronal oblique thin MIP image of the same patient delineates the course of the LAD in the
anterior inierventricular groove and again shows calcifications of the vessel wall.
 CORONARY ARTERIES AND CARDIAC VEINS
c M A X I M U M INTENSITY PROJECTION ( M I P ) O F C O R O N A R Y ARTERIES

>
u

5 Aorta —
"O
c
TO
(/>
.OJ
"E
a
RCA —
<
TO — Left ventricle

£
8
•• — Posterolateral arterv
l/l

ai

U PDA

Right ventricle

— I ett ventricle

Interventruiilar septum

RCA
— I'DA

Tostcrolateral artery

(Top) Coronal oblique MIP image shows the vertical course of the RCA within the right coronary sulcus and its two
terminal branches: PDA and posterolateral ventricular artery. This is the usual branching pattern in a right dominant
coronary artery circulation. The coronary circulation is right dominant if the RCA supplies the PDA and at least a
posterolateral ventricular branch. (Bottom) Axial MIP image, through the base of the heart, shows the horizontal
course of the KCA as it courses to the jx>sterior interventricular septum, before branching into the PDA and
posterolateral ventricular artery. The PDA runs in the posterior interventricular groove. MIP images are useful to
delineate the course of an artery, but should not be used alone to diagnose arterial stenosis, because areas of
I narrowing can be masked by contrast in the plane of reconstruction.
414
 CORONARY ARTERIES AND CARDIAC VEINS
C O R O N A R Y ARTERY ANOMALIES
n

n
o
—I

o
>

—I
Con us artery
5"
V)
QJ
ZJ
RCA - Q.

n
QJ

s.
QJ
Acute marginal artery —
n

— Pulmonary artery

RCA -

— Left main coronary

arterv
Aorta -
— Left coronary sinus

(Top) C o r o n a l o b l i q u e m a x i m u m intensity projection (Mil*) image i n a patient w i t h a separate o s t i u m of t h e conus

artery, w h i c h is arising directly f r o m the right coronary sinus rather t h a n f r o m t h e RCA. ( B o t t o m ) Axial o b l i q u e M i l '
image i n a different patient shows t h e RCA arising f r o m t h e left coronary sinus a n d passing between the aorta a n d
t h e p u l m o n a r y t r u n k . This inlerarterial RCA position has been n o t e d i n a p p r o x i m a t e l y 0.196 of patients u n d e r g o i n g
catheter coronary angiography. It is associated w i t h sudden d e a t h i n about 3 0 % o f patients a n d may relate t o
compression o f t h e right coronary artery between t h e p u l m o n a r y artery a n d the aorta, especially d u r i n g exercise
w h e n d i l a t a t i o n of the aorta occurs. Because of its m u l t i p l a n a r capabilities, c o r o n a r y CTA is especially well-suited tor
the evaluation of congenital anomalies a n d variants of t h e coronary c i r c u l a t i o n . I
435
 CORONARY ARTERIES AND CARDIAC VEINS
SINGLE CORONARY ARTERY FROM THE RIGHT CORONARY SINUS

Left main corunary artery — |

— Aorta
Single coronary artery segment ■
Lett atrium

RCA -

Pulmonary artery
Left main coronary artery
Aorta

Superior vena cava —

(Top) first of three double IK MR images in a 70 year old patient with chest pain. A sagittal image through the root
of the aorta shows a single coronary artery segment arising from the right coronary sinus. Ihc left main coronary
artery arises from the common trunk and is directed upward. (Middle) A sagittal image shows the right coronary-
artery which has a normal course. (Bottom) An axial image shows the left main coronary artery, after looping
anterior to the pulmonary trunk, dividing into the LAD and ICX. The LAD descends in the anterior interventricular
groove while the I.CX, which has a longer course, runs in the upper part of the anterior interventricular groove
(normally where the LAD runs) and then curves to assume its normal course in the left coronary sulcus.
 CORONARY ARTERIES AND CARDIAC VEINS
SINGLE RIGHT CORONARY ARTERY

Left coronary artery

Pulmonary trunk
Surgical clip

RCA proper

Common RCA trunk

Left coronary artery

m-

(Top) Two images in a patient with D-transposition of the great vessels who underwent arterial switch procedure as
an Infant. First image is a thick MIP image showing a single coronary artery arising from the right coronary sinus.
This single artery divides into a left coronary artery and an RCA proper, which continues in the expected course of
the RCA. The anomalous left coronary artery loops in front of the pulmonary trunk in this patient. A single RCA,
with anomalous left coronary artery passing In front of the pulmonary trunk, occurs in about 10% of patients with
D-transposition of great vessels. Note the location of the pulmonary trunk to the right and anterior to the aorta.
(Bottom) Volume rendered image in the same patient shows the anterior course of the left coronary artery, anterior
to the pulmonary trunk.
 CORONARY ARTERIES AND CARDIAC VEINS
ANTERIOR VIEW OF CORONARY VEINS

Oblique vein of left

atrium

Great cardiac vein

Anterior cardiac veins

Posterior vein of left

ventricle
Coronary sinus
opening Into right Coronary sinus
atrium

Small cardiac vein

Right uar^lna! vein Middle cardiac vein

Small cardiac vein

Graphic illustrates the venous drainage of the heart. The great cardiac vein starts at the apex, runs in the anterior
interventricular groove, curves to the left in the coronary sulcus to open at the left end of coronary sinus. The
oblique vein of left atrium runs obliquely on the posterior aspect of the left atrium to merge with the greater cardiac
vein. The small cardiac vein runs in the coronary sulcus to open at the right end of the sinus. The middle cardiac
vein starts at the apex, runs in the posterior interven tricular groove and opens in the right aspect of the coronary
sinus. The posterior vein of left ventricle runs on the diaphragmatic surface of left ventricle to reach the sinus. The
anterior cardiac veins (3 or 4) open directly into the right atrium. The right marginal vein may Join the small cardiac
vein or drain directly Into the right atrium.
 CORONARY ARTERIES AND CARDIAC VEINS
CORONARY SINUS

Great cardiac vein

Left ventricular tributary to great

cardiac vein
Left ventricle Coronary sinus

Pulmonary vein

Ventricular tributary to great

cardiac vein
Left atrium
Greater cardiac vein
Posterior vein of left ventricle Coronary sinus

Middle cardiac vein

Right atrium
Middle cardiac vein

Opening into right atrium

Coronary sinus Posterior vein of left ventricle

(Top) Three different volume rendered images In a patient undergoing coronary CTA show the coronary sinus
venous system. The left lateral view shows the great cardiac vein as It accompanies the LAD in the anterior
interventricular groove, then as It curves in the left coronary sinus to accompany the LCX. The confluence of the
great cardiac vein with the oblique vein of the left atrium (not seen on the image) marks the start of the coronary
sinus. Multiple left ventricular veins drain into the great cardiac vein. (Middle) Posterior view of the coronary sinus
shows its major tributaries: The great cardiac vein, the middle cardiac vein and the posterior vein of the left ventricle.
(Bottom) Diaphragmatic view of the coronary sinus shows it entering into the right atrium. The middle cardiac vein
accompanies the PDA in the posterior interventricular groove.
 CORONARY ARTERIES AND CARDIAC VEINS
DOUBLE SVC

_
Aortic arch
Right superior vena cava ~
-
Left superior vena cava

— Left superior intercostal vein

Right atrium —

Left atrium -

Left superior vena cava

Right atrium

" Coronary sinus

(lop) First of three axial CKCi images in a patient with double SVC. Axial image at the level of the top of the aortic-
arch shows an enhancing tubular structure to the left of the aortic arch. This represents the continuation the left
brachiocephalic vein into a left-sided SVC. (Middle) Axial image at the level of the top of the right atrium shows the
right SVC entering the right atrium. The left superior vena cava lies posterolatcral to the left atrial wall. (Bottom)
Axial image at the level of the base of the heart shows the left SVC terminating in the coronary sinus, which is
slightly dilated. The coronary sinus drains into the right atrium. The left SVC is an embryonic structure that can
[jersist in adult life as a single left or double SVC (0.3% of normal adults and in 4.5% in patients with congenital
heart disease).
 CORONARY ARTERIES A N D CARDIAC VEINS
BIVENTRICULAR PACING

Anterior ventricular
vein

C-reat cardiac vein

Coronary sinus
Approximate orifice of
coronary sinus

Anterior ventricular
vein

Great cardiac vein

Coronary' sinus

(lop) hirst of two chest radiographs of a patient with a dilated cardiomyopatliy a n d biventrkular pacing for cardiac
^synchronisation therapy. This PA radiograph shows a transvenous left ventricular pacing lead extending from the
right atrium retrograde into the coronary sinus, through the greater cardiac vein, and into an anterior ventricular
vein. The coronary sinus lead shows the oblique orientation of the coronary sinus in the coronary sukus. (Bottom)
1 ateral radiograph shows the location and orientation of the coronary sinus on a lateral radiograph. Prolonged
conduction in patients with heart failure leads to asynchronous contraction of the ventricles and decreased cardiac
output. Biventrkular pacing results in synchronization of ventricular contraction and improved cardiac output.
Stimulation of the left ventricle is achieved through the coronary sinus lead.
 PERICARDIUM
c Dermatomes of supraclavicular region; referred pain
Anatomy of the Pericardium to shoulder in cases ot pericardial inflammation
General Concepts Pericardial Vessels
• Pericardium, sac-like m e m b r a n e that surrounds • Arterial supply
heart and p r o x i m a l great vessels c Internal t h o r a c i c arteries
• I ocatcd in a n a t o m i c m i d d l e m e d i a s t i n u m ■ Pericardiacophrenic arteries
• Function ■ M u s c u l o p h r e n i c arteries
c Protects heart Thoracic a o r t a
<- Maintains heart in normal midline position ■ Superior p h r e n i c arteries
c I units heart distention a n d pericardial fluid volume ■ C o r o n a r y arteries
c Pericardial space • Venous drainage
■ Permits cardiac motion and changes in c A/ygos system
morphology Internal t h o r a c i c veins
•- Pericardial link! ■ Pericardiacophrenic veins
■ Provides lubrication during cardiac motion
■ 15-50 111L of serous fluid in normal subjects
Fibrous Pericardium Pericardia! Space & Pericardial
• Cone-shaped sac-like tough connective tissue layer Recesses
c Surrounds heart, but is not attached to it
c l i n e d internally by serous parietal p e r i c a r d i u m General Concepts
Continuous with great vessel adventifia • Serosal pericardial reflections arranged around two
Continuous with p r e t r a c h e a l fascia tubes
• Defines outer boundaries of a n a t o m i c m i d d l e c One tube encloses a o r t a a n d p u l m o n a r y t r u n k
mediastinum c O n e tube encloses superior and inferior v e n a e
• Attachments cavae a n d p u l m o n a r y veins
c Base attached to central t e n d i n o u s portion of • Transverse sinus
diaphragm Passage liclween the two tubes
■ Pcricardiophrenic l i g a m e n t • Oblique sinus
c Anterior surface attached to anterior chest wall Posterior pericardial extension behind left a t r i u m
(|K>sterior aspect of s t e r n u m ) • No c o m m u n i c a t i o n b e t w e e n transverse a n d o b l i q u e
■ Superior sternopericardial ligaments sinuses
r
■ Inferior sternopericardial ligaments Separated by two pericardial reflections
• Conduit for n e u r o v a s c u l a r structures
' Phrenic nerves Transverse Sinus
Pericardiacophrenic vessels • General
Horizontal orientation
Serous Pericardium Posterior to a s c e n d i n g a o r t a and p u l m o n a r y t r u n k
• Closed sac-like m e m b r a n e that surrounds the h e a r t c Superior to left a t r i u m
within the fibrous p e r i c a r d i u m c Superior and anterior to o b l i q u e sinus
• C o n t i n u o u s serosal layer with parietal a n d visceral i May mimic aortic dissection or lymphadenopathy
components • Superior aortic recess
Lined by mesotheiial cells c Superior e x t e n t of transverse sinus
• Parietal p e r i c a r d i u m c Partially surrounds a s c e n d i n g a o r t a
I ines internal surface of fibrous p e r i c a r d i u m c Abuts aorta without intervening fat tissue plane
• Visceral p e r i c a r d i u m Posterior p o r t i o n
c Adherent to heart ■ Also known as superior pericardial recess/sinus
" Also known as e p i c a r d i u m ■ Crescent-shaped lluid collection abutting
■ Covers t h e s u b e p i c a r d i a I fat posterior wall of a s c e n d i n g a o r t a
■ May extend cephalad into right paratrachcal
Pericardial Reflections region
• Superior reflection surrounds ■ May mimic lymphadenopathy
Ascending a o r t a Anterior portion
Pulmonary trunk ■ Triangular-shaped fluid with beak-like extension
• Posterior reflection surrounds between a s c e n d i n g aorta a n d p u l m o n a r y t r u n k
SujK'rior vena cava ■ Mav mimic aortic dissection
o Inferior vena cava Might lateral portion
P u l m o n a r y veins ■ illuid extending between a s c e n d i n g aorta a n d
superior v e n a cava
Pericardial Innervation
• Inferior a o r t i c recess
• Vagus nerves Inferior extension of transverse sinus
• Sympathetic trunks o Crescent-shaped fluid between right lateral
• P h r e n i c nerves lC3, C.4, C5) a s c e n d i n g aorta and right a t r i u m
- Somatic innervation of parietal pericardium
 PERICARDIUM
■ Posterior t o aorta, anterior to left atrium
• Right .iiul left pulnionic recesses
Literal e x t e n s i o n s of transverse sinus
Right p u l n i o n i c recess
■ Inferior to proximal right p u l m o n a r y a r t c r j
" I eft p u l n i o n i c recess
■ Inferior to left p u l m o n a r y artery, superior to left
superior p u l m o n a r y vein
Pericardial Cavity
• Some recesses arise from the pericardia! cavity proper
• Postcaval recess
Small fluid collection along posterolateral aspect of
superior vena cava
• Right a n d left p u l m o n a r y v e n o u s recesses
Small fluid collections along lateral heart borders
Between superior and inferior p u l m o n a r y veins
I eft identified more frequently than right o n ( T
> May mimic lymphadenopathy
Oblique Sinus
• Inferior t o transverse sinus
Separated from transverse sinus by double
pericardial reflection
No c o m m u n i c a t i o n between transverse a n d
o b l i q u e sinuses
• Superior and posterior to left a t r i u m
• Posterior to right p u l m o n a r y artery, medial to
b r o n c h u s intcrmediiis
Sometimes called posterior pericardial recess
• Mav mimic esophageal pathology or foregut cyst
Imaging the Normal Pericardium
General Concepts
• Typically imperceptible o n radiography
• Echocardiography, modality of choice for initial
evaluation
Assessment of pericardial effusion and tamponadc
Inability to assess entire pericardium or detect
pcricardial thickening
Cross-sectional Imaging (CT/MR)
• Normal thickness of 1-2 m m
Combined thicknesses of Fibrous p e r i c a r d i u m a n d
serous parietal/visceral p e r i c a r d i u m
Serous visceral pericardium (cpicardium) closelv
adherent to heart surface
• Most visible anterior to right ventricle
Outlined by subepicardial a n d mediastinal fat
• Visualization/identification of pericardial sinuses and
recesses
Mav mimic lymphadenopathy, dissection
• MR
Pericardial visualization in 8 0 % of n o r m a l subjects
i Normal pericardium exhibits low signal o n T l - and
12-weighted SE images
Outlined by bright signal mediastinal a n d
subepicardial fat
' Increasing thickness near d i a p h r a g m ;
l i g a m e n t o u s insertions
Anatomy Related Imaging
Abnormalities
Congenital Absence of Pericardium
• ( o m p l e t c absence of p e r i c a r d i u m
• Partial absence of p e r i c a r d i u m , more c o m m o n than
complete absence, usually affects left pericardium
a Association with left atrial herniation
Potentially lite-threatening condition
• Imaging
- Cardiac displacement to t h e left and posterior
cardiac rotation with complete absence
Interposition of lung between ascending aorta and
pulmonary trunk o n (T/MK
Pericardial Cyst
• Developmental anomaly characterized by
non-communicating outpouching of parietal
pericardium
• Typically located in a n t e r i o r c a r d i o p h r e n i c angles
(70% right. 2 0 % left)
• Imaging
Smooth, round, ovoid or tear drop shaped mass
abutting the heart
I lomogcneous fluid attenuation/signal
Ihin/imperccptible wall
No contrast-enhancement
Pericardial Effusion
• Abnormal amount of fluid in pericardium
Capacity for accumulation ol 300 nil. of fluid
• Imaging
"Water lxrttle" morphology of cardiopericardial
silhouette
F.picardial (subepicardial) fat p a d sign, water
density band (> 4 m m ) b e t w e e n subepicardial a n d
substernal fat stripes
I lomogcneous water attenuation/signal o n CT/MR
in uncomplicated effusion
c Hemopcricardium
■ High attenuation
■ High signal o n II-weighted MR; low signal o n
gradient-echo cine images
Pericardial Thickening
• Thickness > 4 m m
• Difficult distinction from small pericardial effusion on
C I
• Constrictive pericarditis
Symptomatic patients with ventriculai dysfunction
Thick fibrotic pericardium limits ventricular
expansion
c Etiologies: Radiation, cardiac surgery, infection,
neoplasia, connective tissue disorders
0 Imaging
■ Pericardial thickening/calcitication/adhesions
■ tabular deformity of ventricles (particularly right
ventricle) with decreased volume
■ flat or sigmoid intervenlriculai septum
■ Dilatation of atria, coronary sinus and systemic
veins
The pericardium is a sac-like membrane that surrounds the heart and the origins of the great vessels. It has a conical
shape with the apex of the cone oriented inferiorly and to the left. The pericardium normally contains 15-50 mL of
serous fluid that provides lubrication of its apposing serous surfaces during cardiac motion. Although the heart can
move relatively freely and change its morphology within the pericardia] cavity, the pericardium poses some
restrictions on cardiac motion and pericardiai fluid volume.
 PERICARDIUM

Serous visceral
pericardium Fibrous pericardium

Pericardia! cavity

Serous parietal
pericardium

Pericardial cavity

Mediastlnal fat

Subeplcardial fat

(Top) Graphic shows the anatomy of the pericardial layers. The fibrous pericardium (green) is composed of tough
connective tissue, is continuous with the proximal great vessel adventitia and forms the boundaries of the anatomic
middle mediastinum. The serous pericardium (blue) surrounds the heart with two continuous thin layers lined by
mesothelial cells. The serous parietal pericardium lines the internal surface of thefibrouspericardium. The serous
visceral pericardium (epicardium) lines the heart. Between the two serous layers is a potential space that contains a
small amount of fluid. (Bottom) Graphic shows the pericardial cavity and the thin pericardial layers. Visualization of
the pericardium on cross-sectional imaging is enhanced by subepicardial fat deep to the serous visceral layer and
mediastinal fat surrounding the fibrous and serous parietal pericardial layers.
 PERICARDIUM
ANATOMY OF THE PERICARDIUM

Pericardial reflections

Pericardiophrenlc ligaments Diaphragm

Vascular attachment of fibrous ^

pericardium Serous visceral pericardium

Subeplcardlal fat Serous parietal & fibrous

pericardium

-'» .

Cut surfaces of pericardial

^M
reflections

Serous visceral pericardium

(epicardium)
Subeplcardial fat

C" Es
(Top) Graphic shows the surface anatomy of the fibrous pericardium that forms the boundaries of the anatomic
middle mediastinum. The base of the pericardium is attached to the diaphragm by the pericardiophrenic ligaments
and to the chest wall by the sternopericardial ligaments (not shown). These attachments anchor the pericardium and
prevent excessive cardiac motion. (Middle) Graphic shows the pericardial cavity seen by "cutting away" the anterior
(fibrous and serous parietal) pericardium. The fibrous pericardium is continuous with the great vessel adventitia and
is lined by the serous parietal pericardium, which is continuous with the serous visceral pericardium (epicardium)
that covers the heart and subeplcardial fat. (Bottom) Graphic shows that the fibrous/parietal pericardium has been
removed to reveal the posterior visceral serous pericardium and its reflections.
 PERICARDIUM
ANATOMY OF THE PERICARDIAL RECESSES

Ascending aorta

Superior aortic recess

Pulmonary trunk

Superior vena cava

Left pulmonary veins

Right pulmonic recess Left pulmonic recess

Postcaval recess Left pulmonary

venous recess
Right pulmonary
venous recess
Oblique sinus

inferior vena cava

Graphic depicts the pericardial sinuses and recesses. The anterior pericardium and heart have been removed. Two
tubes, one surrounding the ascending aorta and pulmonary trunk and the other surrounding the superior and
inferior venae cavae and the pulmonary veins are separated by the transverse sinus (*). The transverse and oblique
sinuses are separated by a pericardia] reflection. The superior aortic, right pulmonic and left pulmonic recesses arise
from the transverse sinus. The oblique sinus is located above and behind the left atrium. The postcaval, left and right
pulmonary venous recesses arise from the pericardial cavity proper.
 PERICARDIUM
AXIAL CT, NORMAL PERICARDIUM

Mediastinal fat —

— Pericardium
Subcpicardial fat

- Pericardium

Mi-ili.i-.iiii.il fat —
— Subcpicardial fat

Inferior pericardium — - Mediastinal fat

Pericardium

- Subcpliartli.il fat

(Top) first of three contrast-enhanced axial cardiac gated CT images (mediastinal window) through the heart
showing the appearance of the normal pericardium. Image at the level of the mitral valve shows the anterior
pericardium manifesting as a thin soft tissue line outlined by subepicardial fat posteriorly and mediastinal fat
anteriorly. The thin line represents the combined thicknesses of the fibrous pericardium and the serous parietal and
visceral pericardium. (Middle) Image through the orifice of the coronary sinus demonstrates the anterior
pericardium. The normal thickness of the pericardium is less than 2 mm in most cases, but can normally reach up to
4 mm. (Bottom) Image through the inferior aspect of the heart demonstrates the normal pericardium. Note the
apparent increased thickness of the inferior pericardium.
 PERICARDIUM
C O R O N A L & SAGITTAL CT, N O R M A L PERICARDIUM

Pericardium

Subepicardial fat

Pericardium
Mediastinal fal

Pericardium
1'ulmunary trunk

Subepicardial tat

Mcdiastinal fat

— Pericardium

Ascending aorta -

Pericardium

Mediastina! fat

Pericardium

Subepicardial fat —

(Top) First of three contrast-enhanced cardiac gated CT images (mediastinal window) showing the normal
pericardium. Coronal image through the anterior heart shows the normal pericardium manifesting as a thin soft
tissue line. The superior pericardium manifests as an ill-denned soft tissue hand. (Middle) Sagittal image through the
pulmonary trunk shows the anterior and posterior pericardium. The normal pericardium is usually not visible over
the atria and left ventricle. Note the superior pericardial reflection at the pulmonary trunk where the fibrous
pericardium is continuous with the vascular adventitia. (Bottom) Sagittal image through the ascending aorta
demonstrates the superior pericardial reflection. The superior pericardium surrounds the central great vessels and is
continuous with the vascular adventitia of the ascending aorta.
 PERICARDIUM
AXIAL & CORONAL M R , N O R M A L PERICARDIUM

Pericardium -
Mediastinal tat

Subepicardial fat -

— Pericardium

Pericardium ■ — Diaphragm

Normal pericardial fluid

Pulmonary trunk —
Pericardium

Diaphragm -
— Pericardium

(Top) First of six normal double inversion recovery MR images through the mediastinum. Axial image through the
inferior aspect of the heart shows the normal pericardium manifesting as a thin low signal line outlined by high
signal subepicardial and mediastinal fat. The pericardium is typically best visualized along its anterior surface on Cf
and MR imaging. (Middle) Coronal image through the aortic root shows the superior pericardial reflection that
surrounds the pulmonary trunk. (Bottom) Coronal image through the proximal aortic arch shows the thin low
signal pericardium accentuated by surrounding fat. The superior pericardial reflection is visible over the pulmonary
tmnk and contains a small amount of fluid located within the left pulmonic and superior aortic pericardial recesses
of the transverse sinus.
 PERICARDIUM
SAGITTAL MR, NORMAL PERICARDIUM

Trachea

- Right pulmonary artery

Fluid in superior aortic recess of — — Pericardium

transverse sinus
- Left atrium

I I I ,; (IllllM

Fluid in superior aortic recess of - Right pulmonary artery

transverse sinus

Pericardium —

— Left atrium

Pericardium —

Pericardium

— Pericardium
Pericardium —

(Top) Sagittal image through the ascending aorta shows the normal anterior inferior pericardium. The superior
pericaKlial reflection is also noted as is fluid in the superior aortic recess of the transverse sinus. Note the pericardial
reflection over the right pulmonary artery. (Middle) Sagittal image through the pulmonary trunk shows the anterior
and posterior aspects of the normal pericardium. The pericardium is not visible adjacent to the left atrium. There is a
small amount of fluid in the anterior portion of the superior aortic recess of the transverse sinus. (Ilottom) Sagittal
image through the left lateral aspect of the pulmonary trunk demonstrates partial visualization of the normal
pericardium. In this case, the posterior pericardium over the left ventricle is well visualized.
 PERICARDIUM
AXIAL CT, PERICARDIAL RECESSES

Superior aortic recess, anterior

portion

Superior aortic recess, posterior -

portion

Superior aortic recess, anterior

portion
Superior aortic recess, posterior
portion

Lower paratraclieal lymph nodes

Superior aortic recess, anterior

portion

Left pulmonic recess

Transverse sinus

( T o p ) First of t h r e e axial c o n t r a s t - e n h a n c e d c h e s t ("I i m a g e s ( m e d i a s t i n a l w i n d o w ) of d i f f e r e n t p a t i e n t s s h o w i n g t h e

recesses of the pericardium- The superior aortic recess (an extension of the transverse sinus) has anterior, posterior
and lateral portions. The anterior portion is triangular and projects between the ascending aorta and pulmonary
trunk. The posterior portion is crescentic in shape and is located posterior to the ascending aorta. (Middle) Axial
image through the carina shows the cleft-like anterior and crescentic posterior portions of the superior aortic recess.
Pericardial recesses are distinguished from lymph nodes based on location, morphology and attenuation. (Bottom)
Image through the right pulmonary artery shows the anterior portion of the superior aortic recess and the left
pulmonic recess. These recesses are extensions of the transverse sinus.
 PERICARDIUM
A X I A l & C O R O N A L CT, PERICARDIAL RECESSES

Superior aortic recess, lateral

portion

left pleural effusion

Right pleural effusion —

Superior aortic recess, lateral Superior aortic recess, anterior

portion portion

i'neumopcricardiuni

— Pericardial effusion

Superior aortic recess, anterior

portion

Fluid and air in inferior aortic

recess
Pncumopericardium

— Pericardial effusion

(Top) First of three contrast-enhanced chest CT images (mediastinal window) of a 42 year old man w h o sustained
penetrating chest trauma complicated by pericardial infection. Axial image through the aortic arch demonstrates
fluid in the lateral portion of the superior aortic recess. Bilateral pleural effusions are also present. (Middle) Coronal
image through the anterior portion of the aortic root, shows fluid in the lateral portion of the superior aortic recess.
Note pericardial effusion, pericardial enhancement and pncumopericardium. Fluid and air are also noted in the
anterior portion of the superior aortic recess. (Bottom) Coronal image through the aortic root shows a complicated
pericardial effusion and pneumopcricardium. Fluid and air are seen in the inferior aortic recess which extends
between the ascending aorta and the right atrium.
 PERICARDIUM
AXIAL CT, PERICARDIA! RECESSES

Superior aortic recess, anterior

portion
Ascending aorta -
— I'ulmonary trunk

Transverse sinus

Left atrium -

Superior aortic recess, anterior

Ascending aorta ■ portion

Left pulmonic recess

Superior aortic recess, posterior
portion

I— Type R aortic dissection

Superior aortic recess, anterior

portion

Superior aortic recess, posterior

portion Left pulmonic recess

Right pulmonic recess Transverse sinus

Pericardial reflection
Oblique sinus -

(Top) First of three axial contrast-enhanced chest CT images (mediastinal window) of different patients show the
transverse sinus of the pericardium and its recesses. Image through the left atrium shows the transverse sinus of the
pericardium. (Middle) Image through the pulmonary trunk shows the anterior and posterior portions of the superior
aortic rece.ss of the transverse sinus. The left pulmonic recess of the transverse sinus is also noted. Note chronic type
B aortic dissection. (Bottom) Image through the pulmonary trunk shows the transverse and oblique sinuses of the
pericardium. These sinuses d o not communicate with each other and are separated by a pericardial reflection
manifesting as a tissue plane. The recesses of the transverse sinus (superior aortic, left pulmonic and right pulmonic)
are also shown.
 PERICARDIUM
A X I A L C T , P E R I C A R D I A L RECESSES

Left pulmonic recess

- Pericardia! reflection
Oblique sinus

Post caval recess -

Oblique sinus

Right pulmonary vein recess —

Pulmonary embolus —
Right pulmonary vein recess

(Top) Contrast-enhanced chest CT (niediastinal w i n d o w ) shows fluid i n the o b l i q u e sinus o l the pericardium. There
is also f l u i d i n t h e left p u l m o n i c recess o f the transverse sinus. The transverse a n d o b l i q u e sinuses d o not
c o m m u n i c a t e w i t h each other a n d arc separated by a pericardial reflection. ( M i d d l e ) U n e n h a n c e d axial image
(mediastinal w i n d o w ) t h r o u g h t h e p u l m o n a r y t r u n k shows a small a m o u n t o f f l u i d in t h e postcaval pericardial recess
and i n the o b l i q u e sinus. The postcaval recess arises f r o m the pericardial cavity proper. A densely calcified granuloma
i n seen t h e left h i l u m . ( B o t t o m ) ( o m p o s i t e of axial a n d coronal contrast-enhanced chest CT images <mediastinal
w i n d o w ) of a patient w i t h p u l m o n a r y e m b o l i shows the r i g h t p u l m o n a r y venous recess adjacent t o t h e right inferior
p u l m o n a r y v e i n , f l u i d i n the p u l m o n a r y venous recesses may m i m i c l y m p h a d e n o p a t h y .
 PERICARDIUM
ABSENCE OF PERICARDIUM

kxul thoracic scoliosis

- Unusual cardiac configuration

Right atrium — Right ventricle

— Left ventricle

r— Cardiai apex

Anterior pericardial defect

containing lung

Ascending aorta -

Pulmonarv trunk

( l o p ) Hrst of two images of an asymptomatic 22 year old m a n with congenital absence of the pericardium. I'A chest
radiograph shows upper thoracic scoliosis and an unusual configuration of the heart characterized by an elongate
morphology and an inferior orientation of its long axis. (Middle) Axial double IR magnetic resonance image of the
chest shows displacement of the heart to the left and posterior orientation of the cardiac apex consistent with
absence of the pericardium. (Bottom) Contrast-enhanced chest Cl (lung window) of an asymptomatic 84 year old
man evaluated because of an abnormal cardiac configuration seen on chest radiography (not shown) shows
interposition of lung between the ascending aorta and pulmonary trunk in the expected location of the anterior
portion of the superior aortic recess indicating absence of the pericardium in this area.
 PERICARDIUM
PERICARDIAL CYST
n
rr
m
• ■

-a
fD
-"i

o"
Pericardia! cyst — EL
3

Pericardial cyst —

(Top) First of two images of an asymptomatic 53 year old m a n with an incidentally discovered pericardial cyst.
L'nenhanced chest Cl (mediastinal window) demonstrates an ovoid water attenuation lesion located in the right
cardiophrenic angle and abutting the right anterior pericardial surface. (Bottom) Axial T2-weighted magnetic
resonance image through t h e lesion demonstrates that it has a slightly lobular posterolateral contour a n d
homogeneous internal high signal. No foci of mural thickening or internal septations were identificd.

457
 PERICARDIUM
E PERICARDIA!. EFFUSION
3

in
QJ

U
A/ygos arch — Vascular redistribution

— CJirdiopericardial
enlargement

Subeplcanlial fat

Pericardial effusion —

Mediastinal fat —

(Top) lirst of two images of a 45 year old man witli a pericardial effusion who presented witli mild dyspnea and
chest pain. PA chest radiograph demonstrates cardiomcgaly. The cardiopericardial silhouette exhibits a globular or
so-called "water bottle" morphology. There is mild vascular redistribution and enlargement of the azygos vein
suggesting biventricular dysfunction. (Bottom) left lateral chest radiograph demonstrates cardiomegaly. The
epicardial fat sign, characterized by visualization of a water density band that measures over 4 mm in thickness, is
demonstrated. The water density band represents anterior pcricardial fluid outlined posteriorly by subepkardial fat
and anteriorly by mediastinal fat.
 PERICARDIUM
PERICARDIAL EFFUSION

Pericardia! effusion

Ascending aorta
- Pulmonary trunk

Visceral iierkardium - Subepicardial fat

Parietal pericardium
— Pericardia! effusion

"•"'«-■' i . i ■ < . ; ">.. I f a t

Subepicardial fat

Visceral pericardium
Parietal pericardium

— Pericardial effusion

(Top) First of three axial contrast-enhanced chest CY images (mediastinal window) of a 36 year old man w h o
presented with pericardial effusion secondary to viral pericarditis Image through the pulmonary trunk shows fluid
surrounding the ascending aorta and pulmonary trunk in the expected location of the pericardial cavity. (Middle)
Image through the aortic root shows a moderate pericardial effusion surrounding the heart. There is enhancement of
the serous visceral and parietal pericardial layers likely related to inflammation. (Bottom) Image through the inferior
aspect of the heart demonstrates low attenuation pericardial fluid and e n h a n c e m e n t of the serous visceral
pericardium (epicardium) that covers the heart and the underlying subepicardial fat. The serous parietal pericardium
also exhibits contrast-enhancement consistent with pericardial inflammation.
 PERICARDIUM
PERICARDIAL THICKENING & CALCIFICATION

1'cricardial calcification —

Pericardial calcification
Mild pericardial thickening -

Mild pericardial thickening and -

calcification

— Normal pericardium

(Top) left lateral chest radiograph of an asymptomatic 49 year old man shows anterior curvilinear pericardial
calcification. The heart size, pulmonary vascularity and pleural surfaces are normal. (Middle) First of two axial
contrast-enhanced chest CT images (mcdiastinal window) of a 60 year old man with incidentally discovered
pericardial calcification. Image through the right ventricular outflow tract demonstrates mild thickening and partial
calcification of the anterosuperior pericardium. (Bottom) Image through the mid aspect of the heart demonstrates
mild thickening of the anterior pericardium with focal calcification. There is no associated pericardial effusion or
morphologic abnonnality of the underlying cardiac chambers. Pericardial calcification is typically secondary to prior
injury, infection or connective tissue disease but may also be idiopathic.
 PERICARDIUM
CONSTRICTIVE PERICARDITIS

1'ericardial calcification — '

Right ventricle

Left ventricle

—
Right ventricle

— — Normal pericardium
Pericardial thickening
81 calcification

— Left ventricle
Right atriuin —

(Top) First of two axial images from a contrast-enhanced chest CT (mediastinal window) of a 67 year old man with
diastolic ventricular dysfunction secondary to constrictive pericarditis. Image through the aortic root demonstrates
focal linear calcification of the anterior aspect of the pericardium, bilateral pleural effusions and bilateral lower lobe
relaxation atelectasis. (Bottom) Image through the inferior heart shows discontinuous linear calcification of the
anterior pericardium associated with mass effect on the right ventricle, enlargement of the right atrium and coronary
sinus, bibasilar atelectasis and pleural effusions. The tubular configuration of the right ventricle is consistent with the
diagnosis of constrictive pericarditis, and the presence of pericardial calcification allows differentiation of this
condition from restrictive cardiomyopathy.
 CHEST WALL
! General Anatomy and Function
Chest Wall Anatomy
• Skin, subcutaneous fat
• Blood vessels, lymphatics, nerves
• Bone, cartilage
• Muscles
• Endothoracic fascia, fibroelastic connective tissue
between inner aspect of chest wall and costal pleura
Function
• Musculoskeletal cage: Surrounds cardiorespiratory
system; effects respiration by expanding and
contracting during ventilation
Surface Landmarks
• Suprasternal (jugular) n o t c h : At superior manubrium
ol sternum; between sternal ends of clavicles
• Sternal a n g l e : Landmark for internal thoracic
anatomy; a n t e r i o r projection at level of costal
cartilage of 2nd rib
• Costal m a r g i n : Inferior margins of lowest ribs and
costal cartilages
Skeletal Structures
Thoracic Vertebrae
• Twelve vertebrae (II-T12); normal kyphotic curve
• Articular facets for ribs on vertebrae and transverse
processes (except Tl 1 1 1 2 )
• Broad laminae and spinous processes iprojeiting
downward) overlap with those of vertebra beneath
Shoulder Girdle
• Three synovial a r t i c u l a t i o n s between clavicle,
scapula and proximal h u m e m s
Acromioelavicular, sternoclavicular, glenohumeral
joints
• O n e functional a r t i c u l a t i o n iscapulothoraiic "joint")
Mobile scapula suspended on rib cage by muscles
Sternum
• Flat, broad Inine forms anterior thoracic wall; three
parts ni.iii ubr in in. body, x i p h o i d process)
• M a n u b r i u m forms superior part of sternum
• Body articulates with m a n u b r i u m superiorly, xiphoid
process inferiorly. bilateral costal cartilages of 2nd-7th
ribs
• Xiphoid process variable size, shape, ossification:
articulates with body of sternum superiorly
Clavicle
• Slender, s-shaped hone; connects s t e r n u m t o scapula
Scapula
• I arge. triangular flat bone; parallel to upper |X>sterior
thorax; extends from 2nd-7th ribs bilaterall)
• (ilenoid tossa at glenohumeral joint
Ribs
• 12 pairs, symmetrically arrayed; numbered in
accordance with attached vertebral body
• True ribs (1-7) attach to sternum by costal cartilages
(synovial joints)
false ribs (K-IOl articulate bv costal cartilages with
costal Cartilage of 7th r i b
floating ribs (11-12) d o not articulate with sternum or
rib costal cartilages; short costal cartilages terminate in
abdominal wall muscle
Head articulates with demifacets of two adjacent
vertebral bodies; neck located between head and
tubercle of each rib; tubercle articulates with vertebral
transverse process
Body: Longest part of each rib
Angle: Most posterior part
Costal groove on inner surface of inferior border;
accommodates intercostal ueurovascular bundle
'Muscles
Pectoral
• Pectoralis major: I argest muscle in breast and
pectoral region; originates from anterior chest wall,
sternum, and clavicle; adducts, flexes and medially
rotates arm
• Pectoralis m i n o r : Deep to pectoralis major; originates
from chest wall, inserts o n t o coracoid process ol
scapula; stabilizes scapula
Intercostal
• External: Contained within 11 intercostal spaces;
extend from tubercle of ribs to costochondral junction
• Internal: Middle layer; occupy 11 intercostal spaces;
extend trom border of sternum to angle of ribs
• I n n e r m o s t : form inner layer of chest wall muscles
with snbcostalcs and traiisversus thoracis muscles
Serratus Anterior
• Thin muscular sheet; overlies lateral thoracic cage and
intercostal muscles; arises from upper eight ribs; wraps
around rib cage; inserts along medial border of
anterior surface of scapula
Back Muscles
• Superficial extrinsic muscles (connect upper limbs to
trunk; limb movement): trapezius, latissinius dorsi.
levator scapulae, r h o m b o i d s
• I n t e r m e d i a t e extrinsic muscles I superficial
respiratorv muscles); serratus posterior
• Deep intrinsic muscles (postvertebral muscles;
control posture, vertebral and head movement);
s p l e n i u s muscle, erector s p i n a e muscles, d e e p
traiisversospinalcs muscles
I Vessels
Arteries
• Internal t h o r a c i c (internal m a m m a r y ) : Branch of
subclaviau artery; descends posterior to first six costal
cartilages; supplies upper anterior Chest wall
Supplies a n t e r i o r intercostal arteries to first six
intercostal Spaces
 CHEST WALL
Veins
• Azygos vein receives drainage from posterior
intercostal veins, h e m i - a / y g o s and accessory
hemi-azygos veins
Lymphatics
• i hest wall drainage through thoracic d u c t (right
upper liml), right face and neck drained by right
l y m p h a t i c duct)
Soft Tissues
Skin and Subcutaneous Tissues
• Nipple: Superficial to 4th intercostal space (males and
prepuberal females)
Nerves
• Anterior rami of thoracic spinal nerves ( I I - I'll) supply
skin, tissues of chest wall: form intercostal nerves
• Intercostal nerves run in costal groove, between
internal and innermost intercostal muscles
• liracliial plexus: Branching network of nerve roots,
trunks, divisions, cords and branches
Spinal roots form three trunks; behind clavicle, each
dividing into anterior and posterior divisions
I Anatomic Regions
Thoracic Inlet
• Opening at superior end of thoracic rib cage; conduit
for cervical structures to enter thorax
• Bounded by Tl vertebral body, right and left 1st ribs
and their costal cartilages, and inanubrium of sternum
Thoracic Outlet
• Opening at inferior end ol thoracic rib cage; conduit
lor thoracic structures to exit thorax
• Bounded by T I 2 vertebral Ixxly, right and left 12th
ribs, costal cartilages of 7th 12th ribs, xiphisternal
joint
Suprarlavicular Region
• Supraclaviciil.ir lymph nodes in and around carotid
sheath
• l y m p h drainage ol breast superiorly to supraclavicular
and inferior deep nodes, laterally to axillary nodes,
medially to parasternal (internal mammary) and
mcdiastinal nodes, interiorly to diaphragmatic nodes
Axilla
• Pyramidal-shaped space between lateral chest and
upper arm: Ixxmded by pectoralis muscles (anteriorly),
subscapularis, latissimus dorsi and tcres major muscles
(posteriorly), convergence of axillary fold muscles
(laterally), and clavicle, scapula and outer border of
first rib (apex)
" Axillary lymph nodes drain breast, tlioraioalxlominal
wall above umbilicus, and upper arm
Breast and Pectoral Region
• Anterior and superior part of chest: muscles and fascia
assist movement of upper limb; mammary glands
„n
Imaging
Radiography
• I imited capabilities; may detect congenital
n
deformities, soft-tissue masses, bone destruction 5
Computed Tomography
• I lelical C T and multiplanar reformations optimal for OJ
visualization of osseous and soft-tissue lesions
Magnetic Resonance Imaging
• Multiplanar capabilities and advanced pulse sequences
optimal for chest wall tumor evaluation
Imaging Anatomic Correlations
Congenital and Developmental
Abnormalities
• I'ectus e x c a v a t u m (syn. funnel chest): Abnormal
growth of costal cartilages; sternal depression/rotation:
compression/obscuration ol right heart border on 1'A
radiograph
• I'ectus t arin.iturn (syn. pigeon breast): Abnormal
growth of costal cartilage: sternal protrusion
• Cervical rib: Supernumerary rib, usually arising from
seventh cervical vertebra
• Poland s y n d r o m e : U n c o m m o n ; partial or total
absence of |xxtoralis major muscle; associated
malformations of ipsilateral ribs (2-5) and clavicle;
congenital absence of ipsilateral breast tissue
Inflammatory a n d Infectious Disease
• Primary chest wall infection rare; associated with
i m m u n e suppression, dialx?tes mellitus, trauma
• Heroin addicts prone to septic arthritis of
Sternoclavicular and sternochondral joints
• Secondary involvement more c o m m o n : l-rom
pulmonary infection (tuberculous, fungal) or pleural
empvema lempyema necessitatis)
Neoplasia
• Benign
I i p o m a : Contiguous with tat in chest wall; ("I
numbers diagnostic
S m o o t h pressure erosion ol Ixjne implies slow
growth (e.g., neurotibroma)
• Malignant
C h o i u l r o s a r c o m a : Rib (11%), commonly anterior
rib near coslochondral junction; lytic. expanded,
often thick sclerotic border, chondroid calcification
(60-75%)
Myeloma: Commonly manifests as rib destruction
with associated soft-tissue mass
Metastatic disease: Destruction of ribs, thoracic
vertebrae, scapulae, clavicles, sternum
 CHEST WALL
CHEST WALL OVERVIEW

Sternal notch Stemoclavicular Joint

Acromiodavicular

m
Joint Glenohumeral joint

Manubrium of Left clavicle

sternum

Sternal angle

TYue ribs (1-7)

Body of sternum

False ribs (8-10)

Costochondral
junction Costal margin

Costal cartilage Xiphoid process

Graphic depicts the chest wall structures, forming a musculoskeletal thoracic cage that surrounds the
cardiorespiratory organs and effects respiration by expanding and contracting during ventilation.
 CHEST WALL

Trapezius muscle
Endothoraclc fascia

Posterior splnous
Rhomboid muscle process

Subscapularls muscle Transverse splnous

process

Scapula Facet joint

Teres major

Vertebral body
Latlssimus dorsl
muscle

Serratus anterior
muscle

intercostal vein, artery

and nerve
Internal mammary
External Intercostal artery
muscle
Internal mammary
Internal Intercostal lymph node
muscle
Internal mammary
vein
Innermost Intercostal Transverse thoracic
muscle
muscle

Pectoralis minor Sternum

muscle

Pectoralis major
muscle Costal cartilage
Mammary glands and Subcutaneous fat
ducts

Nipple

Graphic depicts the chest wall layers as visualized in the axial plane including skin, subcutaneous fat, blood vessels,
lymphatics, and musculoskeletal structures. The Innermost layer, t h e e n d o t h o r a d c fascia, is a fibroelastic connective
tissue layer between the inner aspect of the chest wall a n d the pleura.
 CHEST WALL
03
THORACIC INLET, SUPRACLAVICULAR AND AXILLARY REGIONS

Iin

U Tl vertebral body
(thoracic inlet,
posterior border)

Thoracic inlet, lateral

border
Thoradc inlet, lateral
border

Apex of axilla,
posterior boundary Brachial plexus

Subclavian artery and

vein

Apex of axilla, medial

boundary

Axillary artery and

vein

Manubnum of
sternum (thoracic
inlet, anterior border)

Apex of axilla,
anterior boundary

Costochondral
junction

Body of sternum

Xiphoid process of
sternum

Graphic depicts the thoracic inlet, supraclavicular structures, and the axillary regions. The thoracic inlet is bounded
by the Tl vertebral body, the right and left first ribs and their costal cartilages, and the manubrium of the sternum.
The apex of the axillary region Is bounded by the clavicle, scapula, and outer border of the first rib. Vascular
structures allow blood flow to enter and exit the thorax through the thoracic inlet and join with brachial plexus
components to supply the thorax and upper limbs.

I
466
 CHEST WALL
ANATOMY AND MR, INTERCOSTAL REGION
9
I
n
Subcutaneous fat Endothoracic fascia

J Intercostal vein
External Intercostal •*>
muscle
■ — Intercostal artery
Internal intercostal —
muscle
Intercostal nerve
Innermost intercostal
muscle 1—

Visceral pleura

p
w^
Parietal pleura

Collateral branches

Subcutaneous fat
Intercostal
neurovascular bundles

Serratus anterior
muscle

(Top) Graphic demonstrates details of the intercostal region, showing three layers of intercostal muscles (external,
Internal and innermost) between the ribs. The costal groove along the inferomedial aspect of each rib accommodates
the intercostal neurovascular bundle (vein, artery and nerve). Small collateral branches of the major intercostal
vessels and nerves may be present above the body of the subjacent rib. The endothoracic fascia forms a connective
tissue layer between the inner aspect of the chest wall and the costal parietal pleura. (Bottom) Detail of a coronal MR
section through the right lower chest wall demonstrates the Intercostal neurovascular bundle as an ovoid area of
increased signal intensity.

4(>
 CHEST WALL
AXIAL CT, N O R M A L CHEST WALL

in
a> - Sternocleidomastoid muscle
Skin -
U
■ • - Pectoralis major muscle
Subcutaneous fat -
m

Trapczius muscle 1st rib

Rhomboid muscle Transvcrsospmal muscle

Sternohyoid & sternothyroid

muscles
Clavicle
Pectoralis major muscle -
Left subclavlan artery
1st rib
Pectoralis minor muscle
2nd rib

Axillary artery and vein

Humeral head

Trapezius muscle — - Rhomboid muscle

Medial end of clavicle

Medial end of clavicle - - Pectoralis major muscle

- Pectoralis minor muscle

Axillary bundle - - Left axillary vein

- Subscapularis muscle
Teres major muscle —
Supraspinatus muscle
Subscapularis muscle - - Deltoid muscle
Humeral head
- Infraspmatus muscle
Deltoid muscle -
I ■ Scapular spine
(ilenoid of scapula —-
- I'rapezius muscle
—
Scrratus anterior muscle
- Rhomboid muscle
Intercostal muscles —

(Top) First of six axial contrast-enhanced CT images (mediastinal window) demonstrating normal chest wall
structures. The first image demonstrates chest wall muscles in the supraclavicular region. (Middle) CT image through
the lung apices includes normal subclavian and axillary vessels. (Bottom) CT image at the level of the medial
clavicles demonstrates muscles related to the scapula.

I
-J68
 CHEST WALL
AXIAL CT, N O R M A L CHEST WALL
n
(V
• ■

Pectoralis major muscle n

IT-
2
Pecroralis minor muscle -
a>
Latissimus dorsi muscle
Teres major and minor muscles
Subscapularis muscle

lnl'raspinatus muscle
_
Trapezius muscle
Rhomboid muscle

Pectoralis major muscle

Pectoralis minor muscle -

Latissimus dorsi muscle

Teres major and minor muscles
Subscapularis muscle

i— Infraspinatus muscle

Trapezius muscle -
Rhomboid muscle

Pectoralis major muscle -

Serratus anterior muscle -

Teres major muscle

latissimus dorsi muscle
Teres minor muscle
Subscapularis muscle

Infraspinatus muscle
Trapezius muscle

Rhomboid muscle

(Top) Cl image through the level of the aortic arch branches (Middle) CT image at the level of the aortic arch.
(Bottom) CT image through the subcarinai region.

I
46')
 CHEST WALL
AXIAL MR, NORMAL CHEST WALL
TO

QJ

U
External jugular vein - Sternocleidomasloid muscle
Ol

U
r— Scalene muscles

Trapezius muscle
Erector spinae muscles
Eevator scapulae muscle
Spinal cord

Clavicle
I'ectoralis major muscle Subclavian artery and vein

left lung apex

Subscapularis muscle
Humeral head
Glcnoid of scapula

Deltoid muscle
Trapezius muscle
Infrasplnatus muscle — Rhomboid muscle

I'ectoralis major muscle —

Sternum

I'ectoralis minor muscle —

Latissiinus dorsi muscle Serratus anterior muscle

Subscapularis muscle

Scapula
— Rhomboid muscle
Infrasplnatus muscle
— Trapezius muscle

(Top) Hrst of six axial IT-weighted MR images demonstrating normal chest wall structures. The first section is
through the supradavicuiar region. (Middle) Axial MR image through the lung apices. (Bottom) Axial MR image at
the level of t h e aortic arch.

I
■170
 CHEST WALL
AXIAL M R , N O R M A L CHEST WALL
n
3"
rT>
• ■

Pectoralis major muscle - Sternum

n
01
Pectoralis minor muscle
QJ

Latissimus dorsi muscle

Serratus anterior muscle

Subscapularis muscle

Scapula
- Rhomboid muscle
Inbaspinatus muscle -
Trapezius muscle

Sternum
Pectoralis major muscle

Pectoralis minor muscle

— Serratus anterior muscle

Subscapularis muscle

Scapula Rhomboid muscle

Infraspinatus muscle
Trapezius muscle

Pectoralis major muscle -

Serratus anterior muscle

Latissimus dorsi muscle "

Infraspinatus muscle Trapezius muscle

Serrnhis anterior muscle - Transversospinalis muscle

(Top) Axial MR image at the level of t h e aortico-pulmonary window. (Middle) Axial MR image through t h e
pulrnonary arteries. (Bottom) Axial MR image t h r o u g h the lower lobes a n d inferior p u l m o n a r y veins.

I
471
 CHEST WALL
C O R O N A L CT, N O R M A L CHEST WALL

— Sternoclavicular joints

Pectoralis major muscle Pectoralis major muscle

Pectoralis minor muscle Pectoralis minor muscle

Serratus anterior muscle ~ Scrratus anterior muscle

_
Carotid arteries

Subclavian artery
I atissimus dorsi muscle Subclavian vein

V 11atus anterior muscle Serratus anterior muscle

Subscapularis muscle -" Subscapularis muscle

Latissimus dorsi muscle —

Scrratus anterior muscle —

" Serratus an terior muscle

(Top) First of six coronal contrast-enhanced chest CT images (bone window) shown from anterior to posterior
demonstrate normal chest wall muscles. The first section is through the level of the sternoclavicular joints. (Middle)
Coronal CT section through the level of the pulmonary arteries. (Bottom) Coronal CT section through the level of
the carina.
 CHEST WALL
CORONAL CT, NORMAL CHEST WALL

Subscapularis muscle
Infraspinatus muscle
Lcvator scapulae muscle

latissimus dorsi muscle —

— Intercostal muscles

Supraspinatus muscle
Trapezlus muscle

Levator scapulae muscle Subscapularis muscle

Infraspinatus muscle

_
Latissimus ilorsi muscle
— Intercostal muscles

Trapezius muscle - — Supraspinatus muscle

Transvcrsospinalis muscle

Infraspinatus muscle

Latissimus ilorsi muscle

Posterior spinous processes - Intercostal artery

Erector spinae muscle

(Top) Coronal CT section through the level of the descending thoracic aorta. (Middle) Coronal CT section through
the level of the thoracic spinal canal. (Bottom) Coronal CT section through the level of the posterior ribs and
posterior spinous processes.
 CHEST WALL
CORONAL MR, NORMAL CHEST WALL
Slernohyoid muscle
Stcrnocleidomastoid muscle -
Clavicle
Deltoid muscle —
Pectoralis major muscle

— Pectoralis minor muscle

Serratus anterior muscle —

- External oblique abdominal

muscle

Subclavian vein — - Anterior scalene muscle

Clavicle — - Deltoid muscle

Subclavius muscle —

- Scrratus anterior muscle

External oblique abdominal

muscle
- Posterior scalene muscle

Subclavian artery — Anterior aspect of brachial

plexus
Pectoralis major muscle

— Pectoralis minor muscle

- Serratus anterior muscle

External oblique alxltiminal

muscle
(Top) First of six coronal Tl-weighted MR images demonstrating normal chest wall structures (shown from anterior
to posterior). The first section is through the medial clavicles. (Middle) Coronal MR section through the level of the
subclavian veins. (Bottom) Coronal MR section through the level ot the subclavian arteries and anterior aspect of the
brachial plexus.
 CHEST WALL
CORONAL MR, NORMAL CHEST WALL
Brachial plexus — Trapezius muscle
Supraspinatus muscle

Humeral head

Ctenoid of scapula
X— Substapularis muscle

— Serratus anterior muscles

— Latissimus dorsi muscle

Trapezius muscle

Infraspinatus muscle

Substapularis muscle -

Scrratus anterior muscle — Spinal cord

1 atissimus dorsi muscle —

Trapezius muscle

Rhomboid muscle

Scrratus anterior muscle

Intercostal neurovascular
Latissimus dorsi muscle bundles

( l o p ) Coronal MR section through the brachial plexus and prevertebral structures. (Middle) Coronal MR section
through t h e level of t h e thoracic spinal canal. (Bottom) Coronal MR section through t h e level of t h e posterior ribs.
 CHEST WALL
RADIOGRAPHY AND CT, STERNUM

Right 1st rib — — left Ist rib

Right stcrnoclavicular Left sternoclavicular

joint joint

Articulation of right 1st - Articulation of left 1st

rib and lateral aspect of rih and lateral aspect of
manubrium manubrium

Stcrnoclavicular joint
Manubrium of sternum

Right internal
mammary artery Articulation of Ist rib
and manubrium

Body of sternum —

Costochondral Xiphoid process

junction

Costal cartilage
calcification

(Top) Normal eoned-down PA chest radiograph demonstrates partial visualization of the manubrium of the sternum,
the stcrnoclavicular joints, and the characteristic course of the 1st ribs and their articulations with the lateral aspects
of the manubrium. (Bottom) Contrast-enhanced chest CT (3D rendering) of a normal 20 year old man demonstrates
the manubrium, body, a n d xiphoid process of the sternum. The xiphoid process is slender and elongated, a variation
of normal anatomy. There is faint calcification of the 9th and 10th costal cartilages. The internal mammary arteries
are visualized bilaterally.
 CHEST WALL
RADIOGRAPHY AND CT, POLAND SYNDROME
n
3"
O
••
n
Subtle increased lucency, right
rr
hemithorax
OJ

Abnormal contour of right anterior -

chest wall

Right |x.'Ctoral prosthesis

Pectoralis major muscle

Pectoralis minor muscle

Pectoral muscle prosthesis -

(Top) First of three images of a woman with Poland syndrome. I'A chest radiograph demonstrates subtle increased
lucency of the right hemithorax and asymmetry of the breast soft tissue density. (Middle) Lateral chest radiograph
demonstrates asymmetry of chest wall soft-tissues manifesting as an abnormal contour coursing across the anterior
chest wall. The abnormal contour reflects the lack of pectoralis major musculature in the right upper thorax.
Increased density inferiorly represents a prosthesis inserted t o compensate for the lack of musculature in the right
anterior chest wall. (Bottom) Contrast-enhanced chest f T demonstrates a pectoral muscle prosthesis in the
subcutaneous tissues of the right anterior chest wall. There is congenital absence of the right pectoralis major a n d
pectoralis minor muscles. Courtesy of Jerry Speckman, MD, University of Florida. I
477
 CHEST WALL
R A D I O G R A P H Y , PECTUS EXCAVATUM

Indistinct right heart

border

Sternum displaced
posteriorly

(lop) First of four images of a patient with pectus excavatum deformity. PA chest radiograph demonstrates an
indistinct right heart border and exaggerated vertical course of the anterior portions of the ribs. (Bottom) Lateral
chest radiograph demonstrates posterior displacement of the sternum with resultant narrowing of the
anteroposterior distance between the sternum and thoracic vertebrae.
 CHEST WALL
CT, PECTUS EXCAVATUM

Manubrium of sternum -■

Hodv of sternum —

Posteriorly displaced
sternum

Depression in anterior
chest wall

— Atelectasis, left lower

lobe

Bilateral pleural —
effusions

(lop) 3D reformatted chest CT image of rotated thorax demonstrates pectus excavatum with posterior displacement
of the mid-to-inferior body of the sternum. (Bottom) Contrast-enhanced chest CT (mediastinal window)
demonstrates posterior displacement of the lower sternum and associated depression of the anterior chest wall.
 CHEST WALL
R A D I O G R A P H Y , PECTUS C A R I N A T U M

Outward bowing of —
sternum

(Top) First of two chest radiographs of a patient with pectus carinatum. PA radiograph appears normal. (Bottom)
Lateral radiograph demonstrates outward bowing of the sternum and adjacent costochondral elements. There is
increased distance between the upper sternum and thoracic vertebrae.
 CHEST WALL
RADIOGRAPHY, KYPHOSCOLIOSIS

Marked dcxtroscoliosis

Elevated left
hemidiaphragm

Marked thoracic
kyphosis

Elevated left
hemidiaphragm

( l o p ) First o f t w o chest radiographs d e m o n s t r a t i n g marked kyphoscoliosis. I'A radiograph demonstrates marked

dcxtroscoliosis and associated loss o f v o l u m e i n the lefl h e m i t h o r a x o n t h e concave aspect o f t h e thoracic spinal
d e f o r m i t y manifested by elevation o f t h e left h e m i d i a p h r a g m . (Bottom) Lateral radiograph demonstrates marked
k y p h o t i c d e f o r m i t y o f the thoracic spine a n d elevation o f t h e left h e m i d i a p h r a g m .
 CHEST WALL
RADIOGRAPHY, CERVICAL RIBS AND POST-TRAUMATIC DEFORMITY

C7 vertebral body

T l vertebral body

Right cervical rib —

Left cervical rib

Synchondrosis between
cervical r i b a n d 1st rib

Right 1st rib

— Left 1st rib

— Healed fractures of left

5th-9th ribs

(Top) Coned-down PA chest radiograph demonstrates bilateral cervical ribs arising from the C.7 vertebral body. The
distal aspect of the left cervical rib forms a synchondrosis with the mid-portion of the left 1st rib. (Bottom) PA chest
radiograph of a patient who sustained trauma and multiple left rib fractures 10 years prior to this examination
demonstrates deformity of the left lateral chest wall. Multiple healed rib fractures are shown, involving the left 5th
through 9th ribs. Associated mild pleural thickening manifests as hazy opacity overlying the left lateral hemithorax.
 CHEST WALL
R A D I O G R A P H Y A N D CT, COSTAL C A R T I L A G E C A L C I F I C A T I O N n
3"
n
in
■ ■

n
IT
5
OJ

— Costal cartilage
Costal cartilage — calcification
calcification

— Costal cartilage
Costal cartilage calcification
calcification

(Top) I'A chest radiograph o f a 77 year o l d w o m a n demonstrates local a n d band-like calcification o f the costal
cartilages o f t h e 7th t h r o u g h 11th ribs. ( B o t t o m ) 3 D reformatted chest image o f a n elderly female demonstrates
bilateral costal cartilage calcification.

I
4RJ
 CHEST WALL
RADIOGRAPHY AND CT, PSEUDONODULE

Pseudonoduie

Healed fracture, left .Jrd

rib

(Top) PA chest radiograph demonstrates a focal area of increased opacity overlying the anterior aspect of the left 3rd
rib, suggesting the presence of a solitary pulmonary nodule (so-called pseudonoduie). (Bottom) Chest CT (bone
window) demonstrates a healed fracture of the anterior aspect of the left third rib manifesting as a focal area of
sclerotic change that correlates with the suspicious abnormality on the chest radiograph. On chest radiographs, chest
wall abnormalities may mimic the presence of underlying pulmonary pathology.
 CHEST WALL
RADIOGRAPHY, NEUROFIBROMATOSIS

Skin nodules
(ncurofibromas)

Skin nodules
(neurofibronias)

Smooth pressure
erosion, inferior
margin, right 7th rib

(Top) Coned-down chest radiograph of a patient with cutaneous neurofihromatosis demonstrates multiple nodular
opacities overlying the right lung and visible on the skin in the supraclavicular region. Chest wall nodules such as
ncurofibromas, may overly lung parenchyma and mimic the presence of pulmonary nodules. (Bottom) Coned-down
chest radiograph of a patient with neurofihromatosis demonstrates a ncurofibroma in the right posterior chest wall
producing smooth pressure erosion along the undersurface of the right 7th rib. Pressure erosion along an inferior rib
margin and the presence of an associated soft-tissue mass suggests the presence of a slowly growing lesion, such as a
neurofibroma, originating in the intercostal neurovascular bundle. Incomplete bonder visualization and associated
pressure erosion suggests the diagnosis of a neurogenic neoplasm.
 CHEST WALL
RADIOGRAPHY AND CT, EXTRAMEDULLARY HEMATOPOIESIS

Paraspinal masses —

— Expanded antertor rib

Marrow expansion, rill —

a n t l transverse process

Soft tissue masses

adjacent t o areas o f
m a r r o w expansion

(lop) first of two images of a 24 year old man with thalassemia major and profound hemolytic anemia. I'A chest
radiograph demonstrates expansion of ribs and other osseous crythroid bone marrow spaces and coarsened
trabeculation. Bilateral paraspinal soft tissue masses are also present. (Bottom) Contrast-enhanced chest CT (bone
window) demonstrates marrow expansion of skeletal Structures and adjacent soft tissue masses representing
extramedullary hematopoiesis.
 CHEST WALL
CT, CHEST WALE INFECTION

Indistinct area of Increased opacity -

Chest wall abscess -

Lung abscess

Soft tissue mass

Osseous destruction

Right brachioccphaiic vein —

(Top) first ot two images of a 54 year old diabetic m a n with a tender, palpable mass in the right anterior chest wall.
PA chest radiograph demonstrates an indistinct area of increased density overlying the right upper chest wall.
(Middle) Sagittal MR demonstrates a lung abscess extending into the adjacent anterior chest wall, manifesting as a
heterogeneous mass with an irregular central area of low signal intensity. Culture of an aspirated specimen revealed
Streptococcus pneumoniae. (Kottoni) Contrast-enhanced chest CT of a 34 year old heroin addict demonstrates
infection of the right sternoclavicular joint manifesting as osseous destruction and soft tissue mass obscuring tissue
planes and displacing the right subclavian vein posteriorly. Cultures revealed Staphylococcus aureus. Courtesy of
Elizabeth Moore, MD, University of California-Davis.
 CHEST WALL
CT, FIBROUS DYSPLASIA AND CHEST WALL LIPOMA

— Fibrous dysplasia, left 4th rib

Peripheral opacity with incomplete -

border

Chest wall lipoma

Displaced serratus anterior

muscle

(Top) Chest CT (bone window) demonstrates fibrous dysplasia involving the lateral aspect of the left 4th rib,
manifesting as irregular fusiform enlargement and deformity with cortical thickening. (Middle) First of two images
of a 57 year-old man with a chest wall lipoma, manifesting on a coned-down PA chest radiograph as a focal
peripheral opacity in the left hemithorax. The opacity has an incomplete border, a finding consistent with an
extraparenchymal lesion occurring in the pleura or chest wall. (Bottom) Contrast-enhanced chest CT (mediastinal
window) demonstrates a chest wall lipoma manifesting as a fat attenuation lesion producing focal mass effect within
the chest wall and protruding into the thoracic cavity. The lipoma displaces the serratus anterior muscle laterally.
 CHEST WALL
RADIOGRAPHY AND CT, OSSEOUS METASTASES

Focal destruction, right 6th rib -

— Soft tissue mass with

incomplete lx>rders

— Osseous metastases
Osseous metastases -

_
Osseous metastases

■ — Metastatic nodule

— Osseous metastases

(lop) Coned-down PA chest radiograph demonstrates focal destruction of the lateral aspect of the right 6th rib with
an associated soft tissue mass that manifests with incomplete borders. Biopsy revealed metastatic renal cell
carcinoma. (Middle) First of two images of a 53 year old man with metastatic breast cancer. PA chest radiograph
demonstrates diffuse osseous metastases manifesting as sclerotic and lytic: lesions involving the spine, ribs, clavicles,
scapulae and both humeri. (Bottom) Contrast-enhanced chest CT (bone window) demonstrates sclerotic and lytic
metastases involving the thoracic spine, ribs, sternum and scapulae. A metastatic nodule is demonstrated in the left
upper lobe.
 CHEST WALL
RADIOGRAPHY, METASTAT1C BREAST CANCER

Right breast mass —

Right breast mass

(Top) First of three images of a 47 year old woman with mctastatic breast cancer. PA chest radiograph demonstrates a
smoothly bordered mass that appears associated with the medial aspect of the right breast. (Bottom) Lateral
radiograph confirms its association with the right breast but the underlying anterior chest wall is obscured
 CHEST WALL
CT AND ANATOMY, METASTATIC BREAST CANCER

Right breast mass

Axillary vein lymph

nodes
Supraclavlcular lymph
nodes
Sub-clavicular lymph
nodes
Central lymph nodes

Sub-clavicular lymph
nodes
Q Scapular lymph nodes

V'

Internal mammary
lymph node chains
o Pectoral lymph nodes

Inferior external
mammary lymph
nodes

(Top) Contrast-enhanced chest CT (medlastinal window) demonstrates a heterogeneous mass within the right breast
and involvement of the adjacent anterior chest wall and internal mammary lymph nodes. Biopsy revealed invasive
breast cancer. (Bottom) Superficial lymphatic vessels of the thoracic wall converge on the axillary nodes. Axillary
lymph nodes drain lymphatics from the breast, the upper limb, and the thoracoabdominal wall above the umbilicus.
Internal mammary lymph node chains course along each internal mammary artery and drain afferents from the
mammary gland, the anterior abdominal wall, the superior hepatic surface, and deeper parts of the anterior thoracic
wall. Their efferent lymphatics join with tracheobronchial and brachlocephallc nodes to form the
bronchomediastinal trunk.
 CHEST WALL
CT, LYMPHOMA

PrevaMiilar
Right paratracheal ly mphadenopat hy
I \ r 11111 laderu jpiittiy
Left axillary
lymphadenopathy

Right axillary
lymphadenopathy

Right internal
mammary (parasternal) I'revascular
lymphadenopathy lymphadenopathy

Right paratracheal
lymphadenopathy

Left axillary
Right axillary lymphadenopathy
lymphadenopathy

(Top) first of two contrast-enhanced chest CT images (mediaslinal window) of a patient with lymphoma
demonstrates bilateral axillary, prevascular and right paratracheal lymphadenopathy. (Bottom) At the level of the
aortic arch, CT demonstrates bilateral axillary, right internal mammary, prevascular, and right paratracheal
lymphadenopathy and a small right pleural effusion.
 CHEST WALL
CT A N D R A D I O G R A P H Y , C H O N D R O S A R C O M A A N D CHEST WALL METASTASIS

Chondrosarcoma —
C'hondroid
calcification

Left pectoralis major

muscle
Right pectoralis major —
muscle

Left Rth rib lesion

Soft tissue mass

(Top) Contrast-enhanced chest CT (mediastlna] window) of a 43 year old man with chondrosarcoma demonstrates a
large heterogeneous mass w i t h chondroid calcification projecting from the anterior chest wall and right
costochondral region and elevating the right pectoralis major muscle. (Kottom) I'A chest radiograph in a 47-year old
man with metastatic renal cell carcinoma. There is an expansile, lytic lesion in the posterior aspect of the left 8th rib.
An associated soft-tissue mass shows incomplete borders, a finding consistent w i t h a chest wall mass.
 PART 11
Abdomen

Embryology of the Abdomen

Abdominal Wall
Diaphragm
Peritoneal Cavity
Vessels, Lymphatic System and Nerves
Esophagus
Gastroduodenal
Small Intestine
Colon
Spleen
Liver
Biliary System
Pancreas
Retroperitoneum
Adrenal
Kidney
Ureter and Bladder
 EMBRYOLOGY O F THE A B D O M E N
[Cross Anatomy
Early Embryologic Events
• Yolk sac provides nutrition to early embryo
Broad opening into primitive gut
a Yolk stalk is connection between yolk sac and gut
■ Ik-comes progressively longer and thinner as fetus
develops
■ Connects distal midgut to umbilical cord
■ In neonate, atrophies and disappears (failure to
regress completely may result in Meckel
divcrticulum, blind outpouching from distal
ileum
i Gut is suspended from anterior and posterior
abdominal walls by ventral a n d dorsal mesenteries
■ Mesenteries separate t o enclose developing
alimentary tube
• In early fetal life, Important viscera develop in
mesentery of caudal part of foregut
< Fetal stomach is suspended by 2 mesogastria
■ Dorsal mesogastrium Site for developing spleen,
body-tail of pancreas
■ Ventral m e s o g a s t r i u m : Site lor developing liver,
bile ducts, head of pancreas
• Ventral "bud" migrates clockwise around duodenum
and subsequently merges with dorsal bud to join
pancreatic and biliary tree within pancreatic head
• Dorsal part of ventral mesogastrium becomes lesser
oinenlimi
In adult, lesser o m e n t u m includes the gastrohepalic
l i g a m e n t and h e p a t o d u o d e i i a l l i g a m e n t
■ Gastrohepatic ligament carries left gastric artery
and vein, celiac nodes
■ Hepatoduodenal ligament carries portal vein,
hepatic artery, bile duel and hepatic/eeliac nodes
Fetal Vessels
• Major fetal arteries course anteriorly through dorsal
mesenteries from the aorta to supply gut and
intramesenteric viscera
• Umbilical vein
c Carries oxygenated blood from placenta to fetus
o Major source of blood flow to fetal liver
i Lnters liver through ventral part ot ventral
mesentery, which becomes falciform ligament in
adults
c Obliterated umbilical vein becomes l i g a m e n t u m
tercs
• Vitelline veins
c Paired vessels that carry blood from yolk sac to fetus
in 1 st few weeks of gestation
i Give rise to venous plexus within liver
» Precursor t o hepatic a n d portal veins a n d
sinusoids
c Proximal extrahepatic veins evolve into portal
v e n o u s system
■ Carries blood (and nutrients) from gut to liver
■ Proximal vitelline veins are precursors to h e p a t i c
veins
■ Carry blood from liver to heart via inferior vena
cave(IVC)
• Ductus venosus
Derived from left umbilical vein (after right vein has
atrophied)
0 Acts as a bypass ol the liver to carry umbilical vein
blood primarily to IVC and heart
•- In neonate, atrophies t o become l i g a m e n t u m
v e n o s u m ion posterior surface of liver near porta
hepatis)
• Portal sinus
- In fetus, diverts some oxygenated blood from
umbilical vein to liver parenchyma
Liver
• Arises from ventral bud of foregut
• Rapid growth is main factor in distortion of peritoneal
spaces and mesentery
• Rotates counterclockwise and attaches to right side of
diaphragm at bare area
• Rotation of liver results in right peritoneal space
extending to the left, posterior to stomach
1
Becomes lesser sac ( o m e n t a l btirsa)
Spleen
• Develops within dorsal mesogastrium. which
elongates to form gastrosplcuic ligament
■ Carries short gastric vessels and forms left anterior
wall of lesser sac ( o m e n t a l bursa)
I longated caudal parts of gastrosplcuic ligament
hang down like a drape from stomach
■ l-orms greater o m e n t u m and gastrocolic
ligament
i Greater o m e n t u m and gastrocolic ligament carry
gastroepiploic (gastro-oniental) vessels
Pancreas
• Develops within dorsal part of dorsal mesentery,
which usually fuses with posterior abdominal wall
< Leaves onlv a short s p l e n o r e n a l l i g a m e n t
■ Carries splenic vessels a n d tail of pancreas
■ Forms left posterior wall of lesser sac
• Pancreas becomes a retroperitoneal organ
Small and Large Intestine
• Duodenum
. In fetus, is "intraperitoneal", has a mesoduodenum
■ Ventral pancreas also lies in mesoduodenum
i Becomes retroperitoneal organ when ascending
mesocolon fuses to posterior abdominal wall,
"trapping" d u o d e n u m and pancreas in
retroperitoneum
• Small intestine
i Develops within dorsal mesentery which elongates
and persists into adulthood as small bowel
mesentery
■ Carries superior mescnteric vessels
• Large intestine (colon)
Develops as a straight tul>c within dorsal mesentery
• Small and large intestine elongate greatly and herniate
out through fetal umbilicus
• Bowel returns to fetal abdomen after counterclockwise
rotation around the axis ol superior mesenteric vessels
Degree of rotation is variable according to segment
of bowel
■ Transverse colon 90"
■ Ascending colon 1H(T
 EMBRYOLOGY OF THE ABDOMEN
■ Small intestine 270 c
• Ascending and d e s c e n d i n g colon usually lose their
mesentery and become retroporitoneal structures in
adull
Common variant: Ascending colon that is mobile
due to a persistent mesocolon (predisposes to twist
& obstruction of colon, "cecal volvulus")
• Mesentery for transverse colon persists (transverse
mesocolon)
' Attaches to posterior abdominal wall anterior to
pancreas and duodenum
Root ot transverse mesocolon divides peritoneal
cavity o n t o supramesocolic and inframesocolic
components
■ I hese spaces communicate onlv laterally via
paracolic gutters (recesses)
Peritoneal Spaces
• Ventral mesentery resorbs to allow communication
between right and left peritoneal cavity in adults
• Variations in complex rotation, fusion and growth ot
mesenteric viscera result in c o m m o n variations in
peritoneal and retroperitoncal spaces in adults
• All peritoneal recesses potentially communicate
Adhesions between peritoneal surfaces may seal off
loculated collections of fluid
A b d o m i n a l Viscera
• Intraperitoneal contents ot abdomen derive from
Alimentary tube
■ loregut (esophagus, stomach, duodenum);
supplied by branches of celiac artery
• Midgul (small intestine, colon up to splenic
flexure); supplied by superior mesenteric artery
(SMA)
■ H i n d g u t (descending a n d sigmoid colon, rectum);
supplied by inferior mesenteric artery (IMA)
Supporting mesentery
c Intramcseiiterk viscera
■ Develop from buds ("divcrticula") ot ventral or
dorsal forcgut
Extraperitoneal Spaces
• Includes all structures lying lietween posterior
parietal peritoneum and transvcrsalis fascia
• Components: Abdominal r e t r o p e r i t o n e u m and
pelvic e x t r a p e r i t o n c u m iperivesical and prevesical
spaces)
I'revesical space surrounds perirectal and perivesical
spaces
■ Continuous with presacral space and
retroperitoneum
• Mxloininal retro|K'ritoneuni consists ot a n t e r i o r and
posierior pararenal and periicnal spaces
these potentially Communicate with each other,
especially via iuterfascial planes and perirenal
septa
( ommuiiication with intraperitoneal structures
■ Bowel via suhitcritoiieal space Iwtween leaves of
small bowel mesentery and transverse
mesocolon
■ Viscera via ligaments (e.g., gastrohepatic
ligament -» liver; spleen via gastrosplenic a n d
splcnorcnal ligaments)
D e v e l o p m e n t of G e n i t o u r i n a r y (GU) System
• Urinarv system in early fetus
Goes through stages of development similar to those
found in more "primitive" animals (e.g.,
invertebrates, amphibians)
■ In h u m a n fetus, p r o n e p h r o n degenerates and is
replaces by m e s o n e p h r o n
■ Mesonephron degenerates and is replaced by
mctaiiephriMi which develops into permanent
kidney
■ Degeneration proceeds from t o p t o bottom
(cephalnd to caudal); caudal end of mesoncphric
duct persists a n d differentiates into Miillerian and
Woiffian d u c t s (primordial forms of internal
genitalia)
a M c t a n c p h r i c d u c t (ureteric bud)
■ Distal end enters urinary bladder, becomes ureter
■ Proximal end extends into earls kidney and
brandies to form caliecs and collecting d u c t s
Allantois (uraclius)
■ Connects fetal bladder to umbilical cord
■ In neonate. atrophies to become urachal
r e m n a n t ( m e d i a n u m b i l i c a l ligament)
i Development and "ascent" of kidneys
■ Early fetus, kidneys lie low in jx-lvis, close
together, renal hila facing anteriorly
■ Fetal kidneys comprised of contiguous lobules
(which remain unfused in some animals; may
persist as "fetal lobation" in humans)
■ Fetal kidneys successively "recruit'' arterial hlrxx.1
supply from iliac arteries and aorta
■ C o m m o n anomalies: Renal ectopia, usually
accompanied by low position, abnormal rotation,
multiple anomalous blood supply; renal fusion
anomalies (e.g., horseshoe kidney, crossed fused
ectopia)
Genital Tract Development in Fetus
" Male fetus
Miillerian ducts mostly disappear
Wolllian duct gives rise to epididymis, ductUS
deferens, seminal vesicle and ejaculatory tract
Urngenital sinus evolves into urethra and bladder
• female fetus
Lower Miillerian ducts unite to form ulerovaginal
canal
Uutused Miillerian ducts become fallopian tubes
u Invagination of perineum forms distal vagina
• C o m m o n congenital anomalies
Reflect errors of insertion, differentiation,
development of portions of GU system
Often occur in combinations on same (ipsilateral)
side
■ Examples: Renal agenesis + absence of seminal
vesicle
Duplicated ureter may empty into vagina
Distal portions of Gl and GU system may retain
communication, like fetal cloaca
o Rectum and/or vagina may fail to open o n t o the
perineum (e.g., imperforate anus)
11 A m b i g u o u s genitalia, failure of progressive fetal
differentiation may result in perineal structures with
features of both male and female genitalia
 EMBRYOLOGY OF THE ABDOMEN
18 DAY EMBRYO (LATERAL)

Yolk sac

Extra-embryonic
celom

Body stalk (in

umbilical cord)

Midgut

Amniotic fluid

Plane for
cross-sectional image Plane for
#2 cross-sectional image

^^m

Lateral illustration of an 18 day embryo. The roof of the yolk sac becomes incorporated in the form of a tube, the
primitive gut. The cranial end of the tube becomes the foregut and the caudal end, the hindgut.
 EMBRYOLOGY OF THE ABDOMEN
18 DAY EMBRYO (CROSS-SECTION) >
Q.
O
3
CD
3
m
3
cr
Yolk sac
o
o
CQ

Extra-embryonic celom
>
Splanchnic mesoderm cr
o.
o
Mldgut
3
Dorsal mesentery CD
Somatic mesoderm 3

Amniotic cavity

Neural tube

Yolk sac
Extra-embryonic celom

Ventral mesentery

Amniotic cavity Abdominal cavity (left

division)
Splanchnic mesoderm Mldgut
Abdominal cavity
(right division)
Dorsal mesentery

Neural tube

(Top) Cross-sectional illustration along plane #1 indicated o n the lateral 18 day embryo. The mldgut has a wide
communication with the yolk sac at this phase. (Bottom) Cross-sectional illustration along plane #2 indicated on the
lateral 18 day embryo. The gut is suspended by the ventral and dorsal mesenteries.

II
 EMBRYOLOGY OF THE ABDOMEN
4 WEEK EMBRYO (LATERAL)

Extra-embryonic
Yolk sac
celom

Allantois (In umbilical

cord)

Hindgut
v /*r

Pharynx

Lung bud

Stomach
Hepatic dtverticulum
Amniotlc cavity

Plane for
cross-sectional image
Plane for
cross-sectional image

%=
*\

Lateral illustration of a 4 week embryo. The pharynx and lung bud arise from the foregut, along with the stomach.
The allantois connects the body stalk to the hindgut. The yolk sac communicates broadly with the primitive gut.
Errors in development include communication between the foregut branches, such as a tracheo-esophageal fistula.
 EMBRYOLOGY OF THE ABDOMEN
4 WEEK EMBRYO (CROSS-SECTION) >
a.
o
3
CD
Extra-embryonic celom
Yolk sac
m
3

Amnlorlc cavity
o
o
Ventral mesentery CO

Hepatic diverticulum o

CD
Duodenum >
Abdominal cavity Q.
Visceral peritoneum O
and dorsal mesentery B
Dorsal pancreas CD
Parietal peritoneum
3

Neural tube

Amnlotic cavity
Persisting edge of
ventral mesentery

Abdominal cavity

[ £ - Mldgut

Dorsal mesentery

7^B Parietal peritoneum

Visceral peritoneum

(Top) Cross-sectional illustration along plane #1 Indicated on the lateral 4 week embryo. The liver arises from a
ventral bud of the foregut, while the pancreas arises from the dorsal mesentery. (Bottom) Cross-sectional illustration
along plane #2 indicated on the lateral 4 week embryo. The ventral mesentery begins to disintegrate to allow
communication between right and left sides of the abdominal cavity.

II
7
 Gallbladder Ventral pancreas

Umbilical cord
AUantoic stalk
Mesocolon of hindgut

The transverse septum grows as a shelf from the anterior body wall, becoming the ventral part of the diaphragm. The
esophagus and stomach begin to develop as distinct structures. During a period of its development, the esophageal
lumen is occluded and it shares a foregut origin with the trachea. Errors in development may result in esophageal
atresla ot tiacheo-esophageal fistula. The primary gut begins to elongate along with its dorsal mesentery. The hepatic
diverticulum gives rise to the biliary tree and ventral pancreas. The arterial supply to the gut is already defined: Celiac
artery (foregut); superior mesenterlc artery (midgut); and Inferior mesenteric artery (hindgut).
II
 EMBRYOLOGY OF THE ABDOMEN
Cl TRACT DEVELOPMENT (6 WEEKS)

Transverse septum
(diaphragm)
Stomach

Lesser omentum Spleen

Dorsal mesogastrlum
(bulging to the left)

Faldform ligament
Dorsal pancreas
Gallbladder
Ventral pancreas
(within
Primary gut loop mesoduodenum)

Yolk stalk Superior mesenteric

artery (within dorsal
mesentery)
Allantolc stalk Inferior mesenteric
artery (within
Cecum mesocolon)
Urinary bladder

Hindgut

The liver expands within the ventral mesentery, which later disintegrates, leaving only the falciform ligament and
the lesser omentum. The common bile duct, portal vein and hepatic artery traverse the caudal part of the lesser
omentum. The primary gut elongates and hemlates out into the umbilical cord. The primitive gut and urinary
system terminate in the cloaca and connect to the umbilical cord via the yolk stalk and allantois, respectively.
 EMBRYOLOGY OF THE ABDOMEN
c Gl TRACT DEVELOPMENT (8 WEEKS)
E
o
"D
<
<D

O
en
o
o
E
LU
C
<D Diaphragm
E
o
■D
-Q
<
Lesser omen turn

Spleen

Dorsal mesogastrlum
(elongating to form
omental bursa)
Cecum (rotating to Pancreas (within
right above small mesoduodenum)
Intestine)
Superior mesenteric
artery (In dorsal
mesentery)
Urinary bladder Inferior mesenteric
artery (in mesocolon)
Genital tubercle
Urogenltal sinus Urorectal septum

Rectum

The diaphragm Is nearly complete. The liver continues Its rapid enlargement. Only the caudal part of the ventral
mesentery remains (falciform ligament) allowing the more cephalad portions of the peritoneal cavity to
communicate. The dorsal mesogastrlum elongates considerably, forming the left and caudal portions of the lesser sac
The gut continues to elongate and rotates counterclockwise around the superior mesenteric artery within the dorsal
mesentery. The urogenltal sinus has separated from the rectum and anus. Common developmental errors include
midgut malrotation, persistent omphalocele and imperforate anus.

II
10
 EMBRYOLOGY OF THE ABDOMEN
DEVELOPMENT OF LESSER SAC

I I
Arrow (passing into
Stomach lesser sac)

Falciform ligament
Pancreas (within dorsal
mesogastrium)
Umbilical vein
Greater omentum
(growing caudally)
Transverse colon

> • I Small intestine

t,
"Window* opened In
lesser omentum

Anow (passing through

eplplolc foramen)

Greater omentum
(growing caudally)

* - %
(Top) The umbilical vein enters the liver along the caudal (free) edge of the falciform ligament. The duodenum and
pancreas are "Intraperitoneal" at this point. The leaves of the greater omentum elongate to the left and caudally,
expanding the volume of the lesser sac and beginning to cover the transverse colon and small Intestine. (Bottom)
The greater peritoneal cavity and lesser sac communicate through the epiploic foramen.
 EMBRYOLOGY OF THE ABDOMEN
DEVELOPMENT OF Gl TRACT (10 WEEK FETUS)

Cecum (continuing to
rotate after returning
last)
i\ Descending colon
(against dorsal
abdominal wall)

Small Intestine
(elongating and
colling)

Yolk stalk
(disappearing) Umbilical cord

The small intestine has returned to the abdomen, having previously elongated and hemlated out into the umbilical
cord. The yolk stalk (vitelline duct) is disintegrating, having connected the yolk sac to the primitive gut at the level
of the distal small Intestine. The cecum Is the last part of the gut to return and continues to rotate in a
counterclockwise direction until reaching Its adult position In the right lower quadrant. The transverse colon lies
superficial to the intestine. Errors in development include persistence of a part of the yolk stalk (Meckel
divertlculum) and errors of bowel rotation and mesenterlc fusion.
 DEVELOPMENT OF Gl TRACT (16 WEEK FETUS)

Root of transverse Transverse mesocolon

mesocolon
Descending colon
Ascending mesocolon
(triangular fusion)
Duodeno|e|unal
flexure
Duodenum Descending
mesocolon
(quadrangular fusion)
Terminal ileum

Cecum (in final Root of slgmold

position after mesocolon
rotation)
Root of mesentery
Appendix —

By 4 to 5 months of gestation, the ascending and descending colon are fixed In a retroperitoneal location by fusion
of their mesocolons to the posterior abdominal wall. The fusion of the ascending mesocolon covers the duodenum
and pancreas, resulting in their retroperitoneal location. The transverse and sigmoid colon remain intraperitoneal,
suspended on a mesentery. The root of the small bowel mesentery is fused to the posterior abdominal wall but the
intestine is suspended on a long, fan-shaped mesentery.
 EMBRYOLOGY OF THE A B D O M E N
c DEVELOPMENT OF HEPATIC VEINS (4-6 WEEK FETUS)
E
o
-o
JO
<

o
o Sinus venoms

E
LU Vltelline veins
■ ■
(proximal)
C
o Intrahepatlc plexus of
E vltelline veins
o
■D Right umbilical vein

< Left umbilical vein

Vltelline veins (distal)

Hepatic venous plexus

Left umbilical vein
branch

Distal vltelline veins

Umbilical vein

(Top) The vltelline veins return blood from the yolk sac and branch out within the liver to form the hepatic
sinusoids and venous system. They unite again to form the proximal vltelline veins which join with the (initially)
paired umbilical veins to enter the sinus venosus of the heart. (Bottom) Graphic shows the entire right umbilical
vein and much of the left atrophy. The left umbUlcal vein sends a large branch to the liver which anastomoses with
the plexus derived from the vltelline veins. The extrahepatlc (distal) vltelline veins form around the gut, as precursors
to the portal venous system.
II
T-J
 EMBRYOLOGY OF THE ABDOMEN

(Top) The entire right umbilical vein and much of the left have disappeared. The left hepatic branch of the umbilical
vein has become the ductus venosus, which bypasses the liver to deliver oxygenated blood from the placenta directly
to the heart. (Bottom) The portal sinus diverts some oxygenated blood to the liver. The proximal parts of the
vltelline veins have become the hepatic veins, returning blood from the liver to the heart. The distal parts have
developed into the portal venous system, returning blood from the gut to the liver sinusoids.
 EMBRYOLOGY OF THE ABDOMEN
PRENATAL ABDOMINAL CIRCULATION
CD
E
o
"D
<

O Foramen ovale
>. (patent)
O)
o
o
>.
I—
n
E
LU Ductus venosus
O
E Portal sinus
o
■o
Si
< Inferior vena cava
Umbilical vein

Portal vein

Umbilicus

Umbilical arteries
Internal lilac artery

Superior veslcal artery

Placenta

Urinary bladder

view of fetal circulation, not drawn to scale. The placenta sends oxygenated blood and nutrients to the
fetus via the umbilical vein. Some oxygenated blood perfuses the liver via reflux through the portal sinus, while most
bypasses the liver via the ductus venosus which empties into the inferior vena cava. The patent foramen ovale allows
oxygenated blood to pass from the right atrium into the left atrium. The portal vein returns blood from the fetal gut
to the liver, and the aorta carries moderately oxygenated blood to the entire body and returns blood to the placenta
via the umbilical arteries, branches of the internal iliac arteries. The fetal bladder is large and is perfused by branches
of the internal iliac artery.
II
16
 EMBRYOLOGY OF THE ABDOMEN
POST NATAL CIRCULATION >
a.
o
3
CD
3
m
Foramen ovale 3
(closed)
D"
O

o
Ligamentum venosum CD
(obliterated ductus o
>
venosus)
a.
o
3CD

Ligamentum teres
(obliterated umbilical
vein)

Median umbilical
ligament (urachus,
obliterated allantols)

Lateral umbilical
ligaments (obliterated
umbilical arteries)

Urinary bladder

After birth, the umbilical vein is obliterated, becoming the ligamentum teres in the free edge of the falciform
ligament. The ductus venosus also closes, to become the ligamentum venosum. The foramen ovale closes as the lungs
now return oxygen-rich blood to the left atrium and aorta. The umbilical arteries atrophy to become the lateral
umbilical ligaments. The allantols that connected the urinary bladder to the umbilicus closes to become the median
umbilical ligament. Failure of this tract to close results in a urachal cyst or diverticulum,
 EMBRYOLOGY OF THE ABDOMEN
c
0
PERITONEAL REF
■ Bv W m v ■ ^h^r ■ ^ ■ w # ^ M * ■ • ■ « ■

E
o
"a
-Q
<
<D
sz
•4-^
»4—

o
>>
D)
O
O
^
.Q
E Lesser sac (omental
LU
bursa)
C
a>
E
o
Hepatorenal fossa
(Morlson pouch)
<

Parietal peritoneum
Right paracolic gutter Visceral peritoneum

(Top) Graphic of axial section through the upper abdomen shows asdtes (fluid, green) within the subphrenic spaces
bilaterally and lesser sac. The hepatorenal fossa (Morison pouch) is the most dependent peritoneal recess in the upper
abdomen. (Bottom) The paracolic gutters are the main conduit for fluid between the upper (supramesocolic) and
lower (inframesocolic) parts of the peritoneal cavity.

II
18
 EMBRYOLOGY OF THE ABDOMEN
SAGITTAL SECTION OF MESENTERIES & PERITONEAL CAVITY

Lesser omentum
(gastrohepatlc
Lesser sac (omental ligament)
buna)

Pancreas

Transverse mesocolon
Duodenum

Greater omentum
(layers not yet fused)

Mesentery of small
Intestine

m
The peritoneal cavity Is artificially distended, as if insufflated with air. The peritoneum is represented by a white line
covering the entire cavity, lining the inner abdominal wall (parietal peritoneum) & the surface of abdominal organs
(visceral peritoneum or serosa). Organs are considered intraperitoneal if they are mostly covered with peritoneum
(e.g., Intestine) or retroperitoneal if they have no or only partial peritoneal covering. Intraperitoneal and
retroperitoneal compartments communicate via the "subperitoneal" space, between the leaves of the mesenteries.
Note how bleeding or inflammation originating in the (retroperitoneal) pancreas can easily spread through the
mesocolon & mesentery to affect the bowel. The greater omentum is depicted as a 4-layered fold of peritoneum,
although these layers usually fuse together below the transverse colon.
 EMBRYOLOGY OF THE ABDOMEN
PERITONEAL REFLECTIONS & SPACES
CD
E
o

CD
JZ
■ * - •

o
>s

S fissure for Itgamentum

§• venosum
E Greater amentum
* ■
Gastrohcpatic ligament
c Ascites — Stomach
o
§
Spleen
< Liver (bare area)

Right posterior
subphrcnic space

Panimbilical venous
collateral

Falciform ligament
cleft

Ciastrosplenic ligament
(with short gastric
vessels)

Liver (bare area) — Lesser sac (omental

bursa)

(Top) First of eight axial CT sections of a 60 year old m a n with cirrhosis a n d ascites. The ascites distends the
peritoneal cavity and outlines the mesenteries a n d ligaments. Note the bare area, the nonperitonealized attachment
of the liver to the diaphragm, where ascites is excluded. Most mesenteries, omenta a n d ligaments contain enough fal
t o allow t h e m t o be identified (Bottom) Panimbilical venous collaterals have formed in the falciform ligament due
t o portal hypertension, re-establishing a fetal site of collateral circulation.

II
JO
 EMBRYOLOGY OF THE ABDOMEN
CTIONS & SPACES >
CT
a
o
3
a
3
■ -

Transverse colon m
3
Small intestine — cr
Greater omentum
(with gastroepiploic
3
vessels)
o
Mesentery (with o
CQ
superior mescnteric «<
vessels) o
-*,
«-*■

rr
CD
Colon (splenic flexure) >
Paracolie recess Paracolie recess a"
Q.
("gutter") o
3
Interior niesenteric
Ascending colon CD
vessels 3
Duodenum
— Kidney

Umbilical hernia (with

ascltesi

Mesentery (with
superior niesenteric
vessels)
Transverse- colon
Right paracolie gutter
Ascending colon

lleocolic vessels -
Descending colon

I ell paracolie gutter

Interior niesenteric
vessels

(Top) The vessels to the intraperitoneal organs are carried through the various peritoneal reflections (mesenteries,
omenta and ligaments). Vessels to the relroperitoneal organs, including the ascending and descending colon, do not
traverse mesenteries. (Hot torn) The upper and lower portions of the peritoneal cavity "communicate" via the left and
right paracolie recesses ("gutters"), which are formed by reflections of the peritoneum covering the colon and the
inside of the antero-lateral abdominal wall.

II
21
 EMBRYOLOGY OF THE A B D O M E N
PERITONEAL REFLECTIONS & SPACES
<D
E
o
■o
-O
<
sz
Stomach
o
Grealer omcntum
O (with gastroepiploic
vessels)
Transverse colon
%
.o Gastiocolic ligament
E Lesser sac (omeni.il
HI bursa)
•«
c Duodenum -
o
E
o liver
T3
XI
<

— Greater omentum

Gastrocolic ligament
(with gastroepiploic
vessels)

— Lesser sac
Transverse colon —
Pancreas
Duodenum (with
iliverticuliim)
Splenorenai ligament
(with splenic vessels)

Kidney

(Top) The intraperitoneal organs (liver, spleen, stomach, intestine, colon) seem to be suspended acid surrounded by
ascitcs (intraperitoneal fluid), while the retroperitoneal pancreas, duodenum and kidneys are not. (Bottom) The
margins of the lesser sac inciude the stomach, caudate lobe of the liver, gastrosplenic and splenorenai ligaments,
pancreas and the lesser omentum (gastrohepatic and hepatoduodenal ligaments).

II
n
 EMBRYOLOGY OF THE A B D O M E N
PERITONEAL REFLECTIONS & SPACES >
cr
a.
o
3
a
3
• ■

m
Greater omentum 3
(with gastroepiplok cr
vessels) ■3
o
Small intestine -
o
CQ
*<
Mesentery (with
superior mesenteric .Sigmoid colon
a
or
vessels)
CD
Sigmokl mesocolon
(with inferior >
mesenteric vessels) cr
Q.
o
3
CD
13

l ; pipk)ii appendage

Rccto-sigmokl colon

(Top) The s i g m o i d c o l o n is "intraperitoncal", suspended o n t h e siginoid mesocolon t h r o u g h w h i c h the inferior

mesenteric vessels r u n . ( B o t t o m ) Ascites outlines fatty epiploic appendages w h i c h are p r o m i n e n t i n the s i g m o i d
c o l o n . The rectum lies i n the pelvic extraperitoneal space a n d is n o t s u r r o u n d e d b y ascites.
 EMBRYOLOGY OF THE ABDOMEN
MESENTERIES & PERITONEAL SPACES
CD
E
o
-o
<
CD
— Greater omentum
O
Transverse colon —
O
Asdtes (in peritoneal
O cavity)
Mesentery (with
-Q superior mesenteric
vessels)
E
LU
0)
E Duodenum Paracolic gutter
o
Right paracolic gutter - Descending colon
<
Ascending colon I Inferior mesenteric
vessels

Epiploic appendage
Small bowel mesentery —
(with superior Sigmoid colon
mesenteric vessels)
Sigmoid mesocolon
(with inferior
mesenteric vessels)

(Top) First of five axial CT sections of a 50 year old man with cirrhosis and ascitcs. The relationship between the
intraperitoneal a n d retroperitoneal organs is evident in this patient with ascitcs. The vessels, nerves a n d lymphatics
travel through the rctropcritoneum and, for the intraperitoneal organs, extend out through the fibro-fatty tissue in
the mesenteries, between layers of visceral peritoneum. (Bottom) In this and t h e previous images, note the paracolic
gutters, formed by reflections of peritoneum over the ascending and descending colon.
 EMBRYOLOGY OF THE ABDOMEN
MESENTERIES & PERITONEAL SPACES >
Q.
O
Literal umbilical ligament
3
CD
■ •

m
— Sigmoid colon 3cr
•2
o
Inferior mcsentciic vessels
o
CQ
•<

CD
>
Q.
O
3
CD
=3
Interior epigastric vessels

I'crivcsical fat
— Lateral umbilical ligaments
Ascites
Urinary bladder

Inferior epigastric vessels

Urinary bladder
External iliac vessels -

Internal iliac vessels

Rectovesical space (with ascito)

Rectum

(Top) Ascites surrounds the intraperitoneal intestine and Sigmoid colon. (Middle) Ascites outlines the lateral
umbilical ligaments (remnants of the umbilical arteries). The main vessels and nerves supplying the antero-lateral
abdominal wall travel between muscle layers or between the peritoneum and the transversalis fascia, such as the
inferior epigastric vessels, which arise from the external iliac vessels in the pelvis. (Bottom) The rectovesical space is
the most dependent recess of the peritoneal cavity.

II
J)
 EMBRYOLOGY OF THE ABDOMEN
RETROPERITONEAL SPACES & PLANES
E
o
■a

<
CD

O
>>
D)
O

£ Gallbladder

-D
E Inflamed fat (in
HI Duodenum — mesentery and anterior
■ ■
pararenal space)
c
Q)
E Pancreas
o
■o Spleen
-Q
<

Small intestine
(dilated)
Superior mesenteric
vessels
Descending colon
(with surrounding
Duodenum (with inflammation)
feeding tube)

(Top) first of six axial CT sections of a young man with acute pancreatitis. The gallbladder is opacified due to prior
administration of contrast material. The pancreas is enlarged and enhances heterogeneously due to acute
pancreatitis. Inflammation spreads ventrally into the mesentery and laterally throughout the anterior pararenal
space, which is bordered by the peritoneum in front and the perirenal fascia behind. (Bottom) Mesenteric
involvement is evident by infiltration of the fat surrounding the superior mesenteric vessels. Organs sharing the
anterior pararenal space with the pancreas, namely the duodenum, ascending and descending colon, are similarly
involved.
 EMBRYOLOGY OF THE ABDOMEN
RETROPERITONEAL SPACES & PLANES >
Q.
O
3
CD
3
■ ■

m
3
cr
«5
2.
o
CO
%
<
Descending colon
o
—»i
^■*
ZT
CD
Lateroconal plane
>
Q.
Retrorenal plane O
(thickened with
inflammation) 3
CD
3

Right paracolic gutter Posterior pararenal

space
Penrenal space -

(Top) The inflammatory process splits apart and thickens the double-layered renal and lateroconal fascia to reveal
retrorenal and lateroconal planes. (Bottom) The perirenal and posterior pararenal spaces remain nninvolved as the
renal and lateroconal fascia have blocked further spread of inflammation. Intraperitoneal fluid (ascites) in the right
paracolic gutter is adjacent to, a n d difficult to distinguish from, inflammation in the right anterior pararenal space,
which surrounds the ascending colon. Inflammation has breached the posterior parietal peritoneum to cause the
ascites.

II
27
 EMBRYOLOGY OF THE A B D O M E N
RETROPERITONEAL SPACES & PLANES
E
o
•o

<

CD

o
E — Left paracolic gutter
HI Duodenum (transverse)
(with ascites)
■ ■
c
0)
E
o — Renal fascia
•o
<

— Renal fascia

I'orireiial spate

Posterior pararenal
space

(Top) Ascites in the left paracolic gutter lies in the recess lateral to the colon. The space behind the colon and the
thickening of the perirenal fascia are representative of the retroperitoneal (anterior pararenal space) inflammation.
(Bottom) On more caudal section, just above the iliac wing, the leaves of renal fascia approach each other. Caudal to
this point, there is only a single abdominal retroperitoneal space which communicates with the pelvic
extraperitoneal spaces (pre- and perivesical).
 EMBRYOLOGY OF THE ABDOMEN
COMMUNICATION AMONG EXTRAPERITONEAL SPACES >
CT
Q.
O
3
CD
» ■

m
3
«T
«3
o
<§
o
Interior vena cava
3=
CD
Perirenal fascia (plane)
>
Q-
Perirenal septa O
3
CD
3
Retrorenal intcrfascial
plane

Duodenum —

Inferior vena cava

Perirenal space (with —

hemorrhage)

Retrorenal plane —

(lop) hirst of six axial CT sections of an elderly man (on C oumadin therapy) with spontaneous perirenal bleed
Blood spreads through perirenal space along the perirenal septa to "decompress" into the retrorenal intcrfascial plane.
(Bottom) The perirenal space does not extend to the midline, but the intcrfascial planes do, allowing hemorrhage to
surround tile 1VC.
 EMBRYOLOGY OF THE A B D O M E N
C O M M U N I C A T I O N A M O N G EXTRAPERITONEAL SPACES
E
o
■o

<
CD

o
CD
O
o
-Q
E
HI
Perirenal septa —
0)
Posterior renal fascia
E
o
T3 Infra renal —
rctroperitoneal space
<

Aorta (with aneurysm)

Anterior renal tascia —

Anterior renal fascia

Perirenal space —

li-.fi.iuri.il —
retropcritoneal space Posterior perirenal
fascia

(Top) The thickened perirenal septa a n d retrorenal interfascial planes are well-defined. The perirenal space decreases
in diameter caudally as the leaves of t h e renal (Gerota) fascia approach each other. (Bottom) An aortic aneurysm is
noted, but is not the source of the hemorrhage. Caudal to the perirenal space there is only a single infrarenal
retroperitoneal space.

II
30
 EMBRYOLOGY OF THE ABDOMEN
C O M M U N I C A T I O N A M O N G E X T K A I ' E K I T O N E A I SPACES >
CT
Q.
O
3
o
••
m
3

i
CT

Ascending colon —
&
— Infrarenal •<

Infrarenal —
retroperitoneal space
a
retroperitoneal space CD
>
cr
o.
o
3
CD
Z3

Infrarenal —
retroperitoneal space

(Top) The infrarenal retroperitoneal space is contiguous with the psoas muscle and communicates across the
midline. (Bottom) The infrarenal retroperitoneal space communicates caudally with the extraperitoneal pelvic
spaces.

II
11
 EMBRYOLOGY OF THE ABDOMEN
DEVELOPMENT OF GU TRACT

Mesonephion
(pronephron)

Amnlotic cavity

Body stalk (umbilical

m Metanephiic tissue
cord)

Mesonephric tubules

Glomerulus

:-YI-

(Top) The primitive genitourinary system develops In parallel with the gastrointestinal tract. The pronephron is a
transient development in vertebrate animals and degenerates to be replaced by the mesonephron. The mesonephron
also degenerates (in mammals) and is replaced by the metanephron, which will be the permanent kidney. (Bottom)
By the 4th fetal week, the mesonephric tubules and duct are formed. Branched vessels from the aorta reach the blind
ends of the tubules to form glomeruli. Although these achieve excretory function in the human embryo, they
degenerate from the cranial toward the caudal end. The caudal end of the mesonephric duct persists and
differentiates into the Mullerian and Wolffian ducts, which later give rise to the internal genltalia.
 EMBRYOLOGY OF THE ABDOMEN

I
DEVELOPMENT OF GU TRACT (5 WEEK FETUS)

Yolk stalk

Allan to»s

Mesonephion
(pronephron)

Mesonephric duct
Cloaca) membrane
Metanephiogenic
Cloaca tissue

Ureteric bud
(metanephric duct)

I ITii

The metanephric duct (ureteric bud) has grown out of the mesonephric duct near its tennination in the cloaca, and
has extended into the metanephiogenic tissue (kidney). Within the kidney, the ureteric bud branches and expands
to form calices and these arborize to form successive generations of collecting ducts. At the Sth fetal week, the
hlndgut and developing urinary tract both terminate in the blind-ending cloaca.
 EMBRYOLOGY OF THE ABDOMEN
URINARY BLADDER DEVELOPMENT
<D
E
o
■D
.O
<
CD

O
>^
O)
o
o
£>
-Q
E
LJJ Mesonephric duct
C
0)
E
o
TJ Metanephros
<

Urinary bladder Mallertan ducts

(fused)

Uretenc bud
(metanephric duct)

Genital tubercle

Urogenital sinus Urorectal fold

Rectum
Perineum

The development of the genital, urinary and gastrointestinal tracts are closely related. The urorectal fold migrates
caudally to separate the rectum posteriorly from the urogenital sinus anteriorly. The cloacal membrane has broken
down and the rectum and urogenital sinus open onto the perineum. The metanephros (kidney) has migrated
cranially. The mesonephric and metanephric ducts have shifted, with the former now entering the future urethra
and the latter entering the bladder. At this stage, the male and female fetuses are indistinguishable. The mesonephros
degenerates and the mesonephric duct differentiates into Mullerian and Wolffian ducts which are the primordial
forms of the internal genitaiia.
 EMBRYOLOGY OF THE ABDOMEN
DEVELOPMENT OF GU TRACT (20 WEEK MALE FETUS) >
a-
a.
o
3
CD
3
m
cr
o
o
CO

CD
>
Q.
O
Kidney 3
CD
Urachus

Urinary bladder

Seminal vesicle

Ductus deferens

Urethra

Scrota! swelling

In the male fetus, the Mullerian ducts mostly disappear while the Wolffian duct develops and differentiates due to
the influence of testosterone secreted by the ipsilateral testis. During the 4th month of gestation, the caudal end of
the Wolffian duct gives rise to the epididymis, ductus deferens, seminal vesicle and ejaculatory duct. The urogenital
sinus evolves into the bladder and urethra. In both male and female, the allantois has degenerated into the urachus
which usually obliterates in postnatal life to become the median umbilical ligament.

II
35
 EMBRYOLOGY OF THE ABDOMEN
DEVELOPMENT OF GU TRACT (20 WEEK FEMALE FETUS)

Urachus

Urinary bladder
Fallopian tube

Urethra Vagina

Clitoris

Vestibule

In the female fetus, the lower Miillerian ducts unite to form a uterovaginal canal. The unfused portions of the ducts
give rise to the fallopian tubes. The distal part of the vagina forms from imagination of a solid mass of cells between
the uterovaginal canal and the urogenital sinus. Other parts of the urogenital sinus form the bladder, urethra and
vestibule. Accessory glands derived from the urethra are inconspicuous in most females as urethra] and periurethral
glands, while these develop into the prostate gland in males.
 EMBRYOLOGY OF THE ABDOMEN
KIDNEY ASCENTftROTATION (6 WEEK9)
o-
CL
o
Umbilical cord
3
o3
m
Urachus (hidden by Umbilical artery B
umbilical vein) CT
-5
Umbilical vein o
o
(Q
»<
Urinary bladder o—h
,—T-

CD
Metanephnc tissue
(kidney) >
CT
a.
o
3
CD
Z3

Iliac artery

Umbilical artery

Urinary bladder

(Top) The early metanephros (kidneys) lie close together In the pelvis, and may even touch each other. (This may
lead to various anomalies of fusion and ectopic location). (Bottom) The fetal kidneys "face forward".
 EMBRVALAIV o f TUE AB5AJUEM
KIDNEY ASCENT & ROTATION (7 WEEKS)

Umbilical vein
Umbilical artery

Urinary bladder

Urogenital arterial rete

Umbilical artery

(Top) The early metanephios (kidney) lies below the aortic bifurcation. Arterial supply Is from multiple branches of
the aorta, each part of a plexus called the urogenital arterial rete. As the kidneys "ascend" with fetal growth, usually
only one artery remains to supply each kidney. (Bottom) At this stage of development, the fetal kidneys "face
forward". If the fetal kidney falls to ascend normally (remains "ectopic"), it is likely to retain a multiple arterial supply
and fail to rotate medially.
 EMBRYOLOGY OF THE ABDOMEN
KIDNEY ASCENT & ROTATION (9 WEEKS)

Descending colon

Pancreas
Renal artery

Renal artery

(Top) By the 9th fetal week, the kidneys have occupied their retroperitoneal location (along with the panneas and
duodenum). Each kidney is usually supplied by a single arterial branch of the aorta. (Bottom) The kidneys now lie at
about the level of the 3rd lumbar vertebra and have rotated along their longitudinal axis so that the renal hlla face
medially. Fetal lobation remains a distinctive feature, reflecting the lobular origin of the primitive kidney.
 ABDOMINAL WALL
[Terminology
Definitions
• Abdomen is region lietween d i a p h r a g m and jiclvis
Cross Anatomy
Anatomic Boundaries
• Anterior abdominal wall Ixwndcd superiorly by
xiphoid process and costal cartilages of 7th 10th rihs
• Anterior wall hounded interiorly by iliac crest, iliac
spine, inguinal l i g a m e n t and p u b i s
• Inguinal ligament is interior edge ot the aponcurosis
ot the external oblique muscle
Muscles of Anterior Abdominal Wall
• Consist of three flat muscles (external, internal
oblique and transverse atxlominal). and one strap-like
muscle (rectus)
• Combination of muscles and a p o n e u r o s e s (sheet-like
tendons! act as a corset to confine and protect
abdominal \iscera
• I inea alba is a fibrous raphe stretching from xiphoid
to pubis
c i onus central anterior attachment lor abdominal
wall muscles
l : ormed bv interlacing fillers of aponeuroses of the
oblique and transverse abdominal muscles
Rectus sheath is also formed by these aponeuroses
as they surround the rectus muscle
• I x t c r n a l o b l i q u e muscle
I argest a n d most superficial of the 3 flat abdominal
muscles
Origin: External surfaces of ribs 5-12
Insertion: I inea alha, iliac crest, pubis via a broad
aponeurosis
• Internal o b l i q u e m u s c l e
. Middle ol the 3 flat abdominal muscles
c Kuns at right angles to external oblique
Origin: Posterior laver of t h o r a c o l u i n b a r fascia.
iliac crest and inguinal ligament
Insertion: Ribs 10-12 (XMtcriorly, linca alba via a
broad aponcurosis, pubis
• Transverse a b d o m i n a l m u s c l e
Innermost ot the 3 flat abdominal muscles
Origin: lowest six costal cartilages, thoracoluinbar
fascia, iliac crest, inguinal ligament
Insertion: 1 inea alba via broad aponcurosis, pubis
• Rectus a b d o m i n a l muscle
Origin: Cubic symphvsis and pubic crest
Insertion: Xiphoid process and costal curtilages 5-7
c Rectus sheath: Strong fibrous compartment thai
envelops each rectus muscle
Rectus sheath contains s u p e r i o r a n d inferior
epigastric vessels
• Actions of anterior abdominal wall muscles
Support and protect abdominal viscera
Help Ilex and twist trunk, maintain posture
Increase intra-abdominal pressure for defecation,
micturition and childbirth
Stabilize the pelvis during walking, sitting up
• Iransversalis fascia
I ies deep to the abdominal wall muscles and lines
entire abdominal wall
( Is separated from parietal p e r i t o n e u m bv laver ol
c x t r a p c r i t o n e a l fat
Muscles of Posterior Abdominal Wall
• Consist of psoas I major and minor). Hiatus and
qtiadratus lumborum
• Psoas: Long thick, fusiform muscle King lateral to
vertebral column
• Origin: Transverse processes and bodies ol vertebrae
112-15
Insertion: Lesser trochanter of femur (passing
behind inguinal ligament)
Action: Hexes thigh at hip joint; Ix-nds vertebral
column laterally
• lliacus: 1 arge triangular sheet ot muscle King along
lateral side of psoas
Origin: Superior part of iliac fossa
c Insertion: 1 esser trochanter ot lemur (after joining
with the psoas tendon)
1
\ction: "lliopsoas muscle" flexes the thigh
• Q u a d r a t u s l u m b o r u m : I hick sheet of muscle lying
adjacent to transverse processes of lumbar vertebrae
c Origin: Iliac crest a n d transverse processes of lumbar
vertebrae
Insertion: 12th rib
> Actions: Stabilizes position of thorax and pelvis
d u n n g respiration, walking
■ Bends trunk to side
[Clinical Implications
Clinical Importance
• Rectus and iliopsoas muscle compartments are
c o m m o n sites for Spontaneous bleeding in patients
v\ith coagulopathv
>- Rectus sheath is incomplete caudallv; bleeding -*
into extraperitoneal pelvis
• Obesity and lack of exercise result in atrophy ol
abdominal wall muscles
I'annus (panniculus): l a x abdominal wall and
excess subcutaneous fat; max simulate a ventral
hernia clinically and on imaging
c Results in dysfunction affecting micturition,
defecation, etc.
1
Results in c o m m o n occurrence ol abdominal wall
hernias, especially following abdominal surgery
("incisional hernia")
• Congeiiit.il points of weakness in aponeuroses
predispose to other c o m m o n external hernias
Ventral h e r n i a : Through congenital defeit in
aponeuroses forming the linea alha, in the iindline
Spigelian h e r n i a : I ateral to the rectus muscle below
umbilicus through defect in aponeurosis of internal
oblique and transverse abdominal muscles
■ I'xtcrnal oblique aponeurosis is often intact;
hernia sac mav be internnistular
I umbar hernia
■ At congenital point ol deficiency just above iliac
crest = interior l u m b a r t r i a n g l e (ot Petit)
 ABDOMINAL WALL
POSTERIOR ABDOMINAL WALL MUSCLES

I
1
\'r

Central tendon (of Esophagus

diaphragm)
Median arcuate Right cms of
ligament arches diaphragm

Medial arcuate
Oblique «transverse ligament
muscles
Lateral arcuate
Right cms of ligament
diaphragm
Left cms of diaphragm

Quadratus lumbonim
muscle Psoas minor muscle

nti Psoas major muscle

Tliacus muscle

Plriformls muscle
Levator anl muscle

Inguinal ligament
Rectum
Urethra

M Insertion of iliopsoas
f muscle

Lumbar vertebrae are covered and attached by the anterior longitudinal ligament, and the diaphragmatic crura are
closely attached to it, as are the origins of the psoas muscles, which also arise from the transverse processes. Iliacus
muscle arises from the iliac fossa of pelvis and inserts into the tendon of the psoas major, constituting iliopsoas
muscle, which inserts into the lesser trochanter. Quadratus lumbonim arises from the iliac crest and inserts into the
12th rib and transverse processes of the lumbar vertebrae. Diaphragm and transverse abdominal fibers Interlace.
Psoas and quadratus lumbonim pass behind diaphragm under medial and lateral arcuate ligaments.
 ABDOMINAL WALL
ANTERIOR WALL MUSCLES

Iinea alba

External oblique
muscle
Aponeuroses & rectus
sneath
H£Z?I

Umbilicus

Anterior layer of
rectus sheath
mm I
Lz^l
■
Inguinal ligament

■ r K

The aponeuroses of the internal and external oblique and transverse abdominal muscles are two-layered and
interweave with each other, covering the rectus muscle, constituting the rectus sheath and Iinea alba. About midway
between the umbilicus and symphysis, the posterior rectus sheath ends and the transversalls fascia Is the only
structure between the rectus muscle and parietal peritoneum.
 ABDOMINAL WALL
>
Q.
O
3
o
>
Q.
O
3
Rectus muscle
0)

Oblique & transverse

abdominal muscles W

Transversalis fascia

Falciform ligament
(with llgamentum
teres)

Umbilicus

Inferior epigastric
vessels

Panetal peritoneum

Median umbilical
ligament
Lateral umbilical
ligament

Graphic view of anterior abdominal wall from inside. The umbilical ligaments are remnants of the fetal umbilical
arteries and allantois (urachus). The falciform ligament is the remnant of the umbilical vein. All of these converge at
the umbilicus. Transversalis fascia lines muscular wall of abdomen. Epigastric vessels lie between transversalis fascia
and parietal peritoneum.

II
43
 A B D O M I N A L WALL
T H O R A C O ! U M B A K FASCIA

T.iMi.1 lor (jiiiKlroliis —

llMIlllllllllll

Anterior layer
Combined layer till . II IllllilUI I.Ill 111
tliornciiliiiiih.-ir t.isiia

Supi.ispiiious ligameiii

Posterior layer
tll.lMl.llllllllMt KlHi.l

Hit1 thoracolunibar (lunihcKlors.il) fascia is a strong fibrous sheath tiiat encloses the quadratus lumborum and erector
spinae muscles. I he apniicuroscs of the transverse abdominal and internal oblique muscles attach to the combined
or posterior layer of the thnraiolumhar fascia.
 ABDOMINAL WALL
ABDOMINAL WALL MUSCLES >
Q.
O
Linea alba 3
a
Rectus muscle 3
Aponeurosis of external ■ ■
oblique >
Q.
O
External oblique m.

Internal oblique muscle

i
Transverse abdominal
muscle

0)

.v...: | .: fascia

Thoracolumbar fascia

I'soas muscle

Quadratus Lumborum
1 .iiis-.iiiins dorsi muscle - muscle

— Erector spinai- muscle

( l o p ) I-irst of two axial CT sections in a muscular young man. Note t h a t the ajwneuroses of the oblique and
transverse abdominal muscles surround the rectus muscle as the rectus sheath, and then continue to form and insert
upon the linea alba. (Itottom) Aponeuroses of oblique and transverse abdominal muscles blend with and attach to
the thoracolumbar fascia which surrounds the paraspinal and quadratus lumborum muscles.

II
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 ABDOMINAL WALL
ABDOMINAL WALL MUSCLES

— Lines alba

Rectus muscle
Fjtternal oblique
muscle
Internal oblique muscle —

Transverse abdominal
muscle
Inferior vena cava
Aorta

Psoas muscle
Subcutaneous fat
(Camper fascia)
Quadratus lumborum
muscle

Scarpa fascia Erector spinae muscle

Aponeuroses of the
oblique & transverse
abdominal muscles

External oblique m.

Internal oblique muscle

Transverse abdominal Inferior mesenteric

muscle artery (origin)

Thoracoluinbar fascia

(lop) First of eight axial CECT sections in a 29 year old man. The rectus sheath is formed by aponeuroses of oblique
and transverse abdominal muscles which also form the linea alba, the central anterior attachment for anterior
muscles. Subcutaneous tissue has 2 layers, superficial fatty layer (Clamper fascia) a n d deep membranous layer (Scarpa
fascia) that continue down to the j)erineum. (Bottom) Thoracolumbar fascia surrounds the quadratus lumborum and
paraspinal muscles, forms important posterior attachment for abdominal wall muscles. Aponeuroses are the flat
tendons thai extend from the muscles.
 ABDOMINAL WALL
A B D O M I N A L WALL MUSCLES >
Q.
O
3
a
— Umbilicus
>
Q.
O
3

:>

Ascending colon — Bifurcation of aorta

(common iliac arteries)

Quadratus lumboriim -
muscle

— I-rector spinae muscle

— Kectus muscle
(tendinous inscription)

— Lett c o m m o n iliac
Confluence of iliac artery
veins (1VC)

Iliac crest -

— Erector spinae muscle

(Top) The origins of the anterior abdominal wall muscles include the iliac crest and thoracolumbar fascia inferiorly.
The transversaiis fascia lies deep to abdominal wall muscles and lines the entire wall, but is usually not detectible on
imaging studies. (Bottom) Muscle attachments to iliac crest are evident.

II
47
 A B D O M I N A L WALL
ABDOMINAL WALL MUSCLES

Inferior epigastric
artery

External iliac artery

Psoas IImst If Internal iliac artery

Hiatus muscle Common iliac vein

Gluleal muscles

Interior epigastric
vessels

lliopsoas muscle External iliac artery

— External iliac vein

Pirirormis muscle

Gluteal muscles
Sacrum

( l o p ) The inferior epigastric arteries and veins course along t h e underside of t h e rectus muscles and arise from t h e
external iliac vessels, low in pelvis. (Uottom) The external iliac vessels run along surface of iliopsoas muscles.
 ABDOMINAL WALL
A B D O M I N A L WALL MUSCLES >
Q.
O
3
o
■ ■

>
— Rettus muscle K
Iliopsoas muscle — o
3

Femoral head 0)

Obturator intemus
muscle

Ischial spine —

Rectus muscle
(insertion)

Iliopsoas muscle —

Femoral neck Obturator i n t e m u s

muscle

— Ischium

(lop) The iliopsoas muscle leaves the abdomen passing under inguinal ligament. (Bottom) Iliopsoas muscle passes
anterior to femoral head and neck to insert on lesser trochanter of femur. The rectus muscle inserts on the pubis

II
A')
 ABDOMINAL WALL
= ABDOMINAL WALL, MUSCLES & VESSELS

CO
c
:E
o Costal cartilage
E
<

o Rectus muscle —
E
o
■o — Rectus muscle

<
Subcutaneous fal

Tendinous inscription
(of rectus muscles)

Diaphragm

Subcutaneous fat — — Oblique & transverse

alxjominal muscles

— Inferior epigastric
artery

— Rectus muscle

(Top) First o f eight coronal images i n a 54 year o l d m a n . Rectus muscles arise f r o m puhis a n d inseit i n t o x i p h o i d
process a n d costal cartilages 5 t o 7. C e p h a l a d a t t a c h m e n t s of o b l i q u e a n d transverse a l x i o m i n a l muscles i n c l u d e t h e
lower ribs a n d costal cartilages. (Bottom) Rectus sheath contains the superior a n d inferior epigastric arteries, w h i c h
anastomose w i t h each o t h e r near level o f u m b i l i c u s .

II
 A B D O M I N A L WALL
ABDOMINAL WALL, MUSCLES & VESSELS >
Q.
O
3
a
Liver — 3
■ •
— Diaphragm
>
10th rib - Q.
O
3
Gallbladder —
External abdominal
muscle
£D
Internal oblique muscle

Transverse abdominal
muscle

Inferior epigastric
arterv
Rectus muscle

Cellarartery — — Stomach

Hepatic artery
(accessory right)
Superior mesentcric
artery

— Iliac crest

External iliac artery - Deep circumflex iliac

artery

(Top) Attachment of the oblique and transverse abdominal muscles to the lower ribs is evident. (Bottom) Caudal
attachment of the oblique and transverse abdominal muscles to the iliac crest.

II
51
 ABDOMINAL WALL
ABDOMINAL WALL, MUSCLES & VESSELS

CO
rz
E
o
-o — Diaphragm
-Q
<
*• Median arcuate
c Inferior vena cava ligament
0)
E
o
Right renal vein
■D Renal vein & artery

< Aorta

Gluteal muscles —

Adrenals

Iiiacus muscle

(Top) Aorta enters the abdomen behind the median arcuate ligament, the junction of the diaphragmatic crura.
Adrenals lie just lateral to crura. (Bottom) I'soas muscle arises from transverse prcxesses and bodies of lumbar
vertebrae. After joining iiiacus muscle in the pelvis, it passes beneath inguinal ligament to enter thigh and insert on
lesser trochanter of femur.

II
52
 A B D O M I N A L WALL
A B D O M I N A L WALL, MUSCLES & VESSELS >
CL
O
3
TO
• ■

Q.
O
3
9"
03
Transverse process —
Quadratus lumbonim
muscle

Iliac wing —

I llh rib (posterior) —

Quadratus lumboruni
muscle

Spinous process

Iliac wing (posterior)

Sacrum

(lop) Quadratus lumboruni muscle arises from the iliac crest, ilioliimbar ligament and transverse processes of lumbar
vertebrae. (Bottom) Quadratus lumborum passes behind the diaphragm, under the lateral lumbocostal arch (not
evident on imaging studies).

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53
 ABDOMINAL WALL
= A B D O M I N A L WALL MUSCLES

CO

E
o
— Stomach (with
< nasogastric tube)

Median arcuate —
0) ligament
E
o

3 — Aorta

Inferior vena cava —

Oblique & transverse
abdominal muscles

Stomach (fundus)

Crus of diaphragm —

l'soas muscle

Iliacus muscle —

(Top) First of eight coronal CT sections in a 71 year old man. Aorta enters alxJomen just behind the median arcuate
ligament which connects the crura of the diaphragm. (Bottom) Oblique and transverse abdominal muscles stabilize
the trunk by attaching to the lower ribs and the iliac crest and inguinal ligament.

II
54
 ABDOMINAL WALL
ABDOMINAL WALL MUSCLES >
cr
a.
o
3
(D
••
>
Aorta Q.
O
Cms ot diaphragm -
3
ED

CO

Oblique & transverse

abdominal muscles

Psoas muscle —

Hiatus muscle -

Cms of diaphragm

(Top) IliacuS muscle fills much of the iliac fossa and forms the lateral wall of the abdomino-pelvic cavity. (Bottom)
Inferior attachments of the diaphragmatic crura and the origins of psoas muscle include upper lumbar vertebrae and
the anterior longitudinal ligament which covers them.

II
 ABDOMINAL WALL
A B D O M I N A L WALL MUSCLES
TO

CO
c
I — Spleen
o
T3
— Cms of diaphragm
to
<
E
o
■a
JO
<

— Psoas muscle

Diaphragm
Pleural effusion —

(Top) Abdominal wall muscles are t h i n a n d lax in this elderly m a n (Bottom) Note the pleural effusion above the
diaphragm.

II
56
 ABDOMINAL WALL
A B D O M I N A L WALL MUSCLES >
a.
o
3
<D
3
■ ■

&
Q.
O
3
=3

I
Quadratic luinborum
muscle

— l;rector spinae muscle

(Top) Quadratus Iumborum muscle stabilizes the spine and pelvis, connecting 12tli rib to transverse processes of
lumbar vertebrae and to the iliac crest and iliolunibar ligament. (Bottom) More posteriorly, erector spinae muscles
stabilize the spine.

II
57
 ABDOMINAL WALL
RECTUS HEMORRHAGE INTO PERIVESICAL SPACE

— Rectus muscle

I Icmorrhagc within
rectus muscle

Hemorrhage within
extraperitoneal
(perivesical) space

(Top) First of five axial CT images depicting a spontaneous abdominal wall arid extraperitoneal hemorrhage in an
elderly woman receiving anticoagulant medication. The rectus muscles are enlarged due t o hemorrhage within the
rectus sheath. (Bottom) Hemorrhage has "leaked" through the incomplete posterior layer of the rectus sheath to
extend into the extraperitoneal pelvis. Note the cellular-fluid levels within the hemorrhage, called the "hematocrit
sign", indicative of a coagulopathic hemorrhage.
 ABDOMINAL WALL
RECTUS HEMORRHAGE INTO PERIVESICAL SPACE >

o
3
CD
Hemorrhage within extraperitoneal ■ ■
(perivcsii .il) space
>
cr
Q.
o
Uterus
i
Sigmoid colon 13
CO

CO

-- Rectus muscle

Hemorrhage in extraperitoneal
spaces
Fole> c.ithetcr in bladder

i Iterus

Rectum

lendiiii IUS insertion of rectus

on svmphysis pubis

Extraperitoneal (perrvesical)
hemorrhage

(Top) Note the large abdominal extraperitoneal hemorrhage, with the "hematocrit sign". (Middle) The abdominal
cxtrapcritoneal spaces communicate caiidally with the pelvic extraperitoneal spaces, including perivesical space.
(Bottom) The pelvic hemorrhage displaces the uterus, bladder and rectum.

II
 A B D O M I N A L WALL
PANNUS S I M U L A T I N G VENTRAL H E R N I A
CD

CD
C
I
o
T3
<
> ■
C
0)
E
o I Ine Indicating plane of lower
■D axial section
< Gas within Ixiwcl -

Trotubcrant abdominal wall -

(pannus)

rhin abdominal wall muscle n

fascia

Thin abdominal wall muscle fci ~

fascia
Small intestine
Colon

I bin abdominal wall muscle &

fascia

Symphysis pubis

(Top) Elderly w o m a n w i t h a p r o t u b e r a n t a b d o m e n s i m u l a t i n g a ventral hernia. Frontal c o m p u t e d radiograph shows

obese a b d o m e n a n d b o w e l gas b e l o w level o f symphysis pubis. ( M i d d l e ) First o f t w o axial CT sections i n t h e same
p a t i e n t as previous image shows t h e t h i n a b d o m i n a l w a l l is stretched a n d elongated, a l l o w i n g anterior a n d caudal
p r o t r u s i o n o f a b d o m i n a l c o n t e n t s (pannus). (Bottom) This image shows bowel i n p a n n u s below the symphysis
pubis.

II
f>n
 ABDOMINAL WALL
VENTRAL HERNIA, INCARCERATED CAUSING BOWEL OBSTRUCTION >
Q.
O
3
o
3
■ ■
Herniated small bowel >
Q.
O
Small bowel (collapsed
distal to hernia)
Small bowel (dilated CD
proximal to hernia)
CD

Linea alba —

— Rcctus muscle

Small bowel (dilated

proximal to hernia)

(Top) First of two axial CT images shows a segment of small intestine herniated through a defect in the linea alba.
The hernia is "incarcerated" (nonreducible). (Bottom) Small intestine is dilated upstream from the ventral hernia and
collapsed downstream, indicating that the hernia is causing bowel obstruction.

II
(>1
 ABDOMINAL WALL
INCISIONAL HERNIA CONTAINING COLON

— Colon (in subcutaneous fat)

1
I Rectus muscle
— Rectus muscle

<
■ m

c
a
E
o
T3
<

— Thin and lax fascia

Colon -
— Rectus muscle

— Breast

Calcified costal cartilages

(antcro-latcral) Sul)Cutancous fat

— Colon within hernia sac

Colon (opacified by barium)

(Top) first of two axial CT images in a elderly woman shows ventral incisional hernia following laparotomy. Defect
in anterior abdominal wall (through the linea alba) allows herniation of colon and omental fat. (Middle) Rectus
muscles, linea alba and aponeuroses are thin and stretched. (Bottom) Lateral view of barium enema in the same
patient as previous two images. Colon is herniated into the subcutaneous fat, with n o overlying muscle.

II
f,2
 ABDOMINAL WALL
>
CT
Q.
O
3
Hemiated bowel within inguinal
canal
Femoral artery >
Femoral vein
cr
Q.
o
3
13
03

Rectum
cu

Hemiated bowel within inguinal

canal

Small intestine (hemiated into ~

inguinal canal)
Superior pubic ramus

Inferior pubic ramus

(Top) First of two axial CT images in a elderly woman with inguinal hernia causing small bowel obstruction. Note
the dilated small intestine and collapsed rectum. (Middle) A segment of small intestine has hemiated into the
inguinal canal and is causing the bowel obstruction. (Bottom) Barium small bowel follow through in the same
patient as previous two images shows a portion of dilated small bowel is trapped within the inguinal canal, causing
the bowel obstruction.

II
63
 A B D O M I N A L WALL
SPICELIAN HERNIA CAUSING COLONIC OBSTRUCTION

Colon (dilated
proximal to hernia)

Descending colon
(herniatcd)

Umbilicus —

Rcctus muscle

External oblique
muscle

Internal oblique muscle

"transverse abdominal
muscle

(Top) Supine radiograph shows dilated colon and abrupt angulation and hcrniation of the descending colon in a 59
year old man. (Bottom) First of four axial CT sections in same patient as previous image.
 A B D O M I N A L WALL
SPIGELIAN HERNIA CAUSING COIONIC OBSTRUCTION >
Q.
— External oblique aponeurosis O

— External oblique muscle

3
3
■ ■
- Descending colon (in hernia
sac) >
cr
Q.
o
3
■ - Iliac crest
CD

External oblique muscle

Internal oblique muscle

Transverse abdominal muscle

— Descending colon

(Top) Descending colon has hemiated into the subcutaneous fat and is covered only by external oblique muscle and
aponeurosis. (Middle) Compare with the intact muscles of the right anterior abdominal wall. (Bottom) Colon
herniates through a defect in the aponeurosis of the internal oblique and transverse abdominal muscles.

II
65
 A B D O M I N A L WALL
LUMBAR HERNIA

TO
c
"E
o
■o
<
- Oblique & transverse
abdominal muscles
o
E
o Flee edge of abdominal wall
muscles
"O
<

Internal oblique muscle

Transverse abdominal muscle

Latissimus dorsi muscle "■

Quadratus lumborum

l.atissimus dorsi muscle —

Iliac crest -

(Top) first of three axial CT sections in a elderly man with a bulge near his iliac crest. The abdomen has excessive fat
and thin abdominal wall muscles. Abdominal fat bulges out through inferior lumbar triangle. (Middle) There is a
defect in abdominal wall (aponeuroses of oblique and transverse abdominal muscles) covered only by latissimus dorsi
muscle. (Bottom) The oblique and transverse abdominal mustlts fail to attach to iliac crest and thoracolumbar
fascia, resulting in a lumbar hernia.

II
66
 ABDOMINAL WALL
LUMBAR H E R N I A W I T H ASCITES >
Q.
O
3
o
3
■ •

>
Q.
O
3
0)

D)

— Iliac crest

Ascites (in hernia sac) —

(Top) First of two axial CT images shows lumbar hernia with ascites in a 58 year old woman. The abdominal wall
muscles are very thin and weak. (Bottom) Parietal peritoneum and ascites have herniated through a defect in the
aponeuroses of the internal oblique and transverse abdominal muscles.

II
67
 DIAPHRAGM
Gross Anatomy
Diaphragm Components
• Muscular portions originate from thoracolumbar
abdiHIiii 1.1I wall and converge medially as an
aponeurosis (central tendon)
C e n t r a l t e n d o n is fused to tile fibrous pericardium,
but has no osseous attachment
• Origins
Anterior: Xiphoid process
Anterolateral: Ribs fc costal cartilage margins 7-12
■ Interdigitate with transverse abdominal muscle
c Posterolateral: Lumbar vertebrae via the crura a n d
arcuate ligaments
■ Crura of d i a p h r a g m blend with anterior
longitudinal ligament of t h e vertebral column
■ Right crus is longer than left, extends down to L3
vertebra (left t o L2)
■ Liters of right crus surround esophageal hiatus
\ r c u a t e l i g a m e n t s are three, give rise to diaphragm
posteriorly
■ Median a r c u a t e l i g a m e n t unites both crura
■ Median arcuate ligament passes over anterior
surface of aorta (and can compress the celiac
artery in some individuals)
■ Medial a r c u a t e l i g a m e n t s attach to
thoracolumbar fascia over the psoas muscles
■ l a t e r a l a r c u a t e l i g a m e n t s attach to
thoracolumbar fascia over quadratus lumboruni
muscles
■ Vertebrocostal triangle is a thin membrane that
may result from failure of t h e arcuate ligament to
reach t h e 12th rib
• Apertures of diaphragm
•- Vena caval foramen is in t h e right side of t h e
central tendon
■ Usually located at T8 vertebral level
■ May also transmit t h e right phrenic nerve
Lsophageal h i a t u s is just It'll of midline and passes
through t h e right crus of diaphragm
■ Usually at the level of T10 vertebra
■ Also transmits vagus nerves and esophageal
branches of left gastric vessels
c Aortic hiatus
■ Actually passes posterior t o t h e diaphragm and the
median arcuate ligament (rctrocrural space)
■ Also transmits t h o r a c i c d u c t anil a ? y g o u s a n d
heiniazygous veins, individual lymph nodes,
sympathetic trunk
• Actions of diaphragm
c Chief muscle of respiration
c Diaphragm descends to increase thoracic volume
and decrease intra-thoracic pressure
t Helps circulation of blood by creating reciprocal
increases/decreases in thoracic/abdominal pressure
Helps raise intra-abdominal pressure for defecation,
micturition and childbirth
[Anatomy-Based Imaging Issues
Imaging Recommendations
• Diaphragm is difficult to demonstrate on transverse
C T o r MR
<■ Coronal or sagittal plane images show t h e
diaphragm lxUter
Sonography shows diaphragm as echogenic line
• D i a p h r a g m a t i c insertions on the thoracoabdominal
wall may take t h e lorm of thin "slips" of muscle and
tendon, rather than smooth sheet of tissue
c On axial Cl a n d MR sections these can be mistaken
for nodular tumor implants on t h e peritoneum
'. Keys to recognition are continuity on sequential
axial sections and viewing sagittal or coronal
sections
[Clinical Implications |
Clinical Importance
• P e r i d i a p h r a g m a t i c fluid collections are very
c o m m o n with important clinical implications
c Pleural effusions lie alx>ve or "outside t h e confines"
of t h e diaphragm
o Ascites (or a subphrcnic abscess) lies below or
"within the confines" of t h e diaphragm
• l-'.lovatinn of o n e l i e m i d i a p l i r a g m is c o m m o n
May be caused bv abdominal mass displacement
c May be due to paralysis
c Phrenic nerve is the sole motor supply to t h e
diaphragm and can be injured by trauma, thoracic
surgery or thoracic malignancy
Paralysis results in permanent elevation and
paradoxical movement of the hemidiaphragm on
forced inspiration
■ May be due to congenital thinning (eventration)
■ Left > right
• Diaphragm is not always impermeable
o Ascites, pleural effusion, tumor, pus, extraluminal
air may pass from t h e abdomen into the thorax (and
vice versa)
Defects in d i a p h r a g m increase with age and
emphysema
• Congenital defects in diaphragm are c o m m o n
I eft posterolateral defect at vertebrocoslal triangle
is known as Bochdalek h e r n i a (abdominal fat, gut
or viscera may herniate into chest)
C Kvcntration of diaphragm is thinning or absence of
a part of t h e diaphragm
■ I eft > central tendon > right
o Anterior paramedian defect at sternocostal hiatus is
known as Morgagni h e r n i a
■ Right > left
• Acquired hernias are c o m m o n
c Hiatal h e r n i a : Widening of the esophageal hiatus,
allowing part ol t h e stomach to herniate into the
chest
• T r a u m a t i c r u p t u r e : Relatively u n c o m m o n , resulting
from blunt or penetrating trauma
•- More than 9(7X1 are left-sided, through apex or
posterior portion
 DIAPHRAGM
ABDOMINAL SURFACE OF DIAPHRAGM

Xiphoid process (of

sternum)

Central tendon
Costal cartilage
Inferior vena cava
opening

Right cms
Esophageal hiatus

Median arcuate
ligament
Left crus
Right cms
Medial arcuate
ligament
Lateral arcuate
ligament

Quadratus lumborum

Psoas muscle

Graphic view of abdominal surface of diaphragm. Note origins of the diaphragm from the sternum, costal cartilages
and lumbar vertebrae and Insertion into the trefoil-shaped central tendon, the fibrous aponeurosls of diaphragmatic
muscle fibers. Inferior vena cava (FVC) hiatus is through the central tendon. The esophageal hiatus is surrounded by
the right crus. The median arcuate ligament unites the cxura and passes over the aorta just above the celiac axis. The
right crus is longer and thicker than the left, and both Insert Into the anterior longitudinal ligament of the lumbar
spine. The psoas passes behind the medial arcuate ligament, and the quadratus lumborum behind the lateral arcuate
ligament.
 DIAPHRAGM
E NORMAL AXIAL CT SECTIONS, DIAPHRAGM & CRIJR A

-C
Q.

b
0)
E
o
Right crus
Fsophageal hiatus in
< diaphragm
Diaphragm

fissure for ligamentum venosum

Gastroesophageal junction

- Median arcuate ligament

(Top) First of six axial CT sections shows the esophagus entering the abdomen through a decussation (crossing) of
fibers of the right crus. (Middle) The gastroesophageal junction lies just caudal to the esophageal hiatus at the level
of the fissure for the ligamentum venosum. (Bottom) The musculotendinous arch of the median arcuate ligament
joins the two crura.

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70
 DIAPHRAGM
NORMAL AXIAL CT SECTIONS, DIAPHRAGM & CRURA

Pancreas (body)

Crura of diaphrajrm

■— Splenic vein

— Left adrenal

Superior mesenteric vein (SMV)

Superior mesentcric artery (SMAI
Left renal vein

Right cms Left eras

■— Superior mesenteric vein and

artery
Pancreas (head and uncinate)

Right trus Left cms

(Top) The crura may appear somewhat nodular. The adrenals lie just lateral to the crura. (Middle) The right crus is
usually thicker and longer than the left, inserting lower along the lumbar spine (at Li level). (Bottom) On axial CT
sections the crus may be mistaken for an enlarged periaortic lymph node.
 DIAPHRAGM
AORTIC & ESOPHAGEAL O P E N I N G S

Spleen
Liver Cnis of the diaphragm

Kidney

- Psoas muscle

M ( ! I l : , . ! :,

Crura of diaphragm
Spleen

Diaphragm -

liver
Kidney

Psoas muscle

(Top) First of three coronal Ct sections shows aorta entering a b d o m e n between and behind the crura. Psoas enters
abdomen behind medial arcuate ligament, which is difficult to display on imaging. (Middle) The diaphragm is a
smooth sheet of muscle in this patient. (Bottom) Most dorsal section shows diaphragmatic origins on lower ribs and
costal cartilages.
 DIAPHRAGM
AORTIC & ESOPHACEAL OPENINGS >
Q.
O
3
Aorta CO
3
Diaphragm

■D

C.cliac trunk
CO
Superior mcscntcric — 3
artery Pancreas (uncinate
process)

liver

— Right crus

Inferior vena cava

(lop) 1 irst of two sagittal CT sections showing the aorta entering the abdomen behind the diaphragm, specifically,
the median arcuate ligament. Note the normal origin of celiac trunk from the proximal abdominal aorta. (Bottom)
Sagittal section to the right of the previous image shows the inferior vena cava approaching its diaphragmatic hiatus.
The right crus originates along the lumbar vertebrae.

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73
 DIAPHRAGM
CORONAL & AXIAL CT, DIAPHRAGM

liver — i

Right cms

Diaphragm Diaphragm

— Diaphragm

Diaphragm

(Top) Coronal CT section. The diaphragm is a smooth sheet of tissue that abuts the liver and spleen and is otten hard
to distinguish on imaging because it is of similar attenuation (density) as these organs. (Bottom) Axial CT section.
Because of steatosis, the liver is of low density a n d diaphragm is seen as a distinct "white" curvilinear structure.
 DIAPHRAGM
NORMAL DIAPHRAGM, DEMONSTRATION OF CRURA & GE JUNCTION >
cr
Q.
O
3
o
3
j — Diaphragm
0)
Fundus of stomach
Right crus
Fsophageal hiatus — Left crus
i"
3

Fissure for the ligamentum -

venosum
Gaslroesophageal junction

— Stomach (body)

Diaphragmatic crura

(Top) First of three axial CT sections shows the esophagus entering the abdomen through its diaphragmatic hiatus
surrounded by the right crus of diaphragm. Compression of the esophagus by the crus contributes to lower
esophageal sphincter function. (Middle) The gastroesophagcal (GE) junction is normally at about the same
transverse plane as the fissure for the ligamentum venosum of the liver. (Bottom) Caudal to the esophagus hiatus,
the crura join at the median arcuate ligament (just below this section).

II
7S
 DIAPHRAGM
E DIAPHRAGM & GE JUNCTION IN MULTIPLE PLANES
CD
2
.c
Q.

b
■ ■
c
o
E
o
"O
-Q
<

— Esophagea] hiatus (just

above GF. junction)

— Meeting of right & left

crura
Crura of diaphragm

(lop) l-irst of four CT sections of a young man. The gastroesophageal junction is usually seen as a prominent soft
tissue thickening, comprised of the muscular walls and submucosa of the esophagus and stomach. (Bottom) Axial CT
section just below the esophageal hiatus. I he right and left crura join at the midline just in front of the aorta.
 DIAPHRAGM
DIAPHRAGM & CE JUNCTION IN MULTIPLE PLANES >
Q.
O
3
(D
3

— Esophagus
Median arcuate
ligament Gastroesophageal
junction 2
Aorta 3
Inferior vena cava Crura of diaphragm

F.sophageal hiatus in
diaphragm

Median arcuate
Celiac artery — ligament

Superior mesentery
artery

(Top) Coronal CT section shows aorta entering abdomen just behind median arcuate ligament, which joins the right
and left crura. (Bottom) Sagittal CT section. The esophageal hiatus is usually just left and ventral to the aortic hiatus,
but is also considerably more cephalic. The aortic "hiatus" is marked by the median arcuate ligament and its
impression on the celiac tnink.

II
77
 DIAPHRAGM
DIAPHRAGMATIC OPENINCS & MEDIAN ARCUATE LIGAMENT

Median arcuate
ligament
Celiac artery

Superior mesentcric
artery

Confluence of hepatic Hiatus for the IVC

veins & IVC

Median arcuate
ligament

— Celiac artery
Inferior vena cava

( l o p ) first of four CT sections of young woman with abdominal pain. Sagittal CT section shows extrinsic
indentation of the celiac artery by the median arcuate ligament. (Bottom) Coronal CT section shows celiac artery
and the tendinous arch of the median arcuate ligament, which impinges upon it.
 DIAPHRAGM
E SAGITTAL CT, M E D I A N ARCUATE L I G A M E N T
CO

Q.
CO

c
CD Origin of celiac trunk
E
o
-o Celiac trunk
.a
<

Duodenum (3rd part)

Left gastric artery —

Celiac trunk —

— Superior mesentcric
artery

(Top) I'irst of two sagittal views of contrast-opacified arteries of a 30 year old man shows sharply angulated and
narrowed origin of the celiac trunk at its origin from the aorta. (The left gastric artery has a separate origin in this
patient and is also acutely angled and compressed). (Bottom) Post-stenotic dilation of the celiac trunk is present and
the proximal celiac artery is compressed against the superior mesenteric artery. Findings are characteristic of
compression of the celiac trunk by the median arcuate ligament.
 DIAPHRAGM
D I A P H R A G M W I T H LOOSE CRUS & HIATAL HERNIA >
ao
3
(0

g
Di
■D

— I liaiiii hernia (stomach)

Nasogastric (NG) tube 3

Lung (atelectatic
Pleural effusion

Esophageal hiatus

Herniatetl gastric turclia

Atelectatic lung -
I'leural effusion

Nasogastric tube

— Crura of ttiaphragm

( l o p ) First of three axial CT sections in a elderly w o m a n with gastro-esophageal reflux. Ihc gastric cardia has
herniated into the mediastinum. (Middle) The esophageal hiatus is patulous, and the distal esophagus is not
compressed (as it should i>e) by the right cms. This allows the stomach to herniate, and gastric contents to reflux up
into the esophagus. (Bottom) The crura are thin and spaced apart, instead of having joined together in the midline
at this level.

II
HI
 DIAPHRAGM
E DIAPHRAGM WITH PROMINENT SLIPS

x:
a. Diaphragm —

b
• ■
Diaphragm
c Stomach
©
£
o
-Q
<

Slip of diaphragm -

Slip of diaphragm

— Slip of diaphragm

(lop) first of three coronal sections in a elderly woman. Instead of being a smooth sheet of muscle, the diaphragm
may have finger-like "slips" of muscle fibers that extend toward points of attachment along the chest wall. (Middle)
On individual sections, the slips" may appear as nodular "lesions", but can be followed as long thin structures on
contiguous sections. (Bottom) One slip of diaphragm indents the superior surface of the liver. Note the nodular
appearance of the left hemidiaphragm on this section.

II
Hi
 DIAPHRAGM
DIAPHRAGM WITH PROMINENT SLIPS >
Q.
O
3
■ •

CD

Liver —
CO

Diaphragm slips — 3

— Diaphragm slips

(Top) First of two axial C T sections in same patient as previous three images. The finger-like "slips" of diaphragm may
indent the surface of the liver or spleen; they are outlined by subdiaphragmatic fat. (Bottom) On individual CT
sections, the slips may appear as nodular lesions but can be recognized as long thin structures on contiguous sections
that extend to the chest wall.

II
in
 DIAPHRAGM
E DIAPHRAGM SEPARATING PI.FLJRAI & PFRITONFAI FLUID COLLECTIONS
CD

CL
CO

C - — Liver
0)
E
o Atelectatic lung
■D
Pleural effusion (sub-pulmonlc)
<

I'leural effusion

— Confluence of hepatic veins (&

IVC)

Ascites -

Atelectatic lung & diaphragm -

— Pleural effusion

(Top) First of five axial CT sections of a 45 year old man with cirrhosis. Atelectatic lung may be mistaken for the
diaphragm, but it is surrounded by a subpulmonic pleural effusion. (Middle) Atelectatic lung and diaphragm are
held close together by the inferior pulmonary ligament, (liottom) Note the "fuzzy" interface between the pleural
effusion and the surface of the liver, while ascites has a sharp interface, since it lies immediately next to the liver, not
separated by the diaphragm.
 DIAPHRAGM
DIAPHRAGM SEPARATING PLEURAL & PERITONEAL FLUID COLLECTIONS >
Q.
O
3
©
■ ■

V
Ascites — ■o
3"
- i
0)
CQ
3
Diaphragm

Diaphragm
Liver (bare area)

Pleural effusion

Varices (parurnbllical
collateral veins)

Ascites

Diaphragm
Right adrenal

Liver (bare area) Diaphragm

Pleural effusion —

(Top) Ascites and other ahdominai contents are suspended away from the postero-lateral chest wall by the
diaphragm. (Bottom) The diaphragm separates the thorax from the abdomen. Pleural fluid lies above and "outside
the confines of" the diaphragm, while ascites lies below and within the confines of the diaphragm. Ascites cannot
contact the "bare" (nonperitonealized) surface of the liver.

II
85
 DIAPHRAGM
E ELEVATED H E M I D I A P H R A G M , P H R E N I C NERVE INJURY
CD

CL
TO
b
■ ■
c
o
E Left hemidiaphragm (elevated)
o
■c
<

— Stomach

Diaphragm

— Spleen
— Diaphragm

(lop) Frontal radiograph shows marked elevation of the left hemidiaphragm. (Middle) The diaphragm is very thin
and is difficult to see as a distinct structure. (Bottom) An intact hemidiaphragm is indicated by the smooth contour
and by "suspension" of the spleen and abdominal fat away from the chest wall.

II
86
 DIAPHRAGM
C O R O N A L & SAGITTAL CT, EVENTRATION O F D I A P H R A G M >
CT
Q.
O
3
(D
■ ■

o
Qj"
■D
zy
—%
0)
1'ulmonary artery CQ
3

Diaphragm — — Lett atrium

Liver

--J Aorta

Diaphragm
1 iver

Diaphragm

(Top) Coronal (71 view shows a supero-lateral bulge of the liver "dome". (Bottom) Sagittal CT view shows the liver
bulge, characteristic of evcntration (congenital thinning) of the diaphragm, usually an asymptomatic condition.

II
87
 DIAPHRAGM
E BOCHDALEK H E R N I A

Diaphragm
Q- i— Herniation of abdominal (M
03

c
o
E
o
T3

<

Diaphragmatic "slips"

Diaphragm ■ Boehdalek hi'rnia

Bochdalck hernia -

— Diapliragmatic "slips"

(Top) Coronal CT section in an 88 year old male with bilateral Boehdalek hernias shows thin diaphragm with focal
marked thinning or absence of left hemidiaphragm, allowing abdominal fat to herniate into the thorax. (Middle)
First of two axial CT sections shows discontinuity of the diaphragm posterolaterally with focal herniation of fat into
thorax; bilateral Boehdalek hernias. (Bottom) Most caudal Cf section shows diaphragmatic "slips".
 DIAPHRAGM
LARGE HIATAL & MORGACNI HERNIAS >
O"
Q.
O
3
o
3

CO
— Nasogaslric tube curled in
intrathoracic stomach
to
3

Hepatic flexure (of colon)

Omental fat ■ h— Heart

Liver -

Omental fat
— Heart
Hepatic flexure (of colon)

NO tube (curled vvithin Omental iat

intrathoracic stomach)

(Top) Irontal radiograph of a 71 year old man shows herniation of the entire stomach into the chest through a
widened esophageal hiatus (tyj>e IV paraesophageal hernia). (Middle) Coronal CT section shows a large segment of
colon and omental fat within the right hemithorax adjacent to the heart. It has herniatcd through a large anterior
defect on the diaphragm, a Morgagni hernia. (Bottom) Axial CT section shows the intrathoracic stomach in a large
paraesophageal hernia, and the antero-mcdial defect (Morgagni hernia) that allows the herniation of omental fat and
colon.

II
80
 DIAPHRAGM
E TRAUMATIC DIAPHRAGMATIC RUPTURE
CD

Q.
CO

c
E
o
Intrathoracic gas & fluid (in
.a stomach)
<

Nasogastric tube (turned

upward within herniated
stomach)

— Stomach

— NG tube in stomach

Indentation of stomach (by

edge of diaphragmatic detect)

Stomach

( l o p ) first o f five images of a 18 year o l d male w i t h a t r a u m a t i c rupture of t h e d i a p h r a g m . Frontal chest f i l m shows

intrathoracic gas a n d f l u i d , a n d a n u p w a r d d e v i a t i o n o f t h e t i p o f t h e nasogastric tube. The left h e m i d i a p h r a g m is
p o o r l y - d e f i n e d . ( M i d d l e ) The s t o m a c h has herniated i n t o the left h e m i t h o r a x t h r o u g h a diaphragmatic defect, and
has "fallen" against t h e posterior chest w a l l . This is an example o f the "fallen viscus" sign o f diaphragmatic rupture.
The intact d i a p h r a g m suspends a b d o m i n a l contents away f r o m t h e postero-lateral chest w a l l . ( B o t t o m ) T h e medial
surface of t h e stomach is i n d e n t e d b y t h e intact m a r g i n o f t h e left h e m i d i a p h r a g m .

II
W
 DIAPHRAGM
TRAUMATIC DIAPHRAGMATIC RUPTURE >
a
o
3
(D
■ ■

D
0)
T3

CO
3
— NO tube

Stomach (indented by
intact medial portion
of diaphragm)

Stomach
(intrathoracic)

Diaphragm (intact
portion»

— NO tube

— Spleen

(lop) The herniated portion of the stomach lies "fallen" against the posterior chest wall. (Bottom) The medial part of
the spleen is heterogeneous due to a parenchymal laceration and hematoma.

II
01
 PERITONEAL CAVITY
I Terminology
Definitions
• Peritoneal cavity: Potential space in abdomen
between visceral and parietal peritoneum, usually
containing only small amount ol peritoneal fluid (for
lubrication)
• Abdominal cavity: Not synonymous with peritoneal
cavitv
c Contains all of abdominal viscera (intr.i- and
retro|X'ritoneal)
Limited by abdominal wall muscles, diaphragm a n d
(arbitrarily ) bv pelvic brim
^Cross A n a t o m y
Divisions
• Greater sac ot peritoneal cavity
• I esser sac ( o m e n t a l bursa)
Communicates with greater sac via epiploic
foramen (of Winslow)
Hounded in front by caudate lobe. Stomach and
greater o m e n t u m , in back by pancreas, left adrenal
and kidney; to the left bv s p l e n o r e u a l and
gastrosplenic ligaments, to the right by epiploic
foramen and lesser o m e n t u m
Peritoneum
• Thin serous membrane consisting of a single layer of
Pariet.il p e r i t o n e u m lines alxlominal wall; contains
nerves to adjacent abdominal wall and is pain
sensitive (with sharp localization)
o Visceral |>critmiciim (scrovi) lines abdominal
organs; sensitise to pain due lo stretching ol bowel
or mesentery (with poor localization)
Mesentery
• Double laser ot peritoneum that encloses ,\n organ
and connects it to abdominal wall
• Covered on both sides by mesothelium and has a core
of loose connective tissue containing fat, Ivmph
nodes, blood vessels and nerves passing to and trom
\ iscera
• Most mobile parts ol intestine have mesentery, while
ascending and descending colon are considered
retroperitoneal (covered only by peritoneum on their
anterior surface)
• Root ol" mesentery is its attached border with
posterioralHloniin.il wall
• Root of small bowel niesenterv is ~ 15 cm in length
and passes from left side of I 2 vertebra downward and
to the right: contains superior m e s e n t e r i c vessels,
nerves and lymphatics
• Transverse inesocolon crosses almost horizontalls in
Iront ol pancreas, d u o d e n u m and right kidney
Omentum
■ Multi-layered fold of peritoneum that extends from
stomach to adjacent organs
• I esser oineiitniii joins lesser curve of stomach and
proximal d u o d e n u m to liver
Hepatogastric and l i e p a t o d u o d e n a l ligament
components contain c o m m o n bile d m I. h e p a t i c
and gastric vessels a n d portal vein
• Greater o m e n t u m
■i lavered told of peritoneum hanging from greater
curve of the stomach like an apron, covering
transverse colon and much of the small intestine
■ Contains variable a m o u n t s of fat a n d a b u n d a n t
lymph nodes
■ Mobile a n d can fill gaps between viscera
■ \cts as barrier to generalized spread of
intraperitoneal infection or tumor
Ligaments
• All double lavered folds of peritoneum other than
mesentery and o m e n t u m are peritoneal ligaments
• C o n n e d one viscus to another (e.g.. splenoreual
ligament) or a \ istus to abdominal wall (e.g.,
falciform ligament)
• Contain blood vessels or remnants of fetal vessels
Folds
• Reflections of peritoneum with defined borders, often
lifting peritoneum off abdominal wall (e.g., m e d i a n
umbilical fold covers u r a c l m s and extends from
d o m e of urinarv bladder to umbilicus)
Peritoneal Recesses
• Dependent pouches formed b \ reflections of
peritoneum
• Because of clinical relevance, olten h a v c e p o n y m s
|e.g., Morison p o u c h for posterior subficp.it i>
( h e p a l o r e n a l ) recess; p o u c h of Douglas for
rectouteriiie recess|
[Anatomy-Based Imaging Issues ]
Imaging Pitfalls
• Peritoneal cavity and its various mesenteries and
recesses are usually not apparent on imaging studies
unless distended or outlined by intraperitoneal fluid or
air
j Clinical Implications |
Clinical Importance
• Peritoneum that is evident on imaging is thickened
due to inflammation or tumor
Xodular thickening is usually due to malignancy
• Peritoneal recesses are c o m m o n sites for accumulation
of peritoneal fluid tascites). pus or peritoneal t u m o r
implants
• Recesses all potential!! communicate with each other
but become functionally isolated bv processes thai
cause adherence between layers of ]>eritoneum (e.g.,
an abscess)
Phrciiicocolic l i g a m e n t limits spread of fluid Irom
left subphrenic space to left paracolic gutter
 PERITONEAL CAVITY
LATERAL VIEW OF MESENTERIES & PERITONEAL CAVITY

Liver (caudate lobe)

Lesser omentum

Lesser sac

Stomach Pancreas

Superior mesenteric
artery
Duodenum (3rd
portion)

Gastrocolic ligament Transverse mesocolon

Transverse colon

Small bowel
Greater omentum mesentery

■l • r

Sagittal section of the abdomen showing the peritoneal cavity artificially distended, as with air. Note the margins of
the lesser sac in this plane, including caudate lobe of liver, stomach and gastrocolic ligament anteriorly, and pancreas
posteriorly. The hepatogastric ligament is part of the lesser omentum, and carries hepatic artery and portal vein to
the liver. The mesenteries are multi-layered folds of peritoneum that enclose a layer of fat, and convey blood vessels,
nerves, and lymphatics to the intraperitoneal abdominal viscera. The greater omentum is a 4 layered fold of
peritoneum that extends down from the stomach, covering much of the colon and small intestine. The layers are
generally fused together caudal to the transverse colon. The gastrocolic ligament is part of the greater omentum.
 PERITONEAL CAVITY
LESSER SAC & PERITONEAL RECESSES

%*rjM
■
Greater peritoneal
cavity
Lesser omentum Gastrosplenlc ligament

Lesser sac (omental

bursa)
Splenorenal ligament

^
■ Id^m
*
"_
I
i

¥2

Transverse colon

Greater omentum Small bowel mesentery

Descending colon
Ascending colon
Left paracollc gutter

-■..'I

. A

(Top) The borders of the lesser sac (omental bursa) include the lesser omentum, which conveys the common bile
duct, hepatic and gastric vessels. The left borders include the gastrosplenlc ligament (with short gastric vessels) and
the splenorenal ligament (with splenic vessels). (Bottom) The paracolic gutters are formed by reflections of
peritoneum covering the ascending and descending colon and the lateral abdominal wall. Note the innumerable
potential peritoneal recesses lying between the bowel loops and their mesenteric leaves. The greater omentum covers
much of the bowel like an apron.
 PERITONEAL CAVITY
OMENTUM & PERITONEAL REFLECTIONS

Hepatogastric ligament -
Hepatoduodenal —
ligament
Eplploic foramen (of
Wlnslow)

Greater omentum

Left triangular 1.
Coronary ligament of Gastrophrenic L
liver
Phrenicocolic ligament
Root of transverse
Root of transverse mesocolon
mesocolon
Left paracolic gutter

Site of descending
Site of ascending colon colon

Root of small bowel Root of sigmoid

mesentery mesocolon

(Top) The liver has been retracted upward. The lesser omentum is comprised of the hepatoduodenal and
hepatogastric ligaments, forms part of the anterior wall of the lesser sac, and conveys the common bile duct, hepatic
and gastric vessels, and the portal vein. The aorta and celiac artery can be seen through the lesser omentum, as they
lie just posterior to the lesser sac. (Bottom) Frontal view of abdomen with all of the intraperitoneal organs removed.
The root of the transverse mesocolon divides the peritoneal cavity into supramesocolic and tnframesocolic spaces
that communicate only along the paracolic gutters. The coronary and triangular ligaments suspend the liver from the
diaphragm. The superior mesentenc vessels traverse the small bowel mesentery whose root crosses obliquely from the
upper left to the lower right posterior abdominal wall.
 PERITONEAL CAVITY
PERITONEAL SPACES & REFLECTIONS

— Ascites

Liver — Stomach

— Spleen

— Gastrosplenic ligament

Portal vein
— Lesser sac

— Pancreas

( l o p ) First of four axial C l sections of a middle-aged m a n with cirrhosis. Ascites distends the peritoneal cavity,
allowing visualization of recesses a n d peritoneal reflections not normally seen. (Bottom) The lesser sac a n d greater
peritoneal cavity are distended with ascites. The gastrosplenic ligament and pancreas border the lesser sac, as does the
lesser o m e n t u m whose position is marked by the portal vein and celiac trunk.
 PERITONEAL CAVITY
PERITONEAL SPACES & REFLECTIONS
&
a
I
CD
•»
Falciform ligament — T3
CD
2.
O
CD

dreater (lmenlum O
<
Gallbladder
I— Lesser sac

Pancreas

1 eft kidney

Descending colon

Greater omentum

— Transverse colon

— Small intestine
Pancreas (head) —

Liver

Right kidney —

(Top) The falciform ligament suspends the liver from the anterior abdominal wall. The greater o m e n t u m lies
between the bowel and the anterior abdominal wall. (Bottom) The intraperitoneal organs, such as the liver,
transverse colon and small bowel are suspended within the ascites, while the position of the retroperitoneal organs,
such as the kidneys and pancreas, is unaffected.

II
')
 PERITONEAL CAVITY
PERITONEAL SPACES & MESENTERIES

Falciform ligament Diaphragm

— Ascites
Hepatic cyst —
— Gastroesophageal
junction

Bare area of liver —

— I'Icural effusion

— Greater omentum
—
Stomach

Lesser omentum (with — Gastrosplenic ligament

hepatic artery)

Portal vein

( l o p ) First of four axial CT sections of a middle-aged m a n with cirrhosis and ascitcs. The liver is suspended from the
anterior abdominal wall by the falciform ligament, and from the diaphragm by the coronary ligament, between the
leaves of which lies the bare area of the liver. (Bottom) The lesser o m e n t u m and gastrosplenic ligament comprise two
of the walls of the lesser sac.
 PERITONEAL CAVITY
PERITONEAL SPACES & MESENTERIES >
ca
o
3
a
3
■ -

Transverse colon - CD

Transverse mesucolon o'

=3
CD

Small bowel mesentery

o
<
I'iinircas — I Small intestine

Liver

liastrocpiploic vessels

Small bowel (jejunal)

mesentery

Superior mesenteric
vessels
Duodenum (3rd
portion)

(Top) The mesenteries are easily identified by their content of fat (dark in attenuation) and blood vessels.
Retroperitoneal organs, such as t h e pancreas and kidneys remain in normal position surrounded by retroperitoneal
fat that conveys their blood supply. (Bottom) Note the retroperitoneal position of the d u o d e n u m . The third portion
of duodenum crosses behind the superior mesenteric vessels, which supply the small intestine. The branches of the
mesenteric vessels lie within the leaves of the mesentery, surrounded by fat.

II
99
 PERITONEAL CAVITY
DISTENDED PERITONEAL CAVITY
>
CO
O
CD
CD
C
o
<u
Q-
Lavage fluid (in right
subphrenic space)
£
o
■D
.Q
<
I.avage fluid (in left
subphrenic space)
Liver

— Spleen

— Lavage fluid

Bare area of liver —

— Diaphragm

Diaphragm —

(lop) First of seven axial CT sections of an elderly man with renal failure treated with peritoneal dialysis. Contrast
medium was added to the dialysate to identify potential sites of loculated fluid, and accounts for the "white"
appearance of the fluid. The lavage fluid appears relatively dense due to the added contrast medium. Note the
intraperitoneal fluid collecting in the subphrenic spaces. (Bottom) Note how the diaphragm suspends the liver and
spleen away from the chest wall. The bare area of the liver is in direct contact with the diaphragm, but not with the
peritoneal cavity; thus, the lavage fluid is not in contact with the bare area.
 PERITONEAL CAVITY
DISTENDED PERITONEAL CAVITY

Greater omentum -

Fissure for falciform —

ligament Pancreas

■— Splenic artery

Liver -

— Left kidney (atrophic)

(Top) Fluid invaginates into the fissure for the falciform ligament. Note that there is no fluid within the lesser sac. As
a general rule, unless the ascites is tense or of a "local" source (such as a perforated gastric ulcer or pancreatitis), it
remains confined to the greater peritoneal cavity, and does not pass through the epiploic foramen. Note the tortuous
splenic artery, a typical finding in patients with atherosclerosis. The greater onientum "floats" on top of the ascites;
note its fat density with small vessels, its normal appearance. (Bottom) Note the small kidneys, reflecting chronic
renal failure.
 PERITONEAL CAVITY
DISTENDED PERITONEAL CAVITY

I— Small bowel mesentery

Right paracoiic gutter —-j

— Iett paracoiic gutter
Ascending colon -
— Descending colon

Fluid in paracoiic gutter -

Renal allografl

Fluid in pelvic recess

Roof of acctabulum -

— Rectum

(Top) The peritoneal fluid is mostly confined to the paracoiic gutters at this level. (Middle) I he peritoneal fluid is
somewhat loculated, which is typical in the setting of chronic peritoneal dialysis, which results in inflammation and
scarring of the peritoneum over time. Note the transplanted kidney in the left iliac fossa, which had stopped
functioning due to rejection. (Bottom) The most dependent recess of the peritoneal cavity is in the pelvis, which is
distended by dialysis fluid in this patient.
 PERITONEAL CAVITY
MESENTERIES OUTLINED BY ASCITES

Small bowel

Greater omentum

Leaves or small bowel

mesentery

—
Left kidney

Small intestine -

Ascites

Descending colon
Left paracolic gutter

Sigmoid colon

Sigmoid misocolon

(Top) First of three axial CT images in a patient with ascites due to cirrhosis. The leaves of the small bowel mesentery
are separated a n d accentuated by ascites. Each "leaf" of mesentery carries blood vessels, nerves, and lymphatics to a
bowel segment. (Middle) Ascites distends the abdomen to the point of being "tense" (firm to palpation).
Retroperitoneal fat-containing spaces are unaffected. Ascites is present in the left paracolic gutter, the intraperitoncal
recess lateral t o the descending colon. (Iloltom) The sigmoid colon and its mesentery are well-defined by the ascites.
 PERITONEAL CAVITY
PERITONEAL RECESSES (MORISON & DOUGLAS)
>
03
o
03
CD
c
s
CD

0)
E
o
Si
< Hepatorenal recess (of —
Morison)

Uterus

Rectouterinc nicest lof

Douglas)
Rectum

(Top) First of two axial CT sections. The most dependent peritoneal recess in the upper abdomen is the hepatorenal
recess, also known as the posterior subhepatic space, and as Morison pouch. It communicates superiorly with the
right subphrcnic space and interiorly with the right paracolic gutter. (Bottom) The pouch of Douglas, also known as
the rectouterinc recess, is the most dependent recess of the entire peritoneal cavity in either the upright or supine
position, and is a common site for inflammatory, neoplastic or traumatic fluid collections.

II
104
 PERITONEAL CAVITY
I ESSER SAC (OMENTAL BURSA) >
a-
a.
o
3
n>
■ ■

Stomach
Castrosplenic ligament (with CD
short gastric vessels) 2.
O
( eliac artery 13
Splenic vein CD
Splenic artery &L
Spleen O
<

Duodenal bulb Stomach

Lessersac Castrosplenic ligament

Splenorenal ligament (With

splenic arterv N vein)

- Stomach
Creatcr o m e n t u m

Lessor sac

Duodenum (2nd portion!

dastmsplcnic ligament (with
short gastric vessels)
Confluence of splenic K portal I'ancreas
veins
—I— Splenorenal ligament

(lop) I irst of three axial Cl sections. The gastrosplenic ligament connects the stomach to the spleen and carries the
short gastric vessels. Abdominal "ligaments" are double-layered folds of peritoneum that connect one viscus to
another. I'hev contain fat and transmit the vessels, nerves and lymphatics between the retropcritonctim and the
abdominal \"iscera. (Middle) I he gastrosplenic and splenorenal ligaments form the left anterior and posterior walls of
the lesser sac. respectively. (Bottom) Note the structures abutting the lesser sac, including the stomach anteriorly and
the pancreas [xisteriorly.

II
I0S
 PERITONEAL CAVITY
U M B I L I C A L LIGAMENTS, DELINEATED BY ASCITES

Sigmoid mesocolon

Lateral umbilical ligaments — ■

Lateral umbilical ligaments

Inferior epigastric vessels -

- Uladdcrwall

(lop) hirst of three axial CT sections. Ascites outlines the sigmoid mesocolon and small bowel loops. (Middle) The
umbilical ligaments are outlined by ascites. These are the remnants of the fetal umbilical arteries that had connected
the internal iliac arteries to the umbilical cord. I he peritoneal reflections covering these ligaments are the lateral
umbilical folds. (Bottom) The ascites is not loculated. but normal structures, such as the umbilical ligaments and the
wall of the urinary bladder, may be mistaken for septations within the fluid collection.
 PERITONEAL CAVITY
U M B I L I C A L FOLDS (LIGAMENTS) >
Q.
O
3
CD

Urachus CD

Urachal cyst o'

CD
Urinary bladder

Symphysis pubis

Penis

Lateral umbilical ligaments

Median umbilical ligament -

— Urinary bladder

Rectus muscle
Inferior epigastric vessels
Urachal cyst

Urinary bladder

Seminal vesicle

(Top) Sagittal MR section of the pelvis shows a linear structure extending from the umbilicus to the d o m e of the
urinary bladder, the urachus (median umbilical ligament). This is t h e fibrous r e m n a n t of t h e allantois a n d should be
completely obliterated after birth. In some individuals, parts of the tract may remain patent, leading t o a urachal
diverticulum or a urachal cyst, as in this person. (Middle) The median and lateral umbilical ligaments are evident in
this individual on an axial MR section. Recall that these arc covered with peritoneal reflections, called the median
and lateral umbilical folds, respectively. (Bottom) The urachal cyst is evident within the median umbilical fold, on
axial MR section. The bright signal around the cyst indicates inflammation (infection) of the cyst, which brought the
patient to clinical attention. II
107
 PERITONEAL CAVITY
& LOCULATED ASCITES

I
o
"TO
0)
c
o
•c
o
Q.
■ ■

<u
E
o
TJ
<
Loculutcd fluid —

Enhancing rim —

(lop) I irst of two axial CT sections in a patient with abdominal pain and fever following resection of the right lobe
of the liver. Section through upper abdomen shows a large, loculated fluid collection in the right subphrenic space,
with a contrast-enhancing rim or capsule. (Bottom) Lower in the abdomen there are numerous, noncommunicating,
loculated collections of fluid, all of which have distinct, enhancing walls. These were aspirated under CT guidance
and found to contain bilious fluid. Bile leaking into the peritoneal cavity from the cut surface of the liver had
induced an intense peritonitis, accounting for adherence and thickening of peritoneal surfaces.
II
108
 PERITONEAL CAVITY
BACTERIAL PERITONITIS WITH ASCITES & THICKENED PERITONEUM >
Q.
O
3
©

!
Small bowel
O
Colon <

Loculated fluid 3 — Spleen

Mesenteric vessels

Loculated fluid — Loculated fluid

— Enhancing rim
(peritoneum)
Ascending colon

(Top) First of two axial CT sections of a middle-aged man with cirrhosis and acute abdominal pain. Multiple
loculated intraperitoneal fluid collections are noted. Ultrasound-guided aspiration yielded infected ascites,
characteristic of "spontaneous bacterial peritonitis". (Bottom) Each leaf of small bowel mesentery is "stiff" in
appearance, with straightening of the mesenteric blood vessels, and is coated with thickened, contrast-enhanced
peritoneum. The parietal peritoneum is also thickened and contrast-enhanced, causing each loculated collection ot
fluid to have a capsule or rim. Adherence between the inflamed peritoneal surfaces accounts for the loculation of the
fluid.
II
1()<)
 PERITONEAL CAVITY
F I B R O S I N C P E R I T O N I T I S D U E T O PERITONEAL DIALYSIS

Thickened peritoneum —

I i ■! ....iii il f l u i d —

— Small intestine

Thickened visceral
peritoneum

(Top) first of four images of a young woman with chronic renal failure being treated with periloncal dialysis. Axial
Cri" section shows loculated intraperitoneal fluid with a thickened capsule of inflamed peritoneum. (Bottom) The
small bowel appears to be encased In a "cocoon" of thickened visceral peritoneum (serosaj that compresses the bowel
loops together in a rounded mass.
 PERITONEAL CAVITY
FIBROSING PERITONITIS DUE TO PERITONEAL DIALYSIS >
Q.
O
3
o
3
■ ■

CD

O
<

— Descending colon
Ascending colon -

"Encapsulated" small -
bowel

(Top) Note the encapsulated appearance of the small bowel. The lumen of the bowel is also moderately dilated. The
ascending and descending colon are uninvolved, as they lie retroperitoneally. (Bottom) Abdominal radiograph taken
2 hours after ingestion of barium shows slow transit of the barium and dilated small bowel. The small bowel loops
are also crowded together and fixed in position, instead of being freely mobile on their mesentery, as normal. This is
an example of severe fibrosing peritonitis, a rare complication of peritoneal dialysis.

II
111
 PERITONEAL CAVITY
M A L I G N A N T ASCITES, PERITONEAL METASTASES
>
CO
CJ
CD
c Ascitvs —
s - Omental "cake"
I—
<D
D_
■ -

C
I
o
.Q
<

Omental tumor

Colon —
Transverse colon

Tumor implant (peritoneal) —

— Omental tumor

Mescnteric tumor -

Loculatcd ascites —

(Top) First of three axial CT sections of a middle-aged man with colon cancer and a distended abdomen. CT shows a
solid mantle of tissue overlying the colon. This is called an "omental cake", and is virtually diagnostic of malignant
peritoneal implants. (Middle) A nodular iinplanl on the parietal peritoneal surface is also characteristic of peritoneal
malignancy. Recall that the omentuni lies superficial to the colon and small bowel, while the mesentery lies between
the retroperitoneum and the "inside" of the bowel. (Bottom) Omental and mescnteric soft tissue density tumor
deposits are evident, indicating widespread intraperitoneal spread from the primary colon carcinoma.

II
112
 PERITONEAL CAVITY
N O D U L A R O M E N T A L METASTASES >
Q-
O
3
3
a ■
Stomach
CD

8
=3
CD

Omental tumor
o
CD
deposits <

— Colon

- Omental tumor
deposits
Small intestine —

(lop) First of two axial Cl sections of a middle-aged woman with ovarian carcinoma. Subtle soft tissue density
nodules are present in the omental fat overlying the colon and small bowel. Ihese are characteristic of peritoneal
tumor deposits. (Rottoni) The nodular tumor deposits in the o m e n t u m are more evident on this CT section.
Peritoneal spread of tumor is often, but not always, accompanied by malignant ascites, which is absent in this case.

II
Hi
 PERITONEAL CAVITY
PERITONEAL TUMOR & OMENTAL METASTASES
>
03
o
TO
O
c
Tumor implant. —
0) parietal peritoneum

E
O — Lesser sat fluid
T3
<
Oniental tumor

I Tumor implant, lesser

Oniental tumor

Tumor within lesser sat

(Top) First of four axial CT sections of a patient with peritoneal carcinomatosis. Nodular soft tissue density tumor
implants are present within the lesser sac and along the parietal peritoneum. A mass of tumor is noted in the
onientum, a so-called "omcntal cake". (Bottom) Inoculated fluid within the lesser sac is suggestive of infectious
peritonitis or, as in this patient, peritoneal carcinomatosis.

II
114
 PERITONEAL CAVITY
PERITONEAL TUMOR & OMENTAL METASTASES

Omcntal tumor

Loculated lesser sac

fluid

— transverse colon

— Small intestine
Loculated ascites
Oinental tumor

Tumor implant,
parietal peritoneum

(Top) Recall that the omentum should appear as a mostly fatty "apron" of tissue lying over the surface of the bowel
and colon. An extensive soft tissue mass, as in this patient, is indicative of malignancy. (Bottom) loculated ascites is
caused by adhesions (usually from prior surgery), peritonitis, or peritoneal carcinomatosis.
 PERITONEAL CAVITY
PSEUDOMYXOMA PERITONEI, APPENDICEAL CARCINOMA

Scptations within Malignant asiilcs

ascites

Liver

— Spleen

Colon — — Loculatvil ascites

(pseudomyxom.i
perttonel)

— Colon

Livei

Hepatorenal recess
(Morison punch)

( l o p ) First of two axial CT sections of a young man with appendiceal carcinoma with widespread peritoneal spread.
Note the "scalloped" surface of the liver and spleen, and the complex, septated appearance of the ascites. These
findings are characteristic of pseudomyxoma peritonei. in which peritoneal metastases from a mucin-secreting
tumor, such as appendiceal carcinoma, result in profuse accumulation of gelatinous material within the peritoneal
cavity. The loculations and quantity of the material produce the typical mass effect, or indentations, on abdominal
viscera and often result in bowel obstruction. (Bottom) Note the complex, septated appearance of the "ascites'.
which is actually semi-solid gelatinous material. The surface of the liver is markedly distorted, while the kidneys are
unaffected, due t o their retroperitoneal location.
 PERITONEAL CAVITY
P E R I T O N E A L & O V A R I A N METASTASES, GASTRIC C A R C I N O M A >

O
3
a
Stomach
Ascites - TJ
Tumor in gaslroinlii ligament
(D
3.
O
Iivcr - — Transverse colon
CD

Tumor implant, parietal

o
peritoneum 0)
<

Tumor, in gastro-colic ligament

Transverse colon

- Small intestine

Loculdtcd ascitcs

Ascitcs —

Uterus

Right ovary - left ovary

Ascitcs
Tumor in rcctoutcrine recess

- Rectum

('lop) First o f three axial CT sections in a w o m a n w i l h gastric carcinoma, metastatic t o her p e r i t o n e u m a n d ovaries.
The t u m o r encases a n d distorts the stomach, and spreads along the gastro-colic ligament i n t o the transverse c o l o n .
I.oculatcd ascites and parietal peritoneal t u m o r i m p l a n t s are n o t e d . ( M i d d l e ) Extensive t u m o r is present along t h e
transverse colon a n d t h e parietal p e r i t o n e u m . Small howel l u m e n is "dense" due t o oral - enteric contrast m e d i u m .
( B o t t o m ) Loculated ascites a n d peritoneal t u m o r are present i n t h e dependent recesses o f t h e pelvis, i n c l u d i n g t h e
rectouterine recess ( p o u c h of Douglas). Both ovaries are enlarged b y cystic-solid masses, due t o metastatic spread of
t u m o r t o the ovaries. Mctastases t o the ovaries f r o m a gastric carcinoma are referred t o as Krukenberg metastases,
after the pathologist w h o first i d e n t i f i e d this p h e n o m e n o n . II
117
 VESSELS, LYMPHATIC SYSTEM AND NERVES
Terminology
Abbreviations
• Inferior vena cava (IVC)
• Superior mesenteric artery (SMA)
• Superior mesenteric vein (SMV)
• Superior vena cava (SVC")
• Inferior mesenteric artery (IMA)
• Inferior mesenteric vein (IMV)
dross Anatomy | Thoracic duct: Inferior extent is chyle cistern at the
Overview
• Abdominal aorta
Enters a b d o m e n at the T12 level, bifurcates at 14
< Gives rise to arteries in i vascular planes
■ Anterior m i d l i n c p l a n e : Unpaired visceral arteries
to alimentary tract; celiac artery. SMA and IMA
■ Lateral p l a n e : Paired visceral arteries to urogenital
and endocrine organs; renal, a d r e n a l and
g o n a d a l arteries (testicularor ovarian)
■ Posterolateral p l a n e : Paired parietal arteries t o
diaphragm and body wall: subcostal, inferior
p h r e n i c , l u m b a r arteries
• Inferior v e n a c a v a
Returns poorly oxygenated blood t o heart from
lower extremities, abdominal wall, back and
abdominal-pelvic viscera
o Blood from alimentary tract passes through portal
v e n o u s system before entering IVC through h e p a t i c
veins
< Begins at 1.5 level with union of c o m m o n iliac
veins
o Leaves abdomen via IVC hiatus in diaphragm at 1 8
level
i IVC tributaries correspond to paired visceral a n d
parietal branches of aorta
■ Right adrenal vein, left and right renal veins,
right g o n a d a l vein
■ Left a d r e n a l a n d g o n a d a l veins drain into left
renal vein -» IVC
■ Paired parietal branches = inferior phrenic, L3 and
1.4 veins
> IVC and SVC are connected through a7ygous and
a s c e n d i n g l u m b a r veins
■ I hese are important collateral pathways when
SVC or IVC flow is obstructed or slowed
■ Additional collateral pathways include epidural
venous plexus and epigastric veins (anterior
abdominal wall)
o IVC development has complex embryology
■ Various a n o m a l i e s are c o m m o n (up to 10% of
population), especially at and below the level of
renal veins
■ All are variations of persistence/regression of
embryologic sub- and supracardinal veins
• Lymphatics of posterior abdominal wall
o Major lymphatic vessels a n d nodal chains lie along
major blood vessels (aorta, IVC, iliac) and have same
names (e.g., c o m m o n iliac nodes)
i l.vmph from alimentary t r a d , liver, spleen and
pancreas passes along ecliac, superior mesenteric
chains to nodes with similar names (e.g., ecliac
nodes)
■ Afferent vessels from alimentary nodes form
intestinal l y m p h a t i c t r u n k s
■ Cisterna chyli (chyle cistern): Formed by
confluence of intestinal lymphatic trunks and
right a n d left l u m b a r l y m p h a t i c t r u n k s (which
receive lymph from nonalimentary viscera,
abdominal wall ,mi\ lower extremities); may be
discrete sac or plexiform convergence
1.1-2 level
■ Formed by the convergence of main lymphatic
ducts of abdomen
■ Ascends through aortic h i a t u s in diaphragm to
enter posterior mediastinum
■ Lnds by entering junction of left subclavian and
internal jugular veins
i Lymphatic system drains surplus fluid from
extracellular spaces and returns it to bloodstream
■ Has important function in defense against
infection, inflammation and tumor via lymphoid
tissue that is present in lymph nodes, wall of gut,
spleen and t h y m u s
■ Absorbs aw\ transports dietary lipids from
intestine t o thoracic duct and bloodstream
• Major nerves
c Nerves of anterolateral abdominal wall come from
anterior rami of spinal nerves T7-L1
■ Derma t o m e s (areas of sensor) innervation)
resemble oblique stripes around trunk following
slope of ribs, beginning posteriorly over
intervertebral foramen from which spinal nerve
exits
■ Nerves run in n e u r o v a s c u l a r plane lietwecn
transverse alxfominal and internal oblique
muscles; supply muscles and skin
o Nerves of posterior abdominal wall
■ Sensory a n d motor fibers come from anterior and
posterior rami of spinal nerves T12 and Ll-5
( l u m b a r plexus); lie deep to psoas muscle
0 Innervation of abdominal viscera
■ S y m p a t h e t i c i n n e r v a t i o n , from lower thoracic
and abcloniinopelvic s p l a n c h n i c nerves from
spinal cord levels F5-L3; via para-aortic
prevertebral ganglia (innervates blood vessels of
abdominal viscera; inhibitory to parasympathctic
innervation)
■ P a r a s y m p a t h c t i c , from vagus nerve (esophagus
through transverse colon) arid pelvic s p l a n c h n i c
nerve (descending colon t o rectum)
■ Intrinsic p a r a s y m p a t h c t i c ganglia within
muscular wall of stomach and gut, called
m y e n t e r i c plexus (of Aucrbach); promotes
peristalsis a n d secretion (though secretion is
largely controlled hormonallv)
■ Sensory i n n e r v a t i o n of viscera, pain sensation
carried by fillers accompanying sympathetic
nerves: reflex afferent innervation accompanies
vagus (parasympathetic) nerves
 VESSELS, LYMPHATIC SYSTEM AND NERVES
>
CL
o
3
CD
3
<
CD
C/>
(/)
Inferior phrenic CD
arteries

3
"D
ZT
0)
Esophageal branch o'
C/)
Superior adrenal
arteries CO
Cellac artery (trunk)
CD
Inferior adrenal 3
arteries
Middle adrenal artery 0)

Superior mesenteric Left renal artery CD

artery
CD
C/>

Gonadal arteries

Lumbar artery

Inferior mesenteric
artery

Common iliac artery \

Middle sacral artery

t External iliac artery

Internal lilac artery

The major arteries to the gut arise as unpaired vessels from the aortic midllne plane and include the cellac, superior
and Inferior mesenteric arteries. Branches to the urogenltal and endocrine organs arise as paired vessels in the lateral
plane and include the renal, adrenal, and gonadal (testicular or ovarian) arteries. The diaphragm and posterior
abdominal wall are supplied by paired branches in the posterolateral plane, including the inferior phrenic and
lumbar arteries (four pairs, only one of which is labeled in this graphic). The anterior abdominal wall is supplied by
the inferior epigastric and deep circumflex iliac arteries, both branches of the external iliac artery. The inferior
epigastric artery turns superiorly to run in the rectus sheath, where it anastomoses with the superior epigastric artery,
a terminal branch of the internal mammary (thoracic) artery. II
110
 VESSELS, LYMPHATIC SYSTEM AND NERVES
CO CT ANGIOGRAM, NORMAL AORTIC BRANCHES

CD

T3
C
CO

E
£
to
>.
en
o
ro
_C
CL
E
Cellac artery
jo
CD
CO
co
CD
>
C
o Superior mesenteric
E artery
o
T3 Renal veins
.Q
<

Jejunal arteries
Ileocolic arteiy

Internal Iliac artery

External iliac artery

Volume rendered CT angiogram shows the aorta and some of its major abdominal branches. This image was
obtained in the late arterial phase of imaging, resulting in some opaclfication of the renal veins and the supra-renal
inferior vena cava. The infra-renal inferior vena cava is not yet opacined because the circulation to the lower
abdominal organs and legs Is not as abundant nor rapid as It is to the kidneys.
 VESSELS, LYMPHATIC SYSTEM AND NERVES
N O R M A L CATHETER A O R T O G R A M >
Q.
O
3
en
• ■

Renal arteries — <

CD
W
C/>
CD_
Superior mesenteric artery (hi
branches) - Jejunal branches of superior
mesenteric artery
Interior mesenteric artery

I umbar arteries

Common iliac arteries

s
I
— Kidney

Lumbar arteries

Right common iliac artery

— Middle sacral artery

External iliac artery

Internal iliac arteries

(Top) First of three images from a catheter aortogram shows many of the major branches, overlapped to a degree due
to the nonseleclive (upper aortic) injection and the nontomographic nature of the radiograph. (Middle) The four
paired lumbar arteries are well shown, arising from the posterolateral abdominal aorta. A fifth lumbar artery may
arise from the middle sacral or internal iliac artery. (Bottom) Ihe last branches of the abdominal aorta are the middle
sacral and c o m m o n iliac arteries. The latter branch into the external and internal iliac arteries. Ihe internal iliac
(hypogastric) artery supplies all the pelvic viscera and muscles, while the external iliac supplies the anterior
abdominal wall (through the deep circumflex iliac and inferior epigastric arteries) before leaving the abdomen
(behind the inguinal ligament) to supply the lower extremity. II
121
 VESSELS, LYMPHATIC SYSTEM AND NERVES
AXIAL CT, N O R M A L VESSELS
CD

CD

C
ro I Icpatic veins
E
CD
-•-■
CO
>^ Inferior vena cava — t - Aorta
(/)
*—•
TO
-C
Q.
E

CD

CD
>

0)
E Left portal vein
o - Lett gastric artery
■a Celiac artery
- Splenic artery
< Inferior vena cava
Aorta

Splenic artery

Pancreas

- Splenic vein

(Top) First of twelve axial CT sections. Ihe hepatic veins (usually 3 major branches) join the inferior vena cava just
below the diaphragm. (Middle) llie celiac artery is the first (most cephalic) midline branch of the abdominal aorta.
Its three major branches are the left gastric, splenic and common hepatic arteries. (Bottom) The splenic vein and
artery run along the body of the pancreas. The artery is more tortuous (curved) than the vein, and curves into and
out of the plane of axial sections, while the splenic vein usually lies in a straight horizontal plane.

II
122
 VESSELS, LYMPHATIC SYSTEM AND NERVES
AXIAL CT, NORMAL VESSELS >
CT
Q-
O

Common hepatic artery

3
CD
Right & left hepatic arteries — Pancreas <
— CD
Portal vein Splenic artery </>
U>
Spleen <L
en
r-
3

o
C/)

CD
3
Q.

CD
Portal vein - -— Splenic vein
CD
Ui

Renal arteries

— Confluence of splenic &

superior mescntcric veins

- Superior mesenteric artery

Confluence of left renal vein &

IVC

(Top) The main branches of the celiac axis (with many variations) are the common hepatic, left gastric, and splenic
arteries. The hepatic artery is smaller than, and lies ventral to the portal vein at the porta hepatis. (Middle) The
splenic and superior mesenteric veins join to form the portal vein. The renal arteries are the first major paired lateral
branches of the abdominal aorta. The inferior phrenic arteries are the first paired lateral branches, but are much
smaller, less apparent on imaging, and of less clinical importance. (Bottom) The left renal vein usually crosses in
front of the aorta and behind the superior mesenteric arlery to join the inferior vena cava.
 VESSELS, LYMPHATIC SYSTEM A N D NERVES
AXIAL CT, NORMAL VESSELS
CD

CD

T3
C
CD
Superior mesenteric vein - Su[>crior mesenteric artery
E
a Inferior mesenteric artery
w
C/D
o
TO
JC
Q.
E

</>
w
CD
>
■ ■

c
CO
E Common iliac arteries
o
■D
-Q Inferior vena cava —
<

Right common iliac artery Lett common iliac artery

Psoas muscle - — Confluence of the common

Iliac veins

(Top) The superior mesenteric artery usually lies to the left of and is smaller than the superior mesenteric vein. The
inferior mesenteric artery arises from the aorta just above the aortic bifurcation, and supplies the left side of the
colon. (Middle) The aorta bifurcates into the common iliac arteries at the level of the 4th lumbar vertebra, about 2
cm higher (more cephalic) than the confluence of the common iliac veins, which join to form the inferior vena cava.
(Bottom) The confluence of the common iliac veins appears as a "peanut" lying behind the right common iliac
artery.
 VESSELS, LYMPHATIC SYSTEM AND NERVES
AXIAL CT, N O R M A L VESSELS >
CT
Q.
O
3
CD
3
■ ■

<
Iliac arterial branches CD
(/>
f/>
CD
Common iliac vein V)

3
"D
IX
0)
«-*■

o'
if)
I
CD
- Inferior epigastric vessels
3
DJ
=J
Q.
Z
CD
External iliac artery
External iliac vein CD
C/>
Iliac wing
Uterus

Internal iliac vessels

— Sacrum

Femoral artery
Urinary bladder - Femoral vein

Femoral head
Acetahulum

Rectum

(Top) The internal iliac artery gives off numerous small branches to pelvic muscles and viscera. (Middle) The major
pelvic branches of the external iliac artery are the inferior epigastric and deep circumflex iliac arteries, which feed the
anterior abdominal wall muscles from below, and freely anastomose with branches of the superior epigastric and
musculophrenic arteries. These are the terminal branches of the internal mammary (thoracic) artery, and constitute
important collateral pathways in the event of occlusion of the iliac arteries (a relatively c o m m o n result of
atherosclerosis). (Bottom) As the external iliac artery passes under the inguinal ligament it becomes the femoral
artery, which supplies the lower extremity as well as branches t o the anterior abdominal wall and external genitalia.
The femoral artery lies lateral to the vein a n d is smaller in diameter. II
125
 VESSELS, LYMPHATIC SYSTEM AND NERVES
CTA, N O R M A L CELIAC & SMA
CD

CD
Left hepatic artery
Left gastric artery
■D
C Right hepatic artery
CO
— Celiac artery
£
B Proper hepatic artery
Splenic artery
>s (Summon hepatic artery
CO
Superior mesenteric artery
o (iastrtxluodenal artery -
"■•->

CD Jejuna! htanches of SMA

-C
Q-
E
_c/>
CD
CO
C/J
CD
>
• ■

C
Celiac artery
o
E Main portal vein
o Superior mesenteric artery
"O Superior mesenteric vein

<

l.umhar artery —
— Aorta

Common iliac arteries

I eft hepatic artery

Left gastric artery
Right hepatic artery

Superior mesenteric vein

t.astroduixlcnal artery -

Superior mesenteric artery

PancreaticodiKxJenal artery

( l o p ) First of three CT images. Maximum intensity image (MIP) in the coronal plane shows the overlapping branches
of the celiac and superior mesenteric arteries. An arbitrarily set thickness of the plane of reconstruction results in
some peripheral portions of the SMA and splenic artery being excluded from the image. (Middle) A more ventral
plane of coronal section shows peripheral branches of the SMA, and also some of the distal aorta and common iliac
arteries. The portal vein and its major branches are seen faintly, as these CT images were acquired in the
predominantly arterial phase after IV administration of contrast medium. (Bottom) A more ventral coronal section
shows additional branches of the SMA and celiac artery.
II
1J6
 VESSELS, LYMPHATIC SYSTEM AND NERVES
VARIATION, HEPATIC ARTERIES >
cr
a.
o
3

Left hepatic artery <D

Left gastric artery Splenic artery in

V)
Gastroduodenal artery
Catheter

2L

3
■D
IT
0)
£?
o"
\
Right hepatic artery - 3
— Superior mesenteric artery
0)
Q.

z
CD

I
c/>

Replaced left hepatic artery -

Replaced right hepatic artery —

— Left renal arteries

(Top) Hirst of three images showing variations of the origin of the hepatic arteries. Catheter arteriogram with
injection of the celiac trunk shows a normal splenic artery, a large left gastric artery that gives off the left hepatic
artery, a n d the gastroduodenal artery arising directly from the celiac trunk. (Middle) Catheter injection of the SMA
shows the right hepatic artery arising from the SMA. (Bottom) CT Arteriogram, volume-rendered in the coronal
plane, shows "replacement" (aberrant origin) of the left and right hepatic arteries. Also noted are three separate left
renal arteries.

II
127
 VESSELS, LYMPHATIC SYSTEM AND NERVES
VARIATION, H E P /
r2 •^^^

T3
C
03 Left gastric artery
Common hepatic
E artery
Splenic artery
(f) Right & left hepatic
arteries
0)
o Accessory nght hepatic
artery Left renal artery
To
-i—
ex Gastroduodenal artery
E
>^ Supenor mesenteric
_i
to"
<D
en
Right renal artery
C-
1 * *
artery

SI
0)
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• ■

C
CD Inferior mesenteric
E artery
o
T3
<

Right & left hepatic

arteries Sfl

Accessory right hepatic

artery

ti
m r Supenor mesenteric
artery

Inferior mesenteric
artery

(Top) First of two views of a CT arteriogram (volume-rendered, shaded surface display). Note the conventional
origins of all the major abdominal aortic visceral branches. The right hepatic artery, arising from the proper hepatic
branch of the celiac artery, is smaller than usual because there is an accessory right hepatic artery arising from the
superior mesenteric artery, a common variant. (Bottom) Oblique view of CTA clearly shows the origin of the
accessory right hepatic artery from the superior mesenteric artery.
 VESSELS, LYMPHATIC SYSTEM AND NERVES
VARIATION, RENAL & HEPATIC ARTERIES

Splenic artery

Replaced right hepatic artery

Left renal arteries

Right renal artery

I■ H ^H

Replaced right hepatic artery

1
I f

Left renal arteries

CTop) First of three images of a CT arteriogram, volume-rendered. There are three left renal arteries, each having a
separate origin from the aorta. A single right renal artery is present. The right hepatic artery arises from the superior
mesenteric artery, rather than the celiac artery, a common variation called a "replaced" hepatic artery. (Middle) In
this obliquity it is easier to recognize the replaced hepatic artery, but more difficult to distinguish the multiple left
renal arteries from branches of the superior mesenteric artery. (Bottom) The three left renal arteries are best shown in
this obliquity.
 VESSELS, LYMPHATIC SYSTEM AND NERVES
VARIATION, CELIAC ARTERY

Right & left hepatic

arteries Splenic artery

Superior mesenteric
Common hepatic artery
artery
Gastroduodenal artery

Left gastric artery

Celiac (splenic) artery

Superior mesenteric
artery

(Top) Coronal volume-rendered image shows the entire common hepatic artery arising from the superior mesenteric
artery. The left gastric artery also has a separate origin from the aorta, though difficult to perceive on this image. The
"celiac trunk" in this patient consists only of the splenic artery. (Bottom) Sagittal MIP image in the midline shows
the small left gastric artery with its separate origin from the aorta. The celiac trunk, essentially the splenic artery in
this variation, and the origin of the superior mesenteric artery are shown.
 VESSELS, LYMPHATIC SYSTEM AND NERVES
SUPERIOR MESENTERIC ARTERY

Middle colic artcrv

ejundl arteries

Right colic artcrv —

Marginal artery

lluocolic arteiy

Heal arteries

Catheter i n j e c t i o n of t h e superior mesenteric artery shows opacification o f all the arterial branches that supply the
entire small intestine, the appendix, eeeuiii, ascending a n d transverse c o l o n . The marginal artery has a course parallel
to the entire length of the c o l o n a n d anastomoses w i t h the marginal artery o n t h e left, w h i c h is supplied hy branches
o f the interior mesenteric artery. This is an i m p o r t a n t collateral pathway that can supply flow t o parts ol the colon
that w o u l d otherwise be made ischemic due to occlusion of the m a i n t r u n k or branches o f the SMA or IMA.
 VESSELS, LYMPHATIC SYSTEM AND NERVES
tt> CORONAL
W l l V i m f c ABDC
^VBVB^^M
CD
£
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z
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CO Interior phrenic veins

o
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CO
sz
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E
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—I Hepatic veins
C/J
CD Adrenal veins
w
C/)
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C
CD Renal veins
E
o
■D
-Q Left gonadal (ovarian)
Right gonadal vein vein
<

Ascending lumbar Ascending lumbar

vein vein

Middle sacral vein

External iliac vein

Internal iliac
(bypogastnc) vein

*'f

The inferior vena cava begins at the L5 level with the confluence of the common iliac veins, which are themselves
the result of the confluence of the internal and external iliac veins. Note the ascending lumbar veins which
anastomose freely between the IVC, the azygous and hemiazygous and the renal veins. These are an important
pathway for collateral flow in the event of obstruction of the IVC or one of Its major tributaries, and these veins play
an Important role in spread of tumor and infection from the pelvis and spine to the thorax, upper spine and brain.
The right renal vein rarely receives tributaries, while the left receives the gonadal, adrenal, and lumbar veins. The left
adrenal vein also anastomoses with the inferior phrenic vein. The hepatic veins return blood from the liver as they
II join the IVC just below Its hiatus in the diaphragm at about the T8 level.
 VESSELS, LYMPHATIC SYSTEM AND NERVES
IVC DUPLICATION & ANOMALIES

n
i

Q
; i

H
(Top) Four graphics illustrate common variations of the IVC. The labeled lines on the frontal graphics correspond to
the levels of the axial sections. The left graphic shows transposition of the IVC, in which the infrarenal portion of the
IVC lies predominantly to the left side of the aorta. A more common anomaly is shown on the right graphic, a
"duplication" of the IVC in which the left common iliac vein continues in a cephalad direction without crossing over
to join the right iliac vein. Instead, it joins the left renal vein, and then crosses over to the right. The suprarenal IVC
has a conventional course and appearance. (Bottom) The left graphic shows a circumaortic left renal vein, with the
smaller, more cephalic vein passing in front of the aorta & the larger vein passing behind & caudal. The right graphic
shows a completely retroaortic renal vein.
 VESSELS, LYMPHATIC SYSTEM AND NERVES
VARIATION, LEFT-SIDED IVC (TRANSPOSITION)

Inferior vena cava

Retro-aortic- crossing
of IVC

Transposed (lei I-sided)

IV<

I eft lumbar veins

Right lumhar veins

First of three images from a catheter injection of the inferior vena cava shows the vena cava lying to the left of
midline, an anomalous position. In the mid abdomen it crosses over to the right side lx.-hincl the aorta, which results
in compression of the inferior vena cava. The luminal narrowing results in increased flow through collateral venous
channels, including the lumbar veins.
 VESSELS, LYMPHATIC SYSTEM AND NERVES
VARIATION, LEFT-SIDED IVC >
D"
Q.
O
3
<t>

c/)

Left renal vein orifice 3

CO
— Transposed (left-sided)
IVC S
3
0)
I— Common iliac veins
Z
CD

— Vertebral venous
plexus
Ascending lumbar —
veins

(Top) This image shows the c o m m o n iliac, veins and some retrograde opacification of the orifice of the left renal
vein. (Bottom) A later film from the same study shows that contrast material has cleared from most of the inferior
vena cava. while the collateral veins of the vertebral plexus a n d ascending lumbar veins remain opacified. Note the
numerous connections between the venous plexus which surrounds the vertebrae and the lumbar veins.

II
 VESSELS, LYMPHATIC SYSTEM AND NERVES
VARIATION, DUPLICATED IVC

03
E — I .eft renal vein
0) Inferior vena cava
"GO
>s
o Right renal vein
ro

<u
w
to
>
•»
c
0)
E Aorta -
o - Confluence of left-sided IVC &
Right-sided infra-renal IVC
T3 renal vein

<

Aorta -

Right inferior vena cava - Left inferior vena cava

(Top) First of six axial (7T sections showing a duplicated inferior vena cava. At this level the left renal vein lias
received the duplicated infra-renal inferior vena cava and is emptying into the inferior vena cava. Note the much
larger diameter of the left renal vein as a result of this anomaly. (Middle) At this more caudal level the infra-renal
left-sided inferior vena cava has joined the left renal vein. (Bottom) More caudal section shows two venous
structures of similar size running a parallel course on either side of the aorta.

II
146
 VESSELS, LYMPHATIC SYSTEM AND NERVES
VARIATION, DUPLICATED IVC >
Q.
O
3
o
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Aorta — CD
to
</)
Right inferior vena cava - Left inferior vena cava SL
y

3
■o

J8.
o

I
3
CD
ZJ
Q.

CD

CD
—
Right inferior vena cava Left inferior vena cava

( ommnn iliac arteries

Common iliac veins

(Top) More caudal section shows duplication of the inlra-renal inferior vena cava. (Middle) At this more caudal
section the common iliac veins would normally have joined to form the inferior vena cava. Instead, there is a
continuation of the left common iliac vein as it courses in a cephalad path. (Bottom) At this more caudal level, the
position and appearance of the common iliac veins are normal.

II
137
 VESSELS, LYMPHATIC SYSTEM AND NERVES
VARIATION, IVC DUPLICATION

z
■D
C
CO

E Left renal vein

to
Interior vena cava
V)
o
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CD
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Q.
E

CD
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w
■ ■

c
0)
E
o — Left renal vein
■o
.a
< Inferior vena cava

Aorta

Kij'ht suli il IVC (infra-renal) - Left-sided IV( (infra-renal)

(lop) First of five axial CI sections shows an enlarged left renal vein joining the interior vena cava. From this level
cephalad, the inferior vena cava had a normal caliber and course, lying in its usual site to the right of the aorta.
(Middle) More caudal section shows the infrarenal duplicated inferior vena cava joining the left renal vein. (Bottom)
Caudal section below the kidneys shows both the left and right-sided inferior vena cava. Failure to recognise this as a
cylindrical structure in continuity with the common iliac vein caudally and the left renal vein cephalically might
lead to a mistaken diagnosis of a para-aortic mass, such as lymphadenopathv.

II
 VESSELS, LYMPHATIC SYSTEM AND NERVES
VARIATION, IVC DUPLICATION >
Q.
O
3
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<
CD
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Common iliac arteries

3
=r
cs
Common iliac veins
o

CD
3
Q.

CD

C o m m o n iliac arteries

Common iliac veins —

('lop) More caudal section shows the bifurcation of the aorta into the common iliac arteries. At this level the left
common iliac vein would normally have crossed over to join the right common iliac vein to form the inferior vena
cava. (Bottom) More caudal section shows a normal appearance and location of the common iliac veins.

II
1 W
 VESSELS, LYMPHATIC SYSTEM AND NERVES
V A R I A T I O N , C I R C U M A O R T I C RENAL V E I N

I .eft renal vein

(pre-aortic branch)

Inferior vena cava

Aorta

Inferior vena cava filter — Renal calculi

I eft renal vein

(retro-aortic branch)

(lop) hirst of four images in a patient with a circumaorlic left renal vein. Variations of the left renal vein are much
more common than those affecting the right vein. One common anomaly is a circumaortic left renal vein, in which
the pre-aortic branch passes, as usual, between the aorta and the superior mesenteric vessels. The pre-aortic branch is
smaller and more cephalad in position than the retro-aortic component. (Kottom) The retro-aortic branch of the left
renal vein is usually larger and lies about one vertebral body lower (more caudal) than the pre-aortic branch. This
anomaly is of importance if surgery of the left kidney or aorta is being considered, or if interventions on the inferior
vena cava are implemented (such as placement of an inferior vena cava filter in this patient with lower extremity
venous thromboses).
 VESSELS, LYMPHATIC SYSTEM AND NERVES
VARIATION, C I R C U M A O R T I C RENAL VEIN >

a
o
3
o
Catheter in IV<
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Upper pole venous CD
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l i p of catheter i n left
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lj.'ft renal vein
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3
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(7)
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CD

IB
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— Ix-tt renal vein
(retro-aortic branch) z
CD

CD
Cfl

r~
Catheter — i
I
- Pre-aortk branch

Interior vena cava

Ketro-aortic branch

(Top) In a n t i c i p a t i o n of placing an inferior vena cava filter, a catheter was i n t r o d u c e d i n t o t h e inferior vena cava
f r o m an a r m v e i n . The t i p of the catheter is seen c u r v i n g t o the left a n d e n t e r i n g a renal vein b r a n c h that represents
t h e pre-aortic b r a n c h seen o n the CT scan. Note its small size a n d cephalic p o s i t i o n relative t o the retro-aortic
branch, w h i c h is also opacified b y i n j e c t i o n ot contrast material t h r o u g h t h e catheter t i p . ( B o t t o m ) The pre- a n d
retro-aortic branches o f t h e circumaortic left renal vein c o m m u n i c a t e w i t h each o t h e r a n d d r a i n separately i n t o the
inferior vena cava.

II
HI
 VESSELS, LYMPHATIC SYSTEM A N D NERVES
VARIATION, IVC & POLYSPLENIA
CD

z
C
CO
E
B
m

O
*-•
CO

Hepatic veins

HI Azygous vein
w — Hemiazygous vein

>

o
E
o
■D

<

Hepatic veins

Azygous vein

(Fop) hirst of five CT images in a patient with polysplenia syndrome shows an enlarged azygous vein, which serves as
the primary route of venous drainage of the abdomen and lower extremities in this condition. The inferior vena cava
is absent between the level of the renal veins and the hepatic veins, which drain directly into the right atrium.
(Bottom) More caudal image shows a dysmorphic liver and the first of multiple splenic masses.
 VESSELS, LYMPHATIC SYSTEM AND NERVES
VARIATION, IVC & POLYSPLENIA >
a.
o
3
TO
Portal vein 3
■ >

Biliary drainage catheter

Spleens C/>
CO
£P_
Dilated bile duct

£
B
-o
CO
^-
o'
C/)

§
Q.
Spleens z
CD

I
j— Left renal vein (retroaortic)

Colon

Spleen

(Top) More caudal section shows absence o f t h e retrohepatic inferior vena cava. D i l a t i o n o f the intrahepatic bile
ducts is n o t e d , along w i t h a biliary drainage stent. M u l t i p l e splenic masses are n o t e d ; i n this syndrome, these may
n u m b e r f r o m 2-16. ( M i d d l e ) A n associated vascular a n o m a l y is a retroaortic left renal v e i n . Above this level t h e
inferior vena cava is absent, a n d t h e azygous/hemiazygous a n d other collateral veins must return b l o o d t o the heart.
( I t o t t o m ) More caudal section shows all of the c o l o n l y i n g o n t h e left side of the a b d o m e n , w h i l e all of the small
bowel lies t o t h e right. Various lx>wel anomalies, i n c l u d i n g m a l r o t a t i o n , d u p l i c a t i o n , a n d atresia are associated w i t h
the polysplenia syndrome.
II
m
 VESSELS, LYMPHATIC SYSTEM AND NERVES
VARIATION, POLYSPLENIA WITH ANOMALIES OF IVC & SVC
CD

CD

z
C
CTJ
E
CO

CO
o
"■*-'

CO
-C
Q.
E Right-sided SVC —
>>
Left-sided SVC
jo
CD
to
CO
CD
>
• ■

c
CD
E
o
■o
n
<

Arch of azygous vein

(Top) First of eight CT sections in a patient with polysplenia syndrome and associated vascular anomalies shows
duplication of the superior vena cava. (Bottom) The arch of the dilated azygous vein is seen in this more caudal
section as it enters the back of the superior vena cava. Normally the azygous would enter into the superior vena cava
to the right of midline; this is part of the situs anomalies in this syndrome.

II
M4
 VESSELS, LYMPHATIC SYSTEM A N D NERVES
V A R I A T I O N : SVC, IVC & POLYSPLENIA >
c
D.
O

I
-•
V)
v>
to­
ut

3
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3-
ca
o"
en

CD
— Azygous vein
3
0)
ci
CD

CD
C/>

f— Azygous vein

( l o p ) The azygous vein is in an anomalous left-sided position and is dilated due to interruption of the supra-renal
inferior vena cava. This condition is referred to as "azygous continuation of the inferior vena cava". (Bottom) I he
heart appears normal in this patient. 65% of patients with polysplcnia syndrome have an absent supra-renal inferior
vena cava with azygous continuation.

II
145
 VESSELS, LYMPHATIC SYSTEM AND NERVES
V A R I A T I O N : SVC, I V C & POLYSPLENIA

Azygous v e i n

Spleen —

(Top) The hepatic veins empty directly into the right atrium. One of several splenic masses is seen, lying on the right
side of the abdomen instead of the normal left side. (Bottom) More caudal section shows situs ambiguous (rather
than simple situs inversus, or a mirror-image arrangement of the abdominal viscera).
 VESSELS, LYMPHATIC SYSTEM AND NERVES
VARIATION: SVC, IVC & POLYSPLENIA

Azygous vein

Spleens —

Retro-aortic right renal

vein

(Top) Multiple spleens are noted. The liver is more symmetric and midline than normal, part of the situs ambiguous
pattern. (Bottom) A retroaoriic renal vein is noted. Due to the presence of the infrarenal inferior vena cava on the
left side of the abdomen, it is the right renal vein which is retro-aortic in this patient.
 VESSELS, LYMPHATIC SYSTEM AND NERVES
VARIATION, HEPATIC VEINS

Middle hepatic vein

Left hepatic vein
Right hepatic vein

Accessory right hepatic-

vein

Right hepatic vein

Accessory right hepatic — Aorta

vein

(Top) hirst of four CT sections shows variation in hepatic venous drainage into the inferior vena cava. Thick axial
reconstructed CT section shows the three major hepatic veins (left, middle, and right) in addition to an accessory
right hepatic vein which has a separate entry into the inferior vena cava. (Bottom) Coronal CT section shows the
long axes of the right a n d accessory right hepatic veins which have separate orifices in the inferior vena cava. Venous
anomalies, such as these, are important to recognize if hepatic surgery (e.g., partial hepatectomy) is being considered.
 VESSELS, LYMPHATIC SYSTEM AND NERVES
VARIATION, HEPATIC VEINS

Confluence of hepatic
veins (entering IVC)

Main hepatic veins

Tortal vein

Accessory right hepatic —

vein

( l o p ) The three major hepatic veins enter the inferior vena cava just below the d i a p h r a g m . I h e y may have three
separate orifices or may j o i n together before e n t e r i n g the i n f e r i o r vena cava. C o m m o n l y , the left and m i d d l e hepatic
veins j o i n and e m p t y t h r o u g h a single orifice. ( B o t t o m ) N o single plane o f section is sufficient t o show the entire
course ot vessels, t h o u g h .i d i m e n s i o n a l surface renderings are often h e l p f u l , particularly for visualization of arteries,
as these can be rendered q u i t e dense a n d apparent w i t h the IV a d m i n i s t r a t i o n ot a bolus ot contrast m e d i u m . I h i s
M i l ' image i n t h e coronal plane shows t h e portal and hepatic veins w e l l .
 VESSELS, LYMPHATIC SYSTEM AND NERVES
VARIATION, INTERRUPTED IVC
c:
CD

z
■D
C
CO

£E
to
Retropentoneal venous collaterals
CO
O - Basivertebral foramen
Ascending lumbar vein —
IS — Epidural venous plexus
Q.
E
_co
CD
CO
CO

■ ■

C
CD
E
o
■D
-O
< Retropentoneal venous collaterals —

— Epidural venous plexus

Right ascending lumbar vein — — Left ascending lumbar vein

Retro] >eriJoncal venous collaterals --

- Atrophic left kidney

Right kidney -
- Epidural venous plexus

flop) First of five axial CT images in a IS year old male with interruption of the infrarenal inferior vena cava. The
inferior vena cava is absent and is replaced by multiple retroperitonenl venous collaterals. Note the widened
basivertebral foramen due t o dilatation of the basivertebral vein connecting the dilated epidural plexus to the
ascending lumbar veins on both sides of the lumbar vertebral bodies. (Middle) The left lumbar vein joins a medial
root from the left renal vein t o form the hemiazygos vein whereas the right ascending lumbar vein joins a medial
root from the inferior vena cava to form the azygos vein. Note the dilated ascending lumbar veins. (Bottom) Note
the extensive rctroperitoneal venous collaterals replacing the absent inferior vena cava. Incidental note of atrophic
II left kidney with compensatory hypertrophy of the right kidney.
ISO
 VESSELS, LYMPHATIC SYSTEM A N D NERVES
VARIATION, INTERRUPTED IVC

Inferior vena cava —

Azygos vein
Hemiazygos vein

Liver —

Inlerior vena cava —

Azygos vein
I Icmia/.ygos vein

Posterior intercostal
vein

(lop) The hemiazygos vein crosses the midline at l'8 to drain into the azygos vein which drains into the superior
vena cava. This is a crucial pathway for drainage of the lower part of the body in patients with inferior vena cava
obstruction. Note dilatation of both the azygos and hemiazygos veins carrying blood from the lower part of the body
to drain into the superior vena cava. (Bottom) The thoracic epidural venous plexus drains into the azygos and
hemiazygos veins via the posterior intercostal veins. Note the dilated right posterior intercostal vein on this image.
 VESSELS, LYMPHATIC SYSTEM AND NERVES
CORONAL LYMPH NODES
?-***«

k / .

P**K

Celiac nodes
Thoracic duct

Superior mesenteric
nodes
Cisterna chyli

Lumbar trunks (of Intestinal trunk (of

dstema chyli) cisterna! chyli)

Right lumbar
(retro-caval) nodes

Lumbar (para-aortic)
nodes

Aorto-caval nodes
■\

I
Inferior mesenteric
nodes
Common iliac nodes
1 ' I '

External lilac nodes

Internal iliac
(hypogastric) nodes

The major lymphatics and lymph nodes of the abdomen are located along, and share the same name as the major
blood vessels, such as the external iliac nodes, celiac and superior mesenteric nodes. The para-aortic and para-caval
nodes are also referred to as the lumbar nodes and receive afferents from the lower abdominal viscera, abdominal
wall and lower extremities; they are frequently involved in inflammatory and neoplastic processes. The lumbar
trunks join with an intestinal trunk (at about the LI level) to form the cisterna chyli, which may be a discrete sac or a
plexiform convergence. The cisterna chyli and other major lymphatic trunks join to form the thoracic duct which
passes through the aortic hiatus to enter the mediastinum. After picking up additional lymphatic trunks within the
thorax, the thoracic duct empties into the left subclavian or innominate vein.
 VESSELS, LYMPHATIC SYSTEM AND NERVES
NORMAL LYMPHANGIOGRAM >
a.
o
— Lett lumbar (para-aortic) nodes 3
o
3

Right lumbar (para-caval) nodes

s
CO

«<
3

a
o

CD
3

CD

1
Cfl

Common iliac ruxles

Common Iliac nodes

External iliac nodes

(Top) First of three images from a lymphangiogram, in which iodinated oil is slowly infused into the lymphatics of
the fool to produce opacification of the lymph channels a n d nodes. Note the sub-centimeter (short axis) diameter of
these normal retmperitoneal lymph nodes. (Middle) Lymphatic channels and lymph nodes parallel the course of
major blood vessels and share similar names, such as these c o m m o n iliac nodes. (Roltoni) With the availability of
CI, MR and PET (positron emission tomography), lymphangiograms are performed much less frequently t h a n in the
past.

II
153
 VESSELS, LYMPHATIC SYSTEM AND NERVES
LYMPHADENOPATHY D U E T O L Y M P H O M A
<D

Z
■D
C

E
GO

CO
o
Porta hcpatis nodes —
03
-C
D. Mesenteric nodes
E
Portal vein

Porto-caval node
<D
Spleen
CO
Inferior vena cava

>
c Retrocrural nodes

E
o
TJ
-Q
<

Jejuna! vessel

— Mesenteric nodes

Superior mesenteric Duodenum (3rd

vessels portion)

Lumbar nodes

(Top) Rest of four CY sections of a 50 year old woman with non-Hodgkin lymphoma shows splenomegaly and
marked enlargement of multiple upper abdominal lymph nodes. The use of intravenous and oral contrast opacifies
the blood vessels and bowel, respectively, facilitating identification of the nodes. Note enlargement of the retrocrural
nodes that accompany the aorta as it passes behind the diaphragm as it enters the thorax. (Bottom) The lumbar
nodes are often referred to as para- or retro-aortic (or -caval), indicating their position relative to the great vessels.
Note the ventral displacement of the duodenum by the large retroperitoneal nodes, and the mesenteric vessels
surrounded or "sandwiched" by mesenteric nodes.
II
154
 VESSELS, LYMPHATIC SYSTEM AND NERVES
L Y M P H A D E N O P A T H Y DUE T O L Y M P H O M A >
C7
Q.
O
3
CD
3
■ >

<
CD
Cfl
C/3

Mesenteric nodes I—
3
Mesenteric vessels
Spleen zr
0)
o'
(fi
I x i m b a r nodes en
CD
3
Left kidney DJ

CD

CD

_
External iliac nodes

External iliac vessels

O b t u r a t o r nodes

(Top) Normal abdominal lymph nodes are usually less than one cm in diameter. Size alone is not always a reliable
criterion for diagnosing malignant nodal involvement, as benign processes, including infection and inflammation
(e.g., mononudeosis or sarcoidosis) can result in similar nodal enlargement. Conversely, nodes containing malignant
deposits arc not always enlarged. Note that some of the enlarged lumbar nodes are quite low in attenuation (density),
probably due to partial necrosis. (Bottf>m) The major lymphatic channels and nodes follow the major blood vessels
and have similar names.

II
 VESSELS, LYMPHATIC SYSTEM AND NERVES
CO A U T O N O M I C NE!

CD

zC £2
03
E
CD
-*—* Right sympathetic
CO
trunk
t/D
O
TO Thoracic splanchnic
nerves
Anterior vagal trunk
E ^^B
_i
^v
to
Q)
CO Posterior vagal trunk
CO
CD
>
Celiac ganglia
©
E
o Right adrenal plexus Superior mesenteric
ganglion & plexus
.a
< Right sympathetic
trunk Left aorticorenal
ganglion
Left sympathetic trunk
Aortic
(intermesenteric)
plexus
k. " H

Inferior mesenteric
3rd lumbar ganglion
sympathetic ganglion

Superior hypogastrlc
plexus

1st sacral sympathetic

ganglion

Autonomic innervarion of the abdominal viscera comes from several splanchnic nerves and one cranial nerve, the
vagus (CNIO), which deliver presynaptic sympathetic and parasympathetic fibers (respectively), to the aortic plexus
and its sympathetic ganglia. Periarterial extensions of these plexuses deliver postsynaptic sympathetic and
parasympathetic fibers to the abdominal viscera, where intrinsic parasympatrietic ganglia occur. The various plexuses
are mixed, sharing sympathetic, parasympathetic, and visceral afferent fibers. Thoracic splanchnic nerves are the
main source of presynaptic sympathetic fibers to the abdominal viscera. The cell bodies of the postsynaptic
sympathetic neurons constitute the prevertebral ganglia that cluster around the roots of the major branches of the
II abdominal aorta, including the celiac, aortorenal, superior and inferior mesenteric ganglia.
156
 VESSELS, LYMPHATIC SYSTEM AND NERVES
N E U R A L I N V A S I O N BY P A N C R E A T I C C A N C E R

Pancreatic carcinoma - — Superior mesenteric

vessels

Duodenum

Porta hcpatis
Iymphadenopathy

Portal vein

Portocaval
Iymphadenopathy

(Top) First of t w o CT images i n a patient w i t h intractable a b d o m i n a l pain shows a mass i n t h e head of t h e pancreas,
representing carcinoma. T h e fat planes a r o u n d t h e superior mesenteric vessels are i n f i l t r a t e d w i t h tumor. Recall that
t h e celiac a n d superior mesenteric ganglia lie i n this area. Invasion of these structures is c o m m o n in patients w i t h
pancreatic carcinoma a n d is a m a j o r cause o f m o r b i d i t y a n d m o r t a l i t y , as these neural a n d vascular structures c a n n o t
be removed surgically w i t h o u t sacrificing the entire bowel. ( B o t t o m ) A more cephalic section shows t u m o r
i n f i l t r a t i n g a n d enlarging m u l t i p l e regional l y m p h nodes. I n d i v i d u a l a b d o m i n a l nerves a n d ganglia are rarely visible
o n CTOSS-sectional i m a g i n g . Neural p a t h o l o g y may be inferred by i m a g i n g evidence o f a mass a n d clinical signs a n d
s y m p t o m s c o m p a t i b l e w i t h adjacent nerve i n v o l v e m e n t .
 ESOPHAGUS
Terminology
Abbreviations
• Gastrocsophageal reflux disease (Gl RD)
Definitions
A ring: Sporadically imaged Indentation of esophageal
lumen at cephalic end of lower esophageal sphincter
B ring: Transverse inucosal lold marking
esophagogastric junction, often corresponding to
mucosal junction between squamous and columnar
epithelium
Gross Anatomy
Overview
• l.sophagus is fibromuscular tube about 25 cm long
that extends from pharynx t o stomach
• F.nters thorax at about N level; occupies posterior
mediastinum
i n t e r s a b d o m e n through esophageal hiatus in
diaphragm through right cms, at about HO
• Physiologic areas of narrowing or constriction
At its origin by c r i c o p h a r y n g e u s m u s c l e (upper
esophageal sphincter)
i By a r c h of a o r t a (left anterolateral surface of
esophagus)
Bv left m a i n b r o n c h u s
c By d i a p h r a g m (and mucosal, li ring al
gastroesophageal junction about 40 cm from incisor
teeth)
• Mural a n a t o m y
< Has internal circular and external longitudinal
layers of m u s c l e
■ Superior third of esophagus consists of voluntary,
striated muscle; lower xh = smooth muscle;
middle </i = both types
i Lacks serosal lining
■ I ined by stratified squamous epithelium
• Gastroesophageal j u n c t i o n (C.liJ)
o Marked on mucosal surface by Z line: Demarcates
end of smooth, pearlv pink esophageal mucosa
beginning of reddish, textured gastric columnar
mucosa
CitJ attached to liver at fissure for ligamentum
venosum by gastrohepatic ligament
(jf| often appears thickened on axial imaging (may
simulate a tumor)
• Attached to diaphragm by p h r e n i c o e s o p h a g c a l
l i g a m e n t (collagenous band, tends t o weaken &
elongate with age, may lead to hiatal hernia)
• Vessels, nerves, l y m p h a t i c s
i Lsophageal arteries (from aorta) in thorax
o Lett gastric (from celiac) a n d inferior phrenic arteries
in abdomen
' Venous drainage through a/ygous system (systemic)
and left gastric (to portal venous)
< I n n o v a t i o n : Right and left vagus nerves;
sympathetic trunk
Lymphatic drainage
■ 1 ower lh -» left gastric and celiac nodes
■ Upper 'h -* posterior mediastinal nodes
[ Imaging Anatomy
Internal Structures-Critical Contents
• Pharynx
Nasopharynx
■ Fro»m F M W ni v k n i l t o t u n n i *intl n ^ L i t i *
Oro i m c s o p h a r y n x )
■ From soft palate to hyoid lx>ne
Hypo (laryngopharynx)
■ From hyoid to Ixittom of cricopharyngeus muscle
Upper esophageal sphincter
At pharyngoesophageal junction
1
Formed primarily by cricopharyngeus muscle
I ower esophageal s p h i n c t e r
Defined by manomctric evidence of high resting
tone or pressure
1
Essentially synonymous with "esophageal vestibule"
or "phrenic a m p u l l a "
Occasionally recognized radiographically as a 2-4 cm
long luminal dilation between esophageal A and B
rings
Anatomy-Based Imaging Issues
Imaging Recommendations
• Best means of evaluating mucosal disease
(inflammation, superficial lumor): Double contrast
barium esophagram and endoscopy
• Best lest for Gl RD: Lsophagram and pll testing by
esophageal probe or capsule
• Best test for stricture: Single contrast esophagram
• Best test for mass lesion: lsophagram and endoscopv
■ Best test for depth of tumor invasion: Endoscopic
sonography
• Best test for staging esophageal cancer: Combined
PET-CT (positron emission fct computed tomography)
[Clinical Implications
Clinical Importance
• Hiatal h e r n i a and GERD are extremely c o m m o n and
usually occur together
i Hiatal hernia results in loss of the constriction &
angulation of t h e esophagus by the c m s of
diaphragm (part of the lower esophageal sphincter)
Reflux often causes spasm of esophageal
longitudinal muscles, resulting in shortening of
esophagus and more hcrnialion
• Lsophageal varices are c o m m o n
o Submucosal veins drain into systemic is portal
venous system and constitute potential collateral
pathway
Usual form is "uphill varices" d u e to portal
hypertension (cirrhosis) causing hepatofugal flow
(away from liver) through varicose collaterals
around esophagus
a "Downhill varices" result from obstruction of
superior vena cava -» esophageal varices -» inferior
vena cava and portal vein
 >
o.
o
3
a
3
m
en
o
■o
ZT
CD
CQ
C
en

The esophagus enters the thorax at about Tl level behind and slightly to the left of the trachea. It Is usually indented
on its left antero-lateral surface by the arch of the aorta and the left main bronchus. The esophagus is closely applied
to the aorta throughout its course, and may be pushed or pulled by aortic abnormalities, such as aneurysm or ectasia.
The esophagus enters the abdomen at about the T10 level, betweenfibersof the right cms of diaphragm. The
esophageal hiatus lies more caudal than the hiatus for the inferior vena cava, and cephalad to the aortic hiatus.
 ESOPHAGUS
ESOPHAGUS SAGITTAL RELATIONS

Crlcopharyngeus
muscle
Esophagus

Pulmonary artery

Pulmonary veins

Diaphragm

Lesser sac

Stomach (body)

iC*
- ~_ - H

The esophagus is about 25 cm long and extends from the level of the crlcopharyngeus muscle (at the C5-6 level) to
the gastioesophageal junction (at about the TlO-11 level). Note the relationship between the esophagus and adjacent
structures, including the heart, which may indent or displace the esophageal lumen.
 ESOPHAGUS
>
Q.
O
Outer longitudinal 3
muscle layer CD
3
m
Inner circular muscle CO
layer o
"D
zr
0)
Phrenlcoesophageal CQ
Wt ligament (ascending c
leaf) CO

Diaphragm Thickened muscle of

LES

Phrenlcoesophageal
ligament (descending
leaf)

Right cms of
diaphragm

Circular muscle layer of

stomach

nr
Thoracic duct

Paratracheal nodes

Tracheobronchial
nodes

Diaphragmatic nodes

Left gastric nodes

(Top) The esophageal wall musculature consists of an inner circular layer and an outer longitudinal layer. In the
region of the lower esophageal sphincter (LES), the muscle layers are thickened. This, along with diaphragmatic
constriction and the anguiation of the esophagus as it passes into the abdomen and enters the stomach, helps to
prevent reflux of gastric contents The Z line marks the junction of the esophageal and gastric mucosa. (Bottom)
Lymphatic drainage from the upper part of the esophagus is usually to the paratracheal and posterior mediastinal
nodes, while the distal esophagus drains to the diaphragmatic, celiac and left gastric nodes; however, there is
considerable overlap. The tracheobronchial nodes lie near the carina and may be responsible for the formation of
traction diverticula when they become fibrosed, usually as a result of tuberculosis or histopiasmosls. II
K,l
 ESOPHAGUS
NORMAL IMPRESSIONS ON ESOPHAGUS
en
TO
-C
Q.
O
W
LU Right clavicle
■ ■

C
<D
E
o
■a Aortic arch indentation

<

Lett main bronchus

Esophageal lumen

— Aortic arch

— Left main bronchus

(Top) First of two films from a barium esophagram with air contrast (lumen distended by gas from ingested gas
granules a n d water). The esophagus is normal a n d has a featureless smooth inucosal surface. The left anterior wall of
the esophagus is indented by two adjacent structures, the arch of the aorta a n d the left main bronchus. (Bottom)
The esophageal lumen appears narrowed between the aortic arch and the left main bronchus, but this is a normal
finding. The bronchus is identified as t h e air-filled tubular structure next to the esophagus.

II
162
 ESOPHAGUS
B A R I U M E S O P H A G R A M , ESOPHAGEAL A & B RINGS >
a.
o
3
o
3
■ •

m
CO
o
3-
CO
CQ
£Z
V>

Lower esophageal
sphincter

Diaphragmatic
indentation

Stomach —

T — A ring

Phrenic ampulla
I! ring

Hiatal hernia —

Diaphragmatic
indentation

(Top) Two films from a single contrast barium esophagram. This image shows a smooth dilation of the distal few
centimeters of the esophageal lumen, often referred to as the phrenic ampulla or esophageal vestibule. This is the
anatomic correlate to the ITS, which is defined manometrically as the zone of increased resting tone or pressure
within the esophagus. Ihe ITS contributes to the anti-reflux valve effect at the gastroesophageal junction. (Bottom)
Same patient as previous image with film taken during abdominal straining (Valsalva maneuver). A small hiatal
hernia is demonstrated. The A and B rings of the esophagus are well-defined, and mark the upper and lower limits of
the lower esophageal sphincter, respectively. The B ring marks the gastroesophageal junction, which is above the
diaphragm in this patient, indicating a hiatal hernia. li
163
 ESOPHAGUS
(/) N O R M A L GASTROESOPHAGEAL J U N C T I O N
13
O)
CO
Q.
O
W
LU
■ •

C
CD Right cms
E
o
■a
■Q
<

Right cms of diaphragm -

Celiac artery -

Superior mesenteric artery -

Liver —r~

— Stomach

— Gastrocsophageal junction

(Top) first of three CT sections through the upper abdomen. Coronal CT section shows the esophagus and aorta
entering the abdomen. The esophagus enters at about the T10 vertebral level between fibers of the right cms of
diaphragm. Ihe aorta enters at about the T12 level behind the median arcuate ligament of the diaphragm. (Middle)
Sagittal CT section in the midline shows the esophagus and aorta entering the abdomen. Only portions of the celiac
and superior mesenteric arteries are seen in this section, but the origin of the celiac is usually just caudal to the
median arcuate ligament, which marks the entry of the aorta into the abdomen. (Bottom) The gastroesophageal
junction usually lies at the same level as the fissure for the ligamentum venosum in the liver and commonly appears
II thickened relative to the walls of the distal esophagus or proximal stomach.
164
 ESOPHAGUS
GASTROESOPHACEAL JUNCTION >
cr
o.
o
3
a

m
c/)
o
■o
=r
03
co
c
w
Fissure for ligamentum
venosum
Stomach
Right cms
Ciastroesophagedl
junction

Left irus

Falciform ligament

left |x>rtal vein

Fissure for ligamentum

venosum

Right cms

(Top) First of two axial CT sections through the upper abdomen. The esophagus enters the alxlomen through fibers
of the right crus, and the gastroesophagcal junction is normally at about the level of the fissure for the ligamentum
venosum. (Bottom) The decussation (crossing of fibers) of the right crus is well shown on this CT section.

II
165
 ESOPHAGUS
PATULOUS DIAPHRAGMATIC HIATUS WITH HERNIA
CJ)
ro
-C
Q.
O
W
LU
Stomach (Ixxly)

E
o
T3 — Ilerniated stomach (cardia)
< Nasogastric tube

Lung (atelectatic)

Pleural effusion - I

Fissure for ligamentum venosum Crus of diaphragm

- Iliatal hernia (gastric c.irdia)

Nasogastric tube

Diaphragmatic crura

(Top) First of three axial CT sections in an elderly man. In this section through the lower chest, a portion of the
stomach is visualized, opacified by oral contrast medium. (Middle) At the level of the fissure for the ligamentum
venosum, which should mark the gastroesophageal junction, note the wide opening between the crura of the
diaphragm, which has allowed the stomach (gastric cardia) to herniate. This is a sliding hialai hernia. (Hottom) Most
caudal CT section shows a persistent gap between the crura, which should have joined together in the midline at this
level.

II
166
 ESOPHAGUS
ESOPHAGEAL B RING, HIATAL HERNIA >

&
3
••
m
o
T3
=r
a>
to
cto

— Lsophagus

— B ring

— Horniatcd gastric cardia

lsophagus

B ring

Gastric folds

Stomach

(Top) I irsl of two films from a barium esophagram shows a web-like narrowing at the gastroesophageal junction, a
typical feature of the esophageal B ring, which marks the squamu-columnar junction. The B ring is well seen due to
the hiatal hernia and good fluoroscopic technique which has distended the distal esophagus and proximal stomach.
(Bottom) Gastric folds extend above the diaphragm to the B ring, another sign of a hiatal hernia.

II
167
 ESOPHAGUS
c/> STRICTURE AT B RING (SCHATZKI RING)
CT>
CD
-C
CL
O
W
111
■ ■
c
0)
E
o
"D
— Esophagus
<

B ring

Herniated gastric cardia

— Schatzki ring

Hiatal hernia

(Top) First of two films from a barium esophagram shows a narrowed lumen through the B ring, at the
gastroesophageal junction. The lower esophageal ring is thickened and the lumen narrowed due to inflammation
and scarring, almost always due to gastro-esophageal reflux. (Bottom) When the lumen is narrowed through the B
ring, this is sometimes referred to as a "Schatzki" ring after the radiologist who noted that patients with this finding
frequently had complaints of reflux and food "sticking" in their esophagus, sometimes requiring endoscopic
treatment.
II
168
 ESOPHAGUS
CRICOPHARYNGEAL ACHALASIA & HIATAL HERNIA >
Q.
O
3
ro
3
■ ■
m
w
Pharynx o
XJ
IX
0)
C.5 vertebra <Q

Indentation from
cricopharyngeus muscle
Esophagus

Pharynx

Indentation from
cricopharyngeus muscle

Esophagus

Esophagus

- Herniated stomach

- Diaphragm

(Top) First of three films from a barium esophagram. This lateral view shows a rounded indentation of the posterior
wall of the pharyngo-esophageal junction, at the level of the disk space between the 5th and 6th cervical vertebrae.
The pharynx is distended, indicating impaired passage of the barium. These are typical features of spasm or
"achalasia" (failure to relax) of the cricopharyngeus muscle, which is part of the upper esophageal sphincter (Middle)
The cricopharyngeus normally relaxes in anticipation of the arrival of a bolus of food. This lateral film shows
persistent filling of the pharynx and contraction of the cricopharyngeus muscle after the bolus of barium has passed.
(Bottom) A film of the lower chest shows a hiatal hernia. Cricopharyngeal achalasia is often the indirect result of
disordered esophageal molility and acid reflux. II
169
 ESOPHAGUS
"FELINE" ESOPHAGUS
CT>
CO
-C
Q.
O
w
UJ
• ■

c
0)
E
o
T3

<

Esophageal lumen

"Ilerringljone" mucosal
pattern

(Top) Two films from an air-contrast barium esophagram. Both show a peculiar herringbone surface coating pattern,
rather than the normal featureless surface pattern of the esophagus. This is a transient finding and represents the
result of contraction of the muscularis mucosa, and usually results from an episode of reflux which "irritates" the
esophagus. (Bottom) This herringbone-like pattern of barium coating is an uncommon feature in the human
esophagus, but is, apparently, a typical feature of the cat esophagus; hence, the descriptive term "feline esophagus".

II
I/O
 ESOPHAGUS
PARAESOPHAGEAL HERNIA >
a.
o
3
o
m
o
Stomach (fundus) T3
3"
0)
CD
C
Diaphragm

— Stomach (Ixxly)

F.sophagus

liastrii fundus

— Gastric cardia
Indentation by —
hemidiaphragm
— Gastroesophageal
junction

I«ft hemidiaphragm

(Top) First of two films from a barium upper GI series, showing herniation of the gastric fundus, as well as the gastric
cardia. This constitutes a paraesophageal hernia and is considered a more compelling indication for surgical repair
than a simple "sliding" hiatal hernia, which involves only the cardia. (Bottom) In most paraesophageal hernias
(I'Ell), the gastroesophageal junction lies above the diaphragm; these are classified as type 111 I'LH. Those in which
the GL junction is below the diaphragm are classified as a type II PLH. The term "paraesophageal" refers to the
position of the intrathoracic stomach alongside ("para") the esophagus.

II
171
 ESOPHAGUS
PARAESOPHAGEAL HERNIA
Di
03
sz
CL
o
LU
■ ■

c
<L>
E
o
-a
-Q
< Heart

Inferior vena tava —

— Abdominal lal
Stomach (funilus) —

Stomach
(intra-alxlominal)

Esophagus
— Spleen

11> i. i.,ii (i stomach

(Top) First of two axial CJ sections showing a large paraesophageal hernia. Note the position of the herniated
stomach alongside the distal esophagus. Both lie in the mediastinum behind the heart. (Bottom) A more caudal
section shows the distal esophagus just above the GE junction with stomach herniated beside it, constituting a
paracsophageal hernia.
 ESOPHAGUS
ESOPHAGEAL VARICES

I ;;in11.t 1 i 11 venous collateral

I iver

Esophageal lumen
Esophageal varices

Parumhil ical venous collateral

left portal vein

Esophageal varires

l'arumbilical collateral veins -

liver

— Spleen

(Top) First of three axial CT sections in a 43 year old woman with alcoholic cirrhosis. The liver appears nodular and
heterogeneous, findings typical of cirrhosis. Note the contrast-enhancing venous collaterals in the wall of the
esophagus (esophageal varices). (Middle) A very large parunibilical collateral vein communicates with the left portal
vein and fills due to hepatofugal ("away from the liver") flow as a result of cirrhosis and portal hypertension.
(Bottom) Most caudal CT section shows the shrunken, scarred, cirrhotic liver, and the spleen which is enlarged due
to portal hypertension. The parunibilical collaterals will continue caudally to surround the umbilicus like a group of
snakes; hence, the mythologic reference to the head of Medusa ("caput Medusae"), a descriptive term for this physical
finding.
 GASTRODUODENAL
Terminology
Abbreviations
• ( ombined positron emission a n d computed
tomography (I'l-1-( T )
• Superior mesenteric artery (SMA)
[Gross Anatomy | ■ Duodenal bulb is intraperitoncal; remainder
Overview
• Stomach. The alimentary reservoir for mixing and
enzymatic digestion of food
Cardia: Surrounds t h e esophageal orifice into
stomach; lesser and greater curvature meet here
I u n d u s Most cephalic part of stomach; touches lell
hemidiaphragm
Hods: Main portion; principal site of acid
production
Antrum: \estihule; pre-pvloric part ot stomach
Pylorus: Sphincter opening into duodenum; formed
b \ thickened middle laver of smooth muscle and a
thin fibrous septum
Mural a n a t o m y
■ Wall consists ot i lasers of smooth muscle
(outermost = longitudinal; middle = circular; inner
= oblique); circular is thickest
■ Gastric lolds (rugae): Redundant folds ot the
gastric mucosal surface
■ Most evident when the stomach is empty, along
greater curve
■ Mucosa is columnar epithelium
■ Gastric glands: Varv in prevalence in different
parts of the stomach: produce mucous (which
lines and protects gastric surface), pepsinogen
(precursor to pepsin), and hydrochloric acid
(activates digestive enzymes, assists with
breakdown ot food)
Vessels, nerves a n d l y m p h a t i c s
• I esser curvature: Hranches of left a n d right
gastric arteries (lie in lesser omentuni)
■ (ireater curvature: Left a n d right gastro-oiiicntal
(gastrocpiploic) arteries (in greater onientum)
■ Venous drainage into portal vein directlv through
lett a n d right gastric veins and via splenic a n d
superior meseilteric veins
■ I \ mphatic drainage along course ol arteries, then
to celiac n o d e s via efferent lymphatic ducts
■ Innervation: Vagus nerve: I'arasympathetic,
stimulates |)eristalsis and acid production;
sympathetic nerves; celiac and splanchnic ganglia
and plexus (also carry pain receptor nerves)
Greater curvature attached to transverse colon by
gastrocolic l i g a m e n t
■ ( arcinoma can cross from stomach to colon and
vice versa
• Duodenum
Hulb: Triangular first purl
■ Suspended b \ hcpatoduodenal ligament (also
contains bile duct, portal vein and hepatic artery)
Descending (2nd part)
■ Site of major pancreaticobiliary papilla (ol
Vater); entrv of c o m m o n duct and main
pancreatic duct
Transverse (3rd part)
Ascending (4th part)
Mural a n a t o m y
■ Mucosa. subinucosa, circular and longitudinal
smooth muscle
retroperitoneal
■ Hrunuer glands: Most prominent in proximal
d u o d e n u m , secrete fluid with mucous anil
proteolytic enzymes
r
Anatomic relations
■ 2nd and M6 portions of d u o d e n u m are closely
attached to pancreatic head |surgical resection ol
pancreatic head (Whipple procedure) requires
resection of d u o d e n u m , as u e l l |
■ 2nd part of d u o d e n u m lies just anterior to hikim
ot right kidney (inflammation from duodenal
perforation may extend into perirenal space)
■ Duodenojejunal junction usually at about L2 level
(about same level as pvlorus), suspended bv
ligament of Treit/ (extension of right c m s ol
diaphragm)
Vessels a n d nerves
■ Arterial supplv primarily from celiac artery -*
gastroduodenal to pancreaticoduodenal arteries
■ P a n c r e a t i c o d u o d e n a l artery receives brant lies
from celiac and SMA; frequent collateral pathway
in event of occlusion or narrowing of celiac or
SMA
, Clinical Implications
Clinical Importance
• (iastric and duodenal ulcers are c o m m o n
1 tiology is often multifactorial, often (9()%) related
to Helicobacter pylori infection which erodes the
mucosa, making it vulnerable to t h e caustic effects
Of acid and digestive enzymes (pepsin) produced by
stomach
Rich vascular supply makes "uppci Gl" bleeding a
c o m m o n result
• (iastric malignancies are c o m m o n , though more
prevalent in Asia
Rich lymphatic is venous drainage makes nodal fe;
liver metastases c o m m o n at t h e time of diagnosis
• Ircl part of duodenum is adjacent to aorta
Tollowing repair of an abdominal aortic aneurysm, a
fistula mav form to t h e d u o d e n u m , often with fatal
Consequences (aorto-enteric fistula)
• (iastric a n d d u o d e n a l diverlicnla are c o m m o n and
usually asy mptomatic
- Mav be mistaken for upper abdominal cystic mass
(iastric diverticulum can simulate adrenal mass on
( l o r MR
Duodenal diverticulum can simulate a pancreatic
head cystic mass
I'eriampuIIary duodenal diverticulum mav lx*
associated with biliarv dvsfunction
 GASTRODUODENAL

Liver (left lobe)

Fundus
Falciform ligament

Gastroeplplolc artery
branches

Gastrocollc ligament

Greater omentum

f
)
Hepatogastric ligament Left gastric artery

Hepatoduodenal
ligament
Celiac artery

Pylorlc sphincter

Middle (circular)
muscle layer
Outer (longitudinal)
muscle layer

(Top) The liver and gallbladder have been retracted upward. Note that the lesser curvature and anterior wall of the
stomach touch the underside of the liver, and the gallbladder abuts the duodenal bulb. The greater curvature is
attached to the transverse colon by the gastrocollc ligament, which continues interiorly as the greater omentum,
covering most of the colon and small bowel. (Bottom) Lesser omentum extends from the stomach to the porta
hepatls, and can be divided into the broader and thinner hepatogastric ligament and the thicker hepatoduodenal
ligament. Lesser omentum carries the portal vein, hepatic artery, common bile duct and lymph nodes. Free edge of
the lesser omentum forms the vential margin of the epiplolc foramen. CeUac artery can be seen through the surface
of the lesser sac. Note the layers of gastric muscle; middle circular layer is thickest.
 GASTRODUODENAL
DUODENUM, FRONTAL & INTERNAL FOLD PATTERN

Hepatoduodenal
ligament

Right kidney
Transverse mesocolon
Root of transverse
mesocolon
Pancreas Jejunum

Transverse colon
SMA&SMV
Duodenum (3rd
portion)
Root of small bowel
mesentery

Hepatoduodenal
ligament

Pylorus

■
Common bile duct

Major papilla (of Vater)

^H
Proximal jejunum
Pancreatic duct ■

(Top) The duodenum is retroperitoneal, except for the bulb (1st part). The proximal jejunum Is Intraperltoneal.
Hepatoduodenal ligament attaches the duodenum to the porta hepatis and contains the portal triad (bile duct,
hepatic artery, portal vein). The root of the transverse mesocolon and mesentery both cross the duodenum. The third
portion of the duodenum crosses in front of the aorta and IVC, and behind the superior mesenteric vessels (SMA and
SMV). Second portion of duodenum is attached to pancreatic head and lies close to the hilum of the right kidney.
(Bottom) Duodenal bulb is suspended by the hepatoduodenal ligament. Duodenal-jejunal flexure is suspended by
the ligament of Treitz, an extension of the right crus. The major pancreaticobiliary papilla enters the medial wall of
the second portion of the duodenum. Duodenal wall consists of mucosa, submucosa, 2 muscle layers.
Superior pylork iimles

Gastric lymphaiic veswh a^vu.pany the arterit* <>l similar nirrut along the greater an<l lesser cuvaturv*. Lymph
from the arsteriof and posterior sutlers of the stomach drsics to the left gastric ■ id gavtn ■piplotC I ddfc along with
the pancreirirpsplenic R'xJes. Tl»e pyloric nodes drain the Inferior third of the stonui-h, primarily from the l o ^ r
curvature, whUe the distal part of the greittrr curvatuie and the duodtnum dratn to the pan._v itiictfuodenal nortis.
All of these nodal groups subsequently drain to the celiac nodes, which are grouped at the base of the celiac artery.
 GASTRODUODENAL
ARTERIES OF STOMACH AND DUODENUM
> |

I»

fl&

Esophageal branch of
left gastric artery

Inferior phrenic
arteries
Splenic artery
Left gastric artery

Right gastric artery

Left gastroepiplolc
artery

Branches of left &

right gastric arteries

Right gastroepiplolc
artery

■ r

"Conventional" arterial anatomy of the stomach and duodenum (present In only 50% of population) has the left
gastric artery arising from the celiac trunk, supplying the lesser curvature, and anastomosing with right gastric artery,
a branch of the proper hepatic artery. The gastroduodenal artery is the first major branch of the common hepatic
artery and branches into the superior pancreaticoduodenal and right gastroepiplolc arteries. The greater curvature of
the stomach is supplied by anastomosing branches of the gastroepiplolc arteries, with the left arising from the
splenic artery. The duodenum and pancreas are supplied by a rich pancreaticoduodenal "arcade" comprised of
multiple, anastomosing branches from the gastroduodenal and superior mesenteric arteries.
 GASTRODUODENAL

Portal vein Short gastric veins

Coronary (left gastric)

vein

Splenic vein
Right gastric vein
Gastioepiploic veins
Pancreatlcoduodenal
veins
Inferior mesenteric
Superior mesenteric vein
vein

Middle colic veins

Right colic veins Left colic veins

Deocollc veins

Slgmoid veins

Superior rectal vein

Rectal (hemorrhoidal)
veins

Venous draiiuge from the stomach, duodenun, sniall bowel and colon (up to the splenic fie AHA) is to the superior
mesenteric vein. Panovitic ven<ius drainage is to the splenic and supe« • »r meteoterjc veins (SMV). Tie dWer-' ii g
and sigmo'd c-lon drain through the Inferior m.-senteric vein (1MV)- The splenic vein, SMV an J iMV are the main
tributaries of the portal vein. These veins are valve3t«s and flRfy a-mmunicate through num- • .us collateral
patiwiys, which bec-cne important and evident in cases of thromb- >sis or compres-L.n of veins (ej;., spknic win
orvtaion by pancrea'ic caucw, leading to collateral nV«w thn ugh the coronary and short gastric veins (gastric
varices*). TJ ere are also extensive potential collaterals to the systemic venous circulation that become important in
portal hypertension, especially gastroesophageal, p ■ >■ i; bllical, and hemorrhoidal varices.
 CASTRODUODENAL
03 NORMAL STOMACH
C
CD
O
■D

8
U)
TO
o
■ •

c
E
o
■D
.a
<
lundiis

Lesser curvature

Body

Duodenal bulb
— Greater curvature
Pylorus

Duodenum (2nd
portion)

Antrum Duodenum (Ird

poilion i

Frontal f i l m f r o m a b a r i u m upper G l series. The lesser curvature is t h e concave border and t h e greater curvature is the
convex border o f the stomach. The fundus is the uppermost hood-like p o r t i o n of the stomach, w h i c h intersects w i t h
the cardia, where t h e esophagus enters the stomach, at an acute angle. The body is the m a i n p o r t i o n and the a n t r u m
is t h e distal part of t h e s t o m a c h w h i c h empties i n t o the d u o d e n u m t h r o u g h t h e pylorus.

II
180
 GASTRODUODENAL
UPPER C l N O R M A L S T O M A C H & D U O D E N U M >
a.
o
Gastric rugae 3
a
Duodenal bulb ■ >

o
Duodenum (2nd portion) — Gastric rugae

a
o
Q-
CD

Stomach

DiKKlcn.il bulb
Pylorus

Duodenum (2nd portion)

Duodenal bulb
Pylorus
Gastric rugae

Duodenum (3rd portion)

\ — Jejunum

(Top) First of three films f r o m a b a r i u m upper GI series shows the distal stomach a n d d u o d e n u m . Note t h e gastric
folds, or rugae, as s m o o t h , linear f i l l i n g defects in t h e b a r i u m p o o l . ( M i d d l e ) Lateral v i e w f r o m upper GI series shows
the anterior a n d posterior walls o f the stomach, as w e l l as t h e pylorus i n profile. The d u o d e n a l b u l b is w e l l distended,
w i t h its n o r m a l triangular shape. ( B o t t o m ) N o t e t h e s m o o t h mucosal surface of t h e d u o d e n a l b u l b a n d t h e feathery
fold pattern of the r e m a i n i n g d u o d e n u m and j e j u n u m .

II
161
 CASTRODUODENAL
TO AXIAL CECT, N O R M A L C A S T R O D U O D E N A L A N A T O M Y
C
CD
T3
o
■D

ro
O
■ ■

c Liver
0)
E
o Stomach (body)
■o
— Left gastric artery
<
I'ortal vein
Gastroepiploic vessels
Caudate Iolx?

Spleen

Falciform ligament
Lesser omentum

Stomach

Right portal vein —

— Celiac artery

Right adrenal gland — Left adrenal gland

(Top) 1 irst of four axial CT sections shows the normal relations of the stomach to adjacent organs. Note that the
stomach may be compressed by an enlarged liver or spleen. (Bottom) Note the fat-containing lesser o m e n t u m that
carries vessels and lymphatics to the stomach and liver.

II
l«2
 GASTRODUODENAL
A X I A L CECT, N O R M A L C A S T R O D U O D E N A L ANATOMY >

o
3
CD

O
Iivcr —
Stomach

Gastric antrtim - Q.
( olnn (splenii flexure) c
o
Q.
Gallbladder — CD
Pancreas (body) =J
Duodenal bulb — cu
Splenic vein

Liver (left lobe) -

Gastric antrum

Gallbladder —

Duodenum(2nd -
|K>rtion)
Pancreas (head)

(Top) The posterior wall of t h e stomach ahuts t h e pancreas, w i t h o n l y t h e lesser sat l y i n g between. The gallbladder
abuts t h e gastric a n t r u m a n d d u o d e n a l b u l b . The greater curvature touches t h e splenic flexure o f c o l o n ( B o t t o m )
The gastric a n t r u m abuts the pancreatic head posteriorly a n d t h e gallbladder laterally.

II
183
 GASTRODUODENAL
GASTRIC & DUODENAL ARTERIES
c
a>
■o
o
-o
2
■*-•

t/>
ro
CD
••
c
<u
E
o
TJ
<

Spleen

Right gastric artery —

Splenic artery

I'mpt'r hepatic artery 1 eft gastric artery

(..isi i lnuiK i•. 11 artery

(ummon hepatic
artery

Right gastrm-pipluit
artery

Superior - Angiographit catheter

pancreatieDduinleiial
artery

Catheter arteriogram, ecliac artery. The main branches of the celiac trunk are the left gastric, splenic and c o m m o n
hepatic arteries. The lesser curvature of the stomach is supplied by the left and right gastric arteries, with the latter
being a branch of the proper hepatic artery. The greater curvature is supplied by the right AIK\ left gastroepiploic
arteries, branches of the gastroduodenal and splenic arteries, respectively. The splenic artery also supplies short
gastric arteries to the Hindus. The gastroduodenal artery gives rise to the superior pancreaticocluodenal arteries which
anastomose with branches from the superior mesenterk artery to supply rich flow to the pancreas and duodenum.
There are numerous congenital variations in the blood supply to the upper abdominal organs, and many
II interconnecting pathways of the celiac and superior mesenteric arteries and their branches.
IH4
 GASTRODUODENAL
CATHETER & CT ANC.IOC.RAPHY, ARTERIAL VARIATIONS >
CT

Left inferior phrenic artery

a
I
Short gastric arteries re
3
■ •
Right hepatic artery
o
Lett gastric artery CD

CastroduocJenal artery
Splenic artery 3
Q.
^ o
Right gastroepiplon artery CL
(D
Posterior inferior 3
CO
pancrcaticoduodenal artery
- i — Anterior inferior
pancrcaticoduodenal artery

— Left hepatic artery

Right hepatic artery Left gastric artery

Left gasti i< vein

(.astroduodenal artery
Portal vein
Common hepatic arter>'

Lett portal vein

— Left hepatic artery

Right poi ial vein

— Left gastric arlery

— Celiac artery
— Common hepatic artery

(Top) Catheter angiogram shows the c o m m o n hepatic artery arising f r o m t h e celiac axis, its most c o m m o n
arrangement, a n d g i v i n g rise t o the gastroduodenal and r i g h t hepatic arteries i n this i n d i v i d u a l . ( M i d d l e ) C o r o n a l
r e f o r m a t i o n of a ("I scan, displayed as a C T angiogram f o l l o w i n g IV a d m i n i s t r a t i o n o f contrast material. The o r i g i n
Of the left hepatic artery f r o m the left gastric, a c o m m o n variant, is hetter s h o w n o n the C f/\ t h a n the catheter
angiogram. Branches o f the portal venous system are less well opacified due t o the deliberate t i m i n g o f t h e C l scan
t o show t h e arteries preferentially. ( B o t t o m ) The (VI a n g i o g r a m is a d i g i t a l creation generated by the i n i t i a l axial CT
data set a n d it can be rotated i n t o various planes to more o p t i m a l l y display vessels a n d their origins.
II
 GASTRODUODENAL
ARTERIAL VARIATIONS, SEPARATE ORIGIN OF LEFT GASTRIC ARTERY
c
Q)
■D
O
T3
2
o

E
o ■ Common hepatic
13 Proper hepatic artery artery
.Q — Splenic artery
Gastroduodcnal artery
<
Right gastrocpiploic — Celiac trunk
artery

Pancreaticoduodenal
arteries

Spleen

— Left gastric (coronary)

vein
Portal vein

Splenic vein

3
(Top) First of six images of the same patient. Arterial phase of celiac angiogram shows only the common hepatic and
splenic arteries arising from the celiac trunk. The left gastric artery has a separate origin from the aorta in this
individual, as shown on the subsequent CT scan. (Bottom) Venous phase image from celiac angiogram shows the
left gastric vein entering the portal vein near its confluence with the splenic vein.

II
18(.
 GASTRODUODENAL
ARTERIAL VARIATIONS, SEPARATE ORIGIN OF LEFT GASTRIC ARTERY >
a.
o
3
o
3
a ■

a
0)
C/)
o
c
a
CD

— Left gastric artery

Fancreas

Common hepatic
artery
— Splenic artery

•— Renal cyst

(Top) Axial CT section through the upper abdomen shows the left gastric artery arising separately from the aorta,
rather than having its usual origin from the celiac trunk. (Bottom) More caudal Cl section through the ccliac trunk
shows the common hepatic and splenic arteries at their origin. The splenic artery runs a circuitous route, frequently
indenting the dorsal surface of the pancreas. (Incidentally noted is a left renal cyst).

II
187
 Common hepatic
artery Celiac trunk
Splenic artery

Left renal arteries

Superior mesenteric

SE artery

(Top) Sagittal reformation of CT data set shows the origins of the celiac and superior mesenteric arteries from the
proximal abdominal aorta. Barely seen is the small left gastric artery, which has a separate origin from the aorta In
this man. (Bottom) Frontal volume rendered CT anglogram from the same original CT data set demonstrates the
major visceral branches of the abdominal aorta. From cephalad to caudal these are the celiac, superior mesenteric,
renal and inferior mesenteric arteries.

II
I OR
 GASTRODUODENAL
BRUNNER GLAND HYPERPLASIA >
cr
a.
o
3
o
3
*-

CD

3
Q.
c
&
CD
13

lined, n.il hull)

KnmiUT glands

li.istru aiitniin

l*yloms

DiiiHlrnuni (2nd
portion)

Film from an upper O l scries shows n u m e r o u s p o l y p o i d f i l l i n g defects in t h e d u o d e n a l b u l b characteristic o f

hypc-rplastic Brunner glands. These glands are n o r m a l constituents ol the duodenal w a l l , more numerous i n the b u l b
and second p o r t i o n . I'hey are n o r m a l l y o n l y 1 or 2 n u n in diameter a n d are usually n o t evident o n radiographic
studies. The Rrunner glands secrete a clear f l u i d that contains m i l l us a n d a weak proteolytic e n z y m e acting in an acid
milieu.

II
18«l
 GASTRODUODENAL
to PERFORATED D U O D E N A L ULCER
CD

2
■s>

CD
■ •

c Gastric antrum
CD
— Par
E
o Pylorus 1
■o
.Q Duodenal bulb Splenic vein
<

— lixtralumiii.il Mas
bubbles

Pancreatic bead

Duodenum(2nd
portion)

Lxtraluniiiial contrast Extraluminal gas

material

(lop) First of six images in a young man with acute abdominal pain. Axial CT section shows extraluminal gas
bubbles dorsal to the pancreas, in the retroperitoneum. (Bottom) More caudal CT section shows high density
contrasl material that has "leaked" out of the lumen of the second portion of the duodenum. The lumen of the
duodenum is distorted.

II
iyu
 GASTRODUODENAL
PERFORATED D U O D E N A L ULCER >
ao
3
<D

o
CD
C/>
Superior mesentcric
Pancreas tuncinate vessels
process)
CD
Duodenum (2nd 0)
portion) — Extraluniinal gas

Left renal vein

I'anireas (head)

Duodenum(2nd
portion) Extraluniinal contrast
&gas

(Top) Lxtraluminal gas tracks along the course of the third portion of d u o d e n u m , which is the only segment of
bowel to cross between the aorta and the superior mesenteric vessels. The only other structures that lie in this space
are the uncinate process of the pancreas and the left renal vein, both of which appear normal in this patient.
(Bottom) The lumen of the second portion of duodenum is distorted as usually occurs as a result of ulceration and
spasm. The extraluniinal gas a n d contrast material appear to lx- leaking from the second or third part of the
duodenum.

II
191
 GASTRODUODENAL
CD PERFORATED DUODENAL ULCER
C
CD

E
3
■D
2
to
CD

■ ■

c
E
o
•a
< Duodenum (3rd
|x>rtion)

— Extraluminal gas
Retroj>eritoneal spread
ot inflammation

— Duodenal bulb

Ulcer

Gastric antrum
Extraluminal gas

— Duodenum(2nd
portion)

( l o p ) I he lumen of the third portion of d u o d e n u m appears to be normal, but extraluminal gas is evident behind the
duodenum. Also note the inflammatory changes in the retroperitoneal space around the right kidney. (Bottom)
Oblique film from an upper Gl series performed with water-soluble contrast medium shows an ulcer at the apex of
the d u o d e n u m , which is the post bulbar segment that begins the second portion of the d u o d e n u m . I he lumen of the
adjacent segment of d u o d e n u m is narrowed due to spasm. Extraluminal gas is present. A perforated ulcer of the
second portion of d u o d e n u m was confirmed at surgery. While the duodenal bulb is intraperitoneal, the rest of the
duodenum is retroperitoneal, which explains the presence of retroperitoneal inflammation a n d gas in this case.
II
19.>
 GASTRODUODENAL
PERFORATED DUODENAL ULCER; TISSUE PLANES >
a.
o
3
(D
— Stomach
3
• ■

CD
CD
< l-xtraluminal gas 3
Gasttoduodenal artery — C
Superior mesentcric
artery R
Pancreatic head
Duodenum (2nd
portion)

Extrapcritoneal
inflammation

Lymph node (enlarged)

— Pancreatic head

Renal fascia (thickened)

(Top) First of two axial CT sections in an elderly m a n with acute abdominal pam shows extraluminal gas near the
second portion of the d u o d e n u m and infiltration of the retroperitoneal (anterior pararenal) space o n the right. The
gastroduodenal artery lies in a plane between the pancreatic head and the second portion of d u o d e n u m . (Bottom)
The second portion of the d u o d e n u m always lies immediately lateral to the pancreatic head. The lumen of the
duodenum is collapsed, and the adjacent retroperitoneal fascial planes and spaces are infiltrated. An adjacent lymph
node is enlarged due to inflammation (reactive hyperplasia). A perforated ulcer was subsequently confirmed.
Inflammation of t h e pancreas or d u o d e n u m will result in infiltration of the anterior pararenal space a n d thickening
of the renal fascia, which forms the dorsal boundary t o this space. II
191
 CASTRODUODENAL
(0 GASTRIC ULCER, PERFORATED INTO LESSER SAC
C
CD
■D
O

2
CO
O
■ ■
C
O
E
o — Stomach
■v
<
Gastrosplenic ligament

Lesser sac fluid

Spleen

Left kidney

— Stomach

— Lesser sac fluid

Portal vein Pancreas

Splcnorenal l i g a m e n t

Colon (splenic flexure)

(Top) first of four images in an elderly man with chronic renal failure and acute abdominal pain. Axial CT section
shows a heterogeneous retrogastric fluid collection within the lesser sac, bounded laterally by the gastrosplenic
ligament. (Bottom) Note the heterogeneity and loculation of the fluid within the lesser sac, representing mostly
blood and gastric juice. The kidneys are atrophic due to chronic renal failure.

II
194
 CASTRODUODENAL
G A S T R I C U L C E R P E R F O R A T E D I N T O LESSER S A C >

O
3
o
3
a ■

Stomach o

o
Q.
Issuer w c f l u i d
13
0)

Stomach —

Ulcer crater

(Top) The stomach is compressed a n d displaced b y the lesser sac f l u i d , w h i c h is heterogeneous a n d of relatively h i g h
density, l.oculatcd lesser sac f l u i d collections are usually the result of pancreatitis or a perforated ulcer of the posterior
wall of the stomach, since these organs abut the lesser sac. ( B o t t o m ) Lateral view f r o m an air contrast tipper G l series
shows a focal o u t p o u c h i n g of b a r i u m f r o m t h e posterior wall of t h e stomach, diagnostic o f a benign gastric ulcer. The
ulcer was c o n f i r m e d by endoscopy and resolved w i t h medical therapy. Recall t h a t t h e lesser sat lies immediately
adjacent t o the posterior wall of the s t o m a c h .

II
195
 GASTRODUODENAL
co GASTRIC CARCINOMA WITH NODAL METASTASES
CD
"D
O

T3
2
-•—*
W
CO
O
• ■

c Stomach (normal)
0)
E
o
■o
<

— Stomach (constricted
by tumor)

Duodenal bulb

Stomach
Nudes —

Gastric wall

(Top) Frontal film from an upper GI series in an elderly man with early satiety and weight loss shows marked
irregular thickening of the wall of the stomach throughout the distal body and antrum. There is an abnipt transition
between the normally distensible fundus and proximal body and the fixed, nondistensible distal stomach. The
duodenal bulb is normal. (Bottom) First of five axial GT sections in the same patient as previous image shows
distension of the proximal stomach and a thin, normal gastric wall. Enlarged lymph nodes are present in the
gastrohepatic ligament (upper left gastric group) due to metastatic spread of tumor.
II
196
 GASTRODUODENAL
GASTRIC C A R C I N O M A WITH N O D A L METASTASES

Stomach

Node

— Distended proximal
stomach

Contracted stomach
(due tn tumor)

— Lymph node
metastase\

( l o p ) The stomach is distended with food and fluid, along with the orally administered contrast medium, due to
gastric outlet obstruction. (Bottom) Note the abrupt transition from the dilated proximal stomach with its thin wall
to the narrowed lumen and thick wall of the distal stomach. When carcinoma affects the distal stomach, it often
results in a rigid, nondistensible condition that obstructs gastric emptying. Spread to upper nodal chains is also
typical.
 GASTRODUODENAL
CO GASTRIC CARCINOMA WITH NODAL METASTASES
C
CD
-o
o

1
■ * - •

to
oCO
• ■
c
CD
E - Contracted stomach
o (due to tumor)
-a
<

—
Omcntum

Nodal metastasis

Gastric a n t r u m

(Top) More caudal CT section. Note the collapsed, constricted lumen of the distal stomach and the thickened wall
due to tumor infiltration. The fat planes next to the stomach are infiltrated due to direct tumor spread through the
wall. (Bottom) A nodal metastasis and generalized infiltration are present in the greater omcntum. The thickened
wall of the gastric antrum is seen in cross section.
 GASTRODUODENAL
C A S T R O C O L I C L I G A M E N T T U M O R EXTENSION >
o-
O
3
o
— Tumor 3
••
— Surgical suture line CD

o
Q-

0)

Gastrocolic ligament

Transverse colon

Descending colon

Metallic slent in stomach

—
Transverse colon
—
Site ot obstruction

Descending colon

(Top) First of three images shows recurrence of gastric carcinoma after prior resection. Axial ( I section shows a
tumor mass adjacent to a line of sutures that mark the resection margin following partial gastrectomy. (Middle)
More caudal section shows tumor in the gastrocoiic ligament, the portion of the greater omen turn that connects the
greater curvature of the stomach with the transverse colon. The tumor distorts and narrows the lumen of the
transverse colon. (Bottom) Frontal film from a barium enema shows complete obstruction to retrograde flow of
barium in the transverse colon. Note the metallic stent that had been inserted into the stomach in an attempt to
prevent complete gastric outlet obstruction. This serves as a radiologic marker for the gastric tumor, and shows how
close the gastric tumor is to the colon, which led to the tumor invasion and obstruction of the colon. II
199
 GASTRODUODENAL
CO DUODENAL COMPRESSION, "SMA SYNDROME"
c
(D
■D
O
13
T3
2
%
CO
O Duodenum (2nd portion) -

c Duodenum (3rd portion) -

0)
E
o
<

— Jejunum
Duodenum

— Stomach

Duodenum - - Superior mesenterit artery'

Aorta

(Top) first o f three images i n a y o u n g w o m a n w i t h post-prandial p a i n , nausea a n d w e i g h t loss. A b a r i u m upper G l

series shows d i l a t i o n o f the second a n d t h i r d p o r t i o n s o f d u o d e n u m , w i t h an abrupt vertical, band-like n a r r o w i n g as
the d u o d e n u m crosses the m i d l i n e . T h e remainder o f t h e t x i w e l is n o r m a l . ( M i d d l e ) Axial C I section shows marked
d i l a t i o n o f the t h i r d p o r t i o n of t h e d u o d e n u m u p t o t h e m i d l i n e . I he j e j u n u m a n d o t h e r b o w e l are n o r m a l .
i Hot l o i n ) As t h e d u o d e n u m crosses between the aorta a n d the superior mesenteric vessels, i t is compressed, a n d the
l u m e n is m a r k e d l y n a r r o w e d . T h i s is sometimes referred t o as t h e "SMA s v n d r o m e " a n d is felt t o cause f u n c t i o n a l
partial o b s t r u c t i o n o f the d u o d e n u m .
II
J(X)
 GASTRODUODENAL
AORTO-E1MTER1C FISTULA >

O
3
(D

o
C/)

Duodenum — — Lumen of anrtit graft

3
Q-
S
Surgical clips &
u

Superior mesenteric arterial

branches Duodenum (3id portion)

— Perigraft fluid

Duodenum Mrd portion)

I xtniluminal gas —

Native aortic wall

(Top) First of three axial CT sections in a elderly m a n who had open surgical repair of an abdominal aortic aneurysm.
Now has upper GI bleeding. CT shows the cephalic end of the graft which has been placed within the aortic lumen
and sutured to the native aortic wall. Note the surgical clips. (Middle) Note that the third portion of the duodenum
is "draped" over the aorta as it passes behind the superior mesenteric vessels. (Bottom) The partially calcified native
aortic wall should be closely applied to the synthetic graft. Instead, there are fluid and gas bubbles in the perigraft
space between the third portion of d u o d e n u m and the aortic lumen. Graft infection a n d a fistula from the aorta to
the d u o d e n u m account for the extraluminal gas and fluid. This was repaired at surgery.
II
201
 GASTRODUODENAL
CO GASTRIC DIVERT! C U L U M
c
<D
■D
O
13
■D
O
TO
O
■ ■

c
0)
E
o
-Q
< — Stomach (fumlus)
Distal esophagus — T

Divert iculum

Gastmesophagcal
junction

Stomach (cardia)

— DivcrticLilum

Spleen

Left adrenal

(Top) First of six images of the same patient. Most cephalad CT section shows a focal outpouching from the posterior
wall of the gastric fundus, near the gastroesophageal junction. (Bottom) The air-fluid level within the diverticulum
helps to identify its communication with the gastric lumen. Note other adjacent structures, such as adrenal and
spleen.

II
202
 GASTRODUODENAL
GASTRIC DIVERTICULUM >
Q.
O
3
o
* ■

o
CD

3
Q.
o
o.
CD
13
CD

Diverticulum

Left kidney

- l.cft kidney

(Top) Even though the diverticulum originates from the intraperitoneal stomach, it appears to be interposed between
the pancreas and left kidney, both rctroperitoneal organs. (Bottom) In cases in which a gastric diverticulum is filled
with fluid or food, rather than gas, it can easily be mistaken for a tumor or cyst, such as one arising from the
pancreas or adrenal gland.

II
20J
 GASTRODUODENAL
03 GASTRIC DIVERTICULUM
C
Q)
■o
O

I
to DivLTtitulum
TO
O
»•
c
a>
E
o
-o — Gastric b o d y
-a
<
Duodenal bulb —

Gastric a n t r u m

— Ciastric f u n d u s

Diverticulum

(lop) Lateral film from an upper Gl series confirms the gastric diverticulum as an outpouching from the posterior
wall of the fundus, just above the gastroesophageal junction. (Bottom) Supine frontal film from upper Gl series; spot
film with barium displayed as "black". The fundus and diverticulum fill with barium. Note the wide "mouth" of the
diverticulum which usually permits free entry and exit of food and fluid.

II
204
 GASTRODUODENAL
LARGE DUODENAL DIVERTICULUM >
o.
o
3
o

O
W

3
Q.
— Stomach C
a
CD

Diverticiilum —

Duodenum (2nd
portion)

— Duodenum (3rd
portion)

Pancreatic head

— Superior mesenteric
vein

Diverticiilum
Duodenum (3rd
portion)

(Top) FtOIItal film from an upper GI series shows a large barium-filled OUtpOUching extending off the third portion
of the duodenum. This is a typical location, but an unusually large size, for a duodenal diverticulum. These arc
usually asymptomatic, but may rupture or bleed, and may be mistaken for ulcers or masses on various imaging tests.
(Bottom) Axial (71' section shows the large diverticulum, filled with food and gas from a recent meal. Orally
administered contrast material opacities the lumen of adjacent bowel loops but fills only the dependent position of
the diverticulum.

II
205
 SMALL INTESTINE
[Cross Anatomy
Overview
• Mesenteric small bowel is Suspended from the
posterior abdominal wall bv a fan-shaped nicsciitcr)
Divisions
• Icjunum
o Begins at d u o d c n o j e j u n a l flexure
■ Duodenojejunal flexure often acutely anguluted;
suspended by the musculotendinous l i g a m e n t of
I roil/ (suspensory ligament of the d u o d e n u m ) ,
extension of right cms of diaphragm
Constitutes about 4 0 % of the length of the intestine
■ About 2-3 meters long
o Usually lies in left upper quadrant
0 Thicker, more vascular wall with tall, closely spaced
circular folds (4-7 folds per inch), lew l y m p h o i d
nodules (Peyer patches) in submucosa
Circular lolds also relerred to as valvulac
c o n n i v e n t e s , plicae circulares, folds of Kerckring
■ Prominence of folds a n d wall thickness vary by
age (more in younger), degree of bowel distent ion
• lieu m
No clear point t>f distinction from jejunum
Constitutes distal 60% of intestine (- 4 meters long)
- Usually lies in right lower abdomen and pelvis
I las thin wall, less vascular, lower and more widely
spaced circular folds, more l y m p h o i d follicles
Ends at ileocecal valve
• Vessels a n d nerves
n All lie between the layers ot the small lx>wcl
mesentery
Superior mesenteric a r t e r y (SMA) supplies entire
intestine
■ Arises from aorta at LI level. 1 cm caudal to celiac
artery
■ Sends - 15-IK branches to intestine
■ Arteries unite to form arches (arterial arcades! ■*
straight arteries (vasa recta)
■ Superior mesenteric vein (SMV) drains entire
intestine
■ Lies to the right of the SMA
■ Unites with splenic vein to form portal vein
behind the pancreatic neck
• I ymphatics
' Begin within the intestinal villi (tiny projection of
mucous membrane) as lacteals
■ Specialized lymphatic vessels that absorb tat from
gut
■ Empty milky chyle into l y m p h a t i c plexuses in
the intestinal walls -» l y m p h a t i c vessels [in
mesentery) —■ lymph nodes
JliXta-intestinal n o d e s near wall of intestine
1
Mesenteric l y m p h n o d e s follow arterial arcades
• Nerves are autonomic
- Sympathetic: Follow SMA a n d its branches, called
the s p l a n c h n i c nerves
■ Effect: Reduce motilily, secretion and vasculurity
< I'arasympathetic: Follow arterial branches
■ Are branches of p o s t e r i o r vagal t r u n k s
■ Increase motility, secretion, vasculurity &
digestion
Includes sensory branches that can detect
stretching & distention. but n o other pain stimuli;
bowel obstruction — distended lumen — spasms
of crampy abdominal pain (colic); poorly
localized
| Anatomy-Based Imaging Issues
Imaging Recommendations
• Bowel ischemia is a major clinical problem
May result from arterial or venous occlusion (SMA or
SMV) or hypoperfusion (e.g., from shock, cardiac
failure)
o Demonstrating patency of vessels and perfusion of
bowel wall is kev
Contrast-enhanced CT is best single study; can be
combined with CT angiography and Ml imaging
o MR angiography has similar role as C r
Catheter angiography usually reserved for high
suspicion of vessel occlusion; allows embolectomv
and stent placement
• Bowel wall thickening
o Almost all acute bowel injuries result in thickening
of submucosal layer of wall ("thickened folds")
o Etiology of submucosal thickening may be suggested
bv the density (attenuation) of the submucosal layer
on CT scanning
■ Cas: Pncuinatosis, as with infarction
■ I ligh density blood: Acute hemorrhage, as with
trauma or spontaneous coagulopathic hemorrhage
■ Fat: Chronic proliferation of fat, as in chronic
inflammation from Crohn disease
Clinical Implications
Clinical Importance
• Bowel o b s t r u c t i o n is a c o m m o n clinical problem
Usual causes are adhesions and hernias (external >
internal)
Much more c o m m o n l y affects the intestine than the
colon; (intestine is longer, more mobile)
Embryology
Embryologic Events
• Lmhryological foregut: Esophagus, stomach,
d u o d e n u m , liver, biliary system
• Miclgut: Small intestine and right side colon
• Hindgut: Left side of colon and rectum
• Foregut and midgut are hernialed into the early fetal
umbilical cord, usually return to abdominal cavity
alter 270 u counterclockwise rotation and then arc-
fixed into position by modification of mesenteries
• F.rrors in this process are c o m m o n
■■
- Malrotation and m i d g u t volvulus
■ May present in infants or adults
■ May cause bowel obstruction and ischemia
 SMALL INTESTINE
>
a-
Q.
O
3
C/)
3
Celiac artery

CD
C/>

5'
CD
Superior mesenteric
artery

Deocollc artery
Jejunal straight arteries

Jejunal arterial arcades

Heal straight arteries

Coronary (gastric) vein

Splenic vein

Middle colic vein

£4
Jejunal veins

Deal veins

(Top) The superior mesenteric artery supplies the entire small Intestine. Arising from the anterior wall of the aorta at
about the LI vertebral level, its first branch Is the Inferior pancieaticoduodenal artery, which supplies the duodenum
& pancreas, and anastomoses freely with branches from the celiac trunk. The next branch is the middle colic,
supplying the transverse colon. Arising from the convex or left side of the SMA are numerous branches to the
jejunum & ileum. Jejunal arteries are generally larger and longer than those of the ileum. After a straight course the
arteries form multiple curvilinear arcades which form lateral communications between the arteries. Finally, straight
arteries (arterlae rectae) extend to & penetrate the wall of the intestine. (Bottom) In number, point of origin, course
& name, the intestinal veins are similar to the arteries.
 SMALL INTESTINE
JEJUNUM

. «

Jejuna! arterial arcade

Je]unal straight artery

Longitudinal muscle
\ \ Circular muscle
i i ¥'+
Submucosa

Mucosa

1.1

V Circular fold & lamina

propria

Lymphoid nodule
LV w *
77
Submucosa

Muscularis mucosa Circular muscle

Longitudinal muscle

(Top) There is no sharp point of demarcation between the jejunum & ileum and both have the same basic structure.
The jejunum has a richer vascular supply, thicker wall and wider lumen. There are five layers of the bowel wall. The
innermost is the mucosa, the absorptive surface of the gut. The jejunal mucosa is extensively plicated (folded) and
these transverse ("circular") folds lie perpendicular to the long axis of the bowel. The other layers are the submucosa,
circular muscle, longitudinal muscle, and serosa, the peritoneal lining of the bowel. (Bottom) The mucosal surface of
the jejunum is increased by prominent villi, fingerlike projections of mucosa. The muscularis mucosa separates the
mucous membrane from the submucosa. The submucosa has a network of capillaries, lymphatics, and a nerve plexus
(of Meissner). The jejunum has few and small, discrete lymphoid nodules.
 SMALL INTESTINE

Submucosal lymphold
nodules

w )

.V^rtsated lymphold
nodule
u %

Submucosa

Circular muscle
\.< .1
Longitudinal muscle

(Top) The lleum is distinguished by a thinner wall, less vascularlty, and less prominent transverse folds and villi than
the jejunum. It has the same five layers of the bowel wall. (Bottom) Low power microscopic view of a section of
lleum. The villi in the lleum are shorter and narrower than in the jejunum and the transverse folds are much less
prominent. They are often not visible on radiographic studies of the intestine. Conversely, submucosal lymphold
follicles become progressively more prominent along the course of the distal small intestine. In the distal Ueum
lymphold follicles may aggregate into macroscopic collections, called Peyer patches, which may be evident as
submucosal "masses" of a few millimeters in diameter on barium studies of the small Intestine.
 SMALL INTESTINE
MESENTERY OUTLINED BY ASCITES

- Transverse colon
TO
E
C/)
m m

c Omentum
a>
E
o
Vessels to ileum -
.a
<
Jejunum

Ascites
Superior mesenteric
vessels
Descending colon

— Jejunal vessels
Ilcocnlic vessels

Ascending colon Descending colon

(Top) First of two axial CT sections in a patient with ascites accentuates the small bowel mesentery as its leaves are
separated by the fluid. The mesenteric vessels, nerves and lymphatics travel to and from the bowel between the layers
of the mesentery, surrounded by a layer of fat and loose connective tissue. Note the superior mesenteric artery and
vein at the base of the mesentery. (Bottom) A section through the right lower quadrant shows the ileocolic vessels
supplying the ileum and ascending colon as well as multiple jejunal vessels to the left of midlinc. The vessels to the
ascending and descending colon travel through the retroperitoneum, rather than through a mesentery.
 SMALL INTESTINE
B A R I U M STUDY, N O R M A L SMALL INTESTINE

— Stomach

Duodenal bulb "

— Jejunum

lleum

—
Transverse colon

- Jejunum

Terminal ileum

lleum

Transverse colon

lleo-cecal valve

— Terminal ik-mn

Cecum

(Top) Hist of three images f r o m a b a r i u m small towel f o l l o w t h r o u g h shows t h e n o r m a l appearance o f the small
intestine. Note the p o s i t i o n of the j e j u n u m i n the left upper quadrant, a n d its p r o m i n e n t , feathery mucosal f o l d
pattern (in the nondistended state). The i l e u m lies p r e d o m i n a n t l y in the right lower quadrant and has a less
p r o m i n e n t f o l d pattern. ( M i d d l e ) I ater image f r o m the same series shows b a r i u m progressively opacifying distal
small bowel a n d c o l o n . Note t h e difference i n spacing between t h e transverse semilunar folds o f the c o l o n a n d the
closely spaced, circular folds of the small towel. ( B o t t o m ) Frontal coned d o w n "spot" image f r o m the same series
shows t h e t e r m i n a l i l e u m , ileo-cecal valve a n d cecum.
 SMALL INTESTINE
ENTEROCLYSIS, N O R M A L SMALL INTESTINE

Naso-cntcric lube —

Duodenum —

Jejunum

— Jejunum

lleum —

(Top) first of two images from an enteroclysis study, in which barium is pumped into the bowel through a
naso-cntcric tube, the tip of which has been advanced to the duodenojejunal junction under fluoroscopic control, liy
bypassing the gastric pylorus and using a pump to infuse barium at about 70 ml per minute, the bowel lumen can be
distended optimally, allowing much better visualization of the circular folds. Note how thin and evenly spaced the
jejunal folds are, with about 4-7 folds per linear inch in the jejunum, and somewhat fewer and less prominent folds
in the ileum, as a general rule. (Bottom) Image from the enteroclysis shows the less prominent fold pattern in the
ileum, compared with the jejunum.
 SMALL INTESTINE
LYMPHOID NODULES >
Q.

I
•-
if)
3
CD

\sct-iu1ing colon

Cecum —

'liTinin.il ik'Uin -
— 1 vmphoid nodules

Oblique image from an air-contrast barium t n e m a show?, the innumerable small lyinphoid nodules (Peyer patches)
which are normal aggregates of lymphoid tissue that lie in the submucosa of the bowel wall. These are more
prominent in the terminal ileum and in younger patients, in general.

II
21 I
 SMALL INTESTINE
CATHETER ANCIOGRAM, SUPERIOR MESENTERIC ARTERY AND VEIN
C

(D

TO
E
C/D
• ■

C
a>
E
o
TJ Middle colic artery
<
Jejunal arteries
Right colic artery

llcocolic artery

Heal arteries

Main portal vein

Middle colic vein Superior mescnteric

vein
Right colic vein

Jejunal veins

llcocolic vein
Heal veins

(Top) first of two images from a catheter injection of contrast material into the superior mesenteric artery shows
multiple (15-18) arterial branches to the small bowel, as well as .1 major branches to the ascending and transverse
colon (ileocolic, right & middle colic arteries), (liottom) Venous phase image from the same study shows the superior
mesenteric vein (SMV) and some of its major tributaries, as well as the portal vein. The veins parallel the arteries and
have similar names.

II
214
 SMALL INTESTINE
CT ANGIOGRAM, SUPERIOR MESENTERIC ARTERY & VEIN

Inferior vena cava Cellac artery

Superior mesenteric
artery

Right kidney

Renal veins

Deocolic artery

Jejuna] branches

Left external iliac artery

Splenic vein

Portal vein

Inferior mesenteric

Superior mesenteric
vein 1, Jejunal veins
|*

Ueocolic veins

(Top) First of two images from an abdominal CT angiogram, late arterial phase, shows the SMA as the second major
midline branch of the abdominal aorta, arising just distal to the celiac artery. The SMA courses over the left renal
vein. The multiple jejunal branches of the SMA are well shown, with their peripheral portions excluded (deliberately)
from the plane of section. The image is rotated to the left. (Bottom) Image from the venous phase of the CTA
(frontal view) shows the major venous tributaries of the portal vein, including the superior mesenteric and splenic
veins. In this patient, the inferior mesenteric vein (which drains the left side of the colon) empties into the superior
mesenteric vein, instead of into the splenic vein, a common variant (30% of population).
 SMALL INTESTINE
0) MESENTERIC N O D E S
-t—
1/1
CD

TO
E
■ ■
c
cu
E
o
"O
-Q — Mesenteric nodes
<
Jejunum

Diuxlcnum

Stomach

Mesenteric vessels Jejunum (with

thickened wall)
Mesenteric nodes

(Top) First of two axial CT sections of a y o u n g man with acquired immunodeficiency syndrome (AIDS) shows
multiple enlarged mesenteric nodes, especially prominent near the jejunum. The nodes have a peculiar low density
center with contrast-enhancing periphery, findings characteristic of "caseation" and strongly suggestive of
mycobacterial disease. In immunosuppressed patients, such as transplant recipients and those with AIDS, infectious
agents, such as mycobacteria, may enter through the bowel, causing the jejuna! wall thickening seen here, with
subsequent involvement of the mesenteric nodes draining these segments of bowel. (Bottom) Note the position of
the mesenteric nodes, "sandwiching" the mesenteric blood vessels. The jcjunal wall is also thickened due to infection
II and inflammation.
216
 SMALL INTESTINE
MESENTERIC NODAL & SPLENIC DISEASE >
a.
o
3
<D
■ ■

C/D
3
0)
— Spleen
CD
in
CD

Mesenterii nodes

—
Retropentoneal nodes

Mesenteric nodes

Duodenum

(Top) I'irst o f three axial C I ' sections i n another y o u n g m a n w i t h AIDS a n d disseminated niycobactorium
a v i u m - c o m p l e x shows splenomegaly w i t h i n n u m e r a b l e t i n y l o w density lesions, due t o infectious granulomas. The
d u o d e n a l a n d jejunal walls a n d the mesenteric nodes have a similar appearance, also due t o mycobacterial i n f e c t i o n .
The nodes almost surround t h e superior mesenteric vessels. ( M i d d l e ) Mesenteric a n d retroperitoneal nodes are
enlarged w i t h central necrosis or caseation, indicated by the l o w density centers a n d contrast-enhancing rims,
characteristic of mycobacterial i n f e c t i o n . ( B o t t o m ) A d d i l i o n a l mesenteric nodes are seen ventral t o the d u o d e n u m
and the superior mesenteric trunks.
II
217
 SMALL INTESTINE
CROHN DISEASE
c
CD

TO Jewelry in umhiliius
E
■ ■ Ascending colon —
c
a>
E
o
■o

Ileum (normal
terminal ileum —
segments)

Ascending colon

llcocecal valve

'terminal ileum

(Top) First of five images of a young woman with Crohn disease, first image from a barium small bowel follow
through shows irregular nodular thickening of the wall of the terminal ileum. (Bottom) The lumen of the terminal
ileum is narrowed and the wall is irregularly thickened. This abnormal segment of bowel appears straightened and
stands away from other segments of bowel, reflecting bowel wall thickening and infiltration of the mesenteric fat to
this segment of bowel. The terminal ileum is usually the first portion of bowel to be inflamed in patients with Crohn
disease, a common inflammatory bowel condition of uncertain etiology. The clinical and radiographic features in
this case are typical of this disease.
II
218
 SMALL INTESTINE
C R O H N DISEASE >

Q.
- Small bowel (normal)
I
CD
3

3
Ileum (inflamed) — 0)

CD
Lymph nodes (enlarged) GO
^ '
CD

Terminal ileum (inflamed) -

Lngorged vessels within mesenteric Uterus

fat

Urinary bladder

- External iliac vessels

Terminal ileum (inflamed)

j — Uterus

Ileum (nurinal)

Rectum

(lop) Axial CT section of the same young woman as previous 2 images shows enlarged lymph nodes near the
terminal ileum, which has a thickened wall. Compare with the normal, and almost imperceptible wall of other,
uninvolved segments of bowel. (Middle) Note the thickened wall of the terminal ileum and the thickened segment
of mesenteric fat with engorged blood vessels, indicating hyperemia (increased blood flow) of the inflamed segment
of bowel. (Bottom) The inflamed terminal ileum that is supplied by the engorged blood vessels is best seen on this
more caudal section. Note the thickened wall of the inflamed segment as opposed to that of the adjacent, uninvolved
ileum.
II
219
 SMALL INTESTINE
CROHN DISEASE WITH MESENTERIC SCARRING

Dilated Ixiwel -

Acute angulation of jcjunal

segment

Jejunum (inflamed) Mesentery (inflamed)

Colon

Jejunum (inflamed) — Mesentery (inflamed)

(Top) Hirst of six images of a patient with Crohn disease'- I-irst image from a barium small bowel follow through
shows a peculiar "stellate" arrangement of small bowel segments, with acute angulation of loops. Some portions of
the bowel lumen are narrowed while others are dilated, indicating some degree of bowel obstruction. (Middle) Axial
Cl section shows extensive infiltration of the mesenteric fat, replacing its normal homogeneous fat density.
(Bottom) The small bowel mesentery is markedly thickened a n d inflamed as are the adjacent segments of small
bowel, including much of the jejunum.
 SMALL INTESTINE
C R O H N DISEASE W I T H M E S E N T E R I C S C A R R I N G

Jejunum muinvolvcd)

— lejunum (inflamed)

— Jeiunal segments (inflamed)

—
Me.scntiTk vessels

Jejunal segment (augulated)

(Top) I h e mesenteric fat is thickened ("proliferated"), a characteristic feature of c h r o n i c i n f l a m m a t o r y c o n d i t i o n s ,

such as C r o h n disease. ( M i d d l e ) Note the t h i c k walls a n d distorted l u m e n o f t h e i n v o l v e d jejunal segments a n d the
thickened, inflamed mesentery. ( B o t t o m ) A more caudal section shows a n acutely angulated segment of j e j u n u m ,
corresponding w i t h similar f i n d i n g s o n t h e small bowel f o l l o w t h r o u g h exam.
 SMALL INTESTINE
BOWEL ISCHEMIA, SMA STENOSIS
c
to
0)

C3

E
0)
E
o
-Q
<

I— Superior mesenterii
artery

Small intestine —
(dilated)

(Top) First of seven images of an elderly patient with chronic abdominal pain, worse after eating. This axial CI
section shows marked narrowing at the origin of the superior mesenteric artery due to atherosclerosis. (Bottom) A
more caudal section shows multiple dilated segments of small bowel, especially ileum.
 SMALL INTESTINE
BOWEL I S C H E M I A , S M A STENOSIS >

oa
3
3
* ■

C/)
3
Ileum (dilated)

Terminal ileum

Thickened transverse
folds

( l o p ) The l u m e n o f t h e t e r m i n a l i l e u m is n o r m a l o r slightly narrowed, w h i l e that ot more p r o x i m a l ileal loops is

dilated. Findings suggested a f u n c t i o n a l o b s t r u c t i o n o f the distal small intestine, but the etiology was unclear at this
p o i n t . ( B o t t o m ) Image f r o m a b a r i u m small bowel f o l l o w t h r o u g h c o n f i r m s d i l a t i o n o f p r o x i m a l arid m i d small
bowel, w i t h a t r a n s i t i o n t o collapsed distal bowel. Also evident is t h i c k e n i n g o f t h e transverse folds of some o f t h e
dilated segments of i l e u m , i n d i c a t i n g some f o r m o f i n j u r y t o t h e b o w e l wall causing submucosal swelling.

II
223
 SMALL INTESTINE
BOWEL ISCHEMIA, SMA STENOSIS
C
to

03 Aorta
E
U)
Celiac artery -

E
o

< Superior mesenterie artery

Celiac artery

Superior mesenterie artery

SMA (following dilation & stent

placement)

(Top) A sagittal reformation of the CT scan shows marked narrowing of the base of the superior mesenterie artery,
a n d moderate narrowing of the celiac artery. (Middle) A lateral view of a catheter angiogram confirms significant
atherosclerotic narrowing of the origins of the celiac a n d superior mesenterie arteries. Balloon dilation of the SMA
was performed, followed by placement of a metallic stent to maintain vessel patency. (Bottom) A repeat angiogram
in the lateral projection shows the markedly increased diameter of the SMA following dilation and stent placement.
The patient's symptoms were attributed to "intestinal angina" and resolved following angioplasty of the SMA.

II
224
 SMALL INTESTINE
I N F A R C T I O N , W I T H PNEUMATOSIS >
Q.
O

Colon - 3
C/D
Portal venous gas
3
0)

Stomach CD
CO

CD

Gas within mesenteric vein - Dilated jejimal segments

(las within wall of bowel ~

Gas within wall of bowel

(Top) First of three axial CT sections in an elderly patient with severe alxlominal pain and hypotension shows
extensive gas within the intrahepatic portal vein branches. Portal venous gas is distinguished from biliary gas, as the
former flows to the periphery of the liver, while biliary gas collects more centrally as it flows toward the duodenal
papilla. (Middle) More caudal section shows gas within the wall of dilated segments of ileum in the right lower
quadrant. The jejunum is dilated, b u t its wall is normal. Gas is present in t h e mesenteric vein draining the ileal
segment with the pneumatosis (intramural gas). (Bottom) More caudal section shows ileal segments with
pneumatosis, due to bowel infarction. The ischemic mucosa has broken down, allowing gas from the bowel lumen to
enter the submucosal layer. This gas, in turn, enters the mesenteric & portal veins. II
225
 SMALL INTESTINE
SMALL INTESTINE I N F A R C T I O N , V E N O U S T H R O M B O S I S
c
'■>->

in

CD
E
CO
■ ■

c
o
E
o
•a
Superior mesenteric
< vein

Superior mesenteric
artery

lUlematous mesentery — — Thick bowel wall

(lop) lirst of five axial CT sections in a patient with severe abdominal pain shows a normal caliber and uniformly
enhancing lumen of the superior mesenteric artery, while the lumen of the SMV is distended and partly occluded by
(non-enhancing) clot. (Bottom) More caudal section shows diffuse edema of the mesentery and a thick-walled
segment of small bowel, indicative of some sort of acute injury (in this case, acute ischemia).

II
226
 SMALL INTESTINE
SMALL INTESTINE INFARCTION, VENOUS THROMBOSIS >
CT
ao
Normal bowel 3
— Isihemk bowel CD
••

3
CD

Normal bowel

Ischcmic bowel

!.-ii( • -i u ■! mesentcric vein

■ Superior mesenteric artery

(Top) More caudal CT section shows focal bowel wall thickening. Compare with the almost imperceptible wall
thickness of normal bowel. (Middle) Note the thickening of the wall of the jejunal segment that was ischemic due to
thrombosis of its superior mesenteric venous tributary. (Rottom) Magnified view of axial CT section shows
thrombosis (nonenhancement) of this portion of the superior mesenteric vein, near the site of entry of the |e|unal
tributaries. At surgery, a segment of infarcted jejunum was resected and thrombus was removed from the lumen of
the SMV. I he patient was subsequently confirmed to have a hypercoagulable condition that predisposed him to
spontaneous venous thromboses.
II
127
 SMALL INTESTINE
CD SMALL INTESTINE OBSTRUCTION

in

CD

TO

E Dilated jejunum
if)
• ■

c
CD
E
o
■o
< Normal caliber ileum —

— Air-tluid levels in bowel

(Top) First of four images of a patient with abdominal distention and crampy pain. A supine image of the abdomen
shows dilated segments of proximal small bowel (jejunum) in the left upper quadrant. Distal small bowel and colon
are of normal caliber. (Bottom) An upright image demonstrates multiple air-fluid levels within the dilated segments
of bowel, a characteristic feature of small bowel obstruction.

II
228
 SMALL INTESTINE
SMALL INTESTINE OBSTRUCTION

— Dilated jejunum

Descending colon

— Stomach

Portal vi'in -

Ascending colon —
— Descending colon

— Aorta
Ileum —

(Top) Axial CT section (same patient as previous 2 images) shows dilated jejunum, with air-fluid levels, and
"collapsed", normal caliber ileum and colon. (Bottom) Coronal reformation of the CT scan shows the dilated
jejunum and the collapsed ileum and colon, which are beyond the point of obstruction. An adhesive band was found
at surgery to be the cause of the bowel obstruction.
 SMALL INTESTINE
PLAIN IMAGE, MALROTATION

— Feeding tube (in

stomach)

Feeding tube (in

duodenum)

Small intestine —

— Colon

(lop) First of 5 images showing malrotation. Frontal radiograph shows a feeding tube which has been advanced
through the nose and stomach. The course of the tube within the duodenum shows that the duodenum is "looped"
upon itself to the right of midline, instead of crossing the midline, as the third portion of the duodenum does
normally. (Bottom) Frontal radiograph shows the duodenum and small bowel (marked by the feeding tube and gas)
in the right up|jer quadrant. Gas and stool within the colon suggests that all of the colon lies to the left of midline.
 SMALL INTESTINE
CT, MALROTATION >
CT
Q.
O
3
o
■ •

Feeding tube (in duodenum) 3

5L
5"
0
(A
=♦.

CD

Feeding tube (in duodenum) -

Jejunum
Colon

(Top) Axial CT section (same patient as previous 3 images) shows the radiopaque feeding tube coiled within the
duodenum, all of which lies to the right of mklline. The SMV lies ventral and to the left of the SMA, which is
opposite to its usual relation. (Middle) All four portions of the d u o d e n u m lie to the right ot midline, as marked by
the feeding tube. The colon lies to the left of midline. (Bottom) All of the jejunum lies to the right of midline, a n d
all of the colon lies to the left, characteristic of midgut malrotation (nonrotation). At this axial level, the third
portion of the duodenum would normally cross the midline between the aorta a n d the superior mesenteric vessels.

II
 SMALL INTESTINE
CD BARIUM STUDY, MALROTATION
c
CD

Duodenum —
CD
E
(/)
a a

C
£ Jejunum —
o
<

lleum —

Splenic flexure

Hepatic flexure —

— Ascending colon

(lop) First of two images from a barium small bowel follow through exam shows essentially all of the small intestine
lying to the right of midline. The duodenum never crosses the midline, and the jejunum is not in its usual left upper
quadrant location. (Bottom) Delayed frontal image from small Ixnvel study shows all of the colon lying in the left
side of the abdomen. The descending and sigmoid colon and rectum, all parts of the embryological hindgut, are in
normal position. It is the embryological midgut which has failed to rotate properly on its return from the umbilical
cord to the peritoneal cavity, resulting in the abnormal position of the small bowel and right side of colon. This
situation can predispose to twisting (volvulus) of the bowel & its blood vessels around an abnormally short
II mesenteric root with obstruction of the bowel lumen or its vessels.
232
 SMALL INTESTINE
MALROTATION >
ao
3
o
3
■ *

3
0)

1
IransviTH' colon

— Cecum

Delayed image from a barium small bowel follow through shows all of the small intestine lying to the right of
midline, while all of the colon lies to the left. The embryologic niidgut lias failed to rotate properly on its return to
the abdominal cavity in fetal life, resulting in malrotaiion of the small intestine and the colon up to the splenic
flexure. This subject shows n o signs of bowel obstruction or volvulus at the time of this exam.

II
2.J3
 SMALL INTESTINE
CO MIDGUT VOLVULUS WITH INFARCTION
'■*-•

E
if)
a ■

C
o Gas in mesenteric veins —i
Small bowel
E Small bowel (gas-filled) -
o
TJ - Gas within bowel wall

<

- Dilated small bowel

- Twisted mesenteric root

Gas-filled small bowel —

- Small bowel

(Top) First of 6 CT images, including 3 coronal and 3 axial sections. This coronal section shows dilated small bowel
that is distended with fluid in the left side of the abdomen, while bowel loops in the right side are distended with
gas. Branching air density also indicates gas within the intestinal wall and in the mesenteric veins draining the small
intestine. Note the "swirled" or twisted appearance of the mesenteric vessels as they converge near the midiine; these
findings are indicative of midgut volvulus and infarction. (Middle) Coronal section shows the dilated small bowel
segments and the twisting of the mesenteric root. (Bottom) Coronal section shows the twisted and distended small
bowel segments.
I!
234
 SMALL INTESTINE
M I D C U T VOLVULUS WITH INFARCTION

Gas in rnesenterk veins

Gas distended small bowel -

X
— Fluid distended small txiwcl
*
Mesenteric vessels

Gas within mesenteric veins — Dilated small bowel loops

— Mesenteric vessels

— Mesenteric venous RUS

— Twisted mesenteric vessels

(Top) Axial CT section shows twisting of the mesenteric vessels, mesenteric venous gas, and small bowel distended
with gas or fluid. (Middle) Axial seclion shows distended, thick-walled bowel a n d mesenteric venous gas, indicative
of bowel infarction. The "whirled" (twisted) mesenteric vessels indicate volvulus as the reason for the bowel
infarction. (Bottom) Axial section shows more of the infarcted bowel and the spiral appearance of the mesenteric
root, indicative of volvulus.
 SMALL INTESTINE
CD CONGENITAL DUPLICATION CYST
C
to
CD

CO Duplication cyst
E Normal small bowel
C/)
■ •

Dilated small Dowel i Pancreas

c
0)
E
o
■D

<

Duplication cyst

Small bowel (partially obstructed) Normal small bowel

Cyst wall -

— Small bowel mucosa

(Top) I irst of three images of a young man with crampy abdominal pain. Axial CT shows a spherical mass with an
air-fluid level adjacent to a dilated segment of small bowel that has paniculate matter and gas within it, simulating
stool, a common feature of small bowel obstruction. (Middle) The cystic mass communicates with the bowel lumen,
as shown by its air-fluid level. (Bottom) Surgical specimen photograph shows a probe passing from the small bowel
lumen into the cyst, which was lined by intestinal mucosa. Congenital duplications or cysts may occur along the
entire length of the alimentary tube. In rare cases, long segments of bowel or colon may be duplicated. These lesions
may remain asymptomatic or may become infected or cause bowel obstruction. They may or may not communicate
II with the lumen of the gut.
lib
 SMALL INTESTINE
MECKEL DIVERTICULUM >
CL
o
3
<0
3
■ ■

w
3
— Meckel diverticulum 0)
CD
en
Cecum - 5"
— Terminal ileum CD

— Meckel diverticulum

Stones within diverliculum

— Wall of diverticulum

Stones within diverticulum

Heal mucosa

(Top) First of three images demonstrating a Meckel diverticulum. Graphic shows a blind-ending diverticulum arising
from the antimesenteric border of the distal ileum, a characteristic appearance of a Meckel diverticulum. This is a
remnant of the embryologic omphalomesenteric or vitelline duct, also known as the yolk stalk, which normally
connects the fetal gut t o the yolk sac. This connection atrophies and disappears soon after birth in most individuals.
(Middle) Axial CT section shows a blind-ending sac, or diverticulum, arising from the distal ileum which contains
rounded stones or enteroliths. All the remaining bowel was normal in appearance. (Bottom) Photograph of the
resected specimen shows the opened diverticulum and some of the dark brown stones or enteroliths that had formed
within it. II
2i7
 COLON
Cross Anatomy
Overview
• Colon (large intestine): Organ responsible for
absorption of water from liowel contents (chyme) that
was not digested a n d absorbed by small intestine
o Converts contents into semisolid stool or teces that
is stored until defecation occurs
Segments
• C e c u m : First part of colon, about 7 cm in length
c I ooscly attached to posterior a n d lateral abdominal
wall by peritoneal (cecal) folds
< Receives terminal ileum through ileocecal valve
■ Valve lips have variable submucosal fat content
usually evident o n CT
■ Valve usually prevents reflux of colonic contents
into intestine
o Appendix ("vermiform" appendix)
■ Blind intestinal divertieulum 6-15 cm in length
■ Has mesentery ( m e s o u p p e n d i x )
■ Always arises from t i p of cecum but may point
and lie In many locations ( 7 i retrocecal)
c Cecum a n d appendix supplied by ileocolic a r t e r y
and vein
• Ascending colon
< From cecum (1st semilunar fold at ileocecal valve) t o
transverse colon
c Supplied by right colic branch of superior
mesenteric artery (SMA) and superior mesenteric
vein tSMV) in retropentoneum
• transverse colon
Supplied by middle colic branch of SMA and SMV
< Vessels, nerves, lymphatics through transverse
mesocolon
• Descending colon
Supplied by inferior mesenteric artery (IMA) a n d
inferior mesenteric vein (IMV)
' Retroperitoneal location
• Sigmoid colon
i Mobile, on long sigmoid mesocolon
Supplied by IMA and IMV
n Quite variable in length, redundancy, location
• Rectum
c final 15-20 cm of colon; rectosigmoid j u n c t i o n at
lumho-sacral level (variable)
o Lies in extraperitoneal pelvis
o Has several rectal folds (valves) analogous t o
semilunar folds of colon
c Has continuous layei o t longitudinal muscle, rather
than taeniae (separate bands of muscle) in colon
o Has mesenteric (superior rectal branches of IMA and
IMV) and systemic vessels (middle and inferior
rectal branches ol internal iliac vessels)
Mural (Wall) Anatomy
• Same basic components: Mucosa. submucosa, double
layer muscularis, serosa (for intrapcritoncal parts) a n d
submucosa (adventitia for extraperitoneal parts)
• Longitudinal muscle layer not continuous (unlike
intestine) b u t separated into taeniae
• Unlike intestine, mucosa of colon n o t covered with
villous projections
• Submucosa contains numerous, discrete lympltoid
follicles that may be apparent as subtle s-4 n u n
nodules o n double-contrast barium enema exam
• t a e n i a e coli: I hrer thickened, flat bands of smooth
muscle constituting outer longitudinal layer of smooth
muscle
• Haustra: Sacculations of colon wall caused by
contractions of taeniae, separated by semilunar folds
• Semilunar folds (plicae semilunares)
' furrows between haustra
c Consist of mucosa, submucosa a n d circular muscle:
(small bowel folds lack muscle layer)
• I'piploic (omental) a p p e n d a g e s (or appendices)
• Subserosal pockets of fat extending off colonic
surface
Clinical Implications
Clinical Importance
• A p p e n d i i ilis
o Occlusion of lumen c o m m o n , leading t o
appendicitis
c Initial symptoms are vague periumbilical discomfort
due t o distention a n d stretching of wall
■ Localized pain a n d tenderness in lower quadrant
due to inflammation of parietal peritoneum
• Diverticulosis
c All parts of colon except rectum may develop
diverticula
■ Most prevalent i n s i g m o i d c o l o n
c Protrude through weak points in colonic wall where
nutrient arteries penetrate muscle coat
May perforate (= diverticulitis)
C o m m o n in Western society with high fat, low fiber
diet
• L'.piploii a p p e n d a g i t i s
Appendages m a y twist a n d infarct
Leads to symptoms similar to diverticulitis
• Colonic volvulus
Sigmoid mesocolon may be long with a narrow base
of attachment to posterior abdominal wall
■ Predisposes to volvulus (twisting) of colon that
often obstructs lumen a n d compresses vessels;
may lead to ischemia a n d perforation
c Cecum a n d ascending colon may also lie on
mesentery, also predisposing to volvulus,
obstruction a n d ischemia ("cecal volvulus")
• Rectal carcinoma
Because of systemic a n d portal venous drainage,
may metastasi/e t o systemic sites (lungs, bones, etc.)
as well as liver (colon carcinoma almost always
metastasizes to liver first)
• Colonic i s c h e m i a is c o m m o n , despite frequent
anastomoses between branches ot SMA a n d IMA
"Watershed" sites (splenic tlexure and sigmoid
colon) most c o m m o n sites of ischemia, mavbe d u e
to congenital deficiency of vascular anastomoses
 COLON
COLON & ITS MESENTERY

■
Taenlaecoll
Semllunar folds

Ileocecal valve

Eplplolc appendage

Rectal valves
1
^B
Levator anl muscle

I Transveise mesocolon

Jejunum

■
Small bowel mesentery

■ /
v-
I Sigmold mesocolon

(Top) Graphic shows surface and mucosal view of the colon. The appendix & ileocecal valve enter the cecum, the
first part of the colon, with the ileocecal valve acting as a sphincter to prevent reflux. The semllunar folds lie at right
angles to the long axis of the colon and are analogous to the rectal folds (valves). The outpouchings between the
folds are the haustra, and the spaces between the transverse folds are wider than in the small intestine. The
longitudinal muscle layer of the rectum Is continuous, as it Is in the small Intestine. In the colon, this layer is
separated into three thickened flat bands of muscle, called the taeniae coli. (Bottom) The ascending and descending
colon are largely retroperitoneal, while the transverse and slgmoid colon have a mesentery (mesocolon). Graphic
shows the transverse mesocolon and colon are reflected upward.
 COLON
ARTERIES
o
o
O
c
E
o
<

Arc of Riolan
Marginal artery
Marginal artery

Middle colic artery

Superior mesenteric
Right colic artery artery

Left colic artery

Ileocolic artery
Inferior mesenteric
artery

Superior mesenteric
artery Slgmold arteries

Superior rectal artery

Inferior rectal artery

Graphic shows the small intestine has been removed and the transverse colon has been reflected upward. This shows
the conventional depiction of the superior mesenteric artery supplying the colon from the appendix through the
splenic flexure, and the inferior mesenteric artery supplying the descending colon through the rectum. The cecum is
supplied by the ileocolic branch, the ascending colon by the right colic, and the transverse colon by the middle colic
artery. These arterial branches are highly variable and all are connected by anastomotic arterial arcades and by the
marginal artery (of Drummond) and arc of Riolan which also anastomose with branches of the inferior mesenteric
artery that feed the descending & sigmoid colon. The arcades give off the straight arteries (arteriae rectae) to the
II colonic wall.
240
 COLON
VEINS

Left gastric vein

Splenic vein

Pancreas

Inferior mesenteric
vein

The veins that drain the colon generally follow a similar course and have similar names as the arteries that they
accompany. The inferior mesenteric vein drains the left colon and empties into the splenic vein, or less commonly,
the superior mesenteric or portal vein. The superior and inferior mesenteric veins lie just deep to the neck of the
pancreas.
 COLON
ILEOCECAL REGION

Ueocolic artery

Supenor mesenteric
artery

Ileocolonlc fossa

\
$

Ileocecal fold

Appendiceal artery

Mesoappendlx

(Top) The cecum is the blind-ending pouch that lies caudal to the ileocecal valve. It is usually the widest part of the
colon and is easily distended with intestinal gas and the fluid contents that empty into it from the small intestine.
The cecum usually rests in the right iliac fossa near the external iliac vessels & illacus muscle, but may extend down
into the pelvis. (Bottom) Graphics show variations of the posterior peritoneal attachments of the cecum, with the
dark area representing the retroperitoneal attached segment. Note that the cecum is usually relatively mobile, as is
the appendix and terminal ileum, while the ascending colon is usually fixed retroperitoneal 1 y The appendix can,
and often does, lie in a retrocecal space. An especially "free" (unattached) cecum & ascending colon predisposes to
volvulus and obstruction of this part of the colon.
 COLON
LATERAL VIEW, RECTOSIGMOID

Sacrum

Rectosigmoid junction

Rectouterine pouch (of

Douglas)

Rectum & rectal fascia

Bladder & vesical fascia

Levator ani muscle

External anal sphincter

Rectoveslcal space
&
Peritoneal reflection Urinary bladder

Levator ani (puborectal

portion) Prostate

f -.1

(Top) The sigmold colon is on a mesentery while the rectum is retroperitoneal. The anterior surface of the rectum
has a peritoneal covering, which extends deep in the pelvis in women, forming the rectouterine pouch (of Douglas)
as it is reflected along the posterior surface of the uterus. The rectum is narrowed as it passes through the pelvic
diaphragm and then enters the anal canal with three levels of the anal sphincter (deep, superficial & subcutaneous).
The rectum has a continuous external longitudinal coat of muscle, unlike the colon with its discontinuous rows of
taenlae. (Bottom) The rectoveslcal space (recess) is the most dependent portion of the peritoneal cavity in men. The
anterior wall of the rectum has more contiguity with the peritoneal cavity than its lateral or posterior walls.
 COLON
RECTAL VEINS & VALVES

V
v Inferior mesenteric
vein

Superior rectal
(hemorrholdal) vein

Internal Iliac
(hypogastrlc) vein
Rectal valves

^H
Middle rectal
(hemorrholdal) vein

Levator anl muscle

Dentate line
Infenor rectal
(hemorrholdal) vein
Internal hemorrtioidal
plexus

External hemorrholdal
plexus

The rectal valves (folds) are crescentic infoldings of the wall that include the mucosa, submucosa, & circular muscle
layers. The dentate line marks the squamo-columnar boundary. The veins of the rectum return blood to two different
systems; the superior rectal to the portal system and the middle & inferior rectal to the inferior vena cava. These
anastomose with each other & have important clinical implications (patterns of hematologic spread of rectal cancer;
perirectal varices in portal hypertension). The external hemorrholdal plexus lies in the subcutaneous tissue
sunounding the anus, while the internal plexus is in the submucosal tissue of the rectum. These veins have no valves
& are easily distended due to portal hypertension or chronic straining at stool, resulting in "hemorrhoids" which are
common, painful swellings that may bleed &/or thrombose.
 COLON
BARIUM ENEMA, NORMAL COLON >
a
o
3
o
3
■ ■

— Splenic flexure
o
Hepatic flexure — o
o
=3

Transverse colon —

— Descending colon

— Sigmoid colon

Haustra — — Seniilunar folds

Ascending colon —

Appendix — — Sigmoid colon

Cecum —

(Top) First of five images from an air-contrast barium enema with the patient in a prone position shows barium
pooling in the dependent portions of the transverse and sigmoid colon. Note the "radiologic" hepatic & splenic
flexures of the colon, which are the most cephalic portions of the transverse colon. The "anatomic" flexures are the
transitions from the retroperitoneal ascending (and descending) colon to the inlraperitoneal transverse colon.
(Bottom) In this supine position image, barium pools in the ascending & descending colon, as well as the rectum.
Note the transverse seniilunar colonie folds, and the haustra, the saccular outpouchings of the lumen between the
folds. Colonie transverse folds are spaced farther apart than those in the small intestine, a useful marker in
distinguishing among bowel segments on plain radiographs. II
245
 COLON
BARIUM ENEMA, NORMAL COLON
o
o
O
--
c
o
E
o
Seinilunar folds
<

Air-fluid levels

Air-fluid levels

Sacrum

Sigmoid colon -

Rectal valves (folds)

Coccyx

(Top) Upright position image from an air-contrast barium enema shows barium pooling in dependent hau.stra and
curvatures of the colon. (Middle) A left lateral decubitus image shows barium pooling in the dependent left
(descending) colon and within dependent haustra. This patient has a relatively long and curving ("redundant")
colon, a common variant of no clinical concern, although this condition makes colonoscopic inspection of the entire
colon difficult. (Bottom) A "cross table lateral" image, with the patient in the prone position shows barium pooling
along the anterior surface of the rectum & colon. Note the rectal valves (folds), which are analogous to the seinilunar
folds of the colon.
 COLON
NORMAL ILEOCECAL VALVE >
Q.
O
3
CD
■ ■

o
o
o
— Jejunum 3

Iieocecal valve

Cccum

Ileum

terminal ileum -

Cccum
Ileum

Iieocecal valve

Terminal ileum

(Top) Barium small bowel follow through image shows a normal iieocecal valve. The "lips" of the iieocecal valve
compress the terminal ileum as it enters the cecum. In most patients, this prevents reflux of colonic contents into the
small intestine. (Itottom) Axial ( T scan from t h e same patient as t h e previous image shows normal low attenuation
(density) within the "lips" of the iieocecal valve, due to fibro-fatty tissue. This constitutes a useful anatomic marker
for identification of the iieocecal valve on CT sections.

II
247
 COLON
c NORMAL APPENDIX
_o
o
U
••
C
0)
E Liver -
o
■D
Si Right kidney
<
Appendix

Ileum -

Appendix
Cecal tip

— Iliac arteries

Ascending colon -

Appendix (base) -

(Top) First of six CT sections of a patient with a normal appendix shows the appendix lying in a vertical position
with its tip in the right upper quadrant, next to the liver on this coronal section. If this patient were to develop
appendicitis, the point of maximum tenderness would not be in the "expected" right lower quadrant site. While the
appendix always arises from the tip of the cecum, it may extend on its mesoappendix in any direction, much like the
hand of a clock. In this patient, the appendix is pointing to "12 o'clock". (Middle) The normal appendix has a small
amount of fecal content and gas, with a luminal diameter less than 6 mm and a thin wall. The base of the appendix
is seen at the tip of the cecum. (Bottom) A more anterior coronal section shows the normal ascending colon and
II cecum as well as normal small intestine.
248
 COLON
NORMAL APPENDIX >
a
o
3
m
«*

Ascending colon —
o
o
o

Liver (inferior tip ot right lobe) -

Appendix

Ascending colon

Apjx'ndix

RK
Ascending colon

Appendix -

(Top) Axial CT section shows the tip of the appendix lateral to the right lobe of the liver. (Middle) The appendix
commonly lies behind the cecum and ascending colon, as in this subject. The appendix may be intra- or
retroperitoneal. (Rottom) Note the thin wall and gas content of the appendix, as well as the homogeneous,
noninflamed appearance of the penappendiceal fat planes.

II
249
 COLON
SUPERIOR MESENTERIC VESSELS
o
o
O
c Middle colic artery
O
E Su|>erior mesenteric
o artery
T3 Riglit colic artery —
.a
<
Marginal artery
Jejunal arteries

Ileocolic artery

Angiographic catheter

Superior mesenteric

Right colic vein — ' -- •

Jejunal veins

Ileocolic vein —

(Top) First of two image's from a catheter injection of the superior mesenteric artery shows the jejunal arteries arising
from the left or convex side of the SMA and the colic branches from the right side. The middle colic is the first
colonic branch of the SMA and supplies the transverse colon. The ascending colon is supplied by the right colic, and
the cecum, appendix & ileum by the ileocolic artery. There are many variations of this pattern and multiple
anastomoses between colonic arteries, most notably through the marginal artery which connects branches of all
colonic arteries. (Bottom) Venous phase of the angiogram shows opacification of the major branches of the SMV.
These follow the same course and have similar names as the major arteries. The SMV usually joins with the splenic
II vein just behind the neck of the pancreas to form the portal vein.
250
 COLON
INFERIOR MESENTERIC VESSELS >

&
3
o
• ■

o
o
o
Left colic artery 3

Interior mesenteric
ariery
Marginal artery

Signioid ariery

Superior rectal .—
(hemorrhoiddl) artery

Confluence oi IMV &

splenic vein

Left colic vein

Inferior mesenteric
vein

Signioid vein

Superior rectal —
(hemorrhoidal) vein

(Top) First of two images from a catheter injection ot the inferior mesenteric artery shows its major branches,
including the left colic (to the descending colon), sigmoid and rectal arteries. The marginal artery parallels the course
of the entire colon, gives rise to the terminal straight branches, and forms an important pathway for collateral flow
to segments of the colon. The marginal artery connects branches of the SMA and IMA and these collateral vessels
may be sufficient to maintain colonic viability even with complete occlusion of the origin of the IMA. The
distribution of the SMA and IMA overlap in the "watershed" region of the splenic flexure. In the setting of shock or
diminished cardiac output, this region is prone to ischemic injury, (bottom) A venous phase image from the inferior
mesenteric angiogram shows the major tributaries of the IMV. II
251
 COLON
£= MESENTERY OUTLINED BY ASCITES
O
O
O
■ ■
c
a>
E
o
"O
-Q Transverse colon —
<
Jcjunal vessels

Heal vessels

Duodenum (3rd
portion)

Ascending colon Descending colon

Right colic vessels Inferior mesenteric

vessels

Greater omenltim

Small bowel mesentery

Inferior mesenteric
vessels
Ascending colon
Descending colon
Right colic vessels

(Top) first of five axial CT sections in a patient with ascites shows the vascular supply t o the bowel. The small bowel
and transverse colon receive their supply through the mesentery & transverse mesocolon, resix'ctively, and these are
highlighted by mesenteric fat and separated by ascites in this subject. The ascending & descending colon are
retroperitoneal as are their vessels. The origin of the IMA is seen on this section, arising from the distal aorta just
caudal and dorsal t o the 3rd portion of the d u o d e n u m . (Bottom) This section clearly shows t h e distinction between
the intra- and retroperitoneal bowel segments a n d their blood supplies.

II
252
 COLON
MESENTERY OUTLINES BY ASCITES >
a-
Q.
O
3
o
- tpiploU appendages

- Sigmoid colon
o
o
o
Sigmoid mesocolon

Inferior mcsentcric vessels

— Piverticiilum
Small intestine

- Sigmoid colon

L'rrihilieal lolds

Urinary bladder
Ascites

Diverticula

Kccto-sigmoid junction

(Top) More caudal section shows the sigmoid colon on its mesocolon which carries the sigmoid hranclics of the
interior mescnteric vessels. Note the normal epiploic appendages, vestigial fattv tags on the antiinesenteric surface ol
the colon. (Middle) The sigmoid colon is mobile on its mesocolon a n d is surrounded by ascites in this subject. One
of many diverticula is identified. (Bottom) The recto sigmoid junction marks the transition from the intraperitoneal
sigmoid colon to the extraperitoneal rectum. Diverticula potentially affect all portions of the colon, especially the
sigmoid, but spare the rectum.

II
253
 COLON
c INFERIOR MESENTERIC VESSELS, ASCITES
_c
o
u
■ ■
c
<u
Confluence of SMV <s splenic vein -
E
o Pancreas
"D
-Q Superior mesenteric artery -
< Left renal vein

Ascites

— Inferior mesenteric vein

Duodenum -
— Pancreas
Superior mesenteric vessels

Superior mesenteric vein

Superior mesenteric artery -

Inferior mesenteric vein

(Top) first of six axial CT sections in a patient with ascites shows the confluence of the splenic and superior
mesenteric veins behind the neck of the pancreas, forming the portal vein. (Middle) A more caudal section shows
the confluence of the inferior mesenteric and splenic veins behind the body of the pancreas. (Bottom) The inferior
mesenteric vein has a cephalo-caudal course and small size, making it difficult to identify on many axial CT studies.
 COLON
I N F E R I O R MESENTERIC VESSELS, ASCITES >

TA&, Superior mescnteric vessels

Q.
O
3
o
3
a ■

Duodenum
o
m— Left colic vein o
o
— Descending colon 3

^A— Junction of descending is

sigmoid colon

Left colic vein

■ Sigmoid colon
Small intestine

— Sigmoid vein

(Top) A more caudal section shows the left colic vein draining the descending colon. (Middle) 1 he left colic vein
joins with tributaries from the sigmoid colon. (liottom) The sigmoid colon a n d its vessels are seen within the
sigmoid mcsotolon. Veins arc generally larger in calilx-r and less tortuous t h a n arteries.

II
2S5
 COLON
c INFERIOR MESENTERIC VESSELS, ASCITES
o
o
O
• ■

c
G)
E
o
-o
.£3 — Fpiploic appendage
<

— Sigmoid colon

Sigmoid vessels

Astites

l-.piploic appendages

Sigmoid diverticula

(Top) I irst of two axial CT sections in a patient with ascites shows the sigmoid colon and its mesocolon which carries
the vessels to & from the colon. Note the epiploic appendages, fatty tags on the antimesenteric border that are
especially prominent in the sigmoid colon. These are normal anatomic features that are made more evident by the
presence of ascitcs. (Bottom) Another common, though abnormal, feature of the sigmoid colon is the presence of
diverticula, which are outpouchings of the mucosa & submucosa through the muscle layers of the colonic wall.

II
256
 COLON
NORMAL EP1PLOIC APPENDAGES >
cr
Q.
O
3
o
3
■ ■

o
O
o
Ascitcs 3

F.piploic appendages
— Sigmoid colon

^ ^

Epiploit ap|X'nilagi's

w^
SMi'm
^B^^^fl

(Top) First of two axial CT sections in a patient with ascites shows multiple fat-density epiploic appendages arising
from the wall of the sigmoid colon. These are present in nearly all individuals, but are usually not evident on
cross-sectional imaging because the fat-density appendages are indistinguishable from the mesentcric & omcntal fat
that normally abut the colon. (Bottom) The epiploic appendages can be quite elongated, as in this subject, and may
twist and infarct, leading to localized pain and tenderness, symptoms that mimic those of diverticulitis.

II
257
 COLON
c ACUTE A P P E N D I C I T I S
o
o
O
■ ■
c
G)
E Cecum -
o
T3

< Mural thickening of cecum

Base of appendix

Cecum —

lleum
External & internal iliac arteries
Mesoappendix - ■

Appendix ■

Psoas muscle i— Right common iliac vein

l.ymph node External ft internal iliac arteries

Appendix ■ Psoas muscle

( l o p ) First of five CT sections of a young man with acute appendicitis shows mural thickening of the wall of the
cecum at the base of the appendix. (Middle) More caudal section shows normal distal ileum opacified by enteric
contrast material. Arteries are densely opacified by IV contrast material, while the veins have n o t yet become
opacified. Vascular a n d enteric contrast material aid in distinguishing normal structures from the nonopacified
lumen of the appendix. Appendicitis occurs when the lumen of the appendix is occluded by inspissated stool
(fecalith) with subsequent distention & inflammation of the appendix. Note the enhancing, thickened wall of the
appendix and infiltration of the surrounding fat planes. (Bottom) More caudal section shows the inflamed,
II obstructed appendix a n d an enlarged reactive lymph node.
25B
 COLON
ACUTE APPENDICITIS >
a
o
3
<i>
3
••
o
o
o
ZJ

Ascending colon

Appendix

Psoas muscle

Ascending colon "

Ileocecal valve

Iliac arteries
(.ei urn

(Top) A coronal CT reformation shows the thick-walled appendix lying medial to the ascending colon and adjacent
to the psoas muscle. In patients with acute appendicitis, the psoas muscle is often inflamed, causing pain when the
leg is flexed a n d straightened. (Bottom) The wall of the cecum is thickened due t o inflammation from the
contiguous appendix.

II
2.sy
 COLON
DIVERTICULITIS
o
o
O
*>
c
0)
E Diverticula — — Descending colon
o
■o
Si
<

— Sigmoid colon

Rectum —

— Urinary bladder

- Diverticula

Sigmoid colon

-3 Diverticula

(Top) First of five images of a patient with diverticulitis and a colo-vesical fistula. An oblique image from a barium
enema shows marked spasm and luminal narrowing of the sigmoid colon and opacification of the urinary bladder
through a fistula (that is not evident on this image). Numerous diverticula are seen in the descending & sigmoid
colon. (Bottom) Axial CT section shows multiple gas- and contrast-filled diverticula arising from the sigmoid colon.

II
 COLON
DIVERTICULITIS >
O.
O
3
O
■ »

Diverticula o
o
Pericolonic fluid
o
3

Divertitula (contrast-filled)

Urinary Madder

Gas in bladder

1,'rine in bladder

Vagina

Rectum

(Top) More caudal CT section shows extraluminal fluid adjacent to the sigmoid colon, due to perforation of the
diverticula and inflammation. (Middle) More caudal CT section shows pericolonic fluid & infiltration and several
diverticula with high density contents clue to retained enteric contrast material. The inflammatory process is
contiguous with the top of the urinary bladder. (Bottom) More caudal CT section shows a gas-fluid level in the
urinary bladder, indicative of a colovesical fistula.

II
261
 COLON
c EPIPLOIC APPENDAGIT1S
o
o
O
■ ■

c
£
o
-a
<
— Infarctitl epiploic
appendage

— Descending colon

— Small intestine

I'ericolonic
inflammation

— Descending colon

rsoas muscle —

(Top) First of two CT sections in a patient with acute left lower quadrant pain shows inflammation of the fat planes
anterior to the descending colon. In the middle of the inflammation is an oval fat-density lesion that represents an
in fa re ted epiploic appendage. Recall that the normal epiploic appendage is a tag of fat that extends off the
antimesentcric border of the colon. (Bottom) The absence of diverticula and the presence of the central fat density in
the inflammatory focus help to distinguish epiploic appendagitis from divcrticulitis which causes very similar clinical
signs ft symptoms.
II
262
 COLON
COLON POLYPS >
cr
Q.
O
3
CD
a
o
o
o
Sessile polyp 3

Pedunculated polyp

Semllunar folds

Haustra

(Top) Graphic shows two common shapes of colonic polyps: A pedunculated polyp on an elongated stalk, and a
sessile, or relatively flat, polyp. In adults, most polyps are adenomatous (gland-forming) and are considered
precursors to colon cancer. For this reason, surveillance techniques, such as colonoscopy and barium enema, are
recommended to detect polyps so that they can be removed before undergoing malignant degeneration. (Bottom)
"Spot film" from an air-contrast barium enema reveals a spherical pedunculated polyp on a long thin stalk. A polyp of
this size (about 1 cm) is usually benign, but should be resected, preferably via colonoscopy.
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263
 COLON
c SIGMOID VOLVULUS
o
o
O
■ •

c
0)
E
o Sigmoid volvulus

— Dilated colon

— Rectum (collapsed)

Transverse colon -

Sigmoid colon

— Dilated sigmoid colon

Collapsed sigmoid colon Twist of sigmoid blood vessels

& lumen

(Top) Graphic shows a sigmoid volvulus, in which the sigmoid colon is twisted around the base of its mesocolon.
The sigmoid lumen and blood vessels are occluded which may lead to ischemia & perforation. (Middle) A frontal
abdominal film shows massive dislention and elongation of the sigmoid colon, which has a shape likened to a
football or coffee bean, with the "seam" representing the apposed walls of the sigmoid. The sigmoid extends above
the transverse colon which is only moderately distended with gas. The distal rectosigmoid colon is collapsed.
(Bottom) Axial CT section through the point of volvulus shows abrupt narrowing & twisting of the sigmoid lumen
and its blood vessels. All of the colon upstream from the volvulus is dilated, but especially the sigmoid colon itself.
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264
 CECAL VOLVULUS >
O"
Q.
O
3
o
■ *

o
o
o
* / 3

Appendix
Cecum

Spinal fusion rods

Cecum

Ileocecal valve

Point of twist

(Top) Graphic shows typical cecal volvulus. The ascending colon is usually fixed in a retroperitoneal location.
Patients who have an elongated cecum & ascending colon that is on a mesentery are prone to twisting and
obstruction of these segments, resulting in obstruction of the bowel lumen and blood vessels of the twisted colonic
segment. Note that the cecum is dilated and displaced toward the left upper quadrant. The discoloration represents
Ischemlc injury to the bowel. (Bottom) First of three frontal abdominal radiographs of a patient who had a recent
spinal fusion shows massive distention of the right side of the colon, actually, the cecum and a portion of the
ascending colon, that are inverted & obstructed. II
265
 COLON
CECAL VOLVULUS

Ascending colon —

Cecum (is ascending

colon)

Point of twist &

obstruction

Descending colon

Ascending colon
Cecum (& ascending
colon)

— Rectum

(Top) Image from a barium enema shows retrograde opacification of normal colon, with abrupt obstruction in the
ascending colon (Bottom) "Post-evacuation" image shows collapsed normal colon and massive distention of the
cecum and the twisted portion of the ascending colon, diagnostic of cecal volvulus.
 COLON
COLON CANCER >
cr
Q.
O
3
3
• ■

o
o
o
Colon carcinoma 13

Colon carcinoma

-- Sigmoid colon

Rectal balloon -

Sigmoid colon
Cocum

Carcinoma

Rectum

( l o p ) G r a p h i c shows a typical "apple-core" n a r r o w i n g of the c o l o n i c l u m e n by a circumferential tumor. Carcinoma is

often a scirrhous mass that leads t o l u m i n a l n a r r o w i n g a n d partial o b s t r u c t i o n . ( M i d d l e ) A lateral view f r o m a
b a r i u m enema shows abrupt, irregular n a r r o w i n g o f t h e s i g m o i d c o l o n by a carcinoma. ( R o t t o m ) A n axial C l section
shows gas a n d feces w i t h i n t h e c o l o n , except for t h e s i g m o i d c o l o n where the l u m e n is markedly narrowed and o n l y
a soft tissue mass is seen, representing the p r i m a r y carcinoma.

II
267
 COLON
c RECTAL C A R C I N O M A WITH METASTASES
o
o
O
- ■

c
O
E Liver
o
TJ
-Q
<

I wig nietastases —r-

Superior mescnterif vessels

I.ett renal vein —
Mesenterii mM1<I1 metastasis

— Nodal metastases

Nodal metastases

(Top) First of five C f Sections of a m a n with rectal carcinoma shows numerous lung nodules representing pulmonary
nietastases. (Middle) A more caudal section shows lumbar retroperitoiical and mesenteric nodal metaslases. Note the
absence of liver metastases. Colon carcinoma usually spreads to the liver via the portal venous system, and systemic
nietastases are encountered less commonly a n d only late in the disease. Conversely, rectal cancer may spread via
systemic venous a n d lymphatic drainage, bvpassing the liver. (Bottom) A more caudal section shows extensive
retroperitoneal nodal metastases.

II
268
 COLON
RECTAL C A R C I N O M A W I T H METASTASES >

a
o
3
<D
■ ■

o
o
o
=3
Sigmoid colon

Rectal tumor Rectal lumen

I'rinary blaiktcr

Tumor

Rectal lumen

(Top) Gas i n the rectal l u m e n indicates displacement and n a r r o w i n g o f t h e rectum b y a b u l k y tumor. ( B o t t o m ) A

more caudal section shows extensive pcrirectal t u m o r f i l l i n g m u c h o f t h e pelvis a n d displacing t h e urinary bladder.

II
 COLON
c ISCHEMIC COLITIS
o
o
O
■ ■
— Ischemic colon
c
E
o
<

Healthy colon

■- - Ischemic colon

- Stomach

Atheromatous plaque ■—■— Ischemic colon

Small intestine

(Top) Graphic shows the typical effect of hypoperfusion ischeniic injury of the colon. The "watershed" region of the
splenic flexure, where the distribution of the superior and inferior mesenteric arteries intersect, is the most
vulnerable segment. Note the luminal narrowing and wall thickening. (Middle) First of five CT sections shows
luminal narrowing and suhmiicosal edema within the splenic flexure region of the colon. (Bottom) The ischemic
injury to the colon extends into the distal transverse and proximal descending colon.

II
270
 COLON
ISCHEMIC COLITIS >

a
o
3
a>
■ ■

Hepatic flexure o
o
Ischemic colon (splenic flexure) o
3

— Transverse iolon

— Descending colon

Descending colon

_
Sigmoicl colon

(Top) The w a l l of the hepatic flexure is n o r m a l ; compare w i t h the thickened wall of the splenic flexure. ( M i d d l e ) The
m i d transverse and descending colon are n o r m a l as is t h e small intestine. Note t h e thickness o f t h e n o r m a l towel
wall w h i c h is almost imperceptihle o n these sections, measuring o n l y ahout 2 m m i n thickness. (Bottom) Most
caudal section shows n o r m a l distal colon and small intestine.

II
271
 SPLEEN
[Cross Anatomy
Overview
• Spleen is t h e t h e largest lymphatic: organ
C Size is variable
■ Usually not more than 1Z cm long, 8 cm wide, o r
S cm thick
■ Usual volume range 100-250 c m \ mean 150 c m 1
in adults
■ Volume > 470 t i n ' = splenomegaly
c Functions
■ Manufactures lymphocytes, filters blood (removes
damaged red blood cellsfcrplatelets)
■ Acts as blood reservoir: Can expand or contract in
response to changes in blood volume
• Histology
Soft organ with fibroelastic c a p s u l e entirely
surrounded by peritoneum, except at splenic hilum
I rabeculae: Extensions of the capsule into t h e
parenchyma; carry arterial & venous branches
Pulp: Substance of t h e spleen; w h i t e p u l p =
lymphoid nodules; r e d p u l p = sinusoidal spaces
containing blood
C Splenic cords (plates of cells) lie between sinusoids;
red pulp veins drain sinusoids
■ Relations a n d vessels
Spleen contacts the posterior surface of t h e stomach
and is connected via t h e gastrosplcnic ligament
(GSL)
■ GSL is the left anterior margin of t h e lesser sac
■ GSL carries the short gastric & left gastroepiploic
arteries and venous branches to spleen
c Contacts t h e pancreatic tail a n d surface of left
kidney a n d is connected t o these by the s p l c n o r e n a l
l i g a m e n t (SRI.)
■ SRI carries splenic arterial and venous branches
to spleen
■ SRI is the left posterior margin of t h e lesser sac
(omcntal hursa)
Splenic vein runs in groove along dorsal surface of
pancreatic IxnJy and tail
■ Receives t h e inferior m e s e n l e r i c vein (IMV)
■ Combined splenic a n d IMV join superior
mesentcric vein t o form p o r t a l vein
Splenic a r t e r y (from celiac), often very tortuous
I Anatomy-Based Imaging Issues
Key Concepts
• Spleen shows h e t e r o g e n e o u s e n h a n c e m e n t o n
arterial phase enhanced CT or MR imaging
Reflects lack of capillary bed, presence of red a n d
white pulp and sinusoidal architecture
Can be mistaken for pathology o n abdominal CT or
MR exam
• Spleen has highly variable size and shape
Imaging accurately detects s p l e n o m e g a l y a n d may
suggest its cause (e.g., with cirrhosis = portal
hypertension: with Ivmphadenopathy = lymphoma,
mononiK li-osis, etc.)
• Spleen is c o m m o n l y injured in blunt trauma,
especially with fracture ol the left lower ribs
e Parenchymal laceration & capsular tear often result
in substantial intraperitoneal bleeding
• Spleen texture
Soft & pliable, relatively mobile
Easily indented & displaced by masses and even
loculated fluid collections
Changes position in response t o resection of
adjacent organs (e.g., post-nephrectomy)
Clinical Implications
Clinical Importance
• Neoplastic involvement
Spleen is c o m m o n l y involved in Hodgkin a n d
non-Hodgkin l y m p h o m a a n d leukemia (often result
in massive splenomegaly)
c Uncommonly involved with other metastatic
disease (direct invasion by gastric or pancreatic
cancer; metastatic melanoma)
Rarely the site of other primary malignancy
• Tail of pancreas contacts splenic hilum
Pancreatic tail lies in splenorenal ligament (can be
considered intraperitoneal)
c Pancreatitis can extend into splenic hilum, result in
intrasplenic pseudocyst
• Splenic infarction
- Relatively c o m m o n cause of acute left upper
quadrant pain
o Appears as sharply marginated wedge-shaped, ixjorly
e n h a n c i n g lesion(s) abutting splenic capsule
Etiologies
■ Sickle cell a n d other hemoglobinopathies
■ "Spontaneous" in any cause of splenomegaly
■ Lmbolic (e.g., I.V. drug abuse, endocarditis, atrial
fibrillation)
[Embryology
Embryologic Events
• from dorsal mesogastrium during 5th fetal week
• Normally rotates to t h e left
• Usually fixed into lett subphrenic location by
peritoneal reflections linking it t o diaphragm,
abdominal wall, kidney & stomach
• Usually develops as o n e "fused" mass of tissue
Practical Implications
• Accessory spleen found in 10-.{0% of population
< Usually small, near splenic hilum
c Can enlarge & simulate mass, especially after
splenectomy
• Spleen may be o n a long mesentery
- "Wandering spleen" may be found in any
abdominal or pelvic location
• Asplenia a n d polysplenia
c Rare congenital conditions associated with other
cardiovascular anomalies, situs inversus, etc.
Polysplenia can be simulated by splenosis
(peritoneal implantation of splenic tissue that may
follow traumatic splenic injury)
 SPLEEN
SPLEEN & ITS RELATIONS >
O.
o
3
a
Gastric impression
3
U)

Stomach CD
CD
3
Renal impression

Prominent medial
lobuiation

Kidney

Stomach

Spleen

Lesser omentum Gastrosplcnlc ligament

Splenic artery

Splenorenal ligament

Splenic vein
Inferior mesenteric
vein
Root of transverse
mesocolon

(Top) Graphic shows the medial surface of the spleen & representative axial sections at three levels through the
parenchyma. The spleen is of variable shape & size, even within the same Individual, varying with states of nutrition
and hydiation. It is a soft organ that is easily Indented by adjacent organs. The medial surface Is often quite lobulated
as it Is interposed between the stomach & the kidney. (Bottom) The liver is retracted upward & the stomach
transected to reveal the pancreas and spleen. The splenic artery & vein course along the body of the pancreas, & the
tail of the pancreas lies within the splenorenal ligament. The gastrosplenlc ligament carries the short gastric & left
gastroepiploic vessels to the stomach and spleen. The splenic vein receives the inferior mesenteric vein & (olns the
superior mesenteric vein behind the neck of the pancreas to form the portal vein. II
271
 SPLEEN
c AXIAL CT, NORMAL SPLEEN
<D
.2
Q.
CO
•• — Stomach
c
o
E
o Short gastric & left
TJ gastroepiploit vessels
-O
<

Spleen

r— Splenic flexure (colon)

(lop) Hirst of 3 axial CT sections shows a normal spleen abutting the left hemidiaphragm. The short gastric and left
gastroepiploic vessels lie in the gastrosplenic ligament and supply both the stomach and spleen. (Middle) Note the
relation between the spleen and the left ("splenic") flexure of the colon. (Bottom) The body of the pancreas courses
along the splenic vein and the tail of the pancreas inserts into the splenic hilum. Note the relation of the spleen to
the left kidney.
 SPLEEN
CORONAL CT, NORMAL SPLEEN >
Q.
O
3
Q
■ ■

W
— Spleen "O
CD
CD
ZJ
— Left kidney

Spleen

— Left kidney

(Top) First of two coronal CT images shows a normal spleen in its subdiaphragmatic location. Note the normal fatty
clefts in Die splenic parenchyma. Infoldings of the splenic capsule into the parenchyma are called traheculae, and
these carry the branches of the splenic vessels. (Bottom) Note the close relation between the spleen and the left
kidney.

II
275
 SPLEEN
c NORMAL SPLEEN
CD
O
CL
C/)
■ ■

c
0)
E
o
■D
-Q
— Stomach
<

Gastrosplenic ligament

Spleen

Stomach

— Splenic flexure

— Pancreas (tail)

— Splenic hilum

(Top) First of five axial CT sections shows a normal spleen and its relations. Note the fat-containing gastrosplenic
ligament which carries the short gastric and left gastroepiploic vessels to the stomach and spleen. (Bottom) The tail
of the pancreas courses with the splenic vessels through the splenorenal ligament and lies in the splenic hilum. The
tail of the pancreas is the only intraperitoneal portion of this organ. Processes that affect the pancreatic tail,
including pancreatitis and cancer, can easily extend into the splenic hilum and invade the splenic parenchyma.

II
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 SPLEEN
NORMAL SPLEEN >
C7
O.
O
3
o

if)
-g.
Pancreas CO

Splenic vein
3

Splenic artery
_
Splenic vein
— Pancreas

I eft adrenal ■

Lett kidney -

Pancreas

Left adrenal
- Accessory spleen
I.ell kidney

( l o p ) The splenic vein runs in a transverse plane in a groove in the dorsal surface of the pancreas. This is a reliable
anatomic marker to help identify the pancreatic body. (Middle) The splenic artery has a much more Circuitous route,
especially in older individuals and frequently moves into and out of the axial plane of CT sections. (Bottom)
Accessory splenic tissue is found in u p to 30% of the population. As in this example, it is usually seen as a small,
spherical "mass" in the splenic hilum.

II
277
 SPLEEN
c SPLENIC LIGAMENTS & VESSELS
CD

••
c
E
o
■o — Greater omeiitiim
3 I.iver
Ascites
Stomach

Bile ducts (containing gas) - -

Gastrosplenic ligament

— Stomach
Bile durt (with gas)

Gastrosplenic ligament

Lesser sac

- Splenorenal ligament

( l o p ) First of five axial CT sections in a man with ascites that helps to accentuate the peritoneal ligaments that carry
vessels to and from the spleen. Axial image shows ascites surrounding the liver a n d spleen. (Middle) The
gastrosplenic ligament is the peritoneal reflection that connects the stomach and spleen; it carries t h e short gastric
a n d left gastroepiploic vessels t o both organs. (Bottom) The gastrosplenic and splenorenal ligaments form the left
lateral margin of the lesser sac and convey blood vessels, nerves, a n d lymphatics to the spleen.
 SPLEEN
SPLENIC LIGAMENTS & VESSELS >
a
o
3
3
■ ■

C/>
■o
CD
CD

Gastmsplenic ligament
Splenic artery -

— Lesser sai

Splenic vein Splenorenal ligament

Pancreas

Left kidney

Pancreas

Confluence of splenic
& portal vein Splenorenal ligament

(lop) The (main) splenic artery and vein course along the pancreas and enter the spleen through the splenorenal
ligament. (Bottom) The splenic vein runs parallel to the body of the pancreas a n d lies in a groove along its dorsal
margin.

II
270
 SPLEEN
c ANGIOGRAM, SPLENIC VESSELS

Q-
C/D
■ ■

c
o
E
o
"D
-Q
< Left hepatic" arlery —

Lelt gastric artery

— Splenic artery

Gastroduodenal artery

Portal vein

— Splenic vein

Superior mesenteric
vein

(Top) A catheter injection of the celiac artery shows the typically tortuous course of the splenic artery. This
individual exhibits a common variant in which the right hepatic artery arose from the superior mesenteric artery and
is, therefore, not opacified on this injection. (Bottom) The splenic vein joins the superior mesenteric vein to form
the portal vein. The inferior mesenteric vein, draining the left side of the colon, usually joins the splenic vein just
prior to its confluence with the superior mesenteric vein.

II
280
 SPLEEN
HETEROGENEOUS SPLENIC ENHANCEMENT >

&
3
n>
• ■

— Spleen

— Spleen

(Top) First of two axial CT sections through a normal, though prominent, spleen. This image was obtained in the
predominantly arterial phase of e n h a n c e m e n t (about 45 seconds after the start of the intravenous injection of
contrast medium) a n d shows heterogeneous e n h a n c e m e n t of t h e splenic parenchyma. This reflects t h e unique
histology of the spleen, with cords of tissue and sinusoidal spaces, rather than a capillary bed as is found in most
organs. (Bottom) A repeat CT section after about an 80 second delay shows homogeneous e n h a n c e m e n t of the
splenic parenchyma. The liver is cirrhotic.

II
_»M1
 SPLEEN
SPLENIC TRAUMA
0
Q.
••
C
0)
E
o
TJ
<
Splenic laceration

I'erisplenic hematoma

- Splenic laceration

Splenic laceration

(Top) First of three axial CT sections in a man with a blunt traumatic laceration of the spleen shows heterogeneous
clotted blood (hematoma) surrounding the spleen. A linear lucency in the lateral side of the spleen represents the
splenic laceration. (Middle) A more caudal section shows continuation of the irregular parenchymal laceration.
(Bottom) Note that the lateral surface of the spleen is flattened by the hematoma. The hematoma is lentiform and
mostly subcapsular (within the splenic capsule), although the presence of blood lower in the abdomen (not shown)
indicates that the capsule was torn, as usually results from significant splenic trauma.

II
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 SPLEEN
LYMPHOMA >
cr
a
o
3
(D

Spleen
Enlarged nodes — 3

local splenic lesion

Enlarged nodes (mesenteric) —
Enlarged nodes

Mesenteric nodes — — Mesenteric vessels

Rctroperitoneal (luml»ar) nodes

(lop) First of three axial CT sections in a patient with night sweats and tever shows an enlarged spleen and
numerous enlarged upper abdominal lymph nodes. (Middle) The presence of focal splenic lesions and mesenteric
lymphadenopathy is strongly suggestive of non-Hodgkin rymphoma, which was subsequently proven by lymph
node biopsy. (Bottom) Note how the superior mesenteric vessels are "sandwiched" between massively enlarged
nodes, an appearance that is characteristic of widespread non-Hodgkin lymphoma.

II
_*RJ
 SPLEEN
c SPLENIC VEIN OCCLUSION, CANCER
0)
a.

o
E
o
Perigastric varices
.a
<

—
Lett gastric v e i n - Perigastric varices

Portal vein

I lepatic artery

Portal vein Splenic artery

— Pancreatic- r a n t e r

(Top) First of six CT images from a patient with carcinoma of the pancreas shows enlarged perigastric varices, which
are collateral veins connecting with the short gastric veins and splenic vein tributaries. (Middle) The splenic vein
should be opacified and visible on this section. Instead, collateral perigastric varices return blood to the portal vein
via the left gastric (coronary) vein. Note the normal appearance of the liver; perigastric varices in the absence of
cirrhosis & portal hypertension are indicative of splenic vein occlusion, usually due to pancreatic carcinoma or
chronic pancreatitis. (Bottom) A hypodense, poorly enhancing mass is seen in the body of the pancreas, totally
encasing the splenic artery & vein, as well as the hepatic artery. This is a typical appearance for pancreatic ductal
II carcinoma, with vascular invasion precluding surgery.
2I\4
 SPLEEN
SPLENIC VEIN OCCLUSION, CANCER >
Q.
O
3
I lepatic artery —
Splenic artery 5
• m

C/>
-&_
Portal vein CD
— Pancreatic cancer
CD
3

— I'erigastric varici-s
Panireas (normal)

Aorta -

Portal vein —

—
Superior mcscntcric vein

Right kidney —

Ciastroepiploic vein

(lop) I he pancreatic tumor and its effect on the splenic vessels are well shown on this section. (Middle) Note the
difference hetween the normally enhancing neck & head of the pancreas and the hypo-enhancing tumor in the
hody. (Hottom) Coronal reformation of the axial CT sections is displaved to accentuate the vessels in this image
obtained during the venous phase of enhancement. Note the absence of filling of the splenic vein, due to
encasement by the pancreatic tumor. Blood from the spleen is returned to the liver via collaterals that course along
the surface of the stomach, including the short gastric, left gastric and gastroepiploic veins.

II
2m
 SPLEEN
c INTRASPLENIC PSEUDOCYST

Q. — I'seudocyst
in
••
c — Stomach

E
o
TJ
<

- Kidney

(Top) First of three axial CT sections in a patient with recurrent pancreatitis shows the stomach compressed between
two pseudocysts. One of these is within the splenic capsule and causes marked compression of the splenic
parenchyma. (Middle) More caudal section again shows the encapsulation of the splenic pseiidocyst and its effect on
the splenic parenchyma. (Bottom) There is relatively little infiltration of the peripancreatic fat planes at this time
and level. Inflammation from the tail of the pancreas has entered the spleen via the splenic hilum. Recall that the tail
of the pancreas lies within the splenorenal ligament, as do the main splenic vessels; spread of inflammation (or
tumor) from the pancreatic tail into the spleen is relatively common.
II
2B6
 SPLEEN
CHRONIC SPLENIC INFARCTION >
IT
Q.
O
3
o

o
CD

— Heart (enlarged)

— Liver

Stomach

— Spleen (calcified)

(lop) I irst of two axial CT sections of a 35 year old man with sickle cell anemia and abdominal pain shows
cardiomegaly. (Bottom) More caudal section shows that the spleen is very small and densely calcified, characteristic
ol chronic splenic infarction that occurs typically in patients with sickle cell disease. Ihe spleen is nonfunctional in
this setting and the term "autosplenectomy" is sometimes applied to this condition.

II
287
 SPLEEN
c SPLENIC INFARCTION & CYST

a.
c/)
■ ■

c
E
o
TJ
<

Acute splenic infarcts

Stomach

Splenic cyst

(Top) First of four CT sections of a patient with heart failure, a ventricular assist device, and acute abdominal pain
shows wedge-shaped regions of nonenhancing splenic parenchyma that extend to the capsular surface, characteristic
of acute splenic infarctions. (Bottom) CT image obtained seven days later shows interval development of splenic
cysts, near water density lesions that may develop after splenic infarction or other forms of injury

II
-'88
 SPLEEN
SPLENIC INFARCTION & CYST >
ao
3
Ventricular assist
device • ■

"D
CD
CD

— Spleen (normal)

— Splenic cysts

Ventricular assist
device

Stomach

Splenic cyst

(Top) Additional splenic cysts now occupy the regions of the spleen that were infarcted. (Bottom) By imaging alone,
it is often impossible to distinguish an acquired splenic cyst (as in this case) from a congenital (epithelial lined) cyst.
Patient history and visible evolution of the cyst, as in this subject, arc more reliable criteria.

II
2H9
 SPLEEN
c ACUTE SPLENIC INFARCTION

CL

- Splenic capsule
0)
Stomach —
E
o
T3
XI
Infarcted spleen
<
Viable spleen

- Diaphragm

Pleural effusion —

Intarctcd spleen

Viable spleen

■ Infarcted spleen

Viable spleen

(Top) First of five axial CT sections in a young man with mononucleosis shows large areas of nonenhancing splenic
parenchyma. (Middle) The spleen is enlarged due to mononucleosis and the nonenhancing parenchyma is indicative
of acute infarction, which may occur in any setting of splenomegaly. (Bottom) The infarcted parenchyma is still
limited by an intact splenic capsule. Rupture of the capsule might result in intraperitoneal bleeding and would likely
require urgent splenectomy for treatment.
 SPLEEN
ACUTE SPLENIC INFARCTION >
Q.
O
3
CO
3
*•
C/)
■o
CO
CO
3

B — Viable spleen

pancreas

— Infarcted spleen

(Top) A more caudal section shows the infarcted. nonenhancing, portions of the spleen as distinct from the
enhancing, viable portions. (Bottom) Stum- heterogeneity within the infarcted portion of the spleen is due to clotted
blood.

II
 SPLEEN
ACCESSORY SPLEENS AFTER S P L E N E C T O M Y

— Accessory spleen

Stomach

— Stomach

Colon (splenic flexure)

— Pancreas

— Accessor)' spleens

( l o p ) First ot t w o axial C I sections o f a patient w h o has had a prior splencctomy shows one of several spherical
masses i n the left upper q u a d r a n t . ( B o t t o m ) More caudal section shows t w o more splenic masses that represent
enlarged accessory spleens that have h y p e r t r o p h i c d t o compensate for t h e surgical r e m o v a l of t h e " m a m " spleen. A
similar situation may occur after t r a u m a , a n d many small pieces o f splenic tissue m a y i m p l a n t t h r o u g h o u t t h e
peritoneal cavity a n d acquire a new h l o o d supply, d e v e l o p i n g i n t o m u l t i p l e splenic masses. This latter c o n d i t i o n is
k n o w n as "spleiiosis".
 SPLEEN
ACCESSORY SPLEEN, 1NTRAPANCREATIC >
Q-
O
3
CD
■ ■

C/)
■o
CD
CD
3
Pancreas —

Left adrenal — f

— Spleen
Accessory spleen

Pancreas ■

Splenic vein —

Accessory spleen - Spleen

(lop) First of two axial CI sections through the same anatomic level. First image obtained during the arterial phase
of imaging and shows a spherical, enhancing mass adjacent to the tail of the pancreas and near the splenic hilum.
(Bottom) A more delayed, venous phase image shows that the "mass" and the spleen enhance to the same degree on
both phases, indicating that this is an accessory spleen. Its location in or adjacent to the tail of the pancreas could
lead to the erroneous diagnosis of a pancreatic tumor.

II
29 5
 SPLEEN
ACCESSORY SPLEEN, ENLARGED I N C I R R H O S I S
0)
Q.
CO

0>
E — I'arumbilical varix
o
■D

<

Stomach

Liver —
— Spleen

- Accessory spleen

(lop) hirst of two axial O sections shows a cirrhotic, nodular liver with evidence of portal hypertension, including
varices (enlarged parumbilical vein) and splenomegaly. (Bottom) Near the splenic hilum is a spherical mass
representing an enlarged accessory spleen. Processes that result in splenomegaly may also cause increased size of
accessory spleens that may be present.

II
 SPLEEN
WANDERING SPLEEN >
C
Q.
O
3
• ■

Horseshoe kidney ■D
CD
CD
3

Splenic vein

- Spleen

Splenic infarction -

Splenic infarction
Spleen

(Top) First of three axial CT sections in a subject with several congenital anomalies shows a horseshoe kidney. Note
the splenic vein which could be followed to its junction with the superior mesenteric vein. (Middle) No splenic
tissue was evident in the upper abdomen. This pelvic mass was proved t o be a "wandering spleen" which was on a
long mesentery allowing it to descend into the pelvis. Low density peripheral lesions represent acute splenic
infarctions. (Bottom) More caudal section shows more of the enlarged, pelvic spleen a n d its infarcted portions.

II
2ir,
 SPLEEN
c POLYSPLENIA SYNDROME
<D
0
Q.
(/)
■ ■

C
©
E
o
■Q
<

Heart

liver

Aorla -
Confluence of hc|»tic
veins
— Azygous vein

— Liver

Stomach

Azygous vein
Aorta

(Top) First of four axial CT sections in a patient with polysplenia, a congenital syndrome associated with multiple
anomalies of development, position and rotation of viscera and vessels. This section shows dextrocardia and a
left-sided liver, along with an enlarged azygous vein. The hepatic veins empty directly into the right atrium.
(Bottom) The stomach and liver arc on the "wrong" side, as is the azygous vein which is enlarged due to congenital
absence of the suprarenal 1VC.

II
2 l )fi
 SPLEEN
POLYSPLENIA S Y N D R O M E >
cr
Q.
O
3
CD
3
■ -

-g_
s
Stomach —

Liver

Splenic masses

Stomach —

Splenic masses
Colon (ascending &
descending)

Right kidney (with

cyst)

(Top) M u l t i p l e splenic "masses" are present o n t h e right side o f the a b d o m e n . ( B o t t o m ) M o r e caudal section shows
a d d i t i o n a l splenic masses. I n a d d i t i o n t o the inverted position of the spleen, s t o m a c h a n d liver, all o f t h e c o l o n is
present o n the left side o f t h e a b d o m e n , w h i l e the small bowel was p r e d o m i n a n t l y right-sided.

II
297
 LIVER
Gross Anatomy
Overview
• I ivcr is largest gland & largest internal organ (average
weight - I MX) grams)
c (unctions
■ Processes all nutrients (except lals) absorbed from
Gl tract; conveyed via port.il vein
■ Stores glycogen, secretes bile-
Relations
■ Anterior & superior surtaces are smooth and
convex
■ Posterior & inferior surfaces are indented bv
colon, stomach, right kidney, d u o d e n u m , IVC,
gallbladder
Covered bv peritoneum except at gallbladder fossa.
port.i h e p a l i s and hare urea
■ Hare area: Nonperitone.il posterior superior
surface where liver abuts diaphragm
I'orta hepatis: Site ot entry/exit of the portal vein,
hepatic artery and bile duct
lalciform ligament: Extends from liver to anterior
abdominal wall
■ Separates right & left suhplirenic peritoneal
recesses (between liver £< diaphragm)
■ Marks plane separating medial and lateral
segments of left hepatic lolx-
■ ( arries r o u n d l i g a m e n t dig. teres). lihrous
remnant of umbilical vein
• Vascular supply (unique dual afferent blood supply)
Portal vein
■ Carries nutrients trom gut and hepatotrophic
hormones from pancreas to liver along with
o w g e n (contains 4 0 % more oxvgen t h a n systemic
venous I>I<XMJ)
■ 75-80% of blood supply to liver
Hepatic artery
■ Supplies 20-25% of blocxl
■ I ivcr is less dependent than biliarv tree on hepatic
arterial blood supplv
■ Usually arises from celiac artery
■ Variations are c o m m o n including arteries arising
from superior mesenteric artery
Hepatic veins
■ Usually •■{ (right, middle and lelt)
■ Man) variations ^t accessor) veins
■ Collect blood from liver and return it to IVC at
the c o n f l u e n c e of h e p a t i c veins just below
diaphragm and entrance of IVC into heart
Portal triad
■ At all levels of size and sulxliv ision, branches of
the hepatic artery, portal vein and bile ducts travel
together
■ Blood flows into hepatic sinusoids from
interlobular branches ol hepatic artery & portal
vein -» hepatotytes (clelnxifv blood and produce
bile) -* bile collects into d u d s , blood collects into
central veins -» hepatic veins
• Segniental anatomy of liver
Fight h e p a t i c s e g m e n t s
■ Each receives sccondarv or tertiary branch of
hepatic artery and portal vein
■ Each is drained by its own bile duct tintrahepatic)
and hepatic vein branch
Caudate lobe = segment I
■ Has independent portal triads and hepatic venous
drainage to IVC
I eft lobe
■ I ateral superior = segment 2
■ Lateral inferior = segment .\
■ Medial superior = segment 4A
■ Medial inferior = segment 4B
Right lobe
• Anterior inferior = segment 5
■ Posterior inferior = segment 6
■ Posterior superior = segment 7
■ Anterior superior = segment 8
Anatomy-Based Imaging Issues
Key C o n c e p t s or Q u e s t i o n s
• Designating a n d remembering hepatic segments
Portal triads arc intra-scgmental, hepatic veins are
intcr-segmental
Separating right trom lelt lobe
■ Plane extending vertically through gallbladder
tossa & middle hepatic vein
Separating right anterior trom posterior segments
■ Vertical plane through right hepatic vein
o Separating left lateral from medial segments
■ Plane of the lalciform ligament
Separating superior trom interior segments
■ Plane of main right K lelt portal veins
- Segments are numbered in clockwise order as if
looking at anterior surface ol liver
Imaging Pitfalls
• Because of variations of vascular & biliarv branching
within liver (common), it is frequently impossible to
designate precisely the boundaries lictween hepatic
segments on imaging studies
[Clinical Implications
Clinical Importance
• Advances in hepatic surgcrv (tumor resection,
transplantation) make it essential to depict lobar and
segniental anatomy, volume, blood supply, biliarv
drainage as accurately as possible
^ Combination of axial, coronal, sagittal and 3D
imaging by CT. MR and sonographv may be needed
Invasive' imaging studies (catheter angiography
and percutaneous transhepatic or endoscopic
cholangiographv) can lx j avoided in many cases by
( I K MK angiography and cliolangiography
• 1 iver metastasis are c o m m o n
Primary carcinomas of colon, pancreas, & stomach
are c o m m o n
Portal venous drainage usually results in liver being
initial site ot metastalic spread trom these tumors
• Primary h e p a t o c e l l u l a r c a r c i n o m a
Common worldwide, usually result ol viral hepatitis
H or I , alcoholism
 LIVER
HEPATIC VISCERAL SURFACE >
a
o
3
3

Coronary ligament Diaphragm <

Right triangular Left triangular

ligament ligament

Falciform ligament

Ltgamentum teres

Gallbladder

Gallbladder

Falciform ligament

Porta hepatis

Gastric Impression
Right renal impression

Bare area
Fissure for llgamentum
venosum

Inferior vena cava

(Top) The anterior surface of the liver is smooth and molds to the diaphragm & anterior abdominal wall. Generally,
only the anterior/Inferior edge of the liver is palpable on physical exam. The liver is covered with peritoneum, except
for the gallbladder bed, porta hepatis, and the bare area. Peritoneal reflections form various ligaments that connect
the liver to the diaphragm & abdominal wall, including the falciform ligament, the Inferior edge of which contains
the llgamentum teres, the obliterated remnant of the umbilical vein. (Bottom) Graphic shows the liver inverted,
somewhat similar to the surgeon's view of the upwardly retracted liver. The structures in the porta hepatis include
the portal vein (blue), hepatic artery (red), and the bile ducts (green). The visceral surface of the liver is indented by
adjacent viscera. The bare area is not easily accessible. II
299
 LIVER
HEPATIC ATTACHMENTS AND RELATIONS

Falciform ligament

Coronary ligament
Left triangular
ligament

Adrenal

Right triangular Lesser omentum

ligament

Falciform ligament
Coronary ligament

Left triangular
ligament Sulcus for IVC

Ligamentum venosum Right triangular

ligament
Lateral segment (left
lobe) k ■
Falciform ligament

■--
Medial segment (left
lobe) M
Right lobe

(Top) Liver is attached to the posterior abdominal wall and diaphragm by the left & right triangular and the
coronary ligaments. The falciform ligament attaches the liver to the anterior abdominal wall. The bare area Is in
direct contact with the right adrenal & kidney, and the IVC. (Bottom) Posterior view of the liver shows the
Ilgamentous attachments. While these may help to fix the liver in position, abdominal pressure alone Is sufndent, as
evidenced by orthotopic liver transplantation, after which the Ilgamentous attachments are lost without the liver
shifting position. The diaphragmatic peritoneal reflection is the coronary ligament whose lateral extensions are the
right & left triangular ligaments. The falciform ligament separates the medial & lateral segments of the left lobe.
 LIVER
HEPATIC VESSELS AND BILE DUCTS

Left hepatic vein

Right hepatic vein

w Middle hepatic vein

This graphic emphasizes that, at every level of branching and subdivision, the portal veins, hepatic arteries and bile
ducts course together, constituting the "portal triad". Each segment of the liver is supplied by branches of these
vessels. Conversely, hepatic venous branches lie between hepatic segments and interdigitate with the portal triads,
but never run parallel to them.
 LIVER
HEPATIC SEGMENTS

Segment 8 Segment 4A

Segment 2

Segment 7 Segment 3

Falciform ligament

Segment 6
Segment 4B

Segment 5

Segment 4A

Segment 7 Segment 2

Segment 1

Segment 3

Segment 6

Segment5 Segment 4B

I 1
(Top) First of two graphics demonstrating the segmental anatomy of the liver in a somewhat idealized fashion.
Segments are numbered in a clockwise direction, starting with the caudate lobe (segment 1), which can not be seen
on this frontal view. The falciform ligament divides the lateral (segments 2 & 3) from the medial (segments 4A & 4B)
left lobe. The horizontal planes separating the superior from the inferior segments follow the course of the right and
left portal veins. An oblique vertical plane through the middle hepatic vein, gallbladder fossa and IVC divides the
right & left lobes. (Bottom) Posterior view of the liver shows that the caudate is entirely posterior, abutting the IVC,
ligamentum venosum & porta hepatis. A plane through the IVC and gallbladder divides the left & right lobes.

502
 LIVER
AXIAL CT, N O R M A L LIVER

Middle iU'p.ilic vrin — I ell In : iitic vein

Right hepatk vein -

Middle hepatk vchi

Right [Kirtal vein (anterior segment)

Right hepatk vein

Medial segineiu branch w— t ateral segment branch

Left portal vein

Right portal vein (anterior]

Right hep.iln vein

Right portal vein (| isterior)

(Top) First of nine axial CT sections shows the confluence of the hepatic veins with the IVC just below the
diaphragm and the entrance of the IVC into the right atrium. (Middle) At this level the portal veins run in a
predominantly cephalo-caudal direction and bisect the angle made by the hepatic veins. I'ortal veins generally lie
within hepatic segments, while hepatic veins lie between segments. (Bottom) The horizontal plane defined hy the
left portal vein divides the lateral segment into segment 2 (above the vein) and 3 (below).
 LIVER
A X I A L CT, N O R M A L LIVER

Left portal vein (medial)

Middle hepatic vein —

Right portal vein (anterior) —

Right hepatic vein —

Right portal vein (posterior) -

Hepatic arterv "■

Mam portal vein —

Celiac artery

Right portal vein ((XKterior) —

Accessory right hepatic vein —

Falciform ligament —
Hepatic artery -

Portal vein —

(Top) The plane of section through the long axis of the right portal vein divides segments 7 is 8 (above) from
segments 5 & 6 (Ix'low). Note the relations between the liver, stomach, and pancreas. (Middle) The hepatic artery
arises conventionally in this subject, from the celiac artery. There is an accessory right hepatic vein that drains
directly into the IVC, caudal to the confluence of the other hepatic veins. (Bottom) Note the fissure for the falciform
ligament which separates the medial and lateral segments of the liver (segment 4 from segments 2 & 3).
 LIVER
A X I A L CT, N O R M A L LIVER >
a
o
3
o
Falciform ligament 3
Splenic-portal confluence

Gallbladder -
S

falciform ligament

- Stomach
Duodenum

Gallbladder

Pancreas (head)

falciform ligament

Gallbladder -

(Top) A vertical plane through the falciform ligament separates the medial and lateral segments of the left lobe,
while a vertical plane through the gallbladder fossa and middle hepatic vein separates the right and left lobes.
(Middle) Note the relations between the liver and adjacent organs. (Bottom) The right lobe of the liver extends
much more caudally than the left, occasionally, even into the |>elvis. The considerable variability of the shape of the
liver makes it difficult to identify hepatomegaly by physical examination alone, especially since only the ventral,
inferior edge of the liver can be palpated.

II
«)S
 LIVER
PORTAL V E N O U S SYSTEM
S Left portal vein

c RiRht portal vein -

0)
E
o Superior mesenleric vein
■D
-Q
<

Right ti left common iliac

arteries

Portal vein (to segment 6)

Hepatic vein (to segment 6)

Middle hepatic vein

Right portal vein (anterior)

- Left portal vein
Right portal vein (posterior)

Right hepatic vein

(fop) First of three CT images emphasizing the portal venous system. This coronal reformation of a CT scan in the
venous phase of imaging shows the superior mesenteric vein and its branches as well as the portal vein. The
(arbitrary) thickness and plane of the section exclude the splenic vein and include the iliac arteries. (Middle) Coronal
plane through the posterior segments of the liver shows the hepatic artery and portal vein branches to segment 6.
(Bottom) Thick reconstructed axial section shows a "trifurcation" pattern of the portal vein, in which the left portal
vein and the anterior & posterior branches of the right portal vein all arise directly from the main portal vein.

II
306
 LIVER
ARTERIOGRAM, CELIAC AND HEPATIC ARTERIES

— Left hepatic artery

Right hepatic artery —

— Proper hepatic artery

Common hepatic
artery
Gastroduodenal artery

Selective catheterization of the common hepatic artery demonstrates conventional arterial anatomy, in which all the
hepatic arteries arise from the celiac axis. Variations in hepatic arterial supply are very common and important to
recognize, especially if partial hepatic resection is being considered.
 LIVER
CELIAC AND HEPATIC ARTERIES

Left hepatic artery

Left gastric artery

Right hepatic artery

Splenic artery
Portal vein -
Common hepatic
artery
Proper hepatic artery
Superior mesenteric
Gastrocluodenal artery artery

Hepatic artery

Splenic artery

(Top) First of two CT images showing conventional hepatic arterial anatomy. This coronal reformation shows both
hepatic arteries arising from the proper hepatic artery which, in turn, arises from the c o m m o n hepatic artery. Also
visible are the portal venous branches, less well opacified as this image was obtained in the predominantly arterial
phase of enhancement. (Uottoni) A thick axial reconstructed CT image shows the hepatic a n d splenic arteries arising
from the celiac artery.
 LIVER
M I P , HEPATIC A N D PORTAL VEINS >
D-
O
3
Hepatic veins —
o
3

<
Splenic vein CD

Left portal vein

Right poral vein —

Portal vein — Inferior mesenteric

vein

Superior mesenteric
vein

IVC —

Right hepatic vein

Left hepatic vein

Middle hepatic vein

Splenic vein

— Inferior mesenteric
vein

— Aorta

IVC. —

(Top) l : irst of t w o coronal m a x i m u m intensity p r o j e c t i o n (MIP) images f r o m a contrast-enhanced MR scan shows t h e

major divisions a n d tributaries o f t h e hepatic and portal veins. O n l y a few branches of t h e superior mesenteric v e i n
are i n c l u d e d i n this plane o f section, m a k i n g it appear artifactually small. ( B o t t o m ) In this subject the inferior
mesenteric vein joins the confluence o f t h e superior mesenteric a n d splenic veins. Some o f t h e intravenously injected
contrast m e d i u m is still c i r c u l a t i n g t h r o u g h t h e arteries, resulting in ^ p a c i f i c a t i o n of t h e aorta.

II
 LIVER
S O N O G R A P H Y , N O R M A L ANATOMY

Middle hepatic vein -

— Lett hepatic vein

Right jxirt.il vein

(anterior branch)

Right hepatic vein ——

IV(

— Right kidncv

Right licmidiapliiagm —

(lop) l-irst of two ultrasound images of the li\er. Axial section shows the confluence of the hepatic veins as thev
enter the IVC The portal veins generally have a more prominent, cchogcnic rim. (Bottom) Sagittal section through
the liver shows its smooth and homogeneous echogenicitv with interspersed vessels and small intrahepatie bile
duets.
 LIVER
MULTIPLANAR CT, NORMAL VESSELS

Middle hepatic vein -

— U'lt hepatic vein

Right hepatic vein

Medial segment branch —

— lateral segment branch

Middle hepatic vein I eft |>ortdl vein

Portal vein
Right portal vein
(anterior branch)

Splenic vein
— Right portal vein
Right hepatic vein (posterior branch)

Right portal vein

(segment 7)

Right |x>rtal vein

(segment 6)

(lop) First of six CT sections through normal liver. This thick axial plane reconstruction shows the confluence of the
hepatic veins. (Bottom) Another thick axial reconstructed image shows the intrahepatic portal and hepatic veins.
 LIVER
CD MULTIPLANAR CT, NORMAL VESSELS
>
C
o>
E
o
"O
-D Left gastric artery
<

Left hepatic artery

Splenic artery

C o m m o n hepatic
artery
Right hepatic artery

Superior mesenteric
artery
Gastroduodcnal artery

Left portal vein

— Portal vein

Segment 6 portal
branch

Segment 5 portal
branch

(Top) CT section reformatted into the coronal plane. This image was obtained in the arterial phase of contrast
enhancement and shows the origins of the celiac and superior mesenteric arteries. The hepatic arteries arise
conventionally from branches of the celiac trunk. (Bottom) A coronal image from the portal venous phase of
enhancement shows the major branches of the portal vein.
 LIVER
MULTIPLANAR CT, NORMAL VESSELS

Right hepatic vein — IVC

— Lett gastric vein

Accessory right hepatic — Portal v e i n

Lett gastric vein

Segments 7 S 8 portal
vein Splenic artery

Splenic vein

Interior mesenteric
vein
Superior mesenteric Superior mesenteric
vein artery

(Top) Coronal plane image shows the entry of the right hepatic vein into the IVC. A small accessory right hepatic
vein is also present. The thick plane of reconstruction artifactually suggests thai the portal vein is entering the IVC.
(Bottom) Coronal image includes the major tributaries of the portal vein, including the superior & inferior
mesenteric veins a n d t h e splenic vein. Kecirculation of contrast medium results in residual enhancement of some
arteries that also lie in this plane of section.
 LIVER
AXIAL T2WI FS MR

ivc -

Right hepatic vein

Bile ducts -

Bile ducts —

(Top) First of nine axial 12 weighted fat-suppressed MR images shows relatively low signal from the liver
parenchyma. Flowing blood appears very dark, while static fluid, such as bile and spinal fluid appears quite bright.
(Middle) The branching pattern of the intrahepatic bile ducts is evident. (Bottom) A more caudal section shows the
bile ducts becoming larger as they approach the porta hepatis.
 LIVER
AXIAL T2WI FS MR

Hepatic artery
Common hepatic duct

Portal vein -

Hepatic artery —

Neck of gallbladder
Cystic duct
I'ortal vein

Hepatic artery
Gallbladder - - Splenic artery

Right hepatic artery

Portal vein

(Top) More caudal section shows the usual relation between the bile duct, portal vein, and hepatic artery near the
porta hepatis. (Middle) The neck of the gallbladder and cystic duct are seen on this section. (Bottom] Section
through the porta hepatis shows the hepatic artery and portal vein entering the liver.
 LIVER
AXIAL T2VVI FS MR

Falciform ligament

Duodenum
- Head ot pancreas
i.allbladder -

— Common bile duct

Right kidney

Gallbladder -

Common bile duct

Duodenum Common bile duct

(lop) The common duct leaves the liver, descends medial to the second portion of the duodenum and enters the
pancreatic head. (Middle) The vertical course of the bile duct within the pancreatic head is seen well on this image.
(Bottom) The bile duct is seen just proximal to its confluence with the pancreatic duct and their entry into the
pancreaticobiliary ampulla in the duodenum.
 LIVER
AXIAL T1WI MR, HEPATIC ARTERIAL PHASE

Hepatic veins -

Right portal vein branches —

Middle hepatic vein —

Left portal vein

Right |xjrtal vein (anterior) - Fissure tor the liganicntum

veiiosuiii
Right hepatic vein

— Falciform ligament fissure

Middle hepatic vein

Right portal vein

Right hepatic vein

(Top) First of six axial Tl-weighted MR images obtained during the arterial (portal venous inflow) phase of
contrast-enhancement shows the hepatic veins as dark, uncnhanced structures, while the aorta, arteries, and portal
venous branches are bright due to contrast-enhancement. (Middle) The portal and hepatic venous branches are well
seen on this section. (Bottom) A more caudal section again shows the opacified portal vein branches and the
unopacified hepatic veins.
 LIVER
AXIAL T1WI MR, HEPATIC ARTERIAL PHASE
>

C
0)
E
o Hepatic artery - — Pancreas
■o
JO Portal vein -
<

Right |X>rtal vein (posterior) -

Middle hepatic vein -

— (:eliac artery
Right hepatic vein
Segment 7 portal branch

Segment 6 portal branch -

— Duodenum

Common bile duct

(Top) The pancreas, arteries, and portal veins are well-opacified on this image. (Middle) Note the intra-segmental
position of the portal vein branches, while the hepatic veins lie between segments (in general). (Bottom) On these
Tl -weighted images, static fluid-containing structures, such as the gallbladder and duodenum, appear dark (low
signal).

II
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 LIVER
N O R M A L AXIAL T 1 W I M R , V E N O U S PHASE

Hepatic veins -

Hepatic cyst

- L,ett portal vein

— fissure for the ligamentum

venosum

falciform ligament cleft -

Middle hepatic vein -

Right portal vein

Right hepatic vein -

(Top) first of three axial T'l-weighted MR images obtained d u r i n g t h e hepatic venous phase o f enhancement, w h e n
all the vascular structures i n t h e liver are of bright signal due t o contrast-enhancement. A small cyst is seen adjacent
t o the right hepatic v e i n . ( M i d d l e ) The portal a n d hepatic v e i n branches are all enhanced. ( B o t t o m ) The fissures a n d
paths o f the major veins are w e l l i d e n t i f i e d , a i d i n g in the d e f i n i t i o n o f hepatic segmental a n a t o m y .
 LIVER
LIVER SEGMENTAL ANATOMY
>

C
o — Lett hepatic vein
E
o
T3 Cyst —
Middle hepatic vein
<

Segment 4A Segment 2

falciform ligament cleft

Left purl,d vein

Middle hepatic vein —

Segment 8 -

Right hepatic vein —

Segment 7

Left hepatic artery — — Small cyst

Portal vein —
Caudate lobe (segment 1)

(Top) First of six axial CT sections. Dividing the right a n d left lobes is a vertical plane connecting the middle hepatit
vein a n d the gallbladder fossa. The plane of the falciform ligament divides the medial (segment 4) from the lateral
(segments 2 & 3) left lobe. The cyst is above the plane of the falciform ligament, probably within segment 4A.
(Middle) A vertical plane passing through the right hepatic vein divides segments 5 & 8 anteriorly from segments b
& 7 posteriorly. Segments 7fcc8 lie above the plane of the right portal vein, while segments 5 & 6 lie below it. The
medial segment is sometimes divided into 4A and 4B, with 4A being the more cephalic. (Bottom) A small cyst is seen
in segment 3. The caudate lobe (segment 1) lies high along the posterior surface of the liver, bordered by the portal
II vein and fissure for the ligamentum venosum anteriorly & the IVC posteriorly.
{JO
 LIVER
LIVER SEGMENTAL A N A T O M Y >
a
a.
o
3
a
3

Right portal vein (anterior branch) 3

Right hepatic vein -

Right portal vein (posterior branch) - i

Segment 4B -

I'lane of gallbladder fossa -

Gallbladder -

Segment S

R i g h t I■■•. p i t i i v e i n

Segment ft

(lop) Ihe posterior branch of the right portal vein supplies segments 6 & 7, while the anterior branch supplies
segments § & 8. A vertical plane through the right hepatic vein separates the anterior (segments 5 CJ 8) from the
posterior segments (6 &r 7) of the right lobe. Segments 7 & 8 lie above the plane of the right portal vein while 5 & 6
lie below it. (Middle) A plane passing vertically through the middle hepatic vein and the gallbladder fossa divides the
left and right lobes of the liver. The medial segment (4) lies just medial to this plane. (Bottom) The inferior segments
of the right lobe are seen on this section, segment 5 anterior to the right hepatic vein, and segment 6 posterior to it.

II
121
 LIVER
FALCIFORM LIGAMENT

Falciform ligament —
Left portal vein

Gallbladder

Falciform ligament

Ligamentuin teres

Falciform ligament —> I-.itei.il segment

Right portal vein —i

(Top) First of three CT sections showing the falciform ligament in various planes. Coronal reformation through the
middle of the liver shows the falciform ligament dividing the medial and lateral segments of the left lobe. The
ascending portion of the left portal vein also lies in the falciform ligament. (Middle) A more anterior coronal section
shows the ligamentum teres, the obliterated remnant of the umbilical vein, which lies in the falciform ligament
before leaving the antero-inferior surface of the liver to extend to the umbilicus. (Bottom) This axial section shows
the ligamentum teres within the falciform ligament.
 LIVER
PARUMBILICAL VARICES >
cr
o.
o
3
Parumbilical varices —

Ix'il portal vein

Enlarged spleen

I'atuiiihilkai varkcs —■

(lop) First of four axial CT sections in a patient with cirrhosis and portal hypertension shows large parumbilical
collateral veins (varices) communicating with the left portal vein. Flow within these vessels is "hepatofugal" (away
from the liver), as blood is being diverted away from the liver into the systemic venous system due to the increased
resistance to flow into the liver (portal hy|>ertension(. (Bottom i Note the shrunken, nodular appearance of the liver
and the widened fissures, all characteristic of cirrhosis.

II
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 LIVER
CD
P A R U M B I I I C A L VARICES
>

C
0)
E
o Parumbilical varices -
T3

<

Parumbilical varices — Umbilicus

(lop) As the parumbilical varices run caudally, they approach the anterior abdominal wall and surround the
umbilicus. These are often visible on physical examination and have been likened to the mythological Medusa,
whose hair was a tangle of snakes ("caput Medusae"). (Bottom) The parumbilical varices are evident immediately
below the umbilicus. In fetal life, there are three common areas in which the systemic and portal venous systems
come into contact and form anastomoses, including the parumbilical region, around the distal esophagus, and
around the rectum. These, in turn, are the most common sites of portal-systemic shunts (varices) that develop in
patients with portal hypertension or other etiologies of increased pressure within the venous system.
II
524
 LIVER
CONGENITAL HYPOPLASIA OF SEGMENTS >
a
o
3
Lateral segment n
Left portal vein 3
Medial segment

i
Right portal vein

Colon -

Surgical clip

Segment 3

Surgical clip t.autlatc lohe (segment 1)

(Top) First of three axial C1 sections shows colon in the right subphrenic region normally occupied by the anterior
and medial segments of the liver. This person is asymptomatic and has not had surgical resection nor a history of
liver disease. Note the relative absence of tissue lateral to the left portal vein which lies in the falciform ligament
(boundary between the medial & lateral segments). Ihe anterior branch ol the right portal vein is absent. (Middle) A
surgical clip is present from a prior cholecystectomy, during which the congenital hypoplasia of hepatic segments
was confirmed. (Bottom) Congenital hypoplasia usually affects the anterior and medial segments, though any
portion of the liver may fail to develop normally. This is one of the common causes of so-called "interposition" of the
colon between the liver and the right hemidiaphragm. II
_U5
 LIVER
HEPATIC ARTERIAL VARIANTS

Inferior phrenic artery

Left gastric artery

Left hepatic artery
Right hepatic artery

Splenic artery
Common hepatic
artery

Gastroduodenal artery
Superior mesenteric
artery

Proper hepatic artery

Gastroduodenal artery
Superior mesenteric
Common hepatic artery
artery

fTop) In over 40% of individuals, there are variations in the origin & course of the hepatic arteries that differ from
the "conventional" depiction. In this graphic the left hepatic artery arises from the common hepatic artery, proximal
to the origin of the gastroduodenal artery. The gallbladder and extrahepatic common bile duct are supplied by the
right hepatic artery, as usual. The hepatic artery courses parallel to the portal vein and lies between the vein and the
bile duct. (Bottom) Graphic shows a completely replaced hepatic artery, arising from the superior mesenteric artery
(SMA). In this setting the hepatic artery passes through or behind the head of the pancreas and the portal vein, and
may be inadvertently ligated during pancreatic surgery if this variant is not recognized;
 LIVER
HEPATIC ARTERIAL VARIANTS

Left hepatic artery

Left gastric artery

Right hepatic artery

Gastroduodenal artery

Common hepatic
artery

Accessory left hepatic

"Conventional right 8t artery
left hepatic arteries

Common hepatic Left gastric artery

artery
*

CTop) Graphic depicts a separate origin of the left hepatic artery from the cellac trunk. In addition, the right hepatic
artery Is "replaced", arising from the SMA. The gastroduodenal & cystic arteries arise from the replaced right hepatic,
as is common with this variation. (Bottom) Graphic depicts an "accessory" left hepatic artery, arising from the left
gastric artery. An accessory artery is a vessel In addition to those originating from the conventional depiction; in this
case, there is a left hepatic artery arising from the proper hepatic artery as well. All of these variations are common
and have major Implications for patients undergoing any sort. f upper abdominal surgery, especially partial hepatic
resection or liver transplantation.

.127
 LIVER
ACCESSORY RIGHT HEPATIC ARTERY

Left hepatic artery

Right hepatic artery

Accessory right hepatic

*f
artery

Gastroduodenai artery «*2^

lift
Right hepatic artery

Splenic artery
Accessory right hepatic
artery

Superior mesenteric
artery

• «J

1 " ^ ► «

\t
(Top) First of two shaded surface display, coronally reformatted CT angiogram images shows only a small right
hepatic artery branch from the common hepatic artery. An accessory right hepatic branch arises from the superior
mesenteric artery, a common variant. Note the anastomoses between the accessory right hepatic and gastroduodenai
arteries. (Bottom) Oblique view of the CTA helps to confirm the origin of the accessory hepatic vessel from the SMA.
 LIVER
COMPLETELY REPLACED HEPATIC ARTERY

Left hepatic artery

( Splenic artery
Right hepatic artery

Common hepatic
' artery
Gastroduodenal artery

S* w
L

Left hepatic artery

In w
Right hepatic artery

»„

Gastroduodenal artery

*i
(Top) First of two shaded surface, coronally reformatted images from a CT angiogram shows complete replacement of
the common hepatic artery from the SMA. Both major hepatic arteries and the gastroduodenal artery arise from the
SMA instead of the celiac artery. (Bottom) Oblique view help* to confirm the origin of the arteries.
 LIVER
REPLACED RIGHT AND LEFT HEPATIC ARTERIES

Right hepatic artery -

Gastroduodenal artery -

Right hepatic artery

Left hepatic artery

Left gastric artery —r

Splenic artery

Gastroduodenal artery

(lop) First of three images in a person with separately replaced right Si left hepatic arteries. Coronal CT angiogram
shows the right hepatic artery arising from the SMA. The origin of the left hepatic artery is not shown clearly on this
image. (Middle) A frontal film from a conventional catheter angiogram shows the replaced right hepatic artery
arising from the SMA. (Bottom) Catheter injection of the celiac axis shows the left hepatic artery arising from the left
gastric artery. In this suhject the gastroduodenal artery arises directly from the celiac artery. Variations of hepatic
arterial anatomy are common and are important to recognize when hepatic transplantation, surgery or other
intervention is being considered.
 LIVER
PORTAL VEIN VARIANTS

Splenic vein

Portal vein

Su|xrior mesenteric Inferior mesenteric

vein vein

Portal vein
Splenic vein

Inferior mesenteric
vein
Superior mesentcrk
vein

(Top) MR angiogram (venous phase following IV injection of contrast medium) shows the most common
arrangement of the major tributaries of the portal vein, in which the inferior mesenteric vein joins the splenic vein
just prior to its confluence with the superior mesenteric vein. (Bottom) In this person the MRA demonstrates
confluence of all three major tributaries at a trifurcated confluence.
 LIVER
LIVER VESSELS, UNFAVORABLE FOR TRANSPLANTATION

Left portal vein — 1

Middle hepatic vein —'

Right hepatic vein

Right portal vein

Middle hepatic vein —

Large segment 8 branch Left hepatic vein

Segment 7 branch -

(Top) First of five CT images of a person who was being evaluated as a potential partial liver donor, in which the
right hepatic lobe would be resected and given to a recipient. This axial section seems normal. (Middle) Axial section
also fails to suggest any vascular anomaly. (Bottom) A thick axial reconstructed image shows a large branch from
segment 8 (of the right lobe) draining into the middle hepatic vein. In the usual incision used for harvesting the
right lobe, the liver is divided just to the right of the middle hepatic vein, which would sever the segment 8 branch
and require a separate anastomosis to the recipient IVC.
 LIVER
LIVER VESSELS, UNFAVORABLE FOR TRANSPLANTATION

— IW

Accessory right hepatic —

— Left portal vein

Anterior branch of
right portal vein
Replaced left hepatic
artery
Right hepatic artery

Posterior branch of
right portal vein

(Top) Coronal reformation shows a large accessory right hepatic vein draining segments 5 & 6 directly into the IVC.
If the right lobe were to be used in transplantation, this would require still another separate anastomosis t o the
recipient IVC. (Bottom) Coronal M1P image in the late arterial, early portal venous phase shows a trifurcation
arrangement of the portal vein, in which the anterior & posterior branches of the right portal and the left portal vein
all join at the same point. This anatomical variant makes it difficult for the surgeon to transect the right portal vein
without jeopardizing the left portal vein which must supply the remaining liver of the donor. Due to the various
vascular anatomic variants demonstrated by CT in this person, h e was judged to not he a candidate for living
donation.
 LIVER
CD COLLATERAL FLOW T H R O U G H LIVER
>

C
0)
E
o
"O Collateral veins
.O
<

Tumor obstructing SVC

C— Pleura! effusion

Primary breast tumor

Mediastinal metastases
- Arch of aorta

Collateral veins —■

(Top) First of six CT images in a woman with breast cancer and mediastinal nodal metastases causing obstruction of
the superior vena cava. Contrast injection through a right arm vein shows opacification of numerous collateral veins
in the chest wall that are bypassing the occluded SVC. (Middle) More caudal section shows continuation of the
collateral veins and tumor occluding the SVC. (Bottom) More caudal section shows the primary tumor site in the
right breast and additional mediastinal metastases. Numerous collateral veins are noted in the chest wall and
paraspinal region.

II
H4
 LIVER
COLLATERAL FLOW T H R O U G H LIVER >
CT
D.
O
3
TO
3

- Uitci.il segment <

CD

Collateiiil vein* -

l\(

Normal liver

Patent iv<

(Top) CT image t h r o u g h the liver i n the late arterial phase o f i m a g i n g shows dense opacification o f t h e left lobe ot
the liver a n d opacification o f t h e IVC that is greater t h a n that o f the aorta. This is due t o collateral b l o o d flow
t h r o u g h peridiaphragmatic collateral veins t h a t c o m m u n i c a t e w i t h hepatic veins a n d r e t u r n b l o o d t o the I V C . O n
radionuclide a n d PUT scanning studies this p h e n o m e n o n may appeal as a "hot spot" a n d be confused for a liver
tumor. ( M i d d l e ) More caudal section again emphasizes the collateral f l o w t h r o u g h the liver t o t h e IVC. ( B o t t o m ) A
delayed phase image t h r o u g h t h e same segments ot the liver shows that t h e liver is n o r m a l and the IVC is patent.

II
ns
 LIVER
C I R R H O S I S , VARICES

- tjxiphageal varices

\scites

- Collateral veins (varices)

Cirrlicitk liver

- Spleen

Gastroesophagcal varices

(Top) First of three axial CT images in a patient with cirrhosis and portal hypertension shows massive periesophageal
varices that carry blood through the mediastinum as collateral veins that are bypassing the cirrhotic liver. (Middle) A
more caudal section shows the nodular cirrhotic liver and signs of portal hypertension including splenomegaly,
ascites and varices. (Bottom) A more caudal section shows more of the varices that are present in the wall of the
stomach as well as the esophagus.
 LIVER
LIVER STEATOSIS >

%
3
3
Area o f focal sparing

§
Liver (with steatosis)

— Spleen

Area o f focal sparing

— Porta In patis

Areas ot sparing

(lop) First of three axial nonenhanccd CT sections in a patient with hepatic steatosis ("fatty liver") shows that the
liver appears darker, or less dense, than the spleen, rather than being slightly more dense (higher in attenuation) as
would l>e normal. Note the rounded area of normal density liver just anterior to the porta hepatis that could l>c
mistaken for a focal liver mass. This area of the liver has been spared from steatosis, generally due to variations in
portal venous supply to this part of the liver. (Middle) A magnified view of the same axial section shows the area of
focal sparing and the diffuse steatosis. Common areas for focal sparing are the those abutting the porta hepatis and
gallbladder fossa. (Bottom) A thin band of hepatic tissue abutting the gallbladder fossa is also spared and is of greater
attenuation than the rest of the liver. II
*37
 LIVER
MULTIFOCAL STEATOSIS
>

C
G)
E
o
■D

<

Regions of steatosis —

Hepatic vein branches —

(Top) First of two axial CT sections in a patient with multifocal steatosis (fatty infiltration) of the liver. Nonenhanced
image shows geographic areas within the right lobe that are lower in density than the spleen. The normal liver is
slightly more dense (higher in attenuation) than the spleen on a nonenhanced CT section. (Bottom) CT section
obtained during the IV injection of contrast material shows a normal distribution of hepatic vessels within the areas
of steatosis. The absence of a "mass effect", such as displacement of vessels, helps to distinguish steatosis from a
tumor as the etiology of the abnormal low density areas.
II
ua
 LIVER
POLYCYSTIC LIVER

Kcri.il i vsts

(lop) First of three axial CT sections of a patient with autosomal d o m i n a n t polycystic liver disease shows
innumerable water-density masses within the liver. The cysts enlarge and distort the liver and compress the stomach,
bul rarely cause significant liver dysfunction. (Middle) A more caudal section shows relatively few and much smaller
renal cysts. Patients with polycystic disease may have severe, mild, or n o involvement of either the kidneys and liver.
(Bottom) Note that the cysts are all of homogeneous low density with n o visible wall or mural Modularity, features
that help to distinguish these from hepatic tumors or abscesses. Clinical information, such as the presence or absence
of fever or a known extrahepatic tumor, are also important diagnostic criteria.
 LIVER
LIVER METASTASES

Dilated bile ducts

Dilated bile duets —

Liver metastases ■

Dilated bile ducts —

Feeding artery -

(Top) First of three images of a patient with colon carcinoma. Axial C71 section shows numerous spherical,
heterogeneous masses within all segments of the liver, representing metastatic foci. Some of these have a target
appearance, consistent with central necrosis. Dilated bile ducts are seen within both lobes due to mass effect of
tumor compressing the bile duct lumen. (Middle) Confluent metastases near the porta hepatis cause bile duct
obstruction, with dilation of the intrahcpatic ducts. (Bottom) An axial color Doppler sonographic image also shows
the target appearance of the liver metastases. The color Doppler signal is calibrated to show arterial flow as red and
venous flow as blue. Both arterial and venous flow are evident within and around the metastases.
 LIVER
HEPATOCELLULAR CARCINOMA >
a
o
i
3
<
CD

Portal vein —

Tumor within portal

vein

Tumor

Hypcrvascular portion
of tumor

Enlarged feeding artery —

(Top) First of two contrast-enhance axial CI sections of a patient with chronic viral hepatitis shows a heterogeneous
tumor filling much of the right lobe of the liver. Tumor invasion of the right portal vein is evident as a filling defect
within the contrast-opacified vessel. This is a typical feature of hepatocellular carcinoma and an important staging
criterion, precluding liver transplantation or surgical resection as treatment options. (Bottom) A more caudal section
shows portions of the tumor that are hypcrvascular, enhancing to a greater degree t h a n the normal liver. Note the
enlarged hepatic arterial branches that have been recruited to feed the tumor.

II
141
 BILIARY SYSTEM
j Imaging Anatomy
Overview
• Biliary ducts convey bile from liver to duodenum
c Bile is produced continuously by liver, stored &
concentrated by gallbladder (OB), released
intermittently by GB contraction in response to
presence of fat in duodenum
i Hepatocytes form bile — bile canaliculi —
interlobular biliary ducts -» collecting bile ducts -*
right & left hepatic ducts — c o m m o n hepatic
duct — c o m m o n bile duct
• Bile duct forms in free edge of lesser omentum by
union of cystic duct and common hepatic duct
< Length of duct: 5-15 cm depending on point ot
junction of cystic & common hepatic ducts
< Duct descends posterior &. medial to duodenum,
lying in a groove on dorsal surface of pancreatic
head
Bile duct joins with pancreatic duct to torm
hepaticopani re.itii ampulla (of Vatcr) (dilated
short segment)
( Ampulla opens into duodenum through major
duodenal (licpaticopancTcatic) papilla
■ Surrounded by smooth muscle
< Distal bile duct is thickened into a sphincter (ot
Boyden) and hepaticopancreatic segment is
thickened into a sphincter (of Oddi)
■ Contraction of these sphincters prevents bile from
entering duodenum; forces it to collect in CJB
■ Relaxation of sphincters in response to
parasynipathctic stimulation t» cholecystokinin
(released by duodenum in response to (atty meal)
• Vessels, nerves and lymphatics
o Arteries
■ Hepatic arteries to intrahepatic ducts
■ Cystic artery to proximal common duct
■ Right hepatic artery to middle part ol common
duct
■ Gastroduodenal and pancrcaticaduoilcual
arcade to distal common duct
■ Cystic artery to GB (usually from right hepatic
artery; variable)
< Veins
■ From intrahepatic ducts — hepatic veins
■ from common duct — portal vein (in tributaries)
■ From GB directly into liver sinusoids, bypassing
portal vein
( Nerves
■ Sensory: Right phrenic nerve
■ Parasvmpathetic & sympathetic from Celiac
ganglion and plexus; contraction of GB &
relaxation at biliary sphincters is caused by
parasympathetic stimulation, but more important
stimulus is from hormone cholecystokinin
c Lymphatics
■ Same course and name as arterial branches
■ Collect at celiac lymph nodes and node ot
omental foramen
■ Nodes draining GB are prominent in the porta
hepatis and around pancreatic head
• Gallbladder
•-* - 7-10 cm long, holds up to SO ml of bile
Lies in a shallow fossa on the visceral surface of liver
Vertical plane through GB fossa & middle hepatic
vein divides left & right hepatic lobes
louches & indents duodenum
I undus is covered with peritoneum & relatively
mobile: body is; neck are attached to liver & covered
by hepatic capsule
Hindus: Wide tip ol GB. projects below liver edge
(usually)
Body: Contacts liver, duodenum & transverse colon
- Neck: Narrowed, tapered and tortuous; joins cystic
duct
Cystic duct: 3-4 cm long, connects GB to common
hepatic duct; marked bv spiral folds (of Heister);
helps to regulate bile flow to cr from GB
Anatomy-Based Imaging Issues
Key Concepts
• Direct venous drainage ot GB into liver bypasses portal
venous system, often results in sparing of adjacent
liver from generalized stcatosis (fattv liver)
• Nodal metastasis from GB carcinoma to
peripancreatic nodes may simulate a primarj
pancreatic tumor
• Sonography: Optimal means of evaluating GB for
stones f* inflammation (acute cholecystitis); best
done in tasting state (distends GB)
• Intrahepatic bile ducts follow branching pattern of
|X>rtal veins
Usually lie immediately anterior to portal vein
branch; confluence of hepatic ducts just anterior to
confluence of right & main portal veins
Clinical Implications
Clinical Importance
• Common variations of biliarv arterial & ductal
anatomy result in challenges to avoid injury at
surgery
< Cystic duct may run in common sheath with bile
duct
o Anomalous right hepatic ducts may be severed at
cholecystcctomv
• Close apposition of GB to duodenum can result in
fistulous connection with chronic cholecystitis and
erosion of gallstone into duodenum
• Obstruction of common bile duct is common
Callstones in distal bile duct
c Carcinoma arising in pancreatic head or bile duct
Result is jaundice due to back up of bile salts into
bloodstream
Embryologic Events
• Abnormal embryologkal development of fetal ductal
plate can lead to spectrum of liver & biliary
abnormalities including
( Polycystic liver disease
' Congenital hepatic fibrosis
Biliary hamartomas
( Caroli disease
> Choledochal cysts
 BILIARY SYSTEM

Peritoneal reflection Proper hepatic artery

Gallbladder (body)

I bladder (fundus)
Lesser omentum (cut
edge, anterior)

>l, ' " Duodenum

Colon (hepatic flexure)

- J- Pancreas

I «

Cystic duct
Common hepatic duct

*
Fundus
Common bile duct
Pancreatic duct

- "* l r

(Top) The gallbladder Is covered with peritoneum, except where It is attached to the liver. The extrahepatlc bile duct
hepatic arteryfitportal vein run in the lesser omentum. The fundus of the gallbladder extends beyond the
anterior-Inferior edge of the liver and is In contact with the he^wtlcflexureof the colon. The body (main portion of
the gallbladder) is in contact with the duodenum. (Bottom) 1 tie neck of the gallbladder narrows before entering the
cystic duct, which is distinguished by Its tortuous course and in\ gular lumen. The duct lumen is irregular due to
redundant folds of mucosa, called the spiral folds (of Heister), that are believed to regulate the rate of filling and
emptying of the gallbladder. The cystic duct joins the hepatic Juct to form the common bile duct, which passes
behind the duodenumfitthrough the pancreas to enter the duodenum.
 BILIARY SYSTEM
E VARIANT EXTRAHEPATIC DUCTS
<L>
1/1
>^
CO

rC
Left hepatic duct
Accessory nght hepatic
Right hepatic duct (joining common
c hepatic duct)
s
o
Cystic duct
Accessory left hepatic
< (joining common bile
duct)

Accessory right hepatic

(joining cystic duct)
J&%t

Accessory right hepatic

(joining common bile
duct)

Conventional junction
of cystic & common
hepatic ducts
Low insertion of cystic
duct

Spiral course of cystic

duct around common
hepatic duct

Cystic & common bile

ducts in common
sheath

(Top) Graphic shows the conventional arrangement of the extrahepatic bile ducts, but variations are common (20%
of population) and may lead to inadvertent ligation or injury at surgery such as choiecystectomy, where the cystic
duct is clamped and transected. Most accessory ducts axe on the right side and usually enter the common hepatic
duct, but may enter the cystic or common bile duct. Accessory left ducts enter the common bile duct. While referred
to as "accessory", these ducts are the sole drainage of bile from at least one hepatic segment. Ligation or laceration
can lead to significant hepatic injury or bile peritonitis. (Bottom) The course and insertion of the cystic duct are
highly variable, leading to difficulty in isolation and ligation at choiecystectomy. The cystic duct may be mistaken
II for the common hepatic or common bile duct.
.144
 BILIARY SYSTEM
■i
BILIARY TREE

■1

m#,
W
Right anterior-cephalic Ducts to segment 4
(segments 5 & 8)
Right posterior-caudal
(segments 6 & 7) Ducts to segments 2-3

Right hepatic duct

r Left hepatic duct

I
Minor papula

Hepatoduodenal
papilla (major papilla) %

II
Peritoneal reflection

Inflamed Aberrant bile duct (of

Rokltansky-Aschoff Luschka)
sinus

Gallbladder neck
glands

■I
Gallbladder wall
muscle
- Gallbladder lumen

(Top) Note the distribution of the larger intrahepatic bile ducts. The common bile duct usually joins with the
pancreatic duct in a common channel or ampulla (of Vater), but may enter the major duodenal papilla separately.
The distal bile duct has a sphincteric coat of smooth muscle, the choledochal sphincter (of Boyden), which regulates
bile emptying into the duodenum. When contracted, this sphincter causes bile to flow retrograde Into the
gallbladder for storage. The common hepaticopancreatic ampulla may be surrounded by a smooth muscle sphincter
(of Oddi). (Bottom) The gallbladder body & neck are adherent to the liver and may be bridged by aberrant bile ducts
(of Luschka). Mucus glands are found In the gallbladder neck. Rokitansky-Aschoff sinuses are pseudodlverticula that
extend into the wall and may collect debris, becoming inflanwd.
 BILIARY SYSTEM
E CHOLANGIOGRAM

w
(A

Intrahepatic ducts

0)
E
o
Common hepatic duct
<

Cystic duct

Gallbladder Common bile duct

— F.ndoscope

Gallbladder

Hepaticopancreatic
ampulla

(Top) First of two images from an endoscopic retrograde cholangio-pancreatogram (ERCP) shows normal intra- and
extrahepatic bile ducts. Note the irregular contour of the cystic duct caused by the spiral folds of Heister. The
gallbladder is opacified by retrograde passage of contrast material, with the tip of the endoscopic cannula inserted
into the hcpaticopancreatic ampulla (of Vater). (Bottom) Portions of the intra- and extrahepatic ducts appear to have
an irregular contour, but this is due to incomplete filling. F.RCP studies are monitored in real time by X-ray
fiuoroscopy and multiple films are obtained in different obliquities to distinguish artifacts, such as incomplete filling
and air bubbles, from ductal pathology.
II
1-46
 BILIARY SYSTEM
M R CHOLANCIO-PANCREATOGRAM >
C7
Q.
O
3
3
■ ■

Stomach
C/>
CD
Cystic duct —
3

Gallbladder — Pancreatic duct

— ( ommoii bile duct

DiiiKtenum —

Right hepatic duct I eft hepatic duct

(anterior)

Right hepatic duct

(posterior)
Cystic duct

Pancreatic duct

Gallbladder -

Duodenum —

(lop) lirst of two coronal MR cholangio-pancreatogram (MRCP) images, obtained with heavily T2-weighted images
that show all static collections of fluid, such as ductal structures and bowel, as very bright. The ducts are all of
normal caliber. Note the parallel course of the bile duct and pancreatic duct within the pancreatic head. These ducts
usually join just prior to emptying into the duodenum at the papilla of Vater (Bottom) This Obliquity shows the
main branches of the intrahepatic bile ducts. MRCP and ultrasonography have become the preferred noninvasive
methods of determining the presence and cause of biliary ductal obstruction. Direct cholangiography, such as ERCP,
is usually reserved for cases of known obstruction when endoscopic intervention, such as placement of a biliary
stent, is being considered. II
147
 BILIARY SYSTEM
E A N G I O G R A M , CYSTIC ARTERY
CD

&
C/D

.TO

CD - Proper hepatic artery

■ ■
C
0)
E
o Cystic artery
■a
.a Gastroduodenal artery
<

— Cystic artery

Gallbladder -

Hepatic carcinoma - - Gallstones

(lop) Hrst of three images from a patient with hepatocellular carcinoma. This frontal image from a catheter
angiogram shows the cystic artery stretched along the surface of a distended gallbladder. The cystic artery usually
arises from the right hepatic artery, though this is quite variable. (Middle) Selective injection of the proper hepatic
artery again shows the course of the cystic artery. (Bottom) Axial CT section shows a distended gallbladder with
gallstones. The hepatic carcinoma is seen within the right hepatic lobe. The angiogram was obtained in anticipation
of treating the tumor with hepatic arterial infusion of chemotherapy.

II
548
 BILIARY SYSTEM
BILE DUCT TRJFURCATION >
Q.
O
3
CD
«»

QJ'
<3

CO
CD
3
Surgical pads

Right anterior-
superior ducts

Left hepatic duct

Right posterior-
inferior ducts — Common hepatic duct

— Canula in cystic duct

— Common bile duct

Surgical retractor —

Intra-operative cholangiogram was performed in a subject about to undergo right hepatic lobectomy as a living
donor to a relative with liver failure. The cholangiogram shows a bifurcation pattern of the main ducts draining the
right and left lobes. This is an unfavorable anatomic variant in this setting because the surgical plane of section will
cut across both the anterior and posterior segmental bile ducts, requiring two separate anastomoses to the recipient's
biliary (or enteric) system.

II
 BILIARY SYSTEM
E GALLSTONE ILEUS
CD

ft
t>
m
■ ■
c Gallbladder -
0) - Duodenum (thick-walled)
E (jallstones -
o — Inilammatory infiltration
T3
-Q
<

Gallbladder

Duodenum — ■»

Jejunum (dilated)
lleum (collapsed, normal) -

Gallstone

(Top) First of" three axial CT sections of an elderly woman. The first image shows large gallstones within a distended
gallbladder that is adjacent to a thick-walled duodenum, indicating contiguous inflammation. At this time the
patient had symptoms of cholecystitis. (Middle) CT scan was repeated three weeks later when the patient
complained of crampy abdominal pain and nausea suggesting bowel obstruction. A section through the gallbladder
no longer shows stones, but only gas and fluid. The gallstones had eroded through the wall of the gallbladder directly
into the adjacent duodenum. (Bottom) A more caudal section shows small bowel obstruction, with dilated proximal
segments and collapsed ileum. At the point of transition there is a spherical "mass' with concentric layers of
II calcification, representing a large gallstone that is obstructing the lumen.
150
 BILIARY SYSTEM
CT & MR, GALLSTONES >
a.
o
3
a
3
Gallbladder - ••

i-t-
CD
3

Stomach

Questionable gallstone Pancreas

Gallstones -

(Top) First of three images of a patient with gallstones in the gallbladder. Axial CT shows a normal appearing
gallbladder, with water density bile. (Middle) A more caudal CV section shows a subtle focus of heterogeneous
density that is suggestive, but not diagnostic of a gallstone. Gallstones can vary in density (attenuation) on CT
depending on their chemical composition, from less than water density (pure cholesterol stones), to soft tissue
density, to calcific density (calcium biliruhinatc stones). CT depicts only about 70-80% of gallstones. (Bottom) Axial
T2WI MR clearly depicts two calculi in the dependent position of the gallbladder. Gallstones have no mobile
protons, and appear as foci of very dark signal, regardless of their chemical composition, and are especially evident
on MR sequences that depict fluid as "white" signal. II
151
 BILIARY SYSTEM
E ACUTE CHOLECYSTITIS
2
CO

QQ

o
E
o
"O
<

Gallbladder lumen

Zone of acoustic
enhancement

Gallbladder wall —
(thickened) Gallbladder lumen

Gallstone —

Zone of acoustic —
shadow

(Top) First of two images of a patient with acute right upper quadrant pain. Sagittal sonographic image shows the
sonolucent gallbladder lumen and accentuated through transmission behind the gallbladder, a phenomenon that is
due to the sound waves traveling faster through a liquid medium (bile) than the solid tissue of the liver. (Bottom)
Another sagittal sonogram shows a thickened wall of the gallbladder. A crescentic echogenic gallstone is seen in the
dependent gallbladder. All of the ultrasound beam is absorbed or reflected by the stone, resulting in an "acoustic
shadow" beyond the stone. Focal tenderness can be elicited by pressing the ultrasound transducer over the
gallbladder, inducing the "sonographic Murphy sign". This combination of findings is diagnostic of acute
II cholecystitis, and sonography is the diagnostic procedure of choice in this setting.
$52
 BILIARY SYSTEM
ACUTE CHOLECYSTITIS

Pericholecystic —
inflammation

Gallbladder wall -
(thickened)
Gallstone

—
l'ericholecystic
inflammation

— Duodenum

Pancreas

(Top) First of two images of a patient who had right upper quadrant pain that resolved, although the patient still
appeared ill. CT shows a cholesterol gallstone, essentially isodense (same attenuation) as bile except for a calcified
rim. The gallbladder wall is thickened and there is extensive inflammation of the pericholecystic fat planes. (Bottom)
The pericholecystic inflammation suggests perforation of the gallbladder, which was confirmed at surgery. With
severe cholecystitis, the gallbladder wall may become nccrotic, effectively causing denervation and perforation of the
wall. The nerve damage explains the loss of right upper quadrant pain or tenderness, late in the disease course.
 BILIARY SYSTEM

■
CHOLECYSTITIS & DUCTAL STONES

■AC

Cholelithiasis

Choledocholithiasis

% >

Cystic duct Endoscope

u
Common bile duct

X
Stones (calculi)

(Top) A graphic and three clinical images demonstrate cholelithiasis (stones in the gallbladder) and
choledocholithiasis (stones in the bile ducts). Gallstones are extremely common and may remain asymptomatic.
Stones that become impacted, even temporarily, in the gallbladder neck may cause inflammation and distention of
the gallbladder, clinically referred to as acute cholecystitis. Stones that pass through the cystic duct often cause
biliary colic (spasms of right upper quadrant pain) as they often become trapped within the common bile duct,
causing obstruction. (Bottom) ERCP shows at least two calculi as filling defects within the contrast opadfied distal
common bile duct.
 BILIARY SYSTEM
CHOLECYSTITIS & DUCTAL STONES >
a
o
3
CD
=3
■ •

— 1 ateral segment (#3)

65'

Thickened wall — C/)

Gallbladder — CD
3
— Caudate lobe
Cystic duct

Gallstones

Pancreatic duct

Distal common bile

duct stones

(Top) Axial CT shows opaque (calcium bilirubinate) gallstones in the dependent position of the gallbladder. The
gallbladder wall is thickened due to acute cholecystitis. (Bottom) A more caudal CT section shows small opaque
stones within the distal common bile duct as it joins the pancreatic duct at the hepaticopancreatic ampulla (of
Vater). Obstruction at this level may cause reflux of bile and pancreatic juice into the pancreatic parenchyma,
causing acute pancreatitis.

II
J55
 BILIARY SYSTEM
E IATROGENIC BILE D U C T & ARTERIAL O C C L U S I O N
2

m
■ •
— Dilated bile duets
c
03
E Dilated bile ducts — ■
o
s
<

Surgical clips

- Portal vein
—
Damaged liver parenchyma

Bile duct - - Surgical clips

Hepatic artery

|— Portal vein

( l o p ) I irst of five images of a patient w h o developed acute hepatic failure following laparoscopic cholecystectomy.
An axial CT section shows dilated intrahepatic bile ducts, adjacent t o normally e n h a n c i n g portal veins. (Middle) A
more caudal section shows surgical clips anterior t o the portal vein, at the expected location of t h e c o m m o n hepatic
bile duct and hepatic artery. (Bottom) More caudal CT section shows heterogeneous e n h a n c e m e n t of the liver
parenchyma, and a dilated bile duct that seems to end abruptly at a surgical clip.

II
J56
 BILIARY SYSTEM
IATROGENIC BILE DUCT & ARTERIAL OCCLUSION >
Q.
O
3
o
3
••
QJ'
<3
in
Dilated bile ducts
r-t-
CO
3
— — Surgical clips

Percutaneous
cholaiigiographic
needle

txtravasated bile
tsubhepatic)

Left hepatic artery

Surgical clips
Common hepatic
Right hepatic artery artery
(occluded)

Gastrodnodena] artery

Angiographic catheter

(lop) A iranshepatic cholangiogram shows massive dilation of the intrahepatic bile ducts and complete obstruction
near the porta hepatis. A collection of extraluminal bile indicates disruption of the bile duct. (Bottom) Hepatic
angiography shows complete occlusion of the right hepatic artery adjacent to several surgical clips. At re-exploration,
the hepatic artery and bile duct were found to be occluded by surgical clips which required complex reconstructive
surgery. Iatrogenic injury to bile ducts and vessels is not rare and is more common with laparoscopic surgical
procedures, which may limit visualization of the surgical "field". Due to the complex and highly variable anatomy of
the hepatic vessels and biliary system, injuries to these structures have been especially common.
II
IS7
 BILIARY SYSTEM
E ERCP, COMMON BILE DUCT STONES

V)
>^
CO
c^
TO

m
■ •
Stones in gallbladder Endoscope
c
o
E
o
■a
n C o m m o n bile duct
<

Calculi

Gallbladder

— Pancreas

Stones in gallbladder

C o m m o n hepatic duct
(dilated)

(Top) First of five images of a patient with right upper quadrant pain and abnormal liver function. An ERCP shows
multiple filling defects within the common bile duct and cystic duct, representing ductal calculi. The gallbladder has
not yet been opacificd by retrograde flow of contrast material through the cystic duct. However, gallstones are
evident within the gallbladder due to their faint rim of surface calcification. (Bottom) Axial CT section shows
rim-calcified gallstones within the gallbladder and a dilated common hepatic duct.

II
1S8
 BILIARY SYSTEM
ERCP, COMMON BILE DUCT STONES >
O.
o
3
CD

Pancreatic head

Duodenum Common Nlc duct

CD
3

- Ouctal calculus

Ductal calculus

(Top) A more caudal section shows the dilated common bile duct within the pancreatic head. (Middle) A more
caudal section shows a rim-calcified stone within the distal common bile duct, accounting for the dilation of the
more proximal duel and the elevated "liver enzymes". (Bottom) Axial section through the hepaticopancreatic
ampulla (of Vater) shows an "impacted" stone.

II
J5«l
 BILIARY SYSTEM
E DUCTAL CALCULI

C/D
Intrahcpatic bile ducts (dilated)

■ ■
c
o r— Common bile duct
E
o
■D
XI
< - Pancreatic duct
Ductal calculus -

- Pancreatic duct
Ductal calculus —

Surgical clips

Common bile duct

Ductal calculus —

(Top) lirst of three images of a patient with recurrent right upper quadrant pain one year after cholecystcctomy.
Coronal MRCP image shows dilated intra- and extrahepatic bile ducts. A discreet focus of low (dark) signal is seen
within the distal common bile duct, representing an impacted stone. The pancreatic duct is normal. (Middle)
Another image helps confirm the ductal stone. MRCP is the preferred noninvasive test for diagnosing biliary
obstruction and its specific cause. F.RCP is reserved for patients who would l>enefit from endoscopic intervention,
such as extraction of a ductal stone, or placement of a biliary stent to overcome obstruction. (Bottom) ERCP
demonstrates the ductal stone, having dislodged it from its more distal location near the ampulla. An endoscopic
II papillotomy was performed and the stone was extracted by basket retrieval.
5 Ml
 BILIARY SYSTEM
AMPULLARY CARCINOMA >
a
o
3
o
Dilated bile ducts

Dilated common hepatic duct Dilated pancreatic duct

Common bile duct I'ancreatic duct

Gallbladder

(lop) First of eight images of a patient with painless jaundice. An axial CT section shows dilation of the intrahepatic
bile ducts. (Middle) A more caudal section shows dilation of the extrahepatic bile duct and the pancreatic duct.
(Bottom) A more caudal section shows dilation of the gallbladder as well as the biliary and pancreatic ducts.

II
161
 BILIARY SYSTEM
E AMPULLARY CARCINOMA

t
CD

Duodenum "
co
■ ■
c
o Distal common bile duct
E Distal pancreatic duct
o
■o

<

Pancreatic duct
Common bile duct -

Duodenum -

Mass at duodenal papilla ■■

(Top) Axial section through the pancreatic head shows no pancreatic mass, but the bile and pancreatic ducts remain
markedly dilated, indicating that the level of obstruction is "downstream'' from this point. (Middle) At a level just
proximal to the junction of the common bile and pancreatic ducts, both ducts are dilated. The pancreas is normal in
appearance. (Bottom) At the level of the hepaticopancreatic (major) papilla, there is a soft tissue density mass that
distorts the medial wall of the duodenum, representing an "ampullary" carcinoma, l'eriampullary tumors of the distal
bile duct or pancreatic duct are adcnocarcinomas that have a better clinical prognosis than the more common forms
of pancreatic or bile duct carcinomas.
II
W>2
 BILIARY SYSTEM
AMPULLARY CARCINOMA >
Q.
O
3
CD

Comnion bile duct -

(dilated)
I
Pancreatic duct
(dilated)

l-'ndoscopc

Region of tumor

Duodenal mucosa -

Pcriampulldry tumor —
Lndoscopic probe

(lop) An endoscopic probe has been placed through the periampullary mass with contrast opacification of the
dilated comnion bile and pancreatic ducts. (Bottom) An endoscopic view of the interior of the duodenum shows the
periampullary mass projecting into the lumen. The endoscopic probe or canula has been inserted through the tumor
to opacify the bile duct and pancreatic duct. The mass was resected and proved to be an ampullary carcinoma.

II
 BILIARY SYSTEM
E PANCREATIC HEAD CARCINOMA

t
m
•• liilatecl bile ducts
c
o
E
o
-o
<

Dilated ducts — Porta hepatis lymph node

(enlarged)
Common hepatic duct (dilated)

Gallbladder

Gallbladder

Pancreatic mass (ductal carcinoma)

(Top) First of six images from a patient with painless jaundice. An axial CT section shows a dilated intrahepatic
biliary tree. (Middle) A more caudal CT section shows dilation of the intrahepatic and common hepatic bile ducts.
An enlarged porta hepatis node represents lymphatic metastasis. (Bottom) A more caudal section shows a dilated
gallbladder and a large heterogeneous mass arising from the head of the pancreas. The pancreatic duct is only mildly
dilated, suggesting that the tumor arose from one of the pancreatic ductal side branches, with exophytic growth
causing obstruction of the bile duct preferentially.

II
\M
 BILIARY SYSTEM
PANCREATIC H E A D C A R C I N O M A >
o-
Q.
O
3
I'.mcrc-atic carcinoma
o
■ *

=
Pancreas (normal)

( (ininion bile duct (dilated)

$
3

SM\

I'ancrcatk carcinoma

Dilated bile ducts

- Extrinsic compression oi
c o m m o n Inle d u l l

( l o p ) A more caudal section shows the large, heterogeneous mass arising f r o m the pancreatic head. ( M i d d l e ) Note
t h e irregular c o n t o u r o f the superior mesentcric vein (SMV). M the t i m e o f i n i t i a l s y m p t o m s a n d diagnosis, most
patients w i t h pancreatic carcinoma have unresectable t u m o r s clue to invasion of critical b l o o d vessels, or mc-tastases.
Note this patient's "scaphoid" a b d o m e n , indicative o f recent weight loss. ( B o t t o m ) LRcT f i l m demonstrates the
narrowed l u m e n o f the c o m m o n bile duct as it passes t h r o u g h the head o f the pancreas. Pancreatic carcinoma is a
scirrhous (hard, tibrotic) t u m o r that encases and obstructs b l o o d vessels a n d bile ducts as it surrounds t h e m .

II
J6.J
 BILIARY SYSTEM
BILIARY H A M A R T O M A S

Common hepatic duct

Gallbladder

- Pancreatic duel

Biliary hamartomas —i

Biliary hamartornas —

(Fop) Hist of three coronal MRCP images of the liver and biliary tree demonstrates a normal appearance of the
gallbladder, biliary tree, and pancreatic duct. (Middle) Coronal section shows normal ducts, but there are numerous
small "cystic" structures within the liver that are not in continuity with the bile ducts. (Bottom) Coronal section
shows even more of the dozens of small (< 2 cm) cysts scattered throughout the liver. The large number and small
size of the cystic lesions indicate that these represent biliary hamartomas, which are developmental anomalies due to
failure of involution of embryonic bile ducts that fail to connect with the normal biliary tree. This is an
asymptomatic condition but may be mistaken for more serious conditions such as poiycystic disease or liver
metastases.
 BILIARY SYSTEM
CAROLI DISEASE >
D-
O
3
s
■ •

=
"Cystic" dilations of bile ducts -

Stones within bile ducts

Dilated bile ducts -

Calculi

(Top) First of three MR images from a patient with Caroli disease (communicating cavernous biliary cctasia), a
congenital anomaly that results in multifocal, saccular dilation of the intrahcpatic bile ducts. Axial T2WI shows
multiple high intensity spherical lesions within the liver, representing dilated bile ducts. (Middle) A more caudal
section shows large calculi as low intensity lesions within t h e massively dilated bile ducts. The bile ducts d o not
"arborize", or branch, in a uniform pattern; they are irregularly dilated in a cystic or fusiform pattern. (Bottom) A
coronal section shows the extent of the ductal abnormalities and the large calculi within the dilated ducts.

II
 BILIARY SYSTEM
CHOLEDOCHAL CYST

Cystic dilation of
intiahcpatic ducts

Common bile duct

Pancreatic duct

Gallbladder

Duodenum

(Top) Graphic Illustrates the Todani classification of choledochal cysts. Type I is the most common and represents
fusiform dilation of the extrahepatic bile duct. Type n is a diverticulum of the extrahepatic bile duct (rare). Type III is
also rare, and is a choledochocele, a diverticular expansion of the distal bile duct within the duodenal wall. Type IV is
the second most common type and is cystic dilation of the intrahepatic and extrahepatic bile ducts. Type V is cystic
dilation of the intrahepatic bile ducts and is synonymous with Caroli disease. (Bottom) MRCP of a 2 year old girl
with type IV choledochal cyst. There is cystic and fusiform dilation of both the intrahepatic and common bile ducts.
 BILIARY SYSTEM
CHOLEDOCHAL CYST >
Q.
O
3
CD
■ ■

=
65"

C/)
•<
&
<D
3

— C o m m o n bile duct

— Endoscope

C o m m o n bile duct —

Gallbladder —

(lop) First of two images of a 44 year old woman with recurrent bouts of cholangitis. A coronal MR( .1' image shows
fusiform dilation of the entire cxtrahcpatic bile duct, a type I choledochal cyst. The intrahepatic bile ducts are
normal. (Bottom) An ERCP in the same patient as previous image shows fusiform dilation of the entire extrahepatic
bile duct.

II
169
 PANCREAS
, Gross Anatomy
Overview
• Pancreas: \cccssory digestive gland King in the
retroperitoneum behind stomach
■ Exocrinc function: Pancreatic a c i n a r cells secrete
pancreatic juice — pancreatic d u c t — d u o d e n u m
1 ndocrine: Pancreatic islet cells 10I I a u g e r h a n s )
secrete insulin, glucagon & other polypcptides ■*
portal venous system
Divisions
• Head: Thickest part; lies to the right of superior
mesenterii vessels (SM \, SMV)
Attached to "C" l<x>p of d u o d e n u m (2nd fit 3rd parts)
L'ncinate process: Head extension, posterior to SMV
Bile duct lies along posterior surface ot head, joins
with pancreatic d u c t (of Wirsung) to form
hcpatnpancTcatic a m p u l l a (of Vater)
Main pancreatic ix bile ducts empty into major
papilla in 2 n d portion of d u o d e n u m
• Neck: Thinnest part; lies anterior to SM A, SMV
SMV joins splenic vein behind pancreatic neck to
form portal vein
• Body: Main part; lies to left of SMA, SMV
Splenic \ e i n lies in groove o n |iosterior surface of
Ixxlv
\nterior surface is covered with peritoneum forming
the back surface of the o m e n t a l bursa (lesser sac)
• fail: Lies iK'tween lavcrsnf the s p l e n o r e n a l ligament
in the splenic hilum
Internal Structures
• Pancreatit d u c t (of Wirsung) runs the length of the
pancreas, turning interiorly through the head to join
the bile duct
• Accessory pancreatic d u c t (of Santorini) opens into
the duodenum at m i n o r d u o d e n a l papilla
Usually communicates with main pancreatic duct
Variations are c o m m o n , including a dominant
accessor] duct draining most pancreatic juice
• Vessels, ncr\ es a n d l y m p h a t i c s
- Arteries to head mainly from g a s t r o d u o d e n a l artery
■ Pancrcaticodtiodenal a r c a d e ot vessels around
head also supplied by SMA branches
\rteries to body f* tail Irom splenic artery
i Veins are tributaries of the SMV and splenic vein -*
portal vein
a Autonomic nerves Irom celiac and superior
mesenteric plexus
■ I'arasympathctic stimulation of pancreatic
secretion, but pancreatic juice secretion is mostly
under hormonal control (secretin, from
duodenum)
I ymphatics follow the blood vessels
■ Collect in splenic, celiac, su|K*rior mesenteric
and h e p a t i c n o d e s
Anatomy-Based Imaging Issues
Key Concepts
• Shape, si/e & texture of pancreas are quite variable
Largest in young adults
Atrophy and fatly infiltration with age (> 70),
obesity, diabetes
Pancreatic duct also becomes more prominent with
age (< A m m diameter)
o focal bulge or mass effect is abnormal
• I ocatioil behind lesser sac
\cute pancreatitis often results in lesser sac fluid
(not = pseudoevst)
• Pancreas lies in anterior pararenal space (APS)
Inflammation (from pancreatitis) easily spreads to
d u o d e n u m & descending colon (also lie in APS)
Inflammation easily spreads into mesentery &
mesocolon (roots ol these lie just ventral to
pancreas)
• Obstruction of p a n c r e a t i c d u c t
Relatively c o m m o n result ol c h r o n i c pancreatitis
(fibrosis £*/or stone occluding pancreatic duct), or
pancreatic d u c t a l c a r c i n o m a
• Acute pane, reatitis
Relatively c o m m o n result of gallstone (lodged in
hepatopancrcatic ampulla causing bile to reflux into
pancreas)
May also result from direct damage from alcohol
and other toxins
• Obstruction of splenic vein
C o m m o n result ol pancreatic ductal carcinoma (>
chronic pancreatitis)
Causes dilated venous collaterals including short
gastric and lelt gastric veins (gastric varices)
■ Gastric varices without |K>rtal hypertension =
Splenfc vein occlusion
Clinical Implications
Clinical Importance
• Pancreatic d u c t a l c a r c i n o m a is the 5th leading cause
of cancer death
Patients are usually unresectablc tor cure at time of
diagnosis due t o early spread of cancer to \ital
structures (liver through portal vein drainage; celiac
and superior mesenteric plexus; inaccessible lymph
node groups, superior mesenteric or celiac vessels)
Role ol imaging is to detect t u m o r 1-c signs of
non-resectability to avoid nontherapeutic surgery
• Pancreatic islet cell t u m o r s
Mas IK- benign or malignant
o "Functional" tumors that secrete excess insulin or
glucagon are usually diagnosed early due to
characteristic symptoms and laboratory findings
"Nonfunctional" malignant tumors often diagnosed
late, with extensive liver metastases
o Are usually very vascular o n imaging (unlike
pancreatic ductal carcinoma)
• Pancreatic anomalies are relatively c o m m o n
Pancreas d i v i s u m
■ I ailure of fusion of ventral and dorsal pancreas
■ Predisposes t o acute/recurrent pancreatitis
A n n u l a r pancreas
■ Error in rotation of ventral pancreas
■ Results in a ring of pancreatic tissue that encircles
and narrows d u o d e n u m
 PANCREAS
PANCREAS & ITS RELATIONS

Stomach (cut &

removed)

Spleen

Superior (dorsal)
pancreatic artery
Gastroduodenal artery
Splenic artery

Great pancreatic artery

Posterior superior
pancreattcoduodenal
artery
Anterior superior Transverse colon
pancreaticoduodena]
artery
Duodeno-jejunal
junction
Base of transverse
mesocolon Superior mesenteric
artery & vein

Duodenum
Base of small bowel
mesentery

The arterial supply to the body & tail of the pancreas is through terminal branches of the splenic artery, which are
variable in number & size. The two largest are usually the dorsal (superior) and great pancreatic arteries, which arise
from the proximal & distal splenic artery, respectively. The! arteries to the pancreatic head and duodenum come from
the pancreaticoduodena] arcades that receive flow from thp celiac and superior mesenteric arteries. The superior
mesenteric vessels pass behind the neck of the pancreas in<! in front of the third portion of the duodenum. The root
of the transverse mesocolon and small bowel mesentery -'rise from the surface of the pancreas and transmit the blood
vessels to the small bowel & transverse colon. The splenic vein runs along the dorsal surface of the pancreas. The
splenic vessels and pancreatic tail insert into the splenic hMum.
 PANCREAS
V) AXIAL CT
CO
a?
o
c
co
■ •

C
0>
E - Pancreatic body
o
Portal vein
Pancreatic tail
<
Splenic vein
Left adrenal

Pancreatic neck —
Duodenum (2nd portion) —
- Pancreatic tail

—
Duodenum

Confluence of splenic & sujierior —

mcsenteric veins

(Top) first of five axial CT sections showing a normal pancreas and its relations. The splenic vein lies in a groove
along the length of the body of the pancreas. The tail of the pancreas lies in the splenic hilum within the splenorenal
ligament. (Middle) The neck of the pancreas lies just ventral to the sujierior mesenteric artery and vein. Note the
normal degree of fatty Iobulation of the pancreas, typical of a young to middle-aged person. (Bottom) The head of
the pancreas lies between the confluence of the splenic and superior mesenteric veins and the medial wall of the
second portion of the duodenum.

II
572
 PANCREAS
A X I A L CT >

O-
O
3
CD

13
03
O

0J

Pancreatic head

Duodenum —
Confluence o f SMV & —
splenic vein

Superior mesenteric
vein

— Uncinate process
— Superior mesenteric
artery

(Top) The head o f the pancreas lies lateral t o t h e superior mesenteric v e i n (SMV) o r SMV-portal vein confluence,
w h i l e the u n c i n a t e process lies dorsal t o the SMV. ( B o t t o m ) The u n c i n a t e process is t h a t p o r t i o n of t h e pancreas that
extends dorsal t o the superior mesenteric v e i n (SMV).

II
\7\
 PANCREAS
CO CATHETER A N G I O C R A P H Y , VESSELS
CD

o
c
CD
0-
■ ■

c
CO
E
o
•o
.a
<

(lastroduudtnal artery

-^ Splenic artery

Right gastrocpiploic
artery

Anterior superior
pancrcatitoduodenal
artery
Posterior superior
pancreat icoduodena I
artery Anterior inferior
pancreaticoduodenal
AngiOKraphit catheter
A artery

H — Splenic vein
Portal vein

(Top) First of two images from a celiac angiogram shows the arterial supply of the pancreas and adjacent organs.
Arteries to the pancreatic head and duodenum come from two arcades, the anterior & posterior pancreaticoduodenal
arteries, which anastomose with branches from the superior mesenteric artery. The body and tail portions of the
pancreas are supplied by branches of the splenic artery which are quite variable in size and distribution. Some are
short twigs without specific names, while two are generally larger, the dorsal (superior) and great pancreatic arteries,
which originate from the splenic artery proximally and distally, respectively. The gastroduodenal artery courses
downward behind the first portion of the duodenum and antero-lateral to the head of the pancreas. (Bottom) The
II venous drainage of the pancreas is to the splenic, superior mesenteric & portal veins.
r-i
 >
Q.
O
3
o
3
TJ
CO
13
o
-1
CD
CO
(/)

(Top) Coronal reformation, CT arteriogram demonstrates .'onventional upper abdominal arteries. The anterior and
posterior pancreaticoduodenal arteries arise from the gastr- duodenal artery, and their inferior extensions anastomose
with the superior mesenteric artery. The dorsal (superior) i-rtncreatic artery arises from the proximal splenic artery.
The arterial supply to the pancreas is highly variable and all of the branches anastomose to a considerable degree.
The transverse pancreatic artery runs parallel to the splenk artery along the long axis of the pancreas, also sending
numerous small, anastomotlc branches to the pancreas. (Ifc-ttom) A coronal 3D volume rendered CTA in a different
patient from previous image shows conventional pancreatic arterial anatomy, but variant hepatic, with the left
hepatic artery arising from the common hepatic and the rijrht hepatic from the gastroduodenal artery. II
375
 PANCREAS
AXIAL CT, PANCREATIC ARTERIES

— Pancreas
Common hepatic artery -
Celiac artery -
- Splenic artery

Right gastroepiploic artery

Gastric pylorus

— Pancreas (neck)
Gastroduodenal artery

Dorsal (superior) pancreatic

artery

- Right gastroepiploic artery

Duodenal bulb — r

Pancreatic head
Anterior superior
pancreaticoduodenal artery
Superior mesenteric artery
Posterior superior
pancreaticoduodenal artery

(Top) First of five axial C f sections in the arterial phase of imaging show normal pancreas and conventional arterial
anatomy. The splenic a n d c o m m o n hepatic arteries arise from the celiac trunk a n d supply most of t h e blood supply
to t h e pancreas through m a n y branches, with a highly variable pattern. (Middle) The dorsal (superior) pancreatic
artery courses along the posterior surface of the pancreas in a vertical orientation, a n d is usually the first branch of
the splenic artery. The gastroduodenal artery is the first branch of the c o m m o n hepatic artery and passes behind the
gastric pylorus and duodenal bulb and antero-lateral to the pancreatic head. (Bottom) The three major branches of
the gastroduodenal artery are the right gastroepiploic artery and the anterior a n d posterior superior
pancreaticoduodenal arteries.
 PANCREAS
AXIAL CT, PANCREATIC ARTERIES >
CL
O
3

0)
o
s
03
CO
— Pancreatic head
Anterior and |iosterior -
pancreaticoduodenal
arteries
Duodenum
Superior mesenteric
artery

Superior mesenteric
artery
Duodenum
— left renal vein

(Top) The anterior and posterior pancreaticoduodenal arcades surround the head of the pancreas and anastomose
with the superior mesenteric artery through the inferior branches of these vessels. (Bottom) The
pancreaticoduodenal arcades send branches laterally to the d u o d e n u m and medially t o the pancreas.

II
177
 PANCREAS
AXIAL CT, PARENCHYMA AND VEINS

o
c
03 - Stomach

■ ■

C
a>
E Portal vein - Colon
o
-a
< - Pancreas (tail)

- Spleen
- Splenic vein
- Left adrenal

Right gastroepiploic vein —i—

Portal vein
- Splenic vein
Adrenal glands - (Renal cyst)

Neck of pancreas

Splenic-portal confluence

(Top) lirst of five axial CT sections shows the body and tail of the pancreas lying in a nearly transverse plane, with
the splenic vein running in a groove along its dorsal surface. The body of the pancreas lies just ventral to the splenic
vein, and the adrenal just dorsal to it. (Middle) There are no reliable measures of "normal" pancreatic dimensions.
The normal gland tapers smoothly from the head to the tail, with some thinning through the neck region. Focal
areas of enlargement are suggestive of tumor or focal inflammation. (Bottom) The neck of the pancreas lies just
ventral to the confluence of the splenic and portal veins.

II
178
 PANCREAS
AXIAL CT, PARENCHYMA AND VEINS >
cr
Q.
O

ID
a>
=3
o
0)
Pancreatic head
— Superior mesenteric
vein

Su|KTior mesenteric
Duodenum artery

Inferior vena cava

U n c i n a t e process

— (Renal cyst)

(Top) The head of the pancreas lies between the second portion of d u o d e n u m and the superior mesenteric vessels.
The inferior vena cava lies just behind the head of t h e pancreas (linttom) The uncinate process lies just behind the
superioi mesenteric vein.

II
{7«J
 PANCREAS
CORONAL CT
CO

u
cCD
Q.
■ ■
Stomach
Portal vein
c
CD Gallbladder
O - Pancreas (body)

< Duodenum

— Pancreas (body)

Colon (hepatic flexure) — -»

Superior mesenteric vein

Duodenum Pancreas

Middle colic vein

Superior mesenteric vein -

(Top) First of six coronal CT sections showing normal pancreas and its relations. This most ventral section shows
only the anterior surface of the pancreas. (Middle) The superior mesenteric vein is seen caudal to the pancreas.
(Bottom) As the superior mesenteric vein courses toward the liver, it begins to move dorsally, eventually passing
behind the neck of the pancreas.

II
JBO
 PANCREAS
CORONAL CT >
a
o
i
3
■ *
Neck of pancreas Q)
ID
Splenic vein O
Duodenum ~~
Inferior mesenteric vein
3
Superior mesenteric vein a)

Duodenum
I— Splenic vein

Head of pancreas - Portal vein

Pancreatic tail

Portal vein Spleen

Uncinate process
- Superior mesenteric artery

flop) The confluence of the superior & inferior mesenteric veins with the splenic vein is seen, just dorsal and caudal
to the neck of the pancreas. The head of the pancreas lies between the mesenteric vessels and t h e second portion of
the d u o d e n u m . (Middle) Note the relation between the d u o d e n u m and the head of the pancreas. The splenic vein
runs in a groove along the posterior surface of the pancreas. Note the thin fat plane between the pancreas and the
splenic vein; this plane is often obliterated in cases of pancreatitis or carcinoma. (Bottom) The tail of the pancreas
usually lies in the splenic hilum, within the splenorenal ligament.

II
Ifll
 PANCREAS
AXIAL MR, ARTERIAL PHASE
CO

o
c
■ ■
c
0)
E Portal vein — Pancreas
o
■o
— Splenic vein
<

Neck of the pancreas

Hepatic artery Splenic artery

Portal vein Celiac artery

Pancreatic duct Superior mesenterit vein

Common bile duct —
Superior mescnteric artery
Duodenum -
Uncinate process

(Top) First of three axial MR sections obtained in the arterial phase of contrast opacification showing the
relationship of the body and tail of the pancreas to the splenic vein and the spleen. (Middle) The neck of the
pancreas is its thinnest portion and lies just ventral to the celiac and superior mescnteric vessels. (Bottom) The
uncinate process lies behind the superior mesenteric vein (which is not yet well opacified on this arterial phase
image). Note the common bile duct and pancreatic duct as low signal "dots", passing vertically through the head of
the pancreas.

II
»82
 PANCREAS
AXIAL M R , VENOUS PHASE >
a
o
3
CD
Neck of pancreas
Body ot pancreas
CD
Portal vein - Celiac artery r>
o

Stomach

Neck of pancreas

Portal vein -
Splenic vein

Superior mesenteric vein -

Duodenum - Left renal vein

Uncinate process

(Top) First o f three axial MR sections obtained d u r i n g the portal venous phase o f contrast e n h a n c e m e n t shows the
neck a n d body o f the pancreas i n relation t o the celiac a n d portal vessels. ( M i d d l e ) The neck o f the pancreas lies just
anterior t o the splenic-portal venous confluence. (Bottom) The uncinate process lies posterior t o the superior
nieseiiteric v e i n , but docs not usually e x t e n d b e h i n d t h e artery. The left renal vein o f t e n passes between the superior
mesenteric vessels and the aorta at this level as w e l l . The t h i r d structure that lies i n this space is the t h i r d p o r t i o n o f
t h e d u o d e n u m , w h i c h lies about 2 c m more caudal than the u n c i n a t e a n d renal v e i n .

II
ioi
 PANCREAS
V) MRCP, PANCREATIC & BILE DUCTS
CO

o
c
CO
Q.

0>
E
o
•a
JO
<

Gallbladder

Pancreatic duct
Common bile duct —

A coronal MR cholangiopancreatogram shows normal caliber pancreatic and bile ducts. The common bile duct &
pancreatic duct run a parallel course within the head of the pancreas and join together just prior to emptying into
the duodenum at the hepaticopancreatic papilla (of Vater).

II
Ui-J
 PANCREAS
SPLENIC & PANCREATIC ARTERIES >
a
o
3
n>
-•
"0
DJ
13
O
3
DJ
Splenic artery

Gastroduodenal artery —
Great pancreatic artery

Superior (dorsal) — ]
pancreatic artery
— Transverse pancreatic
artery
Posterior superior —
pancreatlcnduodenal
artery Anastomotit branch

Spleen

Splenic drterv

left easticiepipIoM
artery
Superior (dorsal)
pancreatic artery

Transverse pancreatic
artery

(Top) Selective catheter injection of the celiac artery shows a prominent superior (dorsal) pancreatic artery arising
from the celiac artery itself or the proximal splenic artery (its usual source). The transverse pancreatic artery runs
along the main axis of the pancreas and receives branches from the superior and great pancreatic arteries and from a
separate branch of the SMA, the inferior pancreatic artery. In spite of the name, the "great" pancreatic artery may be
relatively small, as in this subject. A branch of the superior pancreatic artery anastomoses with the
pancreaticoduodenal arcade. (Hot torn) In this subject the splenic artery is very tortuous, a common finding. The
pancreatic arterial supply is mostly through unnamed terminal branches of the splenic artery. Neither the superior
nor the great pancreatic artery are substantial vessels in this subject. II
IfiS
 PANCREAS
SENESCENT CHANGE

o
c
03
CL
•• Pancreas
c
0) Su[)erior mesenteric vein
E
o
Inferior vena cava - Splenic vein
T3
Right renal vein - Left renal vein
<

Duodenal diverticulum -

Pancreatic head

Duodenum
Uncmate process

Left renal vein

(Top) first of three axial CT sections in an elderly patient shows extensive fatty infiltration of the pancreas. While
this can he associated with chronic pancreatitis, diabetes a n d obesity, it is often a normal finding of n o clinical
significance. The pancreatic parenchyma begins t o atrophy and the pancreatic duct may dilate in subjects beyond
the age of seventy, without symptoms or signs of pancreatic insufficiency. (Middle) In patients with extensive fatty
infiltration of the pancreas, as in this subject, the pancreas can be difficult to visualize o n ultrasonography, as it is of
similar echogenicity as the surrounding rctroperitoneal fat. (Bottom) In this subject, the degree of fatty infiltration is
relatively uniform throughout the gland; as in hepatic steatosis, however, this is not always the case.
II
Jfif.
 PANCREAS
VARIANT, ASYMMETRIC FATTY INFILTRATION >

%
3
o
3
■ ■

"0
Pancreas
o
3
w

Pancreatic head & neck

I — Splenic-portal confluence

— SMA K SMV
Head of pancreas

Duodenum (3rd portion)

Duodenum

(Top) First of three axial CT sections of a patient with n o symptoms or signs of pancreatic disease shows a normal
appearing, "soft tissue density" body a n d tail of pancreas. (Middle) A more caudal section shows that the neck and
head of the pancreas are of substantially lower attenuation (density), and might be mistaken for a hypodense.
hypovascular mass, such as pancreatic ductal carcinoma. The absence of dilation of the pancreatic or c o m m o n bile
duct correctly suggests the absence of a neoplastic mass in the pancreas. (Ilottom) The density of the head of the
pancreas is substantially lower than that of the remaining pancreas, but there are n o radiographic or clinical signs ol
tumor or inflammation. The morphology of the pancreatic head may vary from that of the body due to their separate
embryologic development, from the ventral and dorsal pancreatic buds. II
 PANCREAS
CO
ACUTE PANCREATITIS
£o
c
CO
■ ■
c
o
E — Infiltrated pcripancreatic fat
o Splenic-portal confluence "
■o
< —
Body of pancreas

— Descending colon

Lateroconal fascia

Anterior renal fascia

Superior mescnteric vessels - ■

Duodenum (3rd portion)

(Top) First of five axial CT sections of a patient with severe upper abdominal pain following heavy alcohol
consumption shows diffuse infiltration (blurring) of the fat planes surrounding the pancreas, due to acute
pancreatitis. (Middle) The inflammatory process spreads out in all directions. Laterally, it is restrained by the
lateroconal fascia, which marks the lateral margin of the anterior pararenal space. Posteriorly, it is restrained by the
anterior layer of the renal tascia. The pancreas lies within the anterior pararenal space, along with the duodenum and
the ascending & descending colon. (Bottom) The inflammation spreads ventrally and caudally to enter the small
bowel mesentery; note the infiltration of the fat planes around the mescnteric vessels. The roots of the small bowel
II mesentery (& transverse mesocolon) arise from just ventral to the pancreas.
188
 PANCREAS
ACUTE PANCREATITIS >
cr
Q.
O
3
©
3
•-
■D
Q)
=>
O
3
03

Ascites in paracolic
Duodenum gutter

Descending colon

Dilated small bowel —

— Ascites

(lop) On this more caudal section, the lateroconal fascia a n d the parietal peritoneum are adherent t o each other.
The fluid lateral to the descending colon is in the peritoneal cavity (the paracolic gutter), and represents "pancreatic
ascites". (Bottom) Dilated small bowel segments are noted, representing an ileus clue to severe abdominal pain and
abnormal fluid and electrolyte balances, another result of acute pancreatitis.

II
in*»
 PANCREAS
CO PANCREATITIS WITH P S E U D O C Y S T
CO
2?
o
c
TO
CL
m m

i
"O Ascites

<

Pseudocyst in lesser sac —

(upper recess) — Stomach (with
nasogastric tube)

Pleural effusion —

Stomach (with NG
tube)

Pscudocysts

— Splenic artery

(Top) First of four axial CT sections of a patient with recurrent pancreatitis shows ascites and pleural effusions. In
addition, there is a loculated fluid collection in the upper recess of the lesser sac, representing a pseudocyst. (Bottom)
Large loculated pseudocysts in the lesser sac displace the stomach forward. Note the contrast-enhancing wall of the
pseudocyst. Pseudocysts d o not have an epithelial lining but represent loculated collections of pancreatic juice,
necrotic debris and inflammatory exudate with an inflammatory a n d fibrotic wall.

II
?«)()
 PANCREAS
PANCREATITIS W I T H PSEUDOCYST >
cr
a
o
3
o
3
• ■
— Pcngastrii varix

0)
— Stomach (with NCi 3
O
tube)
Q)

I'seuilocyst

rVrigastric varices

Stomach

Pseudocyst

Splenic vein

(Top) I h c stomach is displaced a n d its w a l l is thickened clue t o the adjacent pseudocyst. Pseudncysts often resolve
spontaneously, but mav recjuire drainage due to c o m p l i c a t i o n s such as i n f e c t i o n , hemorrhage, or o b s t r u c t i o n of
bowel Or bile ducts. ( B o t t o m ) The largest pseudocyst is q u i t e septated, as is c o m m o n . N o t e the mass eflect o n t h e
splenic v e i n , resulting i n n a r r o w i n g or occlusion o f this vessel. I'erigastric varices have developed t o return b l o o d
f r o m t h e spleen a n d pancreas t o the portal v e i n , bypassing the obstructed splenic v e i n . Gastric varices i n the absence
o f portal hypertension implies splenic v e i n o c c l u s i o n , usually due t o pancreatitis or pancreatic carcinoma.

II
5')|
 PANCREAS
</> CARCINOMA, DUCTAL OBSTRUCTION
TO

O
c
TO
Q.

£
o
< Portal vein — Focal n a r r o w i n g of
I i 'i I ,iI v e i n

Biliary itenl

— Su[xrior mesi-nteric
vessels

~~ I Hepatic cyst)

Gallbladder - r
— Pancreatic duct
(dilated)

— Splenic v e i n
Pancreatic head ™

■ — Superior mesenteric
vein

(lop) l-'irst of five CT sections of a patient with painless jaundice. This coronal reformation shows a plastic stent in
the extrahepatic bile duct, placed endoscopically to bypass an obstruction of the common bile duct. There is a subtle
narrowing of the portal vein at its confluence with the superior mesenteric vein, (Bottom) A more anterior plane of
reformation shows abrupt narrowing of the pancreatic duct as it enters the head of the pancreas. The abrupt
transition suggests the presence of a pancreatic tumor, though a discreet mass is not evident.

II
592
 PANCREAS
C A R C I N O M A , DUCTAL O B S T R U C T I O N >
Q.
O
3
CD

CO
Pancreatic duct (dilated) =3
o
3

biliary stent
Splenic-portal confluence

SMV (narrowed just caudal to

confluence)

(Top) Axial CT section shows dilation of the pancreatic duct throughout the body a n d tail segments. (Middle) Axial
CT section through the pancreatic neck shows n o obvious mass. (Bottom) A section just caudal t o the confluence of
the superior mesenteric and splenic veins shows abrupt narrowing of the lumen of the SMV. In this patient, the
indirect signs of a pancreatic carcinoma, such as biliary a n d vascular encasement, are more evident t h a n t h e t u m o r
itself.

II
 PANCREAS
CARCINOMA, VASCULAR OCCLUSION
CO

c
CD Perigastric varices
Q_
■ ■

C
<D Coronary (left gastric) vein -
E - Spleen
o
■D Portal vein -
SI
< Superior mesenteric vein —

Right kidney —

- Gastroepiploic vein

Coronary (left gastric) vein ■

Perigastric varices

Portal vein —

(Top) First of six CT images from a patient with pancreatic carcinoma, who presented with weight loss and upper
gastrointestinal bleeding. This coronal reformation highlights the portal venous system and shows complete
occlusion of the splenic vein with extensive collateral flow through perigastric varices and the gastroepiploic vein.
(Middle) Axial CT shows multiple perigastric varices and an enlarged coronary (left gastrici vein. (Bottom) A more
caudal section shows a normal appearing liver and portal vein but no splenic vein. Numerous collateral veins are
noted in the splenic hilum near the tail of the pancreas.

II
.594
 PANCREAS
CARCINOMA, VASCULAR OCCLUSION >
o.
o
3
a>
Hepatic artery — Splenic artery
T)
0)
Portal vein -
Pancreatic tumor u
S0)
V)

— Pancreatic carcinoma

Normal pancreas

Common hile duct

Duodenum

(Top) The hepatic and splenic arteries are encased and narrowed by a large hypodense mass that occupies the body
of the pancreas. The splenic vein should be seen coursing from the splenic hilum, along the body of the pancreas, to
the portal vein. Instead, it has been occluded along much of its length by the pancreatic carcinoma. (Middle) A more
caudal section shows the heterogeneous, hypodense tumor that replaces much of the body of the pancreas. The
tumor encases a n d narrows the hepatic and splenic arteries, indicating that the tumor cannot be resected for cure.
(Bottom) Note the difference between the hypodense (dark) appearance of the pancreatic carcinoma and the normal
pancreatic head and neck sections. The c o m m o n bile duct courses normally through the head of the pancreas.
II
»«r»
 PANCREAS
$ ISLET CELL TUMOR

u
c
a:
••
c
E
o
"O
-Q
<

Pancreas —

(Top) First of two CT sections of a patient with symptoms of palpitations and fainting, found to be due to
hypoglycemia. This coronal reformation of a CT scan shows a hypervascular mass in the pancreatic body. This is the
typical appearance of an islet cell (neuroendocrine) tumor; a benign insulin-secreting tumor ("insulinoma") was
removed at surgery. (Bottom) A thick axial reformation also shows the hypervascular islet cell tumor arising from the
body of the pancreas. The hypcrvascularity of the mass and the absence of ductal obstruction are among the imaging
features that distinguish islet cell tumors from the more common pancreatic ductal carcinoma.
II
.»%
 PANCREAS
PANCREATIC DUCT VARIATIONS >
a.
o
3
CD
3
TJ
Q)
ZJ
Accessory duct (of o
-»
Santorlni) CD
03
(f)
Minor papilla
Double accessory duct
Major papilla

Main duct (of

WUsung)

X Pancreas divtsum (no

Absence of accessory
duct
I communication
between ducts)

7
1
Tortuous pancreatic
duct
Double duct of
Wirsung

Double crossing of Crossing of ducts

ducts

The accessory duct (of Santorlni) originates with the dors 'I pancreatic anlage, which is the larger bud from the
embryologic foregut, comprising the pancreatic body & tall. The main duct (of Wirsung) originates with the ventral,
smaller, anlage that develops into the pancreatic head an-; uncinate process. Usually, the main & accessory
pancreatic ducts fuse and the main duct becomes the primary conduit for drainage of secretions into the duodenum.
The pancreatic duct courses through the center of the gl ind, and is joined by tributaries that enter it at right angles.
In the head, the duct turns caudally & dorsally, and runs parallel to the common bile duct before joining it at the
ampulla of Vater and entering the major papilla. The accessory duct usually enters the duodenum more proximally
through the minor papilla. II
W7
 PANCREAS
PANCREATIC DIVISUM
CO

Endoscope Pancreatic duct (in body)

Q-
• ■
c
a> Common bile duct —
E Accessory dud (of Santorini) —
o
■o
<

- Main duct (of Wirsung)

Major papilla

Common bile duct -

Accessory pancreatic duct (of —

Santorini) Main duct (of Wirsung)

Pancreatic duct
Duodenum —

Common bile duct —

Accessory duct (of Santorini) -

- Main pancreatic duct (of

Wirsung)

(Top) First in series of three images show pancreas divisum, in which the main and accessory ducts fail to fuse. ERC.I'
shows the endoscopic canula in the major papilla with opacification of only the main duct in the pancreatic head
and the common bile duct. (Spasm of the choledochal sphincter prevents distention of the distal ( BD, which
communicated with the main pancreatic duct at the major papilla.) Separate cannulation of the minor papilla had
filled the accessory duct of Santorini and the duct throughout the pancreas. (Middle) An oblique image from the
ERCP shows that the main and accessory pancreatic ducts do not communicate. The accessory duct crosses the
common bile duct. (Bottom) MRCP shows crossing of the common bile duct and the accessory pancreatic duct,
II which diains the body of the pancreas in this subject. The main pancreatic duct is small and not in communication.
 PANCREAS
ANNULAR PANCREAS >
Q.
O

Duodenum (dilated proximally) 3

O
CD
Duct ot Wirsung (pancreatic head)

CJastric antrum
Duodenum (2nd portion)

Duodenum (.Ird portion)

Pancreas

Duodenum (2nd portion)

(Top) First of three images illustrates annular pancreas, in which there is abnormal rotation and fusion of the ventral
& dorsal pancreatic anlage, resulting in a circumferential mass of pancreatic tissue that encircles and narrows the
d u o d e n u m . The duct draining the pancreatic head encircles the second portion of the d u o d e n u m . This condition
may remain asymptomatic or may result in obstruction of the d u o d e n u m , often in neonates. (Middle) A spot film
from a barium upper Cil series shows circumferential narrowing of the second portion of the d u o d e n u m in an adult
patient with long-standing symptoms of early satiety from an annular pancreas. (Bottom) An axial CI section shows
pancreatic tissue completely encircling the second portion of the d u o d e n u m .
II
10«l
 RETROPERITONEUM
[Terminology
Abbreviations
• Perirenal space (PSJ
• Anterioi pararenal space (APS)
• Posterior pararenal space (PPSl
| Imaging Anatomy
Overview
• \ll abdominal contents between parietal peritoneum
and transversalis fascia
• 2 well-defined fnscial planes, (renal K lateroconal
fasciae), separate the retroperitoneum into i
compartments
Perirenal space contains kidney, adrenal, proximal
ureter, a b u n d a n t tat
■ 1 ncloscd by renal fascia
■ Does not extend across abdominal midllne
Anterior p a r a r e n a l space contains pancreas,
duodenum, colon (ascending & descending) and
little tat
Posterior pararenal space contains n o organs, some
tat; continuous with propcritoneal tat
• Renal fascia join and close the pcrircnal space so that
it resembles an inverted cone with tip in iliac fossa
Caudal to the pcrircnal space, the APS and PI'S
merge to form a single iitfrarenal rctro|>critoneal
space
o Inlrarcnal retroperitoneal space communicates
directly with the pelvic prevesical space (ot
Rct/iusi
Anatomic Relationships
• Parietal p e r i t o n e u m separates peritoneal cavity from
APS
• Anterior renal fascia separates pcrircnal Irom APS
• Posterior renal fascia separates perirenal from PPS
• I atcroconal fascia separates APS from PPS and marks
the lateral extent ol the APS
• Renal and lateroconal fasciae are laminated planes and
can form spaces as pathways ot spread for rapid!)
expanding fluid collections or Inflammatory processes
(e.g.. hemorrhage or pancreatitis)
Disease originating in anterior pararenal space (e.g.,
pancreatitis) can extend posterior t o kidney via
interfascial plane
• Anterior renal fascia can "split" into a r c t r o m e s e n t e r i c
plane which is continuous across the midline
abdomen
• Posterior renal fascia splits into retrorenal p l a n e
• I ateroconal fascia splits into lateroconal p l a n e
• AllA of these planes can be called interfascial planes
and all communicate at the junction of the
lateroconal k renal fasciae
• Interfascial planes communicate across the alHlominal
midline and extend into pelvis caudal to the pciircnal
space
■ Great vessels (aorta & I V I )
Occupy poorly defined pre-vertebral portion of
retroperitoneum caudal t o mediastinum
Shared by paraspinal nerve chains (sympathetic),
major lymphatic trunks (including chyle cistern &
thoracic duct), and uieters
Clinical Implications
Clinical Importance
• Disease w i t h i n APS is c o m m o n
| Pancreatic disease > duodenal > colon
Pancreatitis often spreads inflammation and thud
throughout M'S to affect d u o d e n u m fc descending
colon
Perforated duodenal ulcer is most c o m m o n cause of
inflammation, fluid. gBS in right APS. (may also
cause intiaperitoneal gas since duodenal bulb is
intraperitoneal)
• Disease in perirenal Space is c o m m o n
\ n y traumatic, inflammatory or neoplastic process
involving kidney or adrenal
1
Renal fascia is strong fc effective at containing most
primary renal pathology within l*S and excluding
most other processes from PS
■ Pcrircnal space is closed and does not
communicate across the midline or into the
pelvis, but can decompress into interfascial planes
winch do communicate
■ Perirenal space is divided irregularly bv perirenal
b r i d g i n g septa: can result in loculated perirenal
fluid collections that simulate subcapsular
collection; septa may act as conduits Joi fluid or
iulillralive disease (including tumor) t o enter or
leave perirenal space
• Traumatic or spontaneous retroperitoneal
h e m o r r h a g e is c o m m o n
Causes include anticoagulation therapy, ruptured
abdominal aortic aneurysm, bleeding Irom a renal
neoplasm (usual!) renal carcinoma or
angiomyolipoma)
Bleeding commonly spreads along fascial planes to
involve multiple retroperitoneal and pelvic
extrapcritoneal compartments, plus rectus and
iliopsoas muscle groups (in coagulopathic patients)
• Neoplastic involvement of retroperitoneum
Primary carcinoma of kidney, pancreas, colon
(ascending or descending) adrenal, duodenum
o Primary sarcoma, usually liposarcoma, often attains
huge si/e displacing alHlominal viscera before being
diagnosed
Nerve sheath t u m o r s and p a r a g a n g l i o m a s
c Melastases t o retroperitoneal nodes very c o m m o n
(e.g.. I v m p h o m a , p r i m a r y pelvic t u m o r s , including
testes. prost.ite, uterus, ovary)
• Retroperitoneal fibrosis
Chronic intlammatorv process in lumbar
retroperitoneum
Encases aorta. IVC, K ureters in fibrotic mantle of
tissue
• Medial deviation and obstruction ol ureters
 RETROPERITONEUM

Duodenum
Parietal peritoneum
Pancreas
Descending colon

Lateroconal fascia

Anterior & posterior

renal fasciae

The renal and lateroconal fasciae divide the retioperitoneum into three compartments: Anterior pararenal, perirenal
(perinephric), and posterior pararenal spaces. The anterior pararenal space (APS) contains the duodenum, pancreas,
and the ascending/descending colon. The APS compartment is limited anteriorly by the peritoneum which reflects
over the colon to form the paracolic gutter, an Intraperitoneal recess. Lateral to the peritoneum covering the lateral
abdominal wall is retroperitoneal fat, sometimes called the properitoneal fat stripe. The renal fasciae enclose the
perirenal space, and the anterior renal fascia forms the posterior boundary of the APS. The lateroconal fascia forms
the lateral margin of the APS and the medial margin of the posterior pararenal space. The posterior renal fascia
usually joins with the fasciae of the psoas or quadratus lumborum muscle.
 RETROPERITONEUM
RETROPERITONEAL DIVISIONS

Pancreas —-i Anterior pararenal

space

latcroconal fascia
Ascending colon

— Renal fascia
Interfasciai plane
— Perirenal space

Posterior pararenal
space

Duodenum (with
feeding tube)

— Descending colon

Anterior pararenal
space
Latcroconal fascia

Interfasciai plane

(Top) The main divisions of the retroperitoneuni are the anterior pararenal space (in yellow), perirenal space (purple)
and posterior pararenal space (blue), tn addition, the interfasciai planes are shown (green). These are the potential
spaces created by inflammatory processes that separate the double laminated layers of the renal and latcroconal
fasciae. The posterior pararenal space contains no organs, and is synonymous with the propcritoneal fat that extends
along the lateral and anterior abdominal wall. The perirenal spaces do not communicate across the midline, but the
anterior pararenal space and the interfasciai planes do so. (Bottom) lirst of 3 CT images of a patient with acute
pancreatitis shows fluid distending the anterior pararenal space and interfasciai planes. The pancreas, duodenum and
vertical colon segments all lie within the anterior pararenal space.
 RETROPERITONEUM
C O P O N A l & SAGITTAL REFORMATIONS

Kidney Interfascial plane

Perirenal space

Infrarenal retroperitoneal space

Iliac crest

Diaphragm

Liver - — Adrenal

Anterior pararenal space - — Perirenal space

Posterior pararenal space

—
Transverse colon Iliac cresl

Infrarenal retroperitoneal space

Spleen

Stomach

Anterior pararenal space Kidney (within perirenal space)

Duodenum iwith feeding tube) -

Renal fascia

Infrarenal retrojientoneal space - — Iliac crest

(Top) A coronal reformation of the CT scan shows sparing of the perirenal space, which is protected by the renal
fascia from the extensive inflammation that fills the anterior pararenal space, interfascial planes and infrarenal
retroperitoneal space (caudal to the termination of the renal fascia). (Middle) Sagittal graphic through the right
kidney shows the three retroperitoneal compartments. Note the confluence of the anterior and posterior renal fasciae
at about the level of the iliac crest. Caudal to this, there is only a single infrarenal retroperitoneal space. (Bottom)
This sagittal reformation through the left kidney shows the shape of the perirenal space which is "protected" in this
patient by the renal fascia.
 RETROPERITONEUM
E AXIAL CT, NORMAL FASCIAL PLANES
CD
C
2
•c A n t e r i o r renal fascia

CD
Q.
s
"CD
Descending colon (in
Adrenal a n t e r i o r pararenal
m m
space)
C
o
E
o
■a
-Q Kidney
<

Anterior renal fascia

l a t e r o c o n a l fascia

— Posterior renal fascia

— Perirenal b r i d g i n g septa

( I b p ) I irst ot five axial CT sections that show the renal and lateroconal fasciae that define the retroperitoneal spaces.
The renal fascia encloses the perirenal space, which includes the kidney a n d adrenal, and a b u n d a n t fat. (Bottom)
The posterior parietal peritoneum c a n n o t be visualized when normal, but it forms the anterior margin of the anterior
pararenal space, whose posterior margin is the anterior layer of the renal fascia. The descending colon can be seen
within the anterior pararenal space on this image. Note the perirenal bridging septa that potentially divide the
perirenal space into multiple smaller compartments.
II
404
 RETROPERITONEUM
AXIAL CT, NORMAL FASCIAL PLANES >
XT
O.
O
(Hemorrhage in anterior pararenal - I'roperitoneal fat (posterior
3
CD
space) pararenal space) 3
••
1— lateroconal lascia
CD
«■♦

3
Perirenal bridging veplet ■D
3.
O
CD

I— Anterior renal fascia

Posterior pararenal space

(properitoneal lat)

Perirenal space

Posterior renal fascia

(Hemorrhage in anterior pararenal

space)
— Descending colon

Perirenal space - Renal fascia

Lateroconal lascia

f l o p ) More caudal section shows slight thickening of the lateroconal fascia, which forms the lateral margin of the
anterior pararenal space. The fat plane between the lateroconal fascia and the transversalis fascia (which is not
evident on this image) is known as the properitoneal fat, but also as the posterior pararenal space. No organs or
major structures lie within this space, but it is olten involved secondarily by inflammation or bleeding that originate
elsewhere in the retroperitoneum or abdominal wall. (Middle) [he posterior pararenal space is broader and more
evident on this section. (Bottom) Most caudal section below the kidney shows the layers of renal fascia coming
together as the perirenal space narrows like an inverted cone.
II
-40S
 RETROPERITONEUM
PANCREATITIS DEFINING PLANES & SPACES
03
C
B
0)
Q.

s
■ ■

C
©
E
o Inflamed pancreas is
peripancreatic fat
<

— Distal transverse colon

Anterior parareiidl
space

5 — Inflamed mesenteric fat

Descending colon

Anterior is posterior
renal fasciae

(lop) First of four CT images from a patient with acute pancreatitis and inflammation that helps to define the
retroperitoneal spaces. This section shows infiltration of the fat planes surrounding the pancreas, primarily within
the anterior pararenal space. The inflammation spreads laterally to the anatomic splenic flexure, where the colon
leaves its mesocolon to enter the retroperitoneum as the descending colon. (Bottom) The inflammation also spreads
caudally and ventrally to enter the mesentery. Recall that the roots of the mesentery and transverse mesocolon arise
from just in front of the pancreas, and inflammation easily enters the fatty space between the peritoneal reflections.
II
 RETROPERITONEUM
PANCREATITIS DEFINING PLANES & SPACES

Inflammation around —
head of pancreas

— Anterior renal fascia

I atercKonal fascia

Posterior pararenal
space

Adrenal

Perirenal space

— Posterior pararenal
space

— Infrarenal
retroperitoneal space

(Top) The renal and lateroconal fasciae are thickened by inflammation, which has also spread into the posterior
pararenal space lateral to the lateroconal fascia. (Bottom) A coronal reformation of the same CT scan shows normal
("spared") fat in the perirenal space, while the fat in the anterior and posterior pararenal spaces is inflamed. Note how
the layers of renal fascia close off the perirenal space at about the level of the iliac crest. Caudal to the perirenal
space, there is only a single retroperitoneal space, since the anterior and posterior pararenal spaces come together.
This helps to explain how the posterior pararenal space becomes involved in inflammatory or hemorrhagic processes
that originate in the anterior pararenal space.
 RETROPERITONEUM
PANCREATITIS INVOLVING OTHER O R G A N S

I'eri pancreatic
inflammation
Pancreas

Intraporitoncal fluid

Spleen

— Descending colon

Uncinatc process of Latcroconal fascia

pancreas

Interfascial
(retromesenteric) plane

Anterior layer of renal

fascia

Posterior pararenal
space

(Top) First of five axial CT sections of another patient with acute pancreatitis shows extensive infiltration of the fat
planes surrounding the pancreas. Fluid around the spleen is ascites, indicating that the inflammatory process has
extended through the |X>sterior parietal peritoneum to enter the peritoneal cavity. (Bottom) The inflammatory
process has spread laterally through the anterior pararenal space but is prevented from entering the posterior
pararenal space by the lateroconai fascia. The layers of the renal and lateroconal fasciae are expanded by the
inflammation at the point that they join, resulting in fluid tracking through interfascial planes. The descending
colon, also residing in the anterior pararenal space, is contacted by the inflammation.
 RETROPERITONEUM
PANCREATITIS I N V O L V I N G OTHER O R G A N S

Duodenum t3«l portion)

Inflammation

Ascites in paracoHc nutter

Duodenum ■
Descending colon

Posterior pararenal space

(properitoneal fat)

Small bowel (dilated)

Feeding tube (in duodenum) Ascites i n paraciilic g u t t e r

Renal fascia

(Top) A more caudal section shows the duodenum surrounded by inflammation as it too lies in the anterior
pararenal space. (Middle) The parietal peritoneum reflects over the descending colon to form the paracolic gutter, an
intraperitoneal recess. The peritoneum is a thin structure, not normally visualized on imaging, and is easily breached
by inflammatory and hemorrhagic processes. No clear demarcation can be seen between the retroperitoneal
inflammation and the ascites on this section. (Bottom) The contiguous involvement of the retroperitoneal and
intraperitoneal spaces is evident on this section. The retroperitoneal duodenum is encased by inflammation as are
the intraperitoneal small bowel segments, resulting in an ileus (dilated bowel with diminished peristalsis).
 RETROPERITONEUM
PERIRENAL B R I D G I N G SEPTA

A n t e r i o r renal fascia '

I'erirenal septa

A n t e r i o r renal fascia -

Loculated fluid (blood) —

Posterior renal fascia —

(Top) First of two axial C T sections of a patient with perirenal hemorrhage shows numerous curvilinear septations
within the perirenal space caused by hemorrhage tracking along the septa that divide the perirenal space into
multiple compartments. Blood and inflammatory infiltrate can "decompress" along these planes and spread into
other retroperitoneal spaces, (hot torn) loculated fluid within the perirenal space can mimic subcapsular fluid; note
the intact fat plane between the loculated fluid and the surface of the kidney, indicating thai the fluid is confined
within the perirenal space, but it does not spread diffusely to fill the space because of the perirenal septa.
 RETROPERITONEUM
PERIRENAL SPACE WITH B L O O D >
V
a
o
3
a
••
70
CD
- Perirenal hemorrhage 3
■o
CD

oID
Spleen (lacerated) CD
C
Blood tracking along pcrirenal 3
septa

- Active intraperitoneal bleeding

Intraperitoneal hemorrhage

- Renal laceration

- I oculated porirenal homatomas

( l o p ) First of three ( T images from a patient injured in a motor vehicle crash shows heterogeneous e n h a n c e m e n t of
the spleen due t o parenchymal laceration. Coexisting renal injury has resulted in perirenal hemorrhage that is
loculated by perirenal septa. The collection ventral to the kidney simulates a subcapsular hematoma, but spreads
along the surface of the kidney without causing compression of the parenchyma. (Middle) A more caudal section
just below the spleen shows intraperitoneal hemorrhage, with a collection that is isodense t o the contrast-opacified
aorta, indicating active arterial bleeding from the splenic injury. Active hemorrhage of this sort requires urgent
intervention with surgery or angiographic embolization to occlude the bleeding vessel. (Bottom) A deep renal
laceration is seen along with loculated perirenal hematomas. II
-411
 RETROPERITONEUM
E H E M O R R H A G E I N T O EXTRAPERITONEAL SPACES

o — Rectus sheath hcmatomas

c
2
■c
CD
Q.
O
ts
a:
••
sE
o
■a
.a
<

Hemorrhage in prevesical spate

Hemorrhage in prevesical space

(lop) First of five axial C l sections from a patient with spontaneous bleeding from over-anticoagulation. This
section shows high density, heterogeneous masses (hematomas) within the rectus sheath bilaterally, a common site
for spontaneous bleeding in patients with coagulopathy. (Middle) Because the rectus sheath is incomplete
posteriorly along the lower third of the muscle, the bleeding is no longer confined within the rectus sheath, but
extends into the adjacent extraperitoneal spaces, including the prevesical space (of Retzius). The prevesical &
perivesical spaces communicate superiorly with the infrarenal retroperitoneal space and fluid or inflammation may
extend cephalad to involve all three retroperitoneal compartments. (Bottom) A more caudal section shows
II hemorrhage in the anterior abdominal wall (rectus sheath) and extraperitoneal pelvis (prevesical space).
412
 RETROPERITONEUM
HEMORRHAGE INTO EXTRAPERITONEAL SPACES

I'rcvcsical space

Hemorrhage i n
perivesical space

— U r i n a r y bladder

— Rectum

I'rcvcsical space

— Perivesical space

(Top) The prevesical space continues caudally and laterally t o involve the perivesical space lower in the pelvis.
< Bottom) I lemorrhagc spreads extensively through the pelvic extraperitoneal spaces. Involvement of the
extra|)eritoneal pelvic spaces tends to assume a molar tooth" appearance on axial CT sections, as in this image. The
"roots of the tooth" are the extensions into the perivesical space. Extraperitoneal pelvic fluid also commonly extends
posteriorly to the presacral space, which is minimally involved in this patient.
 RETROPERITONEUM
E HEMORRHAGE ACROSS MIDLINE
<i>
c
o
-cr
<D
Q.
O

■ ■ Extravasated urine -
c
CD

I
■D

<

Pancreatic head -

Ixtravasatcd urine -

- Renal fascia

Duodenum -

Kidney (dcvascularized)

Perirenal hlixxl and urine -

Perirenal septa -

(Top) First of six CT sections of a patient with a traumatic renal laceration shows a large perirenal hemorrhage thai
fills the perirenal space. The renal parenchyma appears to be fragmented. (Middle) The deep renal lacerations have
extended into the collecting system, evident as extravasation of contrast-opacified urine. The pancreatic head and
duodenum are displaced by the large perirenal hematoma/urinoma. (Bottom) The lower pole of the right kidney
shows no contrast-enhancement, indicating that the renal artery to this segment has been occluded or avulscd. The
large perirenal collection of blood and urine is spreading along the perirenal septa to decompress into the interfascial
planes. The perirenal space does not extend across the midline; however, the interfascial plane and the anterior
II pararenal space do cross the midline.
414
 RETROPERITONEUM
HEMORRHAGE ACROSS MIDLINE

Duodenum (3rd portion)

i'erircnal space -

Intcrfascial planes

Ascending colon
Perirenal space

Fluid in left paracolic gutter

Posterior pararenal space -

(Top) The fluid crossing the abdominal midline with the duodenum is in the anterior pararenal space and the
interfascial plane. These spaces have become involved secondarily after the renal injury resulted in extensive
perirenal fluid collections that spread along the perirenal septa and separated the two layers of the renal fascia to
form an interfascial plane. (Middle) On this more caudal section there is little fluid within the perirenal space, but
extensive fluid distention of the interfascial planes. Note the spread of fluid into the contiguous psoas compartment
and posterior pararenal space, and the spread across the abdominal midline in front of the aorta and IVC. (Bottom)
The right anterior pararenal spate is relatively spared, as indicated by intact fat planes around the ascending colon.
Blood has leaked through the peritoneum into the paracolic gutter.
 RETROPERITONEUM
COMMUNICATION AMONG EXTRAPERITONEAL SPACES

- Renal fascia

Interfascial planes

- Hemorrhage in interfascial
planes

- Posterior pararenal space

— Perirenal space

- Left psoas

- - Perirenal space
Psoas muscle —
- Posterior pararenal space

(Top) first of eight axial CT sections in a patient with a spontaneous rctroperitoneal hemorrhage related t o
anticoagulation medication. This section shows only subtle thickening of the left renal fascia a n d interfascial planes.
(Middle) Extensive hemorrhage distends the interfascial planes on the left, with contiguous bleeding into the psoas
compartment a n d pararenal spaces. The perirenal space is spared. (Bottom) The hemorrhage is spreading along
curvilinear planes, corresponding t o the interfascial planes a n d the fasciae covering the left psoas, quadratus
lumborum, and transverse abdominal muscles. Coagulopathic hemorrhage often originates in the abdominal wall
muscles, especially t h e rectus a n d iliopsoas, with subsequent dissection into the retroperitoneal spaces.
 RETROPERITONEUM
C O M M U N I C A T I O N A M O N G EXTRAPER1TONEAL SPACES >
Q.
O
3
o

7)
CD
3
- Hcmatocrit sign (cellulat/lluid
level)
Iu
CD

Hemorrhage in infrarenal and

prevesical spaces

Iliopsoas compartment

— Blood in prevesical spate

(Top) A more caudal section shows massive hemorrhage into the psoas compartment and adjacent retroperitoneum.
Note the cellular/fluid level, referred to as the "hcmatocrit sign", that is almost pathognomonie of a coagulopathic
hemorrhage. It indicates gravitational settling of blood cells below a serum level, without clot development. (Middle)
Hemorrhage has spread into the infrarenal retroperitoneal space and continues caudally to involve the pelvic
extraperitoneal spaces, including the prevesical space. The blood remains contiguous and in communication with the
left iliopsoas compartment. (Bottom) Hemorrhage distends the prevesical space.

II
11"
 RETROPER1TONEUM
E COMMUNICATION AMONG EXTRAPERITONEAL SPACES

£
<D

2
IT
••
c
a>
E
o Prevcsical space
■o
XI
<

Urinary bladder -

Perivesical space

Rectovesical pouch
I'rcsacral space
Rectum

Blood in perivesical
spaces

Urinary bladder
(balloon-tipped
catheter)
— Blood in rectovesical
space

Rectum -

(Top) Blotxl tracks from the prevcsical space into the perivesical and presacral spaces. A small amount of blood has
entered the peritoneal cavity and has settled into the rectovesical space or, pouch of Douglas. In this patient, blood
has "descended" from its primary site of origin in the abdominal wall and retroperitoneum to the pelvic
extraperitoneal spaces. The opposite can also happen, as with a pelvic fracture leading to extensive pelvic
extra peritonea I bleeding that extends up into the abdominal retroperitoneum. (Bottom) Note the distinction
between the rectovesical space (pouch of Douglas), an intraperitoneal recess, and the perivesical and presacral spaces,
divisions of the pelvic extraperitoneal spaces.
II
4I«
 RETROPERITONEUM
RETROPERITONEAL LIPOSARCOMA

Duodenum

- Pancreatic head
Myxoid pOItkMi of tumor

Patty components of tumor

Myxoid part of tumor -

Ascending colon

Lipomatous parts of tumor

Ascending colon

1 iposarcoma — Descending colon

(Top) First of three axial CT sections of a patient with vague abdominal discomfort, discovered to have a large
retroperitoneal liposarcoma. This section shows a large heterogeneous mass in the right side of the abdomen. Its
retroperitoneal location is indicated by displacement of other retroperitoneal organs, such as the pancreas, to the left.
The mass has large lipomatous (fatty) elements, similar in density to normal fat around the left kidney. A rounded
part of the mass, however, is of "soft tissue density", probably due to a myxoid component. (Middle) The tumor
compresses and displaces the right kidney, indicating its origin in the perirenal space. The ascending colon is
displaced to the left side of the abdomen. (Bottom) All of the bowel is displaced to the left side of the abdomen by
the tumor. The tumor was resected, along with the right kidney.
 RETROPERITONEUM
RETROPERITONEAL FIBROSIS

Ureteral stent

"Mass"

Ureteral stent

(Top) First of four images of a patient with retroperitoiieal fibrosis. Frontal radiograph shows a left ureteral stent that
was placed to relieve obstruction of the left ureter. The position of the stent indicates medial deviation of the middle
part of the ureter. (Bottom) First of three axial CT sections shows a "mass" encasing the aorta and IVC at the level of
the 3rd lumbar vertebra.
 RETROPERITONEUM
RETROPERITONEAL FIBROSIS >
Q.
O
3
CD

3D
CD
3
<!>

o
— Fibrotk mass
CD
C
Urvteral stem
3

— FlbmtlC mass

Drctcral stc-nt

(Top) A more caudal section shows that the periaortic fibrotic mass has encased the left ureter as well as the great
vessels. The mass appears as a mantle of tissue around the aorta. (Bottom) A more caudal section shows that the
periaortic fibrotic mass has encased the left ureter as well as the great vessels. The mass appears as a mantle of tissue
around the aorta.

II
421
 RETROPERITONEUM
NERVE SHEATH TUMOR

Tumor —

C o m m o n iliac arteries —

C o m m o n iliac artery —

(lop) First of three axial CT sections shows a mass that encases the abdominal aorta with more of a bulky tumor
appearance than would be typical for retroperitoneal fibrosis. The mass is eccentric, and appears to arise in the right
para-aortic region of the retroperitoneum. (Middle) The mass, a nerve sheath tumor, envelops the common iliac
arteries bilaterally. (Bottom) The nerve sheath tumor follows the course of the right common iliac artery. The major
autonomic nerve trunks that innervate the abdominal and pelvic viscera run parallel to the spine, and their major
branches course parallel to major blood vessels.
 RETROPERITONEUM
LYMPHOMA WITH RETROPERITONEAL LYMPHADENOPATHY

Mesenteric nodi'

Portal vein
Portocaval node

Relro|X'ritoiical node

Mesenteric nodes

Retroperiloneal nodes

Fxtcrnal iliac lymphadcnopathy

External iliac vessels

(Top) First of three axial CT sections of a patient who presented with night sweats and weight loss, subsequently
diagnosed with non-Hodgkin lymphoma. This section shows splenomegaly and enlarged lymph nodes in several
groups, including retroperitoneal. (Middle) While enlargement of retroperitoneal nodes is common in lymphoma,
tumor involvement of the mesenteric nodes is especially characteristic ot tfiis malignancy. (Bottom) Massive
enlargement of the external iliac lymph nodes bilaterally is also evident. Lymphoma is the most common
malignancy that causes widespread lymphadcnopathy, involving multiple abdominal nodal chains. Primary pelvic
malignancies may also spread to retroperitoneal nodes.
 ADRENAL
■ Very c o m m o n (at least 2 % of general |K>pulation),
[ Terminology but usually cause n o symptoms
Abbreviations ■ Most are "nonfunctioning" or
• Adrenal corticotrophic h o r m o n e (ACTI I) "non-hvperfunctioning" adenomas; identical on
imaging to tunctional adenomas that cause
Gushing or Conn syndrome
[Gross Anatomy c Usually contain abundant lipid (precursor t o steroid
hormones)
Overview > Lipid is intra t< intercellular, not in macroscopic
• Adrenal (suprarenal) glands are part of the endocrine deposits of fat
and neurological systems . Can be identified by CT and MR sequences that
c Essentially different organs within the same show lipid-rich mass
structure c Best CT technique: N o n e n h a n c c d CT with nodule
Lie within the perirenal space bilaterally, bounded measuring < 15 HU; or enhanced C l with nodule <
by the renal (perirenal) fascia 37 HU or showing "washout" (decreased
Lie above and medial to kidneys enhancement on delayed CT)
c Best MR techniques: In - ancl opposed-phase MR
Relations with signal dropout in nodule on Opposed phase
• Right adrenal is more apical in location ( ushing s y n d r o m e
I ies anterolateral to right cms of diaphragm, medial Due to excess cortisol
to liver, posterior to inferior vena cava (IVC) - Signs: Iruncal obesity, hirsutism, hypertension,
Often pyramidal in shape, inverted "V" shape on abdominal striae
transverse section Causes: Pituitary tumors (-• ACTH). exogenous
• Left adrenal is more caudal, lies medial to uppei pole (medications) > adrenal adenoma > carcinoma
of left kidney, lateral to left cms of diaphragm, C o n n s y n d r o m e (excess aldosterone)
posterior to splenic vein & pancreas Signs: Hypertension, hypokalemic alkalosis
1
Often crescentic in shape, "lambda" or triangular on Causes: Adrenal adenomas > hyperplasia >
transverse section carcinoma
Addison s y n d r o m e (adrenal insufficiency)
Divisions Signs: Hypotension, weight loss, altered
• Adrenal cortex pigmentation
e Derived from mesodcrm c Causes: Autoimmune > adrenal metastases > adrenal
Secretes corticoslcmids (cortisol. aldostcrouei and hemorrhage > adrenal infection
androgens I ' h e o c h r o m o c y t o m a (tumor of adrenal medulla)
• Adrenal m e d u l l a Signs: Headache, palpitations, excessive perspiration
- Derived from neural crest (due to excess catecholamines)
c Part of the sympathetic nervous system c 9 0 % arise in adrenal, 9 0 % unilateral, 9 0 % benign
( h r o m a f f m cells secrete c a t c c h o l a m i n c s (mostly ■ Similar t u m o r arising in other c hromaftin cells of
epinephrine) into bloodstream sympathetic ganglia is called p a r a g a n g l i o m a
• Vessels, nerves & l y m p h a t i c s ( Mav occur in syndromes, including
Arteries ■ Multiple endocrine neoplasia (often with thyroid
■ Superior a d r e n a l arteries: (6-8) from interior & parathyroid tumors)
phrenic arteries ■ Neurofibromatosis
■ Middle a d r e n a l artery: (I) from abdominal aorta ■ Von Hippel Lindau (along with renal & pancreatic
■ Inferior a d r e n a l artery: (1) from renal arteries cysts and tumors. C.NS hemangioblastomas)
c Veins
■ Kigiit a d r e n a l vein drains into IVC
■ Left adrenal vein drains intc) left renal vein [Clinical Implications
(usually after joining left inferior phrenic vein I
■ Nerves Clinical Importance
■ Extensive sympathetic connection to adrenal • Rich blood supply of adrenals reflects important
medulla endocrine function
■ Presynapttc sympathetic fibers from paravertebral c Results in adrenal glands lx>ing c o m m o n site for
ganglia end directly on the secretory cells of hematologic metastases (lung, breast, melanoma,
medulla etc.)
Lymphatics • Adrenal glands are designed to r e s c i n d to stress
■ Drain t o l u m b a r laortic and cavall n o d e s (trauma, sepsis, surgery, etc.) by secreting more
cortisol k epinephrine
" Overwhelming stress may result in a d r e n a l
|rAnatomy-Based Imaging Issues h e m o r r h a g e , acute adrenal insufficiency
(Addisouian crisis)
Key Concepts
• Adrenal (cortical) a d e n o m a s

..
 ADRENAL
ADRENAL VESSELS & RELATIONS

^"***
Inferior phrenic artery
WWW
Superior adrenal
arteries
Middle adrenal artery

Inferior adrenal artery

Left adrenal vein

I
The adrenal glands rest atop the kidneys, with an Interposed layer of fat. Reflecting their critical role In maintaining
homeostasis and responding to stress, the adrenal glands have a very rich vascular supply. The superior adrenal
arteries are short branches of the inferior phrenic arteries bilaterally. The middle adrenal arteries are short vessels
arising from the aorta. The inferior adrenal arteries are branches of the renal arteries. The left adrenal vein drains Into
the left renal vein, while the right adienal vein drains directly Into the IVC. (The size of the adrenal glands Is
somewhat exaggerated in this illustration, to facilitate demonstration of the vascular anatomy.)
 ADRENAL
CD ADRENAL AXIAL ANATOMY & RELATIONS
C
(D
i_

<
■ *

C
a
E
o
"D
<

Pancreas
Splenic vein
Right adrenal Left adrenal

Diaphragmatic crura
Left kidney

Capsule

■ Cortex

Medulla

(Top) The right adrenal is often more cephalic in location, and lies above the right kidney, while the left adrenal lies
partly in front of the upper pole of the left kidney. The left adrenal lies directly posterior to the splenic vein and body
of pancreas, and lateral to the left crus of the diaphragm. The right adrenal lies lateral to the crus, medial to the liver,
and directly behind the inferior vena cava. (Bottom) The adrenal gland is essentially two organs in a single structure.
The cortex is an endocrine gland, secreting primarily cortisol, aldosterone, and androgenic steroids. All of these
hormones are derived from cholesterol, which imparts the characteristic lipid-rich appearance and Imaging
characteristics of the gland. The adrenal medulla is part of the autonomic nervous system and secretes epinephrine
II and norepinephrine.
42 b
 ADRENAL
CT, NORMAL ADRENAL ANATOMY >
O"
Q.
O
3
CD

Splenic vein
Right adrenal
Left adrenal
s
Left kidney

Right adrenal

Left adren.il

- — Splenic vein

— Left adrenal

(Top) lirst of three axial CT sections shows normal adrenal glands bilaterally. The right adrenal is usually suprarenal,
touches the back of the IVC and lies lateral to the right cms isc medial to the liver. The left adrenal usually lies ventral
to the upper pole of the left kidney and behind the splenic vein. The left adrenal often appears as an inverted "Y"
shape, while the right is more like an inverted "V". (Middle) Roth limbs of the right adrenal are seen on this section.
(Bottom) The lowest portions of the adrenals are seen on this section.

II
4_>7
 ADRENAL
CO ADRENAL VENOCRAM
c

a ■

c Right adrenal vein

E
o
■o
-Q
<

— Angiographic catheter
in 1VC

Left adrenal vein

Catheter in If ft renal
vein

(lop) First of two images showing selective catheterization of the adrenal veins in a young woman with
hyperaldosteronism, but no definite mass seen on CT. Selective adrenal vein sampling was requested to assess
unilateral excess aldosterone secretion. A catheter has been inserted through the right femoral vein and the tip was
advanced into the opening of the right adrenal vein. The adrenal veins are very fragile and could be easily ruptured
by a forceful injection of contrast medium. The angiographer must know the vascular anatomy and gently probe the
venous orifice, confirming the location with a small bolus injection of contrast medium, as shown here. (Bottom) A
subsequent image shows the catheter repositioned. The tip has been advanced through the left renal vein to enter
II the left adrenal vein. No attempt is made to opacify the smaller venous tributaries.
428
 ADRENAL
MR, NORMAL ADRENAL ANATOMY >
ao
3

>
IVC
Aorta a.
u
0)

L e f t Y11 r i - n J t. i j ■ I • r. i j; i ■ i
Right adrenal

Right hemidiaphragm

Splenic vein

— Left adrenal

Right cms of diaphragm Left cms

Right adrenal

Right kidney

(Top) l-'irsl of three MR images of normal adrenal glands is a contrast-enhanced Tl -weighted axial image that shows
the thin, parallel limbs of the right adrenal gland. (Middle) A more caudal enhanced section shows the left adrenal.
(Bottom) Coronal IZ-weighted image shows the pyramidal shape of the right adrenal gland in its usual suprarenal
location. The left adrenal is not included in this plane of section.

II
 ADRENAL
CO C O R O N A L , N O R M A L ADRENAL A N A T O M Y
c
e
<
••
C Spleen
0)
E
— I eft adrenal
<
Right adrenal
— Left kidney

Cnira of diaphragm

Left adrenal
Right adrenal

flop) Hirst of two coronal CT sections shows the adrenal glands in their suprarenal location, accounting for the
alternate name, "suprarenal glands". (Bottom) More anterior coronal CT image shows the adrenal glands and their
relations to adjacent structures.

II
-1M)
 ADRENAL
AXIAL & CORONAL, N O R M A L ADRENAL ANATOMY >
Q-
O
3
a
3
•*
Pancreas >
Q.
Splenic vein

2— Left adrenal 0)
Right adrenal

Diaphragmatic crura Left kidney

Right adrenal
Left adrenal

— Azygous vein
Right kidnc)

Right adrenal

(Top) first o f three CT images o f a subject w i t h n o r m a l adrenal glands shows c o n v e n t i o n a l a n a t o m y . ( M i d d l e ) More

caudal section shows b o t h adrenal glands w i t h an inverted "Y" appearance. There is m i l d t h i c k e n i n g o f t h e left
adrenal g l a n d at t h e confluence o f the medial & lateral limbs, a n o r m a l f i n d i n g . ( B o t t o m ) This coronal v i e w
demonstrates the relation between t h e adrenals a n d adjacent organs.

II
-m
 ADRENAL

Graphic shows the appearance of the adrenal and kidney in the fetus and neonate. The adrenal is much larger
relative to the kidney than in the adult. The kidney has a lobuiated appearance, reflecting the ongoing fusion of the
individual renal lobes, each comprised of one renal pyramid and its associated renal cortex.
 ADRENAL
NEONATAL ADRENALS & KIDNEY >
a
o
3
3
■ ■

Adrenal - 3
03

Kidney

Adrenal

Kidney -

(Top) First of three ultrasound images of a neonate, showing the characteristic prominence of the adrenal gland and
the lobation of the renal surface in early infancy. This sagittal image shows the large adrenal gland adjacent to the
upper pole of the kidney. (Middle) Sagittal ultrasound shows the prominent limbs of the right adrenal gland.
(Bottom) Sagittal ultrasound of the kidney shows its lobulated contour, a normal finding in the fetus and neonate.

II
431
 ADRENAL
CO CT, ADRENAL A D E N O M A
c
■D
<
••
c
o
E
o - Pancreas
■o Right adrenal
.a
< - Adrenal adenoma

- Kidney

- Adenoma

- Left adrenal

(Top) first of three axial CT sections shows a typical adrenal adenoma. Within the left adrenal gland is a
homogeneously low density mass (compare with kidney & pancreas). The low density (attenuation) reflects the
presence of intra- a n d extracellular lipid within adenomas, a characteristic feature that allows distinction of
adenomas from other types of adrenal masses. (Middle) The adenoma is present within an otherwise
normal-appearing left adrenal gland. Patients with adenomas may he symptomatic (e.g., signs of excess cortisol or
aldosterone) or asymptomatic. Most subjects have the adrenal lesion discovered incidentally on a CT scan performed
for some other reason a n d have n o clinical symptoms or signs. In this setting, the adenoma is said t o be
II nonfunctional. (Bottom) This section shows a normal appearing lower part of the left adrenal.
•H4
 ADRENAL
M R , ADRENAL A D E N O M A

Adenoma —

Kidney

Adenoma —

(Top) Hirst of four MR images in a patient with a right adrenal adenoma shows a homogeneous rounded suprarenal
mass on a IT-weighted in-phase GRE image. (Bottom) An axial Tl-weighted opposed-phase GRE image through the
same level shows marked loss of signal (lesion darkening) of the adrenal mass, confirming the presence of lipid and
water protons evenly distributed throughout the mass. This finding is diagnostic of adrenal adenoma.
 ADRENAL
TO MR, ADRENAL ADENOMA
C

3
o
E
o
■o
<

Adenoma
— Left adrenal

Right crus -

Kidney —

(Top) An axial I"2-weighted image through the same level shows that the adenoma is of relatively low signal
intensity, unlike the heterogeneous high signal characteristics of most malignant adrenal masses. (Bottom) This
coronal image confirms the suprarenal position and homogeneous low signal of the right adrenal adenoma.

II
 ADRENAL
ADRENAL HYPERPLASIA >
cr
Q.
O
3
■ ■

Right adrenal -
— Left adrenal

Right adrenal
Left adrenal

Lateral limb (right adrenal) Left adrenal

Medial limb

(Top) l-'irst of three axial CT images of a 40 year old woman with congenital adrenal hypcrplasia shows diffuse
enlargement of both adrenal glands, but preservation of their normal shape. (Middle) Each limb of the adrenal is in
excess of 1 cm in diameter, one criterion used to diagnose or suggest adrenal hyperplasia. Most patients with adrenal
hypcrplasia have less markedly enlarged glands due to pituitary (or ectopicl production of excess adrenal
corticotrophic hormone (ACrH). In many cases the adrenal glands may appear normal by imaging. (Bottom) The
striking enlargement of the adrenals is evident on this image.

II
437
 ADRENAL
co PHEOCHROMOCYTOMA

0)
E
o
■o
<

— Spleen
Pheochromocytoma —

Left kidney
Right kidney —

Pheochromocytoma —
Left kidney

(Top) First of four MR images of a patient with episodic hypertension, headaches and flushing. This coronal T2W1
shows a large heterogeneous, bright mass in the right adrenal region. (Bottom) An axial T2VVI shows the large
heterogeneously bright adrenal mass. This is a typical appearance for an adrenal pheochromocytoma. though
diagnosis rests on a combination of clinical, ialx>ratory (excess catecholamines), and imaging criteria.

II
Ai8
 ADRENAL
PHEOCHROMOCYTOMA >
C7
D.
O
3
o
3
■ ■

rhcochromocytoma —
— Left kidney

I'hcochromocytoma —
Lett kidney

(Top) An axial TIWI in-phasc CiRE image shows a heterogeneous. large right adrenal mass. (Bottom) An axial TIWI
opposed-phase GKE image shows no selective signal dropout from the mass, indicating that it does not contain
excess lipid, as would be expected for an adrenal adenoma.

II
4t'»
 ADRENAL
03 A D R E N A L METASTASES
C

■D
<
•-
C
0>
E
o
"O

<

Liver metastasis

— Left adrenal mass

Right adrenal mass

I ivcr ntetastases —

Right adrenal mass Lett adrenal mass

(Top) First of two axial CT sections in a patient with pancreatic carcinoma shows bilateral heterogeneous, nodular
adrenal masses. Also evident are several heterogeneous, low density liver masses. These all represent metastatic foci,
l.ung, breast, and renal cancer, along with malignant melanoma frequently metastasize to the adrenal glands due to
the rich blood supply of the adrenals. (Bottom) A more caudal section shows more of the nodular adrenal
metastases.

II
440
 ADRENAL
ADRENAL INSUFFICIENCY >
a.
o
3
o
D
■ ■

>
i eft adrenal Q.
Right adrenal
O
0)

I— Left adrenal

j — Splenic vein
— Left adrenal

flop) first of three axial CT sections in a patient with adrenal insufficiency (Addison syndrome) due to autoimmune
disease. The adrenal glands are extremely small. (Middle) Ihe small adrenals are again evident. If adrenal
insufficiency were due to adrenal tumors, bleeding, or infection, the glands would be enlarged. (Bottom) The adrenal
glands have a normal shape but are extremely small.

II
111
 ADRENAL
ADRENAL HEMORRHAGE

•-
c
0)
E
o
TJ
Left adrenal
<

Left adrenal hcmatoma

I'.T;;IH adrenal bleeding

— Pancreas

Left adrenal
Right adrenal

Left kidney
Right kidney

(Top) First of five n o n e n h a n c e d axial CT sections in a patient who was hypotensive from hemorrhage due to blunt
abdominal trauma. Both adrenal glands are markedly enlarged a n d t h e left adrenal has heterogeneous high density
material within it, characteristic of acute hemorrhage. (Middle) Bleeding is evident within a n d around t h e adrenal
glands. (Bottom) In this, a n d most patients, t h e adrenal hemorrhage is in response t o the stress of shock, which leads
t o an outpouring of adrenal cortical a n d medullary hormones. Excessive stimulation can result in adrenal
enlargement o r spontaneous adrenal hemorrhage, as in this patient.

II
442
 ADRENAL
ADRENAL HEMORRHAGE >
o-
Q.
o
3
a
>•

CD
=3
03

— Left adrenal

Right adrenal

Pancreas

Left adrenal
ivc:

(Top) A repeat CT scan in the same patient three m o n t h s later shows essentially normal appearing adrenal glands.
Adrenal hemorrhage may result in destruction of the glands with adrenal insufficiency, or the adrenal glands may
survive without permanent damage. (ISottom) The normal left adrenal gland is seen o n this section.

II
443
 ADRENAL
CO ADRENAL CARCINOMA

3 Adrenal mass -

E
o Kidney -

<

Adrenal c a r c i n o m a -

Kidney —

Adrenal c a r c i n o m a

(Top) First of three MR sections in a patient with Gushing syndrome due to adrenal carcinoma. This coronal
T2-weighted MR image shows a heterogeneous. large right adrenal mass. (Middle) An axial T I -weighted MR section
shows the heterogeneous mass above the right kidney. (Bottom) An axial opposed phase GRE image shows no
selective dropout of signal from the mass, indicating that it does not contain excess lipid, as would he exiiected for a
benign adrenal adenoma. The size and heterogenicity of the mass are typical for adrenal carcinoma. Tumors arising
from the right adrenal gland are especially prone to invasion of the IVC through the short right adrenal vein, leading
to lung and systemic metastases.
II
•144
 ADRENAL
GASTRIC DIVERTICULUM SIMULATING ADRENAL MASS >
Q.
O
3
©
3
Stomach ■ ■

£
a

Gastric divertieulum

Left kidney

Divertieulum

- Left adrenal gland

Left kidney

Gastric divertieulum -
— Gastric fundus

(Top) Axial CT image shows a cystic appearing "lesion" in the left suprarenal region, simulating an adrenal mass. The
mass has the same density as the water-filled stomach. (Middle) A more caudal CT section shows part of the normal
left adrenal gland, which is displaced medially by the gastric divertieulum. On axial sections, it is difficult t o
recognize the gastric origin of the divertieulum. Administration of oral contrast medium or gas-producing granules
can be helpful in identification. (Bottom) An oblique film from a barium upper GI series shows the barium-filled
divertieulum, projecting posteriorly from the gastric cardia.

II
445
 KIDNEY
| Cross Anatomy
Overview
• Kidneys arc paired, bean-shaped relroperlloneal organs
I unction: Remove excess water, salts and wastes ot
protein metabolism from tbc blood
Anatomic Relationships
• I ie in retropcritoneum, within peri renal space,
surrounded bv renal fascia (of (ierota)
• Each kidney is - 10-15 cm in length. 5 cm in width
• Moth kidneys lie oil quadratics liimborum muscles,
lateral to psoas muscles
Internal Structures
• Kidneys can be considered hollow with renal sinus
occupied bv tat. renal pelvis, caliccs. vessels and nerves
• Kenal hilum Where artery enters, vein and ureter
leave renal Minis
• Renal pelvis: Funnel-shaped expansion ot the upper
end ot the ureter
Receives major caliccs (inltuidihula) (2 or i), each
ot which receives m i n o r caliccs (2-4)
• Renal papilla: Pointed a|ic\ ot the renal pyramid ot
collecting tubules th.it excrete urine
o Each papilla indents a minor calyx
• Renal cortex: Outer part, contains renal corpuscles
(glomeruli, vessels), proximal portions of collecting
tubules K loop of I len le
• Renal medulla: Inner part, contains renal pyramids,
distal parts ot the collecting tubules and loops of
Henle
• Vessels, nerves, and lymphatics
\rtery
■ Usually one for each kidney
■ Arise troin aorta at about I 1-2 vertebral level
Vein
■ Usually one lor each kidney
■ Lies in front ol renal arlery and renal pels is
c Nerve?.
■ \utonomic from renal and aortiioienal ganglia
and plexus
o Lymphatics
■ lb lumbar (aortic and casall nodes
Anatomy-Based Imaging Issues
Key Concepts
• Accessory renal vessels
Iceessorv arteries and veins are common
May arise from aorta or common iliac vessels
Must I t accounted for in planning surgery (e.g.,
reset lion, transplantation)
Clinical Implications
Clinical Importance
• Renal colic
t alculi ("stones') may form within {* obstruct the
renal caliccs or ureter
■ Causes: Dehydration, gout, urinary infection.
idiopathic
Obstruction plus periodic peristalsis ol ureter result
in spasms ot severe pain, radiating to flank and
groin
• Renal carcinoma
Tumor invasion of renal vein — lung metastases
(common), plus bone is systemic metastases
Strong renal tascia usually prevents direct invasion
of adjacent organs and bodv wall
• Renal cysts
I vtremely common (> 50% of adults have at least
one)
Etiology unknown, but tilled with clear fluid lined
by simple cuboida) epithelium
Imaging studies can usually distinguish from
neoplasm
Embryology
E m b r y o l o g i c Events
• Congenital anomalies of renal number, position,
structure and torm are very common
Often accompanied bv anomalies ol other systems
VAI ER acronym
■ Vertebral
■ Anorectal (e.g., atrcsia)
■ Iracheoesophageal (e.g., I'-E fistula)
■ Radial (e.g., hand & wrist anomalies or absence)
■ Renal (e.g., agenesis, ectopia)
c Congenital absence ot kidney
■ COmmonly associated with ipsilateral anomalies
of geriital tract (e.g., seminal vesicle absence or
cyst; ulerovaginal atrcsia or duplication)
i Anomalies of position (ectopia) are common
■ Often due to failure to ascend from pelvic location
where fetal kidneys lie close together
■ May l>e accompanied by fusion of kidnevs;
crossed fused ectopia and "horseshoe kidney" (\
in 400 adults)
■ Accompanied by anomalies of vessels, ureters
■ More vulnerable to trauma, calculi,
hydronephrosis
Anomalies of structure
■ t ongenitally large septum ol Berlin dobar
dysmorphismi. asymptomatic, but may simulate
mass; in mid-kidney, composed of normal cortex
displacing collecting system
■ fetal lobulations (lohationi. single or multiple
indentations of the lateral renal contours;
represent persistent clefts between renal lobules
(must distinguish from cortical scarring from
infection or ischemia)
■ Partial duplication: Commonly results in
enlarged kidney with 2 separate hila. 2 ureters
imav join downstream or join bladder separately);
duplex kidnev = bit id renal pelvis, single ureter
Autosomal dominant polycystic disease: ( ommon
hereditary disorder characterised by multiple renal
cysts, progressive renal failure & various systemic
manifestations (such as cerebral aneurvsins)
 KIDNEY
KIDNEYS IN SITU >
a-
Q.
O
Inferior phrenic vessels
3
3

CD
Right adrenal vein
Left inferior adrenal
vessels
Renal veins

Left gonadal vein

Right gonadal vein

Superior mesenteric
artery

Gonadal arteries

Inferior mesenteric
artery

Renal artery

Renal vein

Renal pelvis

Capsule (incised &

peeled back)

(Top) The kidneys are retroperitoneal organs that He lateral to the psoas and "on" the quadratus lumborum muscles.
The oblique course of the psoas muscles results in the lower pole of the kidney lying lateral to the upper pole. The
right kidney usually lies 1-2 cm lower than the left, due to Inferior displacement by the liver. The adrenal glands lie
above and medial to the kidneys, separated by a layer of fat and connective tissue. Peritoneum covers much of the
anterior surface of the kidneys. The right kidney abuts the liver, hepatic flexure of colon and duodenum, while the
left kidney is in close contact with the pancreas (tail), spleen, and splenicflexure.(Bottom) The fibrous capsule Is
stripped off with difficulty. Subcapsular hematomas do not spread far along the surface of the kidney, but compress
the renal parenchyma, unlike most perirenal collections. II
447
 KIDNEY
KIDNEY ARTERIES & INTERIOR ANATOMY

Adrenal

Arcuate arteries
Cortical column (of
Bertlnj
Interlobar arteries

Interlobular arteries
Inferior adrenal artery

Superior segmental
Anterior superior
artery segmental artery
Posterior segmental
artery —*-*T
Renal artery Anterior inferior
segmental artery

Inferior segmental
artery
Pelvic & ureteric
branches
Renal pyramid

Renal papilla

Renal cortex

The kidney is usually supplied by a single renal artery, the first branch of which is the inferior adrenal artery. It then
divides into five segmental arteries, only one of which, the posterior segmental artery, passes dorsal to the renal
pelvis. The segmental arteries divide into the Interlobar arteries that lie In the renal sinus fat. Each interlobar artery
branches into 4 to 6 arcuate arteries that follow the convex outer margin of each renal pyramid. The arcuate arteries
give rise to the interlobular arteries that lie within the renal cortex, including the cortical columns (of Bertin) that
lnvaglnate between the renal pyramids. The interlobular arteries supply the afferent arterioles to the glomeruli. The
arterial supply to the kidney is vulnerable as there are no effective anastomoses between the segmental branches,
each of which supplies a wedge-shaped segment of parenchyma.
 KIDNEY
CTUROGRAM

12th rib Minor cahces

Major calices
Renal pyramids

Renal pelvis

Urinary bladder

A coronal reconstruction of a series of axial CT sections can be viewed as a surface-rendered 3D image to simulate an
excretory urogram. The window levels and workstation controls have been set to display optimally the renal
collecting system. The color scale is arbitrary; in this case, opaclfled urine is displayed as "white". Less dense urine
within the renal tubules In the pyramids and the diluted urine within the bladder are displayed as "red". The CT scan
was obtained in deep, suspended inspiration, resulting In caudal displacement of the kidneys. In the supine position
at quiet breathing, the upper poles of the kidneys usually lie in front of the 12th ribs.
 KIDNEY
>% MU1T1PLANAR CT
OJ
C
■g
■ ■
c — S t o m a c h (fundus)
o
E
o
■D
.Q Liver — J
< Spleen

— - Left psoas muscle

Ascending colon —

— Stomach
Superior mesenteric — ■
vein
t — Pancreas

1VC 4 — Left renal v e i n

— Left renal artery

Quadratus lumhorum
muscle

Psoas muscle —

(Top) First of four CT images in different planes in a thin subject with little abdominal fat. Coronal image shows the
kidneys and their neighboring organs and structures. The kidneys lie on the quadratus lumhorum. and lateral to the
psoas muscles. The oblique course of the psoas muscles results in the lower poles of the kidneys lying lateral and
ventral to the upper poles. (Bottom) This axial image is at the level of the upper pole of the right kidney and the
hilum of the left kidney. The left renal vein enters the IVC on this section, after passing behind the superior
mesenteric vessels. The renal hila face anteriorly and medially.
II
4S0
 KIDNEY
MULTIPLANAR CT >
cr
a
o
3
— .Stomach o
3
■ ■

— Spleen a!
Liver (lateral segment) —
CD
— Splenic artery & vein

— Pancreas

Rectus muscle —
— Quadratus lumborum
muscle

— I.iver

Gallbladder —

— Renal pyramids

Major calices —

(Top) Sagittal section through the left kidney; note its oblique orientation with the upper pole lying more posterior
than the lower pole. Note the relationship of the left kidney to the spleen and pancreas. (Bottom) Sagittal section
through the right kidney. The renal pyramids are the groups of renal collecting tubules that appear more dense than
the renal cortex on this late parenchymal phase of CI' imaging, when the urine is being opacified by contrast
material prior t o excretion. Urine in the calices is not yet opacified.

II
451
 KIDNEY
CT, CORTICOMEDULLARY & PYELOGRAPHIC PHASES
C

— 1 horacic vertebra ] 1
E
o Spleen

<

- Major calicos (infuiidilnilal

— Stomach

— Spleen

Renal cortex

Renal medulla (renal pyramids)

—
Major calicos

Renal pelvis (bifid) -

— Minor calicos

Proximal ureter — Renal papillae

(Top) First of three CT images of the kidneys. In the cortico-medullary phase of contrast opacification the urine in
the collecting systems is not yet opacified. The renal pyramids are lucent relative to the cortex. (Middle) The cortex
contains the renal corpuscles (glomcruli *•* proximal luhulcs) while the medulla is comprised of the distal collecting
tubules. Note the peripheral renal cortex and the columns of cortex that are interposed between the renal pyramids.
The greater enhancement of the cortex reflects its increased blood flow compared with the medulla. (Kottom) In this
excretory phase image the calices and renal pelvis are filled with densely opacified urine. The renal pelvis is bifid, a
normal variant. The renal papillae are the apices of the renal pyramids and these are opacified by urine that is
II becoming progressively concentrated within the distal collecting tubules.
4r>2
 KIDNEY
EXCRETORY UROCRAM >
a
o
3

Renal papilla CD
•<

Minor i.ilvx —
Major calyx
(infuncliliiiluni)

Renal pelvis —

Ureter —

Renal papilla

Kenal pelvis

— Major calyx

Minor caliccs

Ureter —

(Top) Frontal film from an excretory urogram, also known as an "intravenous pyelogram" (1VT), shows the collecting
systems and ureters. The right ureter is dilated due to a distal ureteral stone. The renal pelvis is the funnel-shaped
expansion of the upper ureter and it receives two or three major calices (infundihula). Each major calyx receives
several minor calices a n d each minor calyx is indented by a renal papilla, the apex of t h e renal pyramid from which
urine is excreted. Each renal pyramid and its associated cortex form one lobe of the kidney. The rerial lolies are
readily visible in the human fetus and persist in some adults (and many animals). (Bottom) A frontal film following
a left renal angiogram shows the collecting system. The number of major and minor calices can he quite variable
among individuals without clinical consequence. II
453
 KIDNEY
CORONAL OBLIQUE, NORMAL KIDNEY
CD
C
■g

CD
E
o
■o
Adrenal
<

Renal artery

Kidney

Renal vein

Renal sinus fat

Renal pelvis (bifid)

Renal medulla

Renal cortex

(Top) First of four coronal oblique CT images of the left kidney shows the renal artery and vein at the hilum. The
vein usually lies ventral to the artery and the renal pelvis. (Bottom) Note the renal sinus fat which accompanies the
renal vessels (interlobar) and calices in the central "hollow" core of t h e kidney. Note the columns of renal cortex
(columns or septa of Bertin) that lie between the renal pyramids (medulla).

II
 KIDNEY
C O R O N A L O B L I Q U E , N O R M A L KIDNEY >

Q.
O

3
3
• ■

CL
CD

— Renal cortical column

Renal pelvis —

Intcrlobar arteries

( l o p ) Note the p r o m i n e n t , somewhat r o u n d e d renal cortical c o l u m n . these focal collections o l cortical tissue may
protrude i n t o the renal sinus a n d separate t h e pyramids o f the renal medulla a n d may Lie mistaken for a renal tumor.
This is sometimes referred t o as a h y j w r t r o p h i e d c o l u m n of Rertin. ( B o t t o m ) The renal sinus fat and its
a c c o m p a n y i n g vessels a n d calices are well depicted o n this image.

II
455
 KIDNEY
NORMAL ULTRASONOGRAPHY
c
■D

C
Ol Liver —
E - I'erirenal tat
o Kcnal cortex —
■D Renal pyramid
-D Renal sinus
<

I iver —

Renal sinus -

— - Perirenal fat
Renal j>clvis

Liver — Renal cortex

Major calices
Renal sinus —

(Top) First of three ultrasonographic images of the right kidney. This sagittal section shows the long axis of the
kidney. Kenal cortex is usually slightly less echogenic than the liver, while renal sinus fat is quite echogenlc. The
renal pyramids are relatively sonolucent and the renal pelvis, when distended with urine, is anechoic (no echoes). Fat
within the perirenal space creates the echogenic interface between the kidney and the liver. (Middle) This transverse
(axial) image of the kidney shows the echogenic fat within the renal sinus and perirenal space in this thin subject.
(Bottom) A sagittal sonographic image of the kidney shows an electronic cursor being used to measure the
longitudinal axis of the kidney, which is usually 10-15 cm in length.
II
4>d
 KIDNEY
RENAL FASCIA & PERIRENAL SPACE >
cr
Q.
o
3
• n>
3

=3

Anterior renal fascia

Laterotonal fascia

Psoas (major) muscle

Posterior renal fascia

Quadratus lumborum
muscle Latisslmus dorsi muscle

Adrenal
v
Anterior renal fasda

Posterior renal fascia

Hepatorenal fossa
(MorUon pouch)

Peritoneum

iliac crest

Transverse colon
m

(Top) The anterior and posterior layers of the renal fasda envelope the kidneys and adrenals along with the perirenal
fat. Medial to the kidneys, the course of the renal fasda is variable (and controversial). The posterior layer usually
fuses with the psoas or quadratus lumborum fasda. The perirenal spaces do not communicate across the abdominal
midllne. However, the renal & lateroconal fasdae are laminated structures that may be distended with fluid
collections to form interfasdal planes that do communicate across the midllne and also interiorly to the
extraperitoneal pelvis. (Bottom) A sagittal section through the right kidney shows the renal fasda enveloping the
kidney and adrenal. Inferiorly the anterior and posterior renal fasdae come close together at about the level of the
lilac crest. Note the adjacent peritoneal recesses. II
4r>7
 KIDNEY
RENAL FASCIA & PERIRENAL SPACE
■g

CD
E
o
"O
-Q
Anterior renal fascia
<

Left adrenal

Spleen

Kidney

Anterior renal fascia

— Kidney

— Perirenal septa

(Top) first of five axial CT sections demonstrating the contents and boundaries of the perirenal space. The perirenal
space is bounded by the anterior and posterior renal fasciae, and within this space lie the adrenal and kidney, with a
variable number of vessels, nerves and lymphatics. (Bottom) The anterior renal fascia (also known as Gerota fascia) is
well demonstrated on this image. Also note the thin septa within the perirenal fat that may divide this space into
multiple, poorly communicating spaces.

II
458
 KIDNEY
K I D N E Y & P E R I R E N A L SPACE >
C
ao
Anterior renal fascia
3
I ateroconal fascia
Descending colon
a.'
Posterior pararenal space CD
Renal vein
Posterior renal fascia

Perirenal space

- Anterior renal fascia

Lateroconal fascia

Perirenal space

— Posterior renal fascia

Perirenal septa

Kidney (lower pole) Perirenal space ("pararenal fat

capsule")

Posterior pararenal space

("pararenal tat body")
Aponcurosis of transverse
abdominal muscle

( l o p ) T h e r e n a l a n d l a t e r o c o n a l fasciae a r e t h e key p l a n e s t h a t d e f i n e t h e t h r e e d i v i s i o n s of t h e r e t r o p e r i t o n e m n a n d
they are well demonstrated on this image. The descending colon (plus the duodenum and pancreas) lies in the
anterior pararenal space. Ihe lateroconal fascia is the lateral margin of the anterior pararenal space and the medial
margin of the posterior pararenal space. (Middle) Note the confluence of the renal and the lateroconal fasciae and
the renal with the quadratus lumborum fascia. (Bottom) A Hank incision may be used to approach the kidney, and
usually involves dividing the aponcurosis of the transverse alxlominal muscle to enter the retroperitoneum. First
encountered is the fat within the posterior pararenal space, sometimes relerred to as the "pararenal fat body'. Ihe
renal fascia is next seen, within which lies the perirenal space, also known as the "pararenal fat capsule". II
 KIDNEY
PERIRENAL PLANES
a?
c
•• - Pancreas
C - Descending colon
V
E
o
Duodenum
.a
<

- Descending colon

Puodenum — Latcroconal fascia

- Renal fascia

Renal vein —

• Posterior pararenal space

- Pcrirenal bridging sepia

Fusion or renal is quadratus

lumborum fascia

(Top) First of six axial C T sections shows the upper pole of the left kidney surrounded by extensive fat within the
pcrirenal space. The pancreas, duodenum and ascending/descending colon lie anterior to the renal fascia, within the
anterior pararenal space (Middle) The renal and lateroconal fascia are evident on this section. (Bottom) The
posterior pararenal space lies lateral to the lateroconal fascia and is synonymous with the "properitoneal fat stripe"
seen on abdominal radiographs. Note the fusion of the posterior renal fascia with the quadratus lumborum fascia.
Several perirenal bridging septa are visible within the perirenal space.

II
4M)
 KIDNEY
PERIRENAL PLANES

Anterior renal fascia

Peri renal septa

Posterior renal fascia

fusion of renal N: psoas fascia

Anterior renal fascia

Origin of inferior mescnteric artery

Perirenal septum

Lower pole of kidney

Pert renal sjace Renal fascia

(lop) On this section the renal fascia courses medially to fuse with the psoas fascia. (Middle) Some of the perirenal
bridging septa course parallel to the renal capsule and renal fascia and could be mistaken tor the renal fascia.
(Bottom) At a level just caudal to the iliac crest the layers of the renal fascia come close together to almost seal oil
the lower portion of the perirenal space.
 KIDNEY
CATHETER ANGIOGRAM

Arcuate arteries — Inferior adrenal artery

Interlobar arteries
— Superior segmental
artery

Anterior superior
segmental artery

Posterior segmental
artery

Inferior segmental
artery

A selective catheter injection of t h e right renal artery depicts the vessels to the level of the arcuate arteries, which
course along the convex surface of each renal pyramid.
 KIDNEY
RENAL ARTERY VARIANTS

Inferior adrenal artery

Early branching lower

pole renal artery

Right testicular artery

Aberrant upper polar

artery

Aberrant lower polar

artery

(Top) This graphic depicts proximal ramification (early branching) of the renal artety. This may have Important
implications if renal surgery is being considered. For instance, a person with this vascular anatomy might be
considered a poor candidate as a potential living renal donor, as "harvesting" this kidney might jeopardize the
inferior adrenal and lower pole renal artenes. (Bottom) This graphic depicts supernumerary renal arteries arising
directly from the aorta. Some of these enter the kidney at locations other than the renal hilum, close to the renal
poles. These "polar" or "extrahilar" arteries may be llgated or transected unintentionally during renal, aortic, or other
retroperitoneal abdominal surgeries. These are sometimes referred to as "accessory" renal arteries, but each is an end
artery and the sole arterial supply to a substantial portion of the renal parenchyma.
 KIDNEY
>-. MULTIPLE RENAL ARTERIES
CD
C
■g
■ »
c
o Celiac artery —
E
o
Right renal artery Left renal artery
■D
< Superior mesenteric artery

Left renal artery

Superior mesenteric artery

" Jejunal branch of SMA

- Left renal artery

- Inferior polar renal artery

(Top) Pirst of three images of a person being evaluated as a potential living renal donor. This CT angiogram seems to
show normal visceral arterial branches of the abdominal aorta. Overlap between the branches of the left renal and
superior mesenteric arteries prevents confident interpretation, based on this 3D rendering alone. (Middle) A "flush"
aortogram in a single frontal projection also leaves questions about renal and superior mesenteric arterial branches.
(Bottom) A workstation manipulation of the CT angiogram permits subtraction of extraneous overlying vessels to
reveal clearly a substantial aberrant left inferior polar artery arising directly from the aorta. The transplant surgeons
elected to harvest the right kidney for transplantation.
 KIDNEY
RENAL VEIN VARIATIONS

Conventional preaortic renal

kt/ Retroaortic renal vein

Supernumerary renal veins

1 Right gonadal vessels

Left sided IVC (empties Into left

renal vein)

(Top) Anomalies of the renal veins are less common than those of the arteries, but are encountered in clinical
practice and may have important implications. All anomalies are variations of the embryologic development and
persistence of portions of the paired longitudinal channels, the subcardinal and supracardinal veins, which form a
ladderlike collar around the aorta. Normally only the anterior components persist, becoming the renal veins, which
course anterior to the aorta. Persistence of the whole collar results in a circumaortic renal vein, which is depicted In
this graphic. This anomaly is more common than an isolated retroaortic renal vein. (Middle) Persistence of the collar
of veins on the right results in supemumerary right renal veins that encircle the renal pelvis. (Bottom) Persistence of
the left supracardinal vein below the kidney results in a "duplicated" IVC.
 KIDNEY
CIRCUM AORTIC LEFT RENAL VEIN
C

■ Left renal vein

E
o IVC -
■D
-Q
<

- Aorta
IVC filter

Retroaortic left renal vein - - (Renal calculi)

Catheter in IVC —r

Tip of catheter in preaortic left - I'reaortic left renal vein

renal vein

IVC —T

- Retroaortic left renal vein

(Top) First of three images demonstrating a circumaortic left renal vein. This CT section shows a small preaortic
(conventional) left renal vein as it joins the IVC. (Middle) A more caudal section shows a larger retroaortic left renal
vein joining the IVC. Also note the tip of an IVC filter, placed to prevent propagation of blood clots into the lungs
(pulmonary embolism). Knowledge of renal venous anomalies is important to avoid inadvertent injury to the renal
vein during mterventional or surgical procedures involving t h e IVC or aorta. (Bottom) Frontal film from inferior
vena cavagram preceding t h e CT scan. A catheter has been inserted through a n a r m vein a n d advanced so t h a t its tip
is in the left renal vein. Injection of contrast has passed retrograde through the preaortic left renal vein and is
II flowing antegrade through the larger, more caudal retroaortic renal vein.
4M>
 KIDNEY
LEFT RENAL VEIN COMPROMISED BY SMA >
CL
O
3
a
3
IVC Superior mesenteric artery

Kiglu renal artery

Splenic vein

I
Left renal vein

— Left renal vein

1 eft renal artery

Right renal vein - Superior mesenteric artery

Left renal vein

(Top) First of three images showing compression of tile left renal vein. This axial Cl section shows marked
narrowing of the left renal vein as it passes between the aorta and the superior mesenteric artery in this thin woman.
(Middle) A more caudal section shows distention ot the renal vein "upstream" from t h e compressed portion. This
may result in increased pressure within the renal vein with hematuria and flank pain, as in this patient. (Bottom)
This oblique coronal Cl angiogram shows the left renal vein as it passes between the aorta and the SMA.

II
4t»7
 KIDNEY
STACHORN CALCULI
C
•g
**
c
0)
E
o
•o
Si
<

— IVC filter

Renal calculus

— IVC filler

" S t a g h o m " calculus

(Top) Hirst of two (71 sections showing renal calculi. This non-enhanced axial CT section shows a large hypcrdensc
stone within the right kidney. (Bottom) A coronal reformation of the CT scan shows that the renal calculus fills and
conforms to the right renal calices. resembling the horns of a deer ("staghorn calculus"). Fssentially all renal calculi
are dense and easy t o recognize o n CT scans, while many stones are too small or insufficiently opaque to diagnose on
plain abdominal radiographs.

II
4(>K
 KIDNEY
M R , R E N A L CELL C A R C I N O M A >
CT
Q.

— Aorta i
O
3
•*
Q.
Tumor within IVC -

Tumor

Left kidney

1V(. (dbicrtded with tumor)

I eft renal artery

Left renal vein (distended with

tumor)

rumor within IVC

— Tumor in left renal vein

IVC (patent infrarenal)

(Top) First of three MR sections s h o w i n g a large renal cell carcinoma i n the left kidney. T h i s coronal section shows a
large mass that replaces most o f the left kidney. There is a large t i l l i n g defect w i t h i n t h e I V C , the t i p o f w h i c h
extends almost to the level o f the hepatic veins. ( M i d d l e ) A coronal section t h r o u g h the left kidney shows extension
o f the t u m o r i n t o the left renal vein a n d I V C ( B o t t o m ) Renal cell carcinoma often invades the renal vein a n d
extends i n r o the I V C Shedding o f t u m o r cells w i t h i n the IVC frequently results in l u n g a n d o t h e r systemic
metastases.

II
 KIDNEY
CT, RENAL CELL C A R C I N O M A
Q)
c
■ ■
C
©
E
o
■D
Lett renal vein (patent)
<
"Pseudothrombus'' in —
IVC

Right renal vein ■ — Left kidney (with lar^o

tumor)

— Tumor in proximal left

renal vein

Left kidney

— Tumor

(Top) First of four CT images of a patient with a large renal cell carcinoma in the left kidney. This axial
contrast-enhanced section shows tumor filling this portion of the left kidney. The tumor extends into the proximal
portion of the left renal vein, but not into the IVC Note the "pseudothrombus" of the IVC due to mixing of
unopacified blood from the legs and opacified blood from the renal veins. (Bottom) This coronal section shows the
large tumor that replaces most of the left kidney.

II
470
 KIDNEY
CT, RENAL CELL C A R C I N O M A

Aorta

IVC (with —
pseudot h rom bus)

Tumor in left renal

vein

IVC — Aorta

— Tumor

( l o p ) This coronal section shows tumor extending into the left renal vein, lurhulent flow and poor mixing of
opacified and unopacified blood within the IVC simulates tumor invasion. (Bottom) This coronal section also shows
the heterogeneous enhancement of the IVC that could be misinterpreted as invasion by the tumor. Careful analysis
of the axial and coronal sections is essential to avoid this clinically important misdiagnosis.
 KIDNEY
TRANSITIONAL CELL CARCINOMA
CD
C

• a
C
CD
E — rvc
o Renal pelvis (with tumor) -

3 - Aorta

Kidney -

- ivc:

Renal vessels
Kidney -

Renal pelvis (with tumor) —

( l o p ) First of six images of a patient with transitional cell carcinoma of the right renal pelvis. This axial
non-enhanced CT section shows a subtle hyperdcnsr mass within the right renal pelvis, but it is much less dense
t h a n a renal calculus. (Middle) The right kidney appears normal on this section. (Bottom) This section shows the
renal pelvis filled with tumor that, on cursor measurement, showed slight contrast-enhancement. The urine is not
yet contrast-opacified.

II
472
 KIDNEY
TRANSITIONAL CELL CARCINOMA

1
Tumor

Urine

Turaoi

Tumor

(Top) A re|K?al axial section after a 10 minute delay shows contrast-opacified urine and tumor within the renal pelvis.
(Middle) A more caudal section shows the tumor as a filling defect within the opacified urine in the renal pelvis.
(Bottom) A frontal film from a retrograde pyelogram shows the transitional cell carcinoma that arose from the
epithelium of the renal pelvis.

II
473
 KIDNEY
3^ SIMPLE CYST

-o
••
c
a>
E
o
■o
n
<

Cyst

Renal cortex

Cyst

Renal sinus

(Top) I he top image is an axial non-enhanced CT section that shows a water density spherical mass in the right
kidney. The lower image shows that there is no enhancement of the mass or its contents, and there is no visible wall.
These findings are diagnostic of a simple renal cyst. Renal cysts are present in almost 50% of individuals over the age
of 50, and are usually of no clinical concern. (Bottom) An axial sonogram shows a "sonolucent" mass (no internal
echoes), with no visible wall or mural nodularity, findings diagnostic of a simple cyst. The electronic cursor is used to
measure its size.
II
474
 KIDNEY
CONGENITAL ABSENCE OF KIDNEY >
Q.
O

I
■■

CD

I .eft adrenal

Colon
Right kidney

I Irinary bladder

Right seminal vesicle

Rectum

(Top) First of two images of a patient with congenital absence of the left kidney. An axial CT section shows a normal
right kidney and left adrenal gland, but n o left kidney. No kidney was found in an ectopic location. (Bottom) A
more caudal section shows a normal right seminal vesicle, but n o left seminal vesicle. Congenital absence of the
kidney is often accompanied by anomalies in other organ systems, including musculoskeletal, cardiovascular, and
genital. Congenital anomalies of the kidney and genital organs usually occur ipsilaterally (on the same side).

II
475
 KIDNEY
PELVIC KIDNEY
c
■g

o
E
o

<

Left renal vein

Ectopic (pelvic) kidney

(Top) First of two CT sections shows a normal right kidney in its usual location. The left kidney is not seen, though
the left renal vein is present. (Bottom) A CI" section through the pelvis shows an ectopic, malrotated, pelvic, kidney.
In the early embryo, both kidneys lie in the pelvis. As the fetus grows, the kidneys usually "ascend" to their normal
abdominal position, successively recruiting more proximal arterial and venous branches from the aorta and IVC.
Ectopic kidneys are invariably low in position and usually are malrotated with aberrant blood supply from the distal
aorta or iliac arteries.
II
476
 KIDNEY
CROSSED FUSED ECTOPIA >
a
o
3
— Left renal arterv a
3
■ ■

— Left renal vein

a!
13

— Left ureter

Right kidney

Lett renal pelvis

Crossed fused ectopic kidney

(Top) This graphic illustrates the typical appearance of a crossed fused ectopic kidney. The right renal unit develops
normally with conventional vascular anatomy. The left renal unit is fused to the lower pole of the right unit. The left
renal vessels and ureter have their normal origins a n d insertions, hut cross the midline to the left renal unit. Fctopic
kidneys are more vulnerable t o trauma, calculi, and hydronephrosis. (Middle) This axial CT section shows a normal
appearing right kidney. (Bottom) A more caudal section shows the left renal unit is fused t o the lower pole of the
right kidney, and its hilum is directed anteriorly.

II
1
 KIDNEY
HORSESHOE KIDNEY
c
■q

••
c
a>
E
o
-a
3 - Isthmus of parenchyma

Diluted renal pelvis

Diluted calicos

Multiple renal arteries

(Top) first of tour CT images of a horseshoe kidney. This axial section shows the two renal units whose lower poles
are joined across the midline by an isthmus of functioning renal parenchyma. The collecting system of the left renal
unit is dilated (hydronephrotic), indicating ureteral or pelvic obstruction. (Bottom) A coronal Mil' image shows the
"U" or horseshoe-shaped kidney with the lower poles joined across the midline. Note the multiple renal arteries
supplying each half of the kidney. The left-sided hydronephrosis is evident. Hydronephrosis is common in this
anomaly and may be caused by aberrant arteries that compress the collecting system, aberrant & multiple ureters,
renal calculi or even tumor.
II
-J78
 HORSESHOE KIDNEY

Ie
'Right' renal arteries

>
Inferior
artery

'Left' renal arteries

(Top) Frontal view, shaded surface 3D depletion of the CT scan shows the horseshoe kidney crossing the midline
between the aorta and the Inferior mesentertc artery. The multiple renal arteries are evident. The left renal unit
appears "moth-eaten" as a result of its hydronephrosls and decreased parenchymal enhancement, relative to the right
side. The window display was set to display nonnal density renal parenchymal and arterial enhancement. (Bottom)
A posterior view of the horseshoe kidney Is displayed. Note the multiple renal arteries.
 KIDNEY
HYPERTROPHIED COLUMN OF BERTIN
a?
c
•»
c
0) - Normal cortical column
E
o - Renal pyramid
T3
Hypertrophied column of Berlin —
<

^r

Kenal pelvis —

Renal cortex

Renal pyramids

Column of Bertin —

- Renal pyramids

Renal cortex -

- Renal sinus fat

- Column of Berlin

(lop) This graphic depicts a hypertrophied column of Bertin, which is a rounded enlargement of the septal cortical
tissue that separates the renal pyramids. Phis is normal tissue with the same imaging features as other renal cortex,
but it may protrude into the renal sinus fat and may be mistaken for a renal mass. (Middle) This corticomedullary
phase CT section shows a rounded, prominent "mass" of cortical tissue projecting deep into the renal sinus,
seemingly compressing and displacing the renal pyramids in the midpole of the right kidney. The opacified urine is
the result of a prior "timing bolus" of contrast material. (Ik>ttom) A sagittal sonogram shows a rounded "mass", a
hypertrophied column of Bertin, projecting into and displacing renal sinus fat. This has the same echogenicity as
II other cortical tissue. Ihe location, between the upper and midpole of the kidney, is typical.
»fl0
 KIDNEY
FETAL LOBATION >
o-
Q-

i
O

CL

Lobulated surface of fetal kidney -

Left kidney

Kight kidney -

(Top) T h i s graphic depicts the typical lobulated appearance o f t h e kidney i n fetal life, reflecting t h e development of
the kidney f r o m n u m e r o u s lobes, each consisting of a renal p y r a m i d a n d its associated cortex. This may persist i n t o
infancy a n d occasionally i n t o adult life, t h o u g h t o a lesser degree. Note that the adrenal g l a n d is relatively large
compared w i t h the kidney in fetal life a n d c h i l d h o o d . ( M i d d l e ) A n axial contrast-enhanced C'T section o f a n
a s y m p t o m a t i c adult shows a lobulated surface of each kidney, representing persistent fetal l o b a t i o n ( l o b u l a t i o n ) . This
must be distinguished f r o m cortical scarring, i n w h i c h renal tissue is lost as a result o f ischemia o r i n f l a m m a t i o n .
( B o t t o m ) A more caudal section shows t h e lobulated surface o f the r i g h t kidney.
II
481
 KIDNEY
DUPLICATION OF COLLECTING SYSTEM

-^*?

Bifid left ureter

Duplicated right ureter

Coronal reformatted CT urogram shows a bifid left ureter, with two separate ureters leaving the kidney, but joining
dlstally to form a single ureter. The entire right ureter is duplicated, with separate uieteral orifices into the bladder.
Each kidney in this subject had two hila with supernumerary arteries and veins.
 KIDNEY
POLYCYSTIC KIDNEY DISEASE >
a.
o
3
••

Calcified wall of hepatic cysi CL

CD

Hepatic cysts

— Polycystic left kidney

"High density cyst"

Hepatic cvsts

- Polycystic left kidney

Polycystic right kidney

(Top) First of three axial CT sections of a patient with autosomal dominant polycystic disease of the kidneys a n d
liver. This section shows innumerable cysts within the liver, some of which have calcified walls due to prior episodes
of spontaneous bleeding within the cyst. (Middle) In spite of the gross enlargement and distortion of the liver,
hepatic function is normal in this and most patients with polycystic liver disease. Conversely, the polycystic renal
disease is progressive and usually results in renal failure by the sixth decade. This section shows that the left kidney is
virtually replaced by cysts, many of which are of increased density due to spontaneous hemorrhage. (Bottom) A
more caudal section shows cystic disease of the right kidney as well.
II
mi
 URETER AND BLADDER
[Cross Anatomy
Ureter
• Muscular tubes (25-30 cm long) that carry urine from
kidneys to bladder
( ourse along posterior alxlominal wall iii
retropcritoncum, just Ix'hind parietal peritoneum
■ Proximal ureters lie in perircnal space
■ In lower abdomen, lie on psoas muscles
In pels is, lie along Literal walls near internal iliac
vessels
■ At the level ol ischial spines, ureters curve
anteromedially to enter bladder at level of seminal
vesicles (men) or lervix (women)
■ Ureterosesical junction: Ureters pass obliquely
through muscular wall of bladder, creating a valve
effect, preventing reflux of urine
Ihree points ot phxsiological narrowing:
Ureteropelv ii junction, pelvic brim and
ureterosesical j u n c t i o n
• Vessels, nerves a n d l y m p h a t i c s
Arterial branches are numerous and variable, from
aorta, and renal, gonadal. internal iliac, vesical,
rectal arteries
■ Arterial branches anastomose along length of
ureter
c Venous branches K l\ mphatics follow the arteries
with similar names
c Innervation
■ Autonomic Irom adjacent plexuses
■ Cause uretcral peristalsis
■ Also carry pain (stretch) receptors; "stone" in
abdominal ureter perceived as back & flank pain;
stone in pelvic ureter causes lower abdominal K
groin pain
Is mphatics to external ** internal iliac n o d e s
(pelvic ureter), a o r t o c a s a l nodes lalxlomen)
Bladder
• Hollow, distensible vjscus with a strong muscular wall
• I ies in e x t r a p e r i t o n e a l iciropcriloncal) pclvte
• Peritoneum covers dome ot bladdei
Reflections of peritoneum form deep recesses in the
pels ic peritoneal ca\ ity
Rcctovesical pouch is most dependent recess in
men (and in women following hysterectomy)
Vesicouterine p o u c h and rectouterine p o u c h (of
Douglas i arc most dependent in women
• Madder is surrounded bv loose connective tissue a n d
fat
I'erivcsical Space (contains bladder and urachus)
Prcvcsical (ol Rcl/ius) between bladder and
svmphvsis pubis; communicates sii|X?riorlv with
infrarenal retropcritoncal c o m p a r t m e n t ;
communicates posteriorly with presacral space-
Spaces can expand to contain large amounts ot fluid
(as in extraperitoneal rupture of the bladder, and
hemorrhage from pels Ic fractures)
• Wall of bladder composed mostly of detrusor muscle
frigone ot b l a d d e r : triangular structure at base of
bladder with apices marked bv 2 uretcral orifices
and internal urethra) orifice
• \essels. nerves a n d l y m p h a t i c s
\rteries Irom internal iliac
■ Superior vesical arieries and other branches ol
internal iliac arteries in both sexes
1
Venous drainage
■ Men: Vesical & prostatic v e n o u s plexuses -»
internal iliac and internal vertebral veins
■ Women: Vesical a n d ulerovagiiial plexuses -•
internal iliac vein
Vutonomic innersation
■ I'arass mpathelic from pelvic splanchnic k inferior
hspogastric nerves (causes contraction of detrusor
muscle and relaxation of internal urethral
sphincter t o permit emptying of the bladdei)
■ Sensory fibers follow parasympathetic nerves
[Clinical Implications
Clinical Importance
• I reters are otten injured inadvertently during
abdominal or gynecological surgervdue to traction,
causing interruption ol their fragile, short arterial
supph
• I <-topi* ureter
Usually iK(>%) associated with complete ureteral
duplication
Much more c o m m o n in females (l()x)
Ureter from upper renal pole often becomes
obstructed & inserts ectopically (not at trigone)
Causes constant urine dribbling in females (ectopic
insertion below urethral sphincter)
Wcigcrt-Meyer rule: Ureter from upper pole inserts
interior & medial to lowei pole ureter
• t'reterocele: Cystic dilation of distal ureter
Simple lorthotopic) at trigone, with single ureter
Ectopic; inserts below trigone
• Uretcral duplication
Kit id ureter drains a duplex kidney; ureters unite
before entering bladder
• I xtrapi i"itoneal b l a d d e r r u p t u r e
c Urine and blood distend prevesical space; looks like
a "molar tooth" on transverse CT section
Urine often tracks posteriorly into presacral space,
superiorly into tetropcritoneal abdomen
Usually caused b \ pelvic fractures
■ hifraperitoncal b l a d d e r r u p t u r e
Urine flows u p paracolic gutters into peritoneal
recesses <u\d surrounds intestine
r
I su.illv caused by blunt trauma t o an overdistended
bladder
• fetal u r a c h u s forms conduit between umbilicus and
bladder
Usually becomes obliterated -* m e d i a n iniibilic.il
ligament
Mas persist as channel "cyst* or diverticulum
May become infected or lead to carcinoma
• Itladder d i s e r t i c u l a are c o m m o n
Congenital: H u t c h d i v e r t i c u l u m
■ Near ureterosesical junction
Icquircd (usually clue to bladder outlet obstruction)
Can lead to infection, stones, tumor
 URETER AND BLADDER
URETERS, BLADDER AND VESSELS

Superior mesenteric
artery

Ureteric branch from

renal artery

Gonadal (ovarian)
arteries

Inferior mesenteric
artery

Psoas muscle

External iliac artery &

vein
Internal Iliac artery

Uterine artery Ureteric branch from

inferior veslcal artery

Vaginal artery Superior veslcal artery

The ureters receive numerous and highly variable arterial branches from the aorta, and the renal, gonadal, and
internal iliac arteries. These vessels are short and can be easily ruptured by retraction of the ureter during surgical
procedures. The arterial supply to the bladder is also quite variable. Both genders receive supply from the superior
veslcal arteries and from various branches of the internal Iliac arteries. Branches to the prostate & seminal vesicles
(men) also send branches to the inferior bladder wall. In women, branches to the vagina send arteries to the base of
the bladder. Note how the ureters deviate anteriorly as they cross the external (or common) iliac vessels & pelvic
brim. This may constitute a point of relative narrowing where the passage of ureteral calculi (stones) may be
impeded. In the abdomen the ureters course along the psoas muscles.
 URETER AND BLADDER
EXCRETORY UROCRAM, NORMAL IVP
T3
i5
T3
c
CO
t—

£
a?
Z>
■ >
c
o Renal pelvis —
E
o
■o
<

Ureteropelvic junction —

Ureter —

(Site of common or
external iliac vessels)

Urinary bladder - Pelvic brim

Kt lii.i! spine
Ureterovesical
(unction

Frontal film of the abdomen obtained ten minutes following the IV administration of iodinated contrast medium.
The IV contrast media utilized for excretory urography (also known as intravenous pyelography, or IVP) is identical
to that used for a contrast-enhanced CT scan. Because the CT scan can also reveal so much more than the
morphology of the renal collecting system, ureters & bladder, it has largely replaced the IVP for most purposes. The
ureteropelvic junction (UPJ) lies at about the L2 level (lower on standing), while the ureterovesical junction (UVJ) lies
at the level of the ischial spine, or, as shown on axial CT, at the level of the seminal vesicles (men) or the cervix
(women). Note the subtle deviation of the ureters as they cross the iliac vessels and pelvic brim.
 URETER AND BLADDER
SMALL URETEROCELE >
a.
o
3
CD
■ •

s
CD
-1
D)
=J
Q.

DJ
CL
Q.
CD

Simple ureterocele — — Iirin<irv bladder

Simple ureterocele —
Ureterovcsical junction

Semi nil I vesicle H — Ischial spine

( l o p ) A frontal film from an excretory urogram shows a dilated right ureter that terminates in a cystic dilation
within the bladder wall. The appearance of this simple ureterocele has been likened t o the head of a spring onion or
a cobra. (Bottom) An axial CT section obtained several minutes after IV contrast administration shows a fluid level
within the ureterocele with unopacified urine "floating" o n top ol the heavier contrast-opacified urine. Note the
ureterovesical junctions (UVJ) arc at the same level as the seminal vesicles and ischial spines. A ureterocele that
occurs at the trigone (the normal site of the UVJ) is called a simple ureterocele. as opposed to an ectopic ureterocele
at the tip of a duplicated ureter that inserts in an aberrantly low position.
II
-ur
 URETER AND BLADDER
<D
CT UROGRAM, URETERAL DUPLICATION
■D
■D
J9
DQ
■D
C
03
i—
<D

?
■a
C
©
E Duplicated urctci -
— Bifid ureter
o
■o
-Q
<

Duplicated ureter —

(Top) First of two CT urographic images, reformatted from a series of axial, contrast-opacified CT sections. This
subject has complete duplication of the right ureter a n d partial duplication of the left (a "bifid ureter"). The ureter
draining the upper pole of the right kidney inserted into the bladder just below and medial to the ureteral orifice of
the lower pole ureter. In this subject there was n o ureteral obstruction. (Bottom) An oblique rotation of t h e CT
urogram confirms the duplicated and bifid ureters. The kidneys in this subject would each have two sets of hilar
structures (artery, vein, renal pelvis).

II
4HK
 URETER AND BLADDER
URETERAL DUPLICATION >
cr
StCdl in upper pole ureter a.
c
3
IT)

(T)
r—*

~i
Lower pole ureter - CJ
Z>
CL

cu
Q-
Q-

Stent in upper pole ureter -

Dilated lower pole c a l k c

Normal ureter (lower p o l o

Dilated renal pelvis (upper pole
Left ureti'i

(lop) First of three images from a patient with right flank pain. This frontal film from an excretory urogram shows a
ureteral stent within the ureter draining the upper pole of the right kidney, which had been noted to be
hydronephrotic (dilated) prior to stent placement. The collecting system of the right lower pole is also somewhat
dilated due to vesico-ureteral reflux. These are both manifestations of the Weigert-Meyer rule that the ureter draining
the upper pole moiety inserts ectopically and is prone to obstruction, while the lower pole ureter is prone to reflux.
(Middle) The lower pole collecting system may be displaced and rotated, as in this subject, resembling a "drooping
lily". (Bottom) An axial Cl section shows the dilated collecting system of the right upper pole and the normal caliber
ureter draining the lower pole. II
 URETER AND BLADDER
CD ECTOPIC DUPLICATED URETER
■D
T3
J5
CD
X3
CO

ZD
■ •

c
o
E
o Dilated calices, upper
TJ jxile
■Q
<

— Dilated ureter from

upper pole

(Top) First of four images from a patient with an ectopic duplicated ureter. This axial CT section shows a markedly
hydronephrotic upper pole of the left kidney. (Bottom) A more caudal section shows the dilated, unopacified ureter
from the left upper pole, lying medial to the lower pole, which shows no hydronephrosis.

II
-I'll)
 URETER AND BLADDER
ECTOPIC DUPLICATED URETER >
cr
a
o
3
o
p
I lydronephrotic upper
p<>lf c
I
CD
-1
DJ
Upper pole ureter a.
0)
CL
Q.
I Dvver pole collecting CD
svitcm

— Dilated ureter from

upper pole

Ixtopic ureterocele

(Top) Frontal film from an excretory urogram shows a grossly hydroncphrotic upper pole of t h e left kidney and faint
opacification of its ureter. The collecting system of the lower pole is intrinsically normal but is displaced inferiorly,
resembling a "drooping lily". (Bottom) A delayed "post voiding" film of t h e pelvis shows the dilated ureter from the
upper pole terminating in an ectopic ureterocele near the base of the bladder.

II
4<H
 URETER AND BLADDER
RETROCAVAL URETER
■u
■D
15
CD
■o
c
TO
i—

2 IVC —
2
=>
• ■

c Retrocaval ureter —
0)
E
o
-o

Retrocaval ureter

Right ureter
Left ureter

(lop) First of five axial CT sections of a subject with a retrocaval ureter. Ihis section shows the proximal right ureter
being compressed as it passes behind the inferior vena cava. The ureter usually runs parallel to the IVC. This is a
congenital anomaly of the IVC rather than the ureter, representing a persistent subcardinal vein that traps the right
ureter and may result in partial ureteral obstruction. (Middle) A more caudal section shows the ureter passing behind
the IVC. (liottom) After passing behind the IVC the right ureter is of normal caliber.

II
l
4 >2
 URETER AND BLADDER
RETROCAVAL URETER >
cr
a.
o
3
o
3

CD

§
3
a.
CD
Right ureter — Q.
1 eft ureter a.
CD

I'soas muscle

Right ureter C o m m o n iliac arteries

(Top) The ureters normally course along the surface of the psoas muscles. Note the anterior and medial course of the
right ureter, which follows the course of the IVC after passing behind it. (Rottom) The right ureter continues along
the anterior surface of the IVC, rather than lying on the psoas muscle as does the normal left ureter.

II
-J'H
 URETER AND BLADDER
<D UPJ OBSTRUCTION
"D
"O
_ro
CO
"D Renal pelvis (dilated) ■
C
CO
k.
CD Uretrropelvic junction
CD
i—

*•
C
o
E
o
■o
SI
<

1 hi,•.tc-cl renal pelvis

Dilated caliccs

(lop) 1-irst of six images of a patient with congenital obstruction of the ureteropelvic junction (UPJ). A frontal film
from a retrograde pyelogram shows a sharp transition from the normal ureter to a grossly dilated renal pelvis. UPJ
obstruction may be congenital or acquired. (Middle) An axial CV section shows the hydroncphrotic left kidney,
(liottom) A more caudal section shows caliectasis (dilated calices).

II
-I'M
 URETER AND BLADDER
UPJ O B S T R U C T I O N

Right renal artery

— Dilated renal pelvis

Aberrant "accessory" renal
arterv

Right ureter -

— Left renal arterv

Right renal artery

— Aberrant left renal arterv

Right ureter -
Dilated talices

Left renal artery

(lop) A coronal reformation Mil* CT image from the CT scan shows an accessory (aberrant supernumerary) left renal
artery crossing the left UPJ and possibly accounting for the obstruction. Regardless of whether the aberrant vessel is
responsible for the UPJ obstruction, it is important t o recognize the close relation between the vessel and the UPJ to
avoid inadvertent injurv to the artery if surgical repair of the UPJ is contemplated. (Middle) I he normal origins of
the right and left renal arteries are shown on this coronal section. (Bottom) The left renal artery and its relation to
the grossly hydroncphrotic left kidney are well shown on this coronal section.
 URETER AND BLADDER
CANCER OF URETER
■o
■D
TO
CD
■o
c
CO
t-

=>
» ■
c Lett renal pelvis
a>
E
o
<

- I ett ureter

Right ureter
— Left ureter

(lop) lirst of five CT images from a patient with a transitional cell carcinoma or the left ureter. This axial section in
the nephrographic phase of enhancement shows a dilated left renal pelvis. (Middle) A more caudal section, also in
the nephrographic phase, shows a dilated left ureter. No stone or extrinsic mass was seen to explain the ureteral
obstruction. (Bottom) An axial section from the pyelographic phase of enhancement (10 minute delay) shows a soft
tissue mass within the lumen of the left ureter.

II
4<JH
 URETER AND BLADDER
CANCER OF URETER >
Q.
O
3
ID
3
■ ■

C
3
&
~%
Q)
=i
a.
QJ
Q.
Q.

9
Tumor within ureter

Tumor within ureter

(Top) A coronal r e f o r m a t i o n , obtained as part o f t h e CT u r o g r a m p r o t o c o l , shows the mass w i t h i n t h e left ureter,

e x p a n d i n g its l u m e n a n d causing partial o b s t r u c t i o n . ( B o t t o m ) T h i s sagittal section t h r o u g h t h e distal left ureter
c o n f i r m s the presence o f t h e mass, a transitional cell c a r c i n o m a , w i t h i n the ureter. CT allows c o n f i d e n t d i s t i n c t i o n
a m o n g t h e various intrinsic a n d extrinsic causes o f uteteral o b s t r u c t i o n .

II
497
 URETER AND BLADDER
CD FEMALE AND MALE BLADDER
•o
jrj
CQ

rz Fundus (dome) of
CO bladder
1—

£ Peritoneum
i— Body of bladder

C — Left ureteral orifice

0)
E Periveslcal space (with
o pudendal venous
Trigone
■D
SI plexus) Vesical fascia
<
Tendinous arch of
pelvic fascia
Obturator intemus
muscle
Levator ani muscle Urethra

Urogenltal diaphragm
(urethral sphincter)

Vagina

Supraveslcal space Vas deferens

lnterureteric fold
Perivesical space

Prostate
Tendinous arch of
pelvic fascia Urethral sphincter in
urogenltal diaphragm

Penile urethra
Colles fascia

Corpus spongiosum

(Top) A frontal (coronal) section of the female bladder shows that it rests almost directly on the muscular floor of the
pelvis. The dome of the bladder is covered with peritoneum. The trigone is the distinct triangular base of the bladder
whose apices are formed by the ureteral and urethral orifices. The bladder is surrounded by a layer of loose fat and
connective tissue (the prevesical & perivesical spaces) that communicate superiorly with the retroperitoneum.
(Bottom) A coronal section of the male bladder shows that it rests on the prostate, which separates it from the
muscular pelvic floor. The bladder wall is muscular, strong, and very distensible. The ureters enter the bladder
through an oblique anteromedial course that helps to prevent urinary reflux into the ureters. The mucosal surface of
II the ureters is continuous with the bladder and is the same transitional cell type.
 URETER AND BLADDER
INTRAPERITONEAL BLADDER RUPTURE >
a
o
3
CD
3
■ P

- Intraperltoneal fluid (urine & CD

blood) -i

Spleen Q.
Intraperitoneal fluid (urine) ■
5?
DJ
Q.
2

Ascending colon

— Left paracolic gutter

Urine in paracolic nutter

Small bowel
Small bowel -
lnli.i|>< iiluiu-.:l urine

(lop) l-irst of nine CI images showing intraperitoneal rupture of the urinary bladder. The CT scan was obtained after
installation of contrast medium into the bladder. This section shows dense intraperitoneal fluid (urine) surrounding
the liver in the right subphrenic space. The fluid surrounding the spleen is diluted by blood. (Middle) The right
paracolic gutter is distended with intraperitoneal urine. Note that the right paracolic gutter is more dependent and
more voluminous than the left. (Bottom) A more caudal section shows dense urine surrounding small intestinal
loops, confirming the intraperitoneal location of the fluid.

II
-!<><>
 URETER AND BLADDER
INTRAPERITONEAL BLADDER R U P T U R E

Blood clot (hematoma)

Uxtravasated urine -

- Urine within bladder

Intramural bladder hematoma —

Exbaperitoneal pelvic hcmatoma — Urinary bladder

Urine in rectovesical recess

(lop) A section near the dome of the bladder shows a hematoma, surrounded by extravasated urine. (Middle) This
section shows opacified urine within the urinary bladder. The bladder wall is thickened due to mural hematoma and
its collapsed state. (Bottom) Densely opacified urine settles into the rectovesical recess, the deepest intrapcritoncal
recess. The bladder is displaced to the left by the pelvic hematoma.
 URETER AND BLADDER
INTRAPERITONEAL BLADDER RUPTURE >
cr
Small intestine - Q.
O
tntrapcritancal contrast
medium 3
3
••

CO
—*
- Urinary bladder
CO
Q.
CD
OJ
Q.
Q-
CD

in;• .ljn-inoiu'.it contrast material

Sacrum

Urinary bladder -
Rectovesiial recess

Rectum

Symphysis pubis -

I m i.u \ bladder
Contrast material in
rectovesiial pouch
Balloon tip of bladder cathrtci -
I'resacral space

(Top) A frontal film from the cystogram that preceded the CT scan shows rupture of the dome of the bladder, with
intraperitoneal spill of opacificd urine/contrast medium. Note the absence of contrast medium in the perivesical and
prevesical (extra peritonea I) spaces, and the contrast medium outlining small intestinal loops, seen as "filling defects"
in the pool of contrast medium. The urinary bladder is displaced to the left by a pelvic hematoma. (Middle) A
sagittal reformation of the CT scan shows dense contrast material outlining bowel loops and filling the rcctovesical
recess, both findings indicating an intraperitoneal rupture of the bladder. The bladder is distorted and contains
diluted urine and gas, the latter from prior catheterization and contrast instillation. (Bottom) Note the absence of
extravasated urine in the extraperitoneal spaces, including the presacral space. II
".III
 URETER AND BLADDER
EXTRAPERITONEAL B L A D D E R R U P T U R E
CD
-a
J5
CD
■D
C

to - Extravasated urine/contrast
medium

S
0)
E
o
■o
si Penile urethra
<

— Extravasated contrast medium

Contrast in prevesical space (of

Retzius)

Urinary I ladder
Contrast in pcrivesical space

Rectum

(Top) First of six images of a patient with pelvic fractures and an extraperitoncal rupture of the bladder. This frontal
film from a cystogram shows contrast medium being instilled through a catheter placed into the penile urethra.
There is little or no opacification of the urinary bladder, only an amorphous, streaky collection in the pelvis.
(Middle) This CT section shows no contrast medium or urine in the paracolic gutters, as would be expected for an
intrapcritoneal bladder rupture. There is a collection of contrast material just deep to the anterior abdominal wall.
(Bottom) Dense contrast material is present within the prevesical space (of Retzius), the extraperitoncal
compartment that separates the bladder from the anterior abdominal wall and symphysis pubis. Contrast material is
II also present in the perivesical space, immediately surrounding the bladder.
 URETER AND BLADDER
EXTRAPERITONEAL BLADDER RUPTURE >
a
o
3
o
Prevesical space » ■

c
3
<D
-i
Perivesical space OJ
O-
??
0)
Q.
Q.
CD

Fluid in presacral space

Rectum ■

- Gas & fluiil in prevesical space

Bladder base

— Rectum

(Top) Contrast material dissects through the extraperitoneal spaces in the pelvis, all of which communicate.
(Middle) The extravasated fluid extends to the pelvic side walls and to the presacral space, all extraperitoneal. Note
the absence of contrast within the rectovesical pouch. (Bottom) Again note the absence of intraperitoneal fluid in
the rectovesical recess and the large amount of extraperitoneal fluid. The loose areolar tissue (fat and connective
tissue) that occupies the prevesical and perivesical spaces is easily displaced and these spaces may expand to collect
large amounts of extravasated blood (or other fluids).
II
.0!
 URETER AND BLADDER
<D URACHAL CYST
"a
"O
_co
CD
"O
rz - Skin of anterior alxlominal wall
CO
o — Umbilicus
"5
i— Calcification in subcutaneous
Z) tissues
c
o
E
o
T3
<
Umbilicus

- Calcification

Clop) First of five images of a patient with a urachal cyst who presented with infraumbilical pain and a palpable,
tender mass. This lateral film shows a faint calcification in the abdominal wall just inferior to the umbilicus.
(Middle) An axial CT section shows the umbilicus and subtle infiltration of the abdominal fat just deep to it.
(Bottom) A more caudal section shows a calcified lesion within a rounded focus of inflammation. This is a typical
site for the urachus. Chronic inflammation, which can occur within a urachal cyst, often develops calcification.

II
TO4
 URETER A N D BLADDER
URACHAL CYST

— Inflammation

I Urinary hladder

(Top) A more caudal section shows continuation of the inflammatory process in the midline just beneath the
anterior alxlominal wall, again typical for a urachal inflammatory process. (Bottom) The d o m e of the urinary bladder
is seen just inferior t o the midline inflammatory process. At surgery an infected urachal cyst was excised.
 URETER AND BLADDER
URACHAL CANCER
■o
ro — Calcified mass
CO
■D
c
TO
Urinary bladder
£
0)
D — Uterus
••
c
a>
E
o
■D
<

— Urachal tumor

Urinary hladder

— Urachal tumor

(Top) First of three axial CT sections of a woman with a palpable infraiimbilical midline abdominal wall mass. The
mass is heavily calcified and indents the dome of the urinary bladder while also touching the anterior abdominal
wall, a typical location and appearance for a urachal mass. (Middle) The mass is quite elongated and extends
obliquely between the umbilicus and the urinary bladder. (Bottom) A more caudal section suggests that the mass is
invading the anterior superior wall of the bladder. A urachal carcinoma was excised at surgery, along with a portion
of the bladder.

II
r
,06
 URETER AND BLADDER
BLADDER DIVERTICULA AND STONES

— Urinary hludder

Piverticulum

— Diwrticulum

Calculus I bladder
stone)

Bladder diwrlic ulum —

Iil.,iIcli-i divrriiculum

— Calculus

(Top) Hirst ot two axial CT sections of an elderly man with heinaturia and dysuria. This unenhanced section shows
multiple outpouchings from the urinary bladder that represent bladder diverticula. A calculus is present in the
dependent position within one of the diverticula. (Bottom) Additional diverticula and additional stones are seen on
other sections.
 URETER AND BLADDER
BLADDER DIVERTICULUM WITH CARCINOMA

— Bladder diverticulum
Urinary bladder -
Thick wall of diverticulum

Urinary bladder -
— Intramural tumor

Bladder diverticulum

Balloon tip of catheter in bladder -

Seminal vesicle

Diverticulum — Rectum

(Top) Hirst of three axial CT sections of an elderly man with chronic dysuria and recent gross hematuria. This section
shows a thick-walled urinary bladder, often seen in elderly men with bladder outlet obstruction due to prostatic
hypertrophy (BPH). BPH also predisposes to the formation of bladder diverticula and urinary stasis within the
diverticula. Also seen on this section is an eccentric mass, representing a bladder diverticulum, with a very thick wall.
(Middle) As seen within the more dependent right-sided diverticulum, the wall is usually thin, since it does not
contain all the muscle com|>onents of the bladder wall. The wall of the right-sided diverticulum is markedly
thickened, and was found to contain invasive carcinoma at surgery. (Bottom) Some debris is present within the
dependent portion of the right-sided diverticulum, but this was not malignant.
 URETER AND BLADDER
BLADDER CANCER

Urinary bladder
Mass

Seminal vesicle

— Ureteral "jet"

— Tumor

— Bladder tunioi

(Top) lirst of three axial CT sections of a man with gross hematuria. This nonenhanced section shows a soft tissue
density mass within the urinary bladder. A calculus would be much higher in density. (Middle) A section obtained
about 2 minutes after the IV administration of iodinated contrast medium shows the mass as a filling defect within
the bladder. Note the "jet" of contrast-opaiified urine entering the bladder through the left ureteral orifice, indicating
that the tumor is not obstructing the orifice. (Bottom) The mass is arising from the base of the bladder. No invasion
of the surrounding perivesical fat planes is evident. The mass was resected via an cndosco|X' placed into the bladder
via the penis and was a transitional cell carcinoma. The bladder is the most common site of transitional cell tumors,
though they may also occur within the kidneys and ureters.
 PART III
Pelvis

Pelvic Wall and Floor

Vessels, Lymphatic System and Nerves

Female Pelvic Ligaments and Spaces

Uterus

Ovaries

Testes and Scrotum

Penis and Urethra

Prostate and Seminal Vesicles

 PELVIC WALL AND FLOOR
Imaging Anatomy
Anatomic Boundaries
• Iliac crest to perineum
• Divided into false (major) a n d true (minor) pelvis
Dividing point from sacral promontory, along
arcuate and iliopec lineal lines to pubic crest
■ \rcnale line divides flared iliac fossa from inferior,
narrowed portion of iliac bone
False pels is wide "bowl" above line
True pelvis below arcuate line
■ Pelvic inlet upper border of true pelvis (tills
forward approximately 60° from horizontal)
■ Pelvic outlet formed by ischiopubic raini, ischial
spines, inferior symphysis pubis. sacrolulxrous
ligaments and coccvx
Skeletal A n a t o m y
• 4 components
Paired innominate bones, each with three parts
■ Ilium, ischium and pubis
Sacrum
Coccyx
• Kcv ligamentous attachments and foramina
Sacrospinous ligament: From sacrum to ischial
spine
■ Divides greater sciatic foramen a b o v e ligament
from lesser sciatic foramen below
Sdcroluberoiis ligament: from sacrum to ischial
fuberosily
■ Posterior boundary of lesser sciatic foramen
Inguinal ligament: from anterior sii|>crior iliac
spine to pubic tulx.rcle
■ formed from fibers of external oblique
aponeurosis
Obturator foramen
■ formed bv bodv and rami of pubic and ischial
bones
• Male vs. female pelv is
Male pelvis
■ Pubic arch (angle formed bv inferior pubic rami at
symphysis pubis) < 90°
■ Henri-shaped pelvic inlet with narrow outlet
■ Round ohturator foramen
■ Narrow sciatic notch
■ larger, thicker liones
female pelvis
■ flattened pubic arch (> 90°)
■ Oval pelvic inlet with larger pelvic outlet
■ Oval obturator foramen
■ Wide sciatic notch
■ Thinner, more delicate bones
Anterior Pelvic Wall
• Continuation of upper abdominal muscles
Lxternal oblique muscle: I argesl and most
superficial of the t flat muscles
■ Tibers course inferomedially
• Internal oblique muscle: Middle flat muscle
■ Runs suiR-romedially at right angles to external
oblique muscle in alxlomen
■ Muscle fibers become more horizontal in pelvis
and become inleriorlv directed more caudalIv
I ransversus a b d o m i n i s muscle: Inner most flat
muscle with horizontal course
Rcctus a b d o m i n i s muscle
• Vertically directed strap muscle
■ I iuc.i alba
Midline fibrous raphe formed bv ajxineuroses of flat
muscles
• Reel us sheath
Strong fibrous sheath, which invests rcctus
a b d o m i n i s muscles and su|ieriorand inferior
epigastric vessels
formed by aponeuroses of external oblique. Internal
oblique and transversus abdominis muscles
Internal oblique aponeurosis splits in up|>er portion
ol abdominal wall
■ Interior portion joins external oblique
aponeurosis to form a n t e r i o r rcctus sheath
■ Posterior portion joins transversus abdominis
aponeurosis to form posterior rcctus sheath
I owe* third of abdominal wall (below anterior
superior iliac spine) all aponeurosis join and course
anterior to rectus abdominis muscles
■ Creates arcuate line on posterior surface ol
alxtominal wall
■ Wall below arcuate line covered only bv
transversalis fascia, which is separated from
parietal peritoneum bv extrnpciitoneal fat
Inguinal Canal
• Passage through anterior abdominal wall
Conveys spermatic cord in males and round
ligament in females
formed embryologically by evagination ol protcssus
vaginalis through anterior abdominal wall
• Internal o r d e e p ring
Opening through transversalis fascia
located above mid-portion of inguinal ligament
I aleral to inferior epigastric arterv
• l x t e r n a l o r superficial ring
triangular opening of external oblique aponeurosis
lust lateral to pubic tubercle
• llesselbach triangle
Area of weakness in pelvic wall
■ Site of direct inguinal hernias
Medial Ixirdcr: I atcral edge of rectus sheath
I atcral border: Interior epigastric arterv
• Inferior border: Inguinal ligament
Posterior Pelvic Wall (False Pelvis)
■ Psoas and iliacus muscles fuse caudallv to form
iliopsoas muscle
i Inserts on lesser trochanter and is powerful hip
flexor
Pelvic Floor
• C urved bowl so distinct walls not clearly defined
• Posterior wall: Sacrum, coccyx, and piriformis.
coccvgcus muscles
• lateral wall: Ilium, ischium a n d piriformis, obturatoi
interims, levalorani muscles
• Anterior wall: Symphysis pubis, anterior portion of
obturator internus muscle, levator ani muscle
• Floor: Pelvic diaphragm (levalor ani and fascia)
• kcv muscles
 O b t u r a t o r interims
■ Runs from inner surface of obturator membrane to
greater trot hanter
■ Covered by thick fascia uirctis tendinous), which
is origin of pelvic diaphragm
Coccygeus
■ Runs from ischial spine to sacrum and coccyx
1 cvator ani forms pelvic d i a p h r a g m
■ f o r m e d bv .1 muscles: lliocm'cvgcus,
pul)oi occvgeus a n d puborectalis
■ Ml muscles covered by fascial sheath
■ Pierced by urethra, rectum and vagina
■ I'rimarv support tor pelvic organs
■ Critical for maintaining continence, .is well as
normal micturition and defecation
Perineum
• Space interior to levator ani
• Central t e n d o n of |icrincuin {perinea! boils) lormcd
in midline
Behind vagina in females
Behind urethra in males
• Diamond-shaped area Ixirdered by pubic syinphvsis.
ischial tuberosities and coccvx
Subdivided into 2 spaces (tirogcnital and anal
triangles) by line drawn slightly anterior to ischial
tuberosities. along superficial transverse perineus
muscle
• Urogenital triangle contains urethra anil external
genitalia
Muscle development greater in male
■ Paired muscles: Superficial and deep transverse
perineus, bulbocavcrnosus and ischiocavemosus
lirogcnital d i a p h r a g m : Deep transverse perineus
muscle and fascia, urethral sphincter
Female: liartholin glands (greater vestibular glands)
a n d vestibular bulbs
Male: Penile bull)
• Anal triangle contains anus
ldi.iiiii.il in both sexes
Circular external a n a l s p h i n c t e r surrounds anus
and maintains continence
■ i muscle components: Subcutaneous, superficial
and deep
■ fibers extend posteriorlv to form anococcygeal
ligament
Ischiorectal tossa lotated in posterior and lateral
portion of triangle
■ hilled with tat
■ Communicates posteriorly, forming U-shape
around levator ani and anus
■ Bounded posteriorlv by sacrotuberous ligament
and glutens maximus
Clinical Implications
Clinical Importance
• Pelvic wall m u s c u l a t u r e protects and sup|xirts pelvii
viscera, stabilizes pelvis lor ambulation, increases
abdominal pressure tor defecation, micturition and
parturition
I axity or diastasis of musculature results in hernias
■ Incarceration may lead to l«>vvel obstruction
• Pelvic floor m u s c u l a t u r e stabilizes lower pelvis.
controls defecation and micturition, and maintains
continence
Laxity results in pelvic floor descent with
cystoceles/rectoceles, urinary incontinence, fecal
incontinence or constipation
Inguinal Hernia
• Max be either indirect or direct
• Indirect i n g u i n a l h e r n i a
Passes t h r o u g h internal inguinal ring, traverses
inguinal canal to external ring
■ Mav extend into scrotum in males and labia
majora in females
Passes lateral t o inferior epigastric vessels and has
an oblique inferior course
(Considered a congenital delect and associated with a
patent proccssus vaginalis
Sx more c o m m o n than direct inguinal hernias
■ Direct inguinal hernia
Protrusion through llcssclbach triangle
" Generally does not extend into scrotum
Passes medial t o inferior epigastric vessels
Considered an acquired detect
• Inguinal hernias 5-10x more c o m m o n in men
Femoral Hernia
• Begins posterior t o medial portion ol inguinal
ligament
li.ivcrscs femoral c a n a l t o fossa ovalis
• 1 lemiated contents are below inguinal ligament,
lateral to pubic tubercle and medial to femoral vessels
• More c o m m o n in older women
Obturator Hernia
■ I lenii.it ion t h r o u g h o b t u r a t o r canal (superolatcral
aspect of obturator foramen)
• I-Icrniatcd contents may lie between obturator muscles
or between pettineus and obturator extemus
• More common in older women
Sciatic Hernia
• Herniation through greater sciatic foramen lateral!)
into subgluteal region
Perineal Hernia
• Posterior: Through levator ani a n d loccvgcus muscles
• Anterior: I hrough urogenital diaphragm
Pelvic Floor Relaxation
• Weakness in pelvic floor fascia, muscles and ligaments
Almost exclusively in women
■ Incidence increases with age (> 50% of women
o\ci 50 >ears old) and number ol pregnancies
• Mav involve 3 different compartments
Anterior: Cvstocele
Middle: Vaginal prolapse, u t e r i n e prolapse,
enterocele
Posterior: Rcctocclc
• Must examine Ixjlh relaxed and straining with fast
V2W1 or fluoroscopv,
• Graded on degree of descent relative to pubococcygcal
line
 PELVIC WALL AND FLOOR

(Top) 3D CT reconstructions of the male pelvis. There are several striking differences between the male and female
pelvic bones. The bones are thicker and heavier In the male. The pubic arch is higher, with a more narrow angle. The
pelvic inlet is more heart-shaped, and both the inlet and outlet are much narrower compared to the female pelvis.
(Bottom) Superior view of the pelvic Inlet. Note the ischlal spines are easily visible, as the pelvis continues to narrow
at the outlet.
 PELVIC WALL AND FLOOR
3D CT, FEMALE PELVIS

Iliac crest

Sacroillac |olnt
Anterior superior iliac
Sacrum spine

Anterior inferior iliac

spine

Superior pubic ramus

Symphysls publs
Obturator foramen Pubic bone

Ischlal tuberoslty

Pubic arch

Symphysls publs Pubic bone

Diopublc eminence

Tip of coccyx Ischlal spine

fliacbone Ulac crest

Sacroillac joint Sacrum

(Top) 3D CT reconstructions of the female pelvis. There are several striking differences between the male and female
pelvic bones. The bones are thinner and more delicate in the female. The pubic arch is flatter, creating a wider angle.
The pelvic inlet is more oval, and the inlet and outlet are much wider to accommodate childbirth. (Bottom) Superior
view of the pelvic inlet. Note the more widely spaced ischial spines, compared to the male pelvis.
 PELVIC WALL AND FLOOR
3D CT, FEMALE PELVIS

Anterior superior lilac

spine
False pelvis
Antenor Inferior lilac
spine

Arcuate line
lliopubic eminence Sciatic notch

True pelvis
Obturator canal
Pubic bone 4

Pubic tubercle

Symphysis pubis

Ischiopubic raml

Ischium Femoral head

Ischlal spine
Sacrospinous ligament
Iliac bone

Sacrum
Sacrolllac joint

(Top) 3D CT reconstruction of the female pelvis viewed from the medial surface. The arcuate line is a bony
prominence, which courses from the sacral promontory anteriorly towards the lliopubic eminence. The false pelvis is
above the arcuate line, while the true pelvis Is below It. (Bottom) 3D CT reconstruction of the pelvic outlet,
graphically enhanced to show saaospinous ligament. The pelvic outlet is formed by the ischiopubic rami, ischlal
spines, inferior symphysis pubis, sacrospinous ligaments and coccyx.
 PELVIC WALL AND FLOOR
3D CT, MAJOR LIGAMENTS & FORAMINA

Sacrospinous ligament • Greater sciatic foramen

I Lesser sciatic foramen

Sacrotuberous Ugament

Inguinal ligament

Greater sciatic foramen

Sacrospinous ligament
Obturator canal
Lesser sciatic foramen
Obturator membrane

Sacrotuberous ligament

(Top) 3D CT reconstruction of the pelvis, graphically enhanced to show the key ligaments. The sacrospinous
ligament extends between the sacrum and ischlal spine. The greater sciatic foramen is above the sacrospinous
ligament and the lesser sciatic foramen is below it. The saaotuberous ligament has a somewhat broader attachment
to the sacrum and extends to the ischlal tuberosity. It forms the posterior boundary of the lesser sciatic foramen.
(Bottom) The inguinal ligament extends from the anterior superior iliac spine to the pubic tubercle. The obturator
foramen is covered by a membrane except for the obturator canal, which is in the superolateral aspect of the
foramen. The obturator vessels and nerve pass through this opening.
 PELVIC WALL AND FLOOR
ANTERIOR PELVIC WALL

External oblique
muscle (cut edge)
External oblique
muscle
Rectus abdomlnls
muscle Rectus sheath
Internal oblique muscle

Lineaalba
Rectus sheath (cut
edge)
Inguinal canal

Fundlform ligament
Superficial inguinal
ring
Spermatic cord

Rectus sheath

Aponeurosis
Rectus abdomlnls
muscle
Transversalis fascia

Externalfitinternal
oblique & tiansversus Extraperltoneal fat
abdomlnls muscles
Parietal peritoneum

Median umbilical
ligament (obliterated
urachus)

Medial umbilical folds

(obliterated umbilical
arteries)
Urinary bladder

(Top) Anterior abdominal wall muscles. (Bottom) Inner aspect of the anterior abdominal wall, below the level of the
arcuate line. The rectus sheath, which is formed by the aponeuroses of the external and internal oblique and
tiansversus abdomlnls muscles, encloses the rectus muscle both anteriorly and posteriorly in the upper abdomen. In
the pelvis, at the level of the anterior superior iliac spine, the sheath is present only anteriorly. The transition where
this occurs Is called the arcuate line. Only the transversalis fascia covers the posterior rectus muscle below this point,
as depicted in this graphic. Extraperltoneal fat separates the transversalis fascia from the parietal peritoneum.
 PELVIC WALL AND FLOOR
POSTERIOR PELVIC WALL

Psoas minor muscle

Transversus abdomlnis
Quadiatus lumborum muscle with cut edge
muscle

Internal oblique
Psoas major muscle muscle (cut edge)

Mac crest External oblique

muscle (cut edge)

Anterior Diacus muscle

sacrococcygeal
ligament
Anterior superior lilac
Plriformls muscle spine

Coccygeus muscle
Inguinal ligament
Rectum
Amis tendineus
Urethra
lllopsoas muscle

Levator anl muscle

Lesser trochanter

The posterior wall of the false pelvis Is formed by the lilac bones, sacrum, and the illacus and psoas muscles. These
two muscles fuse caudally to form the illopsoas muscle, which passes anterior to the hip joint to Insert onto the lesser
tiochanter of the femur. The posterior wall of the true pelvis if formed by the sacrum, coccyx, and the plriformis and
coccygeus muscles. The inguinal ligament is formed by the external oblique aponeurosis and is continuous with the
fascia lata of the thigh.
 PELVIC WALL AND FLOOR
AXIAL CT

Umbilicus

Kectus abdominis
muscle
External oblique
muscle

Common iliac arteries — Internal oblique muscle

Transversus abdominis
muscle
Psoas minor muscle
Psoas major muscle
Iliac crest
Quadratus lumborum
muscle

— Erector spinae muscle

Rcctus abdominis
muscle External oblique
muscle

Internal oblique muscle

Common iliac arteries —
Transversus abdominis
Psoas minor muscle — muscle

Psoas major muscle

Iliac crest —

Posterior sacrniliac
ligament
— Lrector spinae muscle
Superficial
thoracolumbar fascia

(Top) First of fourteen axial CT images through the pelvis. The pelvis begins at the top of the iliac ctcst and extends
to the perineum. (Bottom) The flat muscles that form the lateral anterior abdominal wall include (from external to
internal) the external oblique, internal oblique and transversus abdominis muscles. The rectus abdominis muscles are
paired, vertically oriented, strap-like muscle running on either side of the midline.
 PELVIC WALL AND FLOOR
A X I A L CT "0
CD
<
VI
■ ■

Linea alba
<
o'
Rectus abdominis
muscle
l-.xternal oblique
muscle 09
Q.
Transversus abdominis — Internal oblique muscle Tl
O
I'soas muscle O
L5 vertebral bodv
lliacus

Iliac bone

Erector spinae muscle

l.inea alba —

Rectus abdominis Internal oblique muscle

muscle

Transversus abdominis

Psoas muscle

Si vertebral body lliacus

Ilium liluteus niedius muscle

dluteus in \:i IUS

muscle
Erector spinae muscle

(Top) The linea alba is a fibrous, midline raphe between the rectus muscles. It is formed by the aponeuroses of the
flat muscles lexternal oblique, internal oblique and transversus alxiominis muscles). (Bottom) The arcuate line (not
radiographically visible) occurs at roughly the level of the anterior superior iliac spine. Above this line, the
aponeurosis of the internal oblique splits. The anterior portion joins the external oblique aponeurosis to form the
anterior rectus sheath. The posterior portion joins the transversus abdominis aponeurosis to form the posterior rectus
sheath.

Ill
11
 PELVIC WALL AND FLOOR
AXIAL CT

I inca alba —

Rectus alxlominis
muscle
Internal oblique muscle —

Iransversus alxlominis
muscle lliacus muscle

I'soas muscle

Ilium — — (Jluteus metlius muscle

Gluteus maximus
muscle

— Erector spinae muscle

I.inea alba —

Rectus alxlominis Inguinal ligament

muscle
Femoral nerve in
iliopsoas groove

Iliopsoas complex

Gluteus minimus
muscle

Ilium — — Ciluieus metlius muscle

Gluteus maximus
muscle
— Erector spinae muscle

( l o p ) Below the arcuate line, all three aponeuroses join and course anterior t o the rectus muscle, making the caudal
portion of the posterior rectus sheath incomplete. In this region, the posterior rectus alxlominis muscle is covered
only by the transversalis fascia, which is separated from the parietal peritoneum by a layer of extraperitoneal fat.
Because the rectus sheath is incomplete in this area, a rectus hematoma or abscess may extend into the
extraperitoneal space. (Bottom) The psoas and iliacus muscles merge to form the iliopsoas muscle, which continues
inferiorly to insert on the lesser t r o t h a n t e r and serves as a powerful hip flexor. The femoral nerve lies in the iliopsoas
groove on its way t o the inguinal canal.
 PELVIC WALL AND FLOOR
AXIAL CT

Linea alba —
Aponeurosis of oblique
Rertus ahdominis and transvcrsus
muscle ahdominis muscles

External iliac vessels — — Iliopsoas complex

(iink us minimus
muscle
Ilium
— Gluteus medius muscle
Piriformis muscle
(ilutcus maxinius
muscle

l.inea alba —

Rectus ahdominis — Sartorious

muscle
— Anterior inferior iliac
spine
External iliac vessels — Iliopsoas muscle

— Gluteus minimus
muscle
Ilium Gluteus medius muscle

Piriformis muscle
Gluteus maximus
muscle

(Top) Note the thinning of the- abdominal wall lateral to the rertus muscle. Ibis is the aponeurosis of the internal
oblique muscle, external oblique muscle and transvcrsus ahdominis muscle. This is a point of inherent weakness and
a Spigelian hernia may occur through this area. The piriformis muscle forms an important part of the posterior and
lateral wall of the true pelvis. (Bottom) Note flow the pelvis narrows inferiorly as it transitions from i h c false pelvis
to the true pelvis.

I
 PELVIC WALL AND FLOOR
AXIAL CT

Sartorious
Rectus atxiominis — tensor tasciac latae
muscle muscle
External iliac vessels - — lliopsoas muscle

— Gluteus minimus
muscle
5 — lliotihial hand
Obturator internus
muscle
— Gluteus meilius muscle

Sacrospinous ligament — Glutens maximus

muscle

Rectus atxiominis —
muscle
Femoral vessels —
— Sartorious
Niopsoas muscle —
— Tensor fasciae latae
Rectus fcmnris muscle muscle
— Gluteus medius muscle

lliotihial hand
Obturator internus —
muscle
Obturator internus
I evator ani muscle — tendon

Ischioreclal fossa — — Gluteus maximus

muscle

(Top) The sacrospinous ligament is an important anatomic landmark, with the greater sciatic foramen being above
this ligament and the lesser sciatic foramen below it. (Bottom) The obturator internus muscle, an important part of
the lateral pelvic floor, exits the pelvis through the lesser sciatic foramen. The tendon of the obturator internus fuses
with the gemellus muscle before inserting on the medial surface of the greater trochanter. Within the pelvis, the
fascia of the obturator internus forms the arcus tendineus, which serves as the origin for the levator ani muscles. The
obturator internus also forms the lateral wall of the ischiorectal fossa.

I
 PELVIC WALL AND FLOOR
AXIAL CT
2.
<
■ ■

1
<
RcCtUS al i d< Ullil I is
muscle
o'
I em oral vessels — — Sartorious

Tensor fasciae latae

I
OJ
Kectus femoris muscle muscle
D
O-
Obturator canal Glutens medius muscle O

Obturator internus m. lliotibial band

Icvator ani muscle Interior gcmellus

complex muscle
Ischiorcctal fossa
iiluuus maximus
muscle

Spermatic cord

Femoral vessels
Sartorious — Iliopsoas muscle

Rectus femoris muscle tensor fasciae latae

I'cctincus muscle muscle
(jluteus medius muscle
Obturator extcrnus m. lliotibial band
Obturator mternus in

Sciatic nerve

Ischiorectal lossa (iluteus maximus

muscle

( l o p ) Inferiorly, the rectus abdominis muscle thins and inserts on the pubic symphysis. (Bottom) The ischiorcctal
fOSSa is filled with fat and communicates across the midline, forming a U-shape around the levator ani and anus. A
perirectal abscess may extend into this space.

Ill
1r>
 PELVIC WALL AND FLOOR
AXIAL CT

Corpus cavemosum
Adductor longus
Femoral vessels muscle

Sartorious — Iliopsoas muscle

Tensor fasciae- latae
Rectus femoris muscle muscle
FVctineus muscle
• — Vastus laleralis
Vastus intermedius
Femur muscle
llintihial band
Adductor magnus m.
Quadratus femoris
Inferior pubic ramus muscle
Ischium Conjoined tendon of
hamstring muscles
Ciluteus maximus
muscle

— Scrotum
SurtorioiiN —
— Tensor fasciae latae
ftectus lemoris muscle — muscle
Adductor longus
muscle- — Vastus laleralis

Adductor brevis muscle Vastus intermedius m.

— Iliotibial band
Femur —
Adductor magnus
muscle
Ciluteus maximus
muscle

(Top) The perineum is the space below the levator ani a n d includes external genitalia, urethra and anus. (Bottom)
More inferiorly, the powerful adductor muscle group is seen.
 PELVIC WALL AND FLOOR
CORONAL T1 MR

Internal oblique muscle

Rectus dtxlominis
muscle

Sartorious muscle

Corpus eavernosum
Corpus spongiosum

Internal oblique muscle

External oblique
muscle
External oblique
muscle
Small b o w e l —
Kectus abdominis
muscle

Internal oblique muscle

Inferior epigastric
vessels

Inguinal ligament

Hesselbach triangle

Corpus eavernosum
Corpus spongiosum -

(Top) First of fourteen coronal II MK images through the abdominal wall. The rectus abdominis muscle originates
from the pubic symphysis and crest, courses superiorly a n d inserts o n t o the anterior surface of the xiphoid process
and medial portion of the 5th-7th costal cartilages. (Bottom) The fibers of the external oblique muscle (partially
seen) are directed inferomedially. The internal oblique muscle runs superomedially in the abdomen but becomes
more horizontal, and eventually courses inferiorly, low in the pelvis. The inguinal ligament extends from the
anterior superior iliac spine to the pubic tubercle. The triangular area bounded by the lateral aspect of the rectus
sheath medially, the inferior epigastric vessels laterally and the inguinal ligament inferiorly is the Hesselbach
triangle, an area of weakness of the anterior abdominal wall.
 PELVIC WALL AND FLOOR
CORONAL T1 MR

— Anterior superior iliac-

f spine
Sigmoid colon

— Sartorius

Inguinal ligament

Inguinal lymph node ^ - ^

Corpus cavcrnosum
Corpus spongiosum

— Rectus femoris muscle

External oblique m.
Internal oblique musi le
I'ransversus abdominis
muscle Anterior superior iliac
spine
Sigmoid colon

Tensor fasciae latae — Iliopsoas muscle

Femoral vein
— Cubic bone
Femoral artery
— t;orpus cavernosuni
Corpus spongiosum
Rectus femoris muscle

(Top) The inguinal ligament is formed by fillers of the external oblique aponcurosis. The inguinal lymph nodes drain
the regional structures including the lower abdominal wall, perineum (including vulva and vagina), anal canal,
scrotum, penis and the lower limb. They drain into the external iliac lymph nodes along the external iliac vessels,
(liottom) The femoral vessels and nerve pass underneath t h e inguinal ligament through the femoral canal. Contents
of the femoral canal include (from lateral to medial): The femoral nerve, artery and vein. The femoral canal is
normally a tight space, but occasionally becomes large e n o u g h to allow hcrniation of abdominal contents into the
canal. Femoral hernias are particularly at risk of becoming incarcerated and strangulated.
 PELVIC WALL AND FLOOR
CORONAL T1 MR

Iliac bone
Tensor fasciae latae

Ciluteus medius muscle

— lliopsoas muscle

Symphysls pubis keclus femoris muscle

origin

Pectincus muscle

Femoral vein
Adductor longus
Vastus latcralis muscle

Vastus medialis muscle

Psoas muscle

lliacus muscle
Glutcus medius muscle

(ilutcus minimus
muscle

lliopsoas muscle

Pectmeus mtistir —

Vastus latcralis muscle

Vastus medialis muscle

Adductor longus
muscle

(Top) The pectincus is a flat, quadrangular muscle in the femoral triangle. It arises from the pectineal line of the
pubis and passes posteroiaterally to insert below the lesser trochanter. (Bottom) The iliacus and psoas muscles, the
largest muscles within the pelvic cavity, fuse- caudally to form the iliopsoas muscle, a powerful hip flexor. After
leaving the pelvis, it inserts on the lesser trochanter of the femur. An iliopsoas bursa. which may communicate with
the hip joint cavity, separates the tendon from the pubic b o n e and the hip joint capsule.
 PELVIC WALL AND FLOOR
CORONAL T1 MR

Psoas muscle -

Iliacus muscle —

Gluteus medius muscle

Gluteus minimus
muscle

Superior pubic ramus

Iliopsoas muscle
Obturator externus
muscle

Adductor brcvis muscle Vastus lateralis muscle

Adductor magnus
muscle Vastus intermedius
muscle
Adductor longus m.
Vastus medialis muscle
Gracilis muscle

Psoas muscle

Iliacus muscle

Gluteus medius muscle

Gluteus minims muscle-

lliofemoral & capsular
ligament

Obturator interims — Obturator interims

muscle muscle
Obturator externus
muscle lliopsoas tendon

Adductor brevis muscle

Vastus lateralis muscle
Adductor magnus
muscle
Femur

Gracilis muscle — Vastus medialis muscle

(Top) The superior pubic ramus forms the superior border of the obturator foramen, which is covered by a strong
membrane. Ihe obturator externus muscle arises from the outer surface of the obturator membrane. (Bottom) The
obturator internus arises from the inner surface of the obturator m e m b r a n e and the adjacent inner surfaces of the
pubic bone and ischium. It passes posterolaterally along the lateral wall of the pelvis t o form a tendon that traverses
the lesser sciatic foramen. Inferior to the ischial spine it turns laterally to insert into t h e medial aspect of the greater
trochanter of the femur.

0
 PELVIC WALL AND FLOOR
CORONAL T1 MR

llidt us muscle i—

Iiluteus medius muscle —

Gluteus minimus
muscle
- Femoral head
Obturator internus
Greater trochanler muscle

Obturator externus
must le — Pubic bone

Adductor magnus —
muscle

Vastus lateralis

Sacroiliac joint Sciatic nerve

_
Gluteus medius muscle

(ilutcus minims muscle

Piriformis tendon
— Obturator internus
Obturator internus —
tendon muscle

Ohiurator externus
muscle Cubic bone

(Top) More posteriorly, the glutens medius a n d minimus muscles are seen inserting o n t o the greater trochanter of
the femur. Both muscles are powerful abductors of the thigh. The obturator externus muscle passes behind the neck
of femur to insert onto the greater trochanter. (Bottom) I he piriformis and obturator internus tendon are seen
inserting o n t o the greater trochanter of the femur. Both muscles are lateral rotators of the hip.
 PELVIC WALL AND FLOOR
CORONAL T1 MR

Gluteus maximus m.

Glutens medius muscle

Superior gemellus
Gluteus minimus m. muscle
I'iriformis tendon
Obturator intemus m.
Obturator interims t.
Obturator intcrnus
tendon Inferior gemellus
muscle
Obturator cxternus
Quadratus temoris muscle
muscle

— Vastus lateralis muscle

Sacroiliac joint

Gluteus maximus
muscle

Oluteus medius muscle

I'iriformis muscle

Obturator intcrnus
muscle

Quadratus femoris
muscle

(Top) Slightly posteriorly, the obturator extemus tendon is shown inserting on the medial aspect of the greater
troehaiiter of the femur. It, too, rotates the hip laterally. (Bottom) The piriformis muscle is seen exiling the pelvis
through the greater sciatic foramen. Once outside the pelvis, it runs inferior to the gluteus medius and may fuse with
it.

>
 PELVIC WALL AND FLOOR
CORONAL T1 MR

Sacroiliac joint

I'iriforniis muscle

— Levator ani muscle

complex

Ischiorectal fossa

— Ischial tuberosity

Sacroiliac joint —

Piriformis muscle

- Levator ani muscle

Rectum — complex
— (iluteus maximus
muscle

— Ischial tuberosity

(Top) The ischiorectal fossa is a pyramid-shaped space, with its base towards the perineum and its apex at the origin
of the levator ani muscle. The ischiorectal fossa lies between the ischial tuberosity and the obturator intcrnus muscle
laterally, and the external anal sphincter and the levator ani muscle medially. The space contains fat, fibrous septa,
pudendal and rectal nerves and vessels (Bottom) The piriformis muscle arises from the anterior surface of the sacrum
and gluteal surface of ilium. Note the close relationship to the rectum, especially on the left.
 PELVIC WALL AND FLOOR
o SAGITTAL T2 MR
o

C
TO External oblique —

1
niuM.lt'
Iliac CreSt —

O
>

> ■
Gluteus medius muscle
W
>
o

(iluteus maximus
muscle

Greater trochanter ot
Tensor fasciae latac — the femur

Vastus lati ralis muscle

External oblique —
muscle
Iliac crest

Gluteus medius muscle

Gluteus maximus
Glutens minimus muscle
muscle

Greater trochanter of
femur
Rectus tcmoris muscle —

Femur

Vastus intermedium
muscle

(Top) First of twelve sagittal T2 MR images through the pelvic wall presented from lateral to medial. Both the gluteus
medius and minimus muscles arise from the dorsal ilium inferior to the iliac crest. The gluteus medius muscle inserts
o n t o the lateral and superior surfaces of greater trochanter, while the gluteus minimus muscle attaches t o the
anterior surface of the greater trochanter. Both muscles are hip abductors. (Bottom) The gluteus maximus is the
largest muscle in the body. Its origin includes the posterior gluteal line, portions of medial iliac crest, sacrum, coccyx
and sacrotuberous ligament. It inserts on the iliotibial tract of the fascia lata and gluteal tuberosity of the femur. It is
the principle extensor of the thigh.
III
_>4
 PELVIC WALL AND FLOOR
SAGITTAL T2 MR

hxtemal oblique —
muscle
Iliac crest —

— Gluteus medius muscle

Glutens minimus — — (JluteilS maximus m.

muscle
— Piriformis tendon

— Obturator internus
tendon
lliofemoral ligament
— Obturator externus t.

Rectus femoris muscle — Quadratus femoris

muscle

Vastus intermedius —
muscle — Femur

External oblique —
muscle

internal oblique muscle

— Glutens medius muscle

— Glutens maximus
muscle
Acetabulum

Sartorius — — Obturator internus t.

— Inferior gemellus m.
lliofemoral ligament
— Obturator extenlus
tendon
Rectus feinoris muscle —
— Femur
Vastus medialis muscle —

(Top) The tendons of the piriformis, obturator internus and obturator externus muscles are seen coursing to their
insertions on the greater trochanter. This group of muscles helps to laterally rotate and abduct the thigh. (Bottom)
The sartorius muscle arises from the anterior, superior iliac spine and courses infcriorly to insert on the medial
surface of the tibial shaft, near the tibial tuberosity.
 PELVIC WALL AND FLOOR
o SAGITTAL T2 MR
o
■D
C
CD

1
O
>
Q. Gluteus minimus m.
Iliopsoas muscle -
v>
> Gluteus medius muscle

Q. Acetabulum

Anterior labrum — Obturator internus

tendon

Inferior gemellus m.
Sartorius muscle —
Quadratus femoris m.

Gluteus maximus m.

Rectus femoris muscle — I Sciatic nerve

Gluteus minimus m.

Iliopsoas muscle — (iluteus medius muscle

Superior gemellus
muscle
Obturator intornus
tendon
Inferior gemellus
muscle
Sartorius muscle — Quadratus temOris m.

Femoral vessels — Gluteus maximus

muscle

(Top) T h e s c i a t i c n e r v e is s e e n j j o s t e r i o r t o t h e q u a d r a t u s f e m o r i s m u s c l e , w h e r e is d e s c e n d s after l e a v i n g t h e pelvis

througli the greater sciatic foramen, below the piriformis muscle. (Bottom) The superior gemellus muscle arises from
the ischial spine, while the inferior gemellus muscle arises from the ischial tuberosity. Both muscles insert on the
medial surface of the greater trochanter of the femur, along with the obturator internus tendon. All three muscles
rotate the hip laterally.

Ill
26
 PELVIC WALL AND FLOOR
SAGITTAL T2 MR

Cecum —

(ilulcus maximus m.

— Iliac hone
lliopsoas muscle —

— Piriiormis muscle

j—— Superior gemellus

muscle
— I — Obturator internus t.

— Inferior gemellus m.

Obturator externus
muscle

Adductor brevii muscle

Sartorius muscle — Adductor magnus
muscle
Adductor longus
muscle

lliacus muscle —
(iluteus maximus
muscle

PSoas muscle —
1'iriformis muscle

Superior gemellus m.

Femoral vessels — — Obturator internus t.

— Inferior gemellus m.

— Obturator extemus
muscle

Adductor brevis — i — Adductor magnus

Adductor longus
muscle

(Top) The close relation between the iliopsoas muscle and the cecum explains the "psoas sign": Pain on extension of
right thigh in patients with an inflamed retrocecal appendix. Inflammation in this area may irritate the iliopsoas
muscle and cause spasm. (Bottom) The piriformis muscle exits the pelvis through the greater sciatic foramen and is
anterior to the gluteus maximus muscle.
 PELVIC WALL AND FLOOR
o SAGITTAL T2 MR
o
LL
■D
C
CO

TO
Sacroiliac joint
O
> lliacus muscle —
GluteUS maximus
CD
muscle
■ •

> Piriformis muscle

CD
0-

— Obturator interims t.

Inferior geniellus m.

Obturator externiis
muscle

Adductor brevis muscle —

Adductor Iongus — Adductor magnus

muscle muscle

Psoas muscle

Sacrum

(iluteus maximus
muscle

Piriformis muscle

Sciatic nerve

Obturator canal Obturator internus

muscle

Obturator externiis
muscle

Adductor brevis muscle —

Adductor lon^us — Adductor magnus

muscle muscle

(lop) More medially, the powerful group of adductor muscles (Iongus, brevis and magnusj are seen anterior and
inferior to the obturator externiis muscle. (Bottom) The sciatic nerve exits the pelvis through the greater sciatic
foramen, inferior to the piriformis muscle. The piriformis syndrome is a condition in which the piriformis muscle
irritates the sciatic nerve, causing pain in the buttocks and referred pain along the course of the sciatic nerve.

Ill
 PELVIC WALL AND FLOOR
SAGITTAL T2 MR

Sairum

< luicus maximus

muscle

Urinary bladder —
— Levator ani muscle

Obturator intemus
muscle

Adductor brcvis —

Adductor longus —
muscle

— Sacrum
Uectus ahdominis —
muscle

— Rectum

Levator ani muscle

Coccyx

Pubic bone Prostate

— Anal canal

Urogcnital diaphragm —

(Top) The levator ani muscle constitutes the pelvic diaphragm and provides support to the pelvic organs. It is critical
for maintaining continence and aiding in normal micturition and defecation. (Bottom) The bladder neck, prostate
and rectoanal junction are above or at the level of the pubococcygeal line, which extends from the last joint of the
coccyx to the lower border of the symphysis pubis.
 PELVIC WALL AND FLOOR
INGUINAL CANAL

Rectus abdominis
External oblique muscle
muscle

Intemal oblique
muscle

Rectus sheath

Transversalis fascia
(level of internal
inguinal ring)
Transversus abdominis
muscle Peritoneum

Internal oblique Cut rectus abdominis

muscle & aponeurosls muscle

Conjoined tendon
Superficial inguinal
Fossa ovalls ring

Cremasteric muscle &

fascia

Greater saphenous

H
The muscle layers of the anterior pelvic wall have been separated to show the inguinal canal. The inguinal canal
extends from the Internal (deep) inguinal ring, an opening through transversalis fascia, to the external (superficial)
inguinal ring, a triangular opening in the external oblique aponeurosls. The canal courses inferomedially and
transmits the spermatic cord in males and the round ligament in females. It is formed embryologically by the
processus vaginalis, an evagination of peritoneum through the abdominal wall. Failure of closure of the processus
vaginalis (patent processus vaginalis) puts the patient at risk for an indirect inguinal hernia.
 PELVIC WALL AND FLOOR
INDIRECT INGUINAL HERNIA

Free intraperitoneal
spill of contrast

Internal inguinal ring —

Inguinal canal —
— Incarcerated bowel
loop

External inguinal ring —

— Hydrocele

Herniogram in a man with an indirect inguinal hernia. The right hemiscrotum was injected with contrast material
and shows a patent processus vaginalis, with a large associated communicating hydrocele. A loop of bowel is seen as
a filling defect within the inguinal canal. Surgery confirmed an indirect inguinal hernia, with an incarcerated small
bowel loop at the external inguinal ring. Herniograms are an antiquated examination but it nicely demonstrates the
course of the inguinal canal, which roughly parallels the superior pubic rarnus.

t
 PELVIC WALL A N D FLOOR
o CT, I N D I R E C T I N G U I N A L H E R N I A
o
T3 Inferior epigastric vessels
Inferior epigastric vessels -
c
CO

TO
o
>

••
(/>
'>
U
D-

— Inferior epigastric vessels

Inferior epigastric vessels

Area of internal inguinal ring

- Small bowel loop

Spermatic cord —

(Top) First of three CT images of a m a n with an indirect inguinal hernia. 1 le had a palpable groin mass hut n o bowel
obstruction. (Middle) The initial bulge through the abdominal wall is lateral to the inferior epigastric vessels. This
represents the area of the internal inguinal ring. (Bottom) The course of an indirect inguinal hernia is lateral t o
medial, following the course of the spermatic cord (round ligament in females). The spermatic cord is being obscured
by the hernia but the normal cord is seen o n the opposite side. Hcrniated contents may extend into the scrotum in
males or labia majora in females.
 PELVIC WALL AND FLOOR
CT, D I R E C T I N G U I N A L HERNIA

Infarcted omentum in hernia

Rcctus ahUominb muscle
Inferior epigastric vessels
Inferior epigastric vessels

Area of Hcssclbach triangle

Infarcted omen turn in hernia

Inferior epigastric vessels

Inferior epigastric vessels

(Top) lirst o f three CT images of a m a n w i t h a direct i n g u i n a l hernia. Direct i n g u i n a l hernias occur t h r o u g h

Hessdbach triangle, a weakness in t h e lower pelvic w a l l . The triangle is f o r m e d by the i n f e r i o r epigastric artery
laterally, lateral edge o f the rectus sheath medially, a n d i n g u i n a l ligament interiorly. ( M i d d l e ) The hernia is medial
t o the inferior epigastric vessels, w h i c h is an i m p o r t a n t i m a g i n g feature used t o diagnose a d i r e c i i n g u i n a l hernia.
( B o t t o m ) Direct hernias are broad-based a n d dome-shaped, a n d seldom e x t e n d i n t o t h e s c r o t u m . A piece o f infarcted
o m e n t u m was f o u n d at surgery.
 PELVIC WALL AND FLOOR
CT, FEMORAL HERNIA

Incarcerated bowel loop -

— Pubic synipbysis

Femoral vessels —

Femoral artery an«J vein -

Incarcerated bowel loop

Dilated small bowel —

Neck of hernia —

Incarcerated bowel loop —

( l o p ) First of three CT images of an elderly woman with a small bowel obstruction secondary t o ari incarcerated
femoral hernia. Femoral hernias traverse t h e femoral canal, which begins posterior to the medial portion of the
inguinal ligament and ends at the fossa ovalis. Hcrniated contents are below the inguinal ligament, medial to the
femoral vessels and lateral to the pubic tubercle. (Middle) Coronal reconstruction shows the proximity of the hernia
to the femoral vessels. The neck is narrow, giving it a characteristic pear shape. (Bottom) Sagittal reconstruction
shows the narrow neck of the femoral hernia, as the bowel loop passes underneath the inguinal ligament.

M
 PELVIC WALL AND FLOOR
CT, OBTURATOR HERNIA

Dilated small bowel

Superior pubic minus

Bowel loop herniati-il through

obturator canal

—
Peetineus muscle

Incarcerated bowel loop

Obturator extemus muscle
Obturator internus muscle

(Top) I irst of three CT images of a an elderly woman with a small bowel obstruction from an incarcerated obturator
hernia. (Middle) The herniated loop of bowel is seen passing just beneath the superior pubic minus. This is the
obturator canal, which in the superolateral aspect of the obturator foramen. Normally only the obturator vessels and
nerve pass through this foramen. (Bottom) The incarcerated bowel loop is between the peetineus and obturator
extemus muscles.

15
 PELVIC WALL AND FLOOR
CT, SCIATIC HERNIA

Uterus -

Lett adnexal structures

Sacrospinous ligament —

Sacrospinous ligament

C^occyx —

Uterus
()vary

Ischial spine - Inferior gluteal vessels

Glutens maximus
muscle

(Top) First of two CT scans shows herniation of the left adnexa, including the ovary, fallopian tube a n d ligamentous
supports through the greater sciatic foramen. The greater sciatic foramen is above the sacrospinous ligament, which
runs from the ischial spine t o the sacrum and coccyx. (Bottom) The ovary completely herniated through the greater
sciatic foramen a n d is seen between the posterior acetabukim and gluteus maximus muscle.
 PELVIC WALL AND FLOOR

Iliac bone

Piriformis muscle

Obturator canal
Ischlal spine
Obturator intemus
muscle
Coccygeus muscle
Arcus tendineus

Uiococcygeus muscle

Pubococcygeus muscle
Rectum

Urogeniral diaphragm
External anal
sphincter
Urethra
Vagina

- ■ ■ * .

J ■

The true pelvis is bowl-shaped, so designation of walls is somewhat arbitrary. The pelvic floor is formed by the
coccygeus muscles and the pelvic diaphragm (levator anl muscles and fascia). The levator anl is composed of three
separate muscles: pubococcygeus, ileococcygeus and puborectalis. The levator ani Is attached to the pubic bones
anteriorly, the Ischlal spines laterally and to the arcus tendineus (thickening in the obturator fascia) between the
bony attachments. The pelvic diaphragm separates the pelvic cavity from the perineum. The lateral and posterior
walls of the true pelvis are formed by the obturator interims and piriformis muscles.
 PELVIC WALL AND FLOOR
FEMALE PELVIC FLOOR/PERINEUM, INFERIOR VIEW

Clitoris

Ischlocavemosus
muscle
Bulbospongiosus
Bulb of vestibule muscle
Perineal Deep transverse
membrane/fascia perineal muscle
Greater vestibular
(Bartholin) gland
Superficial transverse
perineal muscle
Levator ani muscle Perineal body
External anal
sphincter

Gluteus maxlmus
Anococcygeal
ligament muscle
Tip of coccyx

The perineal body is a thickened, midline condensation of fibrous tissue at the midpoint of a line joining the ischial
tuberosities. It is located between vagina and anus in females and between urethra and anus in males. At this point,
several important muscles converge and are attached: The external anal sphincter, the paired bulbospongiosus
muscles, the paired superficial transverse perineal muscles, and fibers of the levator ani. Stretching and tearing of the
attachments of the perineal muscles from the perineal body can occur during childbirth, resulting in loss of support
to the pelvic floor. This results In prolapse of pelvic viscera (cystocele, rectocele and/or enterocele).
 PELVIC WALL AND FLOOR
MALE PELVIC FLOOR/PERINEUM, INFERIOR VIEW

Deep (Buck) fascia of

penis

Ischlocavernosus
muscle
Bulbosponglosus
muscle
Deep transverse
perlneal muscle
Perlneal
membrane/fascia
Superficial transverse Bulbourethral
perinea! muscle (Cowper) gland

Perlneal body
Levator ant muscle

External anal
sphincter muscle

Gluteus maxlmus
muscle
Tip of coccyx

The deep transverse perlneal muscle is covered by a thin sheet of tough deep fascia called the perlneal membrane.
The membrane is pierced by the urethra (also vagina in females) and branches of the pudendal neurovascular bundle.
The deep transverse perlneal muscle and membrane form the urogenltal diaphragm, and provide an attachment for
the external genitalia. No such membrane exists posterior to the transverse perlneal muscles (anal triangle). Note that
in the male, the ischiocavemosus and bulbosponglosus muscles are far more developed than In the female.
 PELVIC WALL AND FLOOR
UROGENITAL & ANAL TRIANGLE

Urogenltal triangle

Superficial transverse
perineus muscle

Anal triangle

Urethra
Urogenltal triangle
Vagina

Rectum
Anal triangle

(Top) The perineum is bordered by the symphysis publs, ischlal tuberoslties and coccyx creating a diamond shape. It
can be subdivided into two triangular compartments by a line drawn slightly antenor to the ischlal tuberoslties along
the superficial transverse perineus muscle, creating the urogenltal triangle anteriorly and the anal triangle
posteriorly. (Bottom) Axial T2 MR of the perineum In a woman, with the urogenltal and anal triangles
superimposed. The urogenltal triangle contains the urethra and vagina and the anal triangle contains the anus.
 PELVIC WALL AND FLOOR
FEMALE PELVIC FLOOR, SUPERIOR & CORONAL VIEW

Fascia of utogenita]
diaphragm

Urethra Puborectalls mn. Je

Vagina
Pubococcygeus muscle
Pectum Obtn, ator muscle &
fascia
Amis tendineus
lllococcygeus muscle

Coccygeus muscle
Acterl-t sacrococcygeal
ligament Piriformis muscle

Sacrum

Fallopian tube
Broad ligament

Round ligament of
uterus

Vagina Obturator vessels &

Obturator lnteu 1 * Levator anl muscle

bchiorectal fossa
De?p tr-.fsvene
per! .cus muscle 6c
Vestibule fascia

(Top) Superior view of the pelvic floor in a female. The levator anl is formed by the pubor- tal s pubococcygeus and
lllococcygeus muscles. The obturator ir i ■ rnus is covered by a fascia, which forms a thick band, the a r c s tendineus or
tendinous arch of the levator an!. This Is a crucial area of attachment for the levator ani. (Bottom) Coronal view of
the pelvic floor In a female at the level of the vagina. The levator ani muscles form the pelvic floor through which
the urethra, vagina and rectum pass, and is the main support for the pelvic organs. The perineuu is space below the
levator ani and inciuoV s the external genitalia. The deep transverse perineus muscle and fascia, along with the
urethral sphincter, form the urogenltal diaphragm.
 PELVIC WALL AND FLOOR
o AXIAL PELVIC FLOOR, FEMALE
o
■D
C ^
TO
— Femoral vessels
TO

O
>

Q. Urinarv bladder
m m

</> Obturator
> neurovascular bundle
0) Femoral head
Q-

— Obturator internus
muscle
Ischiorcct.il fossa
— Levator ani muscle
Anal canal

Obturator internus
tendon
(iluteus maximiis
muscle

Pubic bone " — Pcctineus muscle

- Urinary bladder

Urethra Obturator externus

muscle
I.evatorani muscle -
— Vagina
lsiliiorccI.il fossa — Obturator internus
muscle
Anal canal — 5

- Gluteus maximus
muscle

(Top) First of four axial T2 MK images of the pelvic floor in a female. (Bottom) The levator ani is composed of three
muscles: The pulxxoccygeus, iliococcygeus and puborcctalis muscles. The muscle fitters blend and therefore can not
be discerned as three separate muscles by imaging. The iliococcygeus arises from the ischial spines and arcus
tendineus and is the broadest, most posterior portion of the levator ani. Its most posterior fibers form the
anococcygeal ligament. The pubococcygeus is more anterior arising from the posterior surface of the pubis and arcus
tendineus.
Ill
I.'
 PELVIC WALL AND FLOOR
AXIAL PELVIC F L O O R , FEMALE

Pubic bone — Pectineus muscle

Lateral puhovcsical
ligament
Urethra
Obturator extcrmis
muscle
Vagina —
()bturator internus
iM'liiorettal fossa muscle

Anal canal — I esaior ani muscle

Pubofcctalis
(puborcctal sling)

(iluteus maximus
muscle

I'ectineus muscle
Pubic bone

Urethra - Obturator cxternus

muscle
Vagina
Obturator internus
Ischioreital fossa muscle
Anal canal — 1 evator ani muscle
I'ubori-clalis
(puborcctal sling)

Cilutcus maximus
muscle

( l o p ) I he puborcctalis is the t h i r d and most p r o m i n e n t p o r t i o n o f the levator a n i . This is best appreciated in the
axial plane It fuses w i t h fibers f r o m the opposite side t o f o r m puborcctal sling, w h i c h along w i t h the external anal
sphincter, m a i n t a i n s fecal c o n t i n e n c e . Several studies have s h o w n that the left side o f t h e puborectal sling is thicker
t h a n t h e right side. ( H o t t o m ) The urethra, vagina a n d r e c t u m are surrounded b y the levator ani muscles a n d
u l t i m a t e l y pass t h r o u g h t h e m i n t o the p e r i n e u m . The vagina often has an I I - or U-shaped c o n f i g u r a t i o n w h i c h is the
result of lateral fascia! support provided by the levator a n i .

1
 PELVIC WALL AND FLOOR
CORONAL PELVIC FLOOR, MALE

CituteuS minimus -
muscle Ilium

Urinary bladder —-|

— femoral head

Prostate Obturator internus

nniscle

Obturator externus
muscle

Cluteus minimus
muscle
— Obturator internus
muscle
Seminal vesicle
Iliac bone

I'ubococcygeu* portion
of levator ani muscle

Obturator externus
muscle
— Ischial tubcrosity

( l o p ) first of four coronal IT MR images of the pelvic floor in a male. The true pelvis in a male is much more narrow
than that of the female. (Bottom) The bowel-shaped nature of the levator ani is well appreciated on the coronal
view. Although it can not be discerned as a separate muscle by imaging, the most anterior ]>ortion of the levator ani
is the pubococcygeus muscle.
 PELVIC WALL AND FLOOR
CORONAL PELVIC FLOOR, MALE

Gluteus minimus
muscle I'iriiormis muscle

St 11 in>. i vesicle —
— Arcus tendineus
Rectum — Levator ani muscle

— Obturator interims
muscle
External anal sphincter —

Qu,-;i'.[ :ius femoris Ischial tubcrosity

muscle

Sacroiliac joint

Gluteus minimus
muscle 1'iriformis muscle

Ischial spine lliococcygeus &

coccygeus muscles

Quadratic femoris
muscle

- Isclual tubcrosity

( l o p ) The arcus tendineus is an important source of attachment for the levator ani muscle. It is formed from a strong
fascia! membrane covering the obturator internus muscle. (Bottom) The iliococcygeus forms the most posterior
portion of the levator ani muscle. It arises from the arcus tendineus and ischial spines, and inserts on the sacrum and
coccyx. The coccygeus muscle also arises from the ischial spine and likewise inserts on the sacrum and coccyx. The
coccygeus forms the most posterior support of the pelvic floor. It may not be seen as a discrete muscle but note the
thickening of muscle fibers in this area.
 PELVIC WALL AND FLOOR
CORONAL PELVIC FLOOR, FEMALE

— Iliacus muscle

Acetabulum

Urinary bladder

Obturator interims
muscle

Urethra — Obturatur cxternus

muscle

Sigmoid colon

— Uterus

Urinary bladder

— Lcvatorani muscle
Rectum
I'uhorectalis portion of
levator ani

flop) First of four coronal T2 MR images of the ix-lvic floor in a female. (Bottom) At the rectum, muscle fibers from
the puborectalis portion of the Icvator ani (puborcctal sling) merge with those of the external anal sphincter.
 PELVIC WALL AND FLOOR
CORONAL PELVIC FLOOR, FEMALE

Sigmoid colon

Right ovary
Uterine cervix

Rectum Urinary bladder

— Ixvator ani muscle

lschiorectal fossa

— Small Ixivvel

Piriformis muscle —

Rectum — Urinary bladder

lliococcygeal &
Coccyx coccygeus muscles

(Top) The levator ani muscles forms the pelvic diaphragm a n d is the primary support for the pelvic viscera. The
coronal plane nicely shows the levator ani separating the pelvic organs above, from the perineum and ischiorectal
fossa below. Also note how wide the true pelvis is when compared t o the male. (ISotlom) Hoth the iliococcygeus
(posterior portion of levator ani muscle) and coccygeus muscles insert on the coccyx and sacrum.
 PELVIC WALL AND FLOOR
SAGITTAL PELVIC FLOOR, MALE

Urinary bladder —
Rectum

Prrvcsfcal space r— Coccyx

Prostate
— levator ani muscle

Pubic bone

— Anal canal

Urogenital diaphragm

—
Small bowel

— Sacrum
Urinary bladder -

levator ani muscle

Pubic bone —

(lop) first of two sagittal 12 MR images of the pelvic floor in a male. Hie urogenital diaphragm is formed by the
deep transverse perineus muscle and fascia and the urethral sphincter. Urethral injury following trauma is most
c o m m o n in this area. (Bottom) The levator ani extends posteriorly t o insert on the coccyx and sacrum.
 PELVIC WALL AND FLOOR
SAGITTAL PELVIC FLOOR, FEMALE

1 - Sigmoid colon

Uterus Uterine cervix

Urinary bladder
Rectum
3
Pubic hone "— Coccyx O.
Vagina - ~>— Pubococcygoal lino

Sigmoid colon

Uterine ccr\ ix

w— Rectum
I
Rectoviigin.il i.iMi.i

Coccyx
bevator ani muscle

Small bovwl

- Rectum
Urinary bladder
Pubic iKine
Ivvator ani muscle

(Top) The first of three sagittal F2 MR images of the pelvis in a female showing the relationship of the pelvic organs
to a line extending from the lower border of the pubic symphysis to the last joint of the coccyx (pubOCOCCygeal line).
This line represents t h e plane of pelvic floor. In normal, continent women the bladder neck, vaginal forniees a n d
aiiorectal junction are at or above the pubOCOCCygeal line. (Middle) The posterior vaginal wall and fascial
condensation called the rectovaginal fascia support the rectum and prevent formation of an cnterocelc or rectocele.
(Hot torn) The full length of the pelvic diaphragm is well appreciated on a sagittal view lateral to the midline. The
levator ani muscle group has a broad area of attachment including the pubic bones, arcus tendineus, ischial spines,
sacrum a n d coccyx.
 PELVIC WALL AND FLOOR
PELVIC FLOOR RELAXATION

Cervix
Bladder —
- IHibococcyneal line
Uretllrovcsical junction —
- Rectum

Cervix

I'ubococcygeal line

Cystocele
Rectocele
Urethrovesical junction

I'ubococcygeal line

Vaginal cull
Levator ant
Cystocele

Rectocele
Uretfirovesical junction

(Top) First of two dynamic 12 MR images in a w o m e n with pelvic floor descent. On the relaxed view, the
urethrovesical junction and cervix lie above the pubococcygeal line. (Middle) With straining, there is pelvic floor
descent with a cystocele and rectocele. The uterus has also descended, with the external os now at the pubococcygeal
line. (Rottom) Sagittal T2 MR taken during straining in a different patient shows a cystocele, vaginocelc and
rectocele. Note the abnormal vertical orientation of the levator ani.
 PELVIC WALL AND FLOOR
PELVIC FLOOR RELAXATION

Vagina —
Lett levator ani muscle

Right levator ani

muscle

Femurs —

Vagina

Paperclip on perineum

F.nlerocele — Rectum

(Top) Axial T 2 MR shows an a b n o r m a l r i g h t levator ani muscle i n a w o m a n w i t h pelvic floor relaxation. Note t h e
loss o f support for t h e r i g h t side of the vagina, w h i c h n o w is directed h o r i z o n t a l l y rather t h a n m a i n t a i n i n g the
H-shape c o n f i g u r a t i o n as seen o n t h e left. ( B o t t o m ) Knterocele i n an elderly w o m a n . The small b o w e l is filled w i t h
b a r i u m , w i t h a small a m o u n t in the vagina a n d rectum t o serve as markers ( t h e p e r i n e u m is marked by a paperclip).
The patient is placed i n the lateral p o s i t i o n a n d images are o b t a i n e d at rest a n d w i t h straining. D u r i n g straining
(image shown), there is pelvic floor descent w i t h small bowel prolapsing between the vagina a n d rectum. N o r m a l l y ,
t h e rectovaginal fascia forms a s u p p o r t i n g barrier, a n d bowel can n o t descend i n t o this spare.
 VESSELS, LYMPHATIC SYSTEM AND NERVES
• Internal iliac nodes
Along internal iliac vessels
•' Drainage from inferior pelvic viscera, deep perineum
and gluteal region
' flow into c o m m o n iliac nodes
• C o m m o n iliac nodes
Along c o m m o n iliac vessels
Drainage from external iliac, internal iliac and sacral
nodes
I low into lumbar (lateral aortic) chain of nodes
Nerves
• Sacral plexus
Coalescence ol lumbar and sacral nerves
■ I 4 (minor branch), I S
• Sl-.i (ventral rami), 54 (minor b r a m h )
• Sciatic nerve
Upper hand and major branch of sacral plexus
• Runs on ventral surface of piriformis muscle
Broadest nerve in body (2 cm)
- Exits pelvis t h r o u g h greater sciatic foramen,
below piriformis
- Innervates capsule of hip joint, posterior thigh and
leg muscles
• P u d e n d a ! nerve
I ower band of sacral plexus
■ Ventral rami of S2-4
follows internal pudendal artery
■ Exits pelvis through greater sciatic foramen
■ Curves around sacrospinous ligament to enter
perineum through lesser sciatic foramen
■ I'udendal canal on lateral wall of ischiorectal
tossa
Major nerve supply to perineum and external anal
sphincter
• O b t u r a t o r nerve
Anterior branches of 1,2-4 ventral rami
follows obturator vessels, exiting pelvis through
obturatoi foramen
Innervates hip adductors
• femoral nerve
Posterior branches of L2-4 ventral rami
Descends through psoas muscle into iliopsoas
groove
Exits pelvis beneath inguinal ligament through
femoral c a n a l
■ Most lateral structure in femoral canal
■ Acronvm for femoral canal contents from lateral
to medial = NAVI (nerve, artery, vein, lymphatic)
^ Branches innervate anteromedial thigh
Anatomy-Based Imaging Issues
Imaging Recommendations
• ( T angiographv (CTA) and MR angiography (MRA) are
imaging modalities of choice to evaluate pelvic vessels
■ 3D reconstructions and maximum intensity
projections iMIPl rotated in 360° for complete
evaluation
• Delayed imaging (180 seconds) for evaluation of pelvic-
veins
• Conventional angiography for therapy (emboli/ation)
Clinical Implications
Arterial
• Collateral circulation
o Rich, complex collateral circulation helps ensure
delivery of blood to pelvic organs and lower limbs in
event of proximal obstruction
C o m m o n iliac artery o b s t r u c t i o n
■ Ipsilateral lumbar and contralateral lateral sacral-*
internal iliac -* retrograde into external iliac arterv
Internal iliac a r t e r y o b s t r u c t i o n
■ Lumbar-* iliolumbar arteries
■ Median sacral -» lateral sacral arteries
■ Superior rectal -* inferior rectal arteries
■ Deep femoral artery -» femoral circumflex
branches -* inferior gluteal arteries
External iliac artery o b s t r u c t i o n
■ Posterior trunk of internal iliac — deep iliac
circumflex artery -* c o m m o n femoral artery
■ Anterior trunk of internal iliac — circumflex
femoral branches of deep femoral artery
Venous
• Rectal plexus is a major site of porto-systemic
collaterals in patients with portal bypertension
Hemorrhoids represent engorged collaterals
• Ovarian vein t h r o m b o s i s
I'ostpartum septic thrombosis ol ovarian vein
90% occur on right side
• May Thtirner syndrome
Compression, thrombosis and eventually occlusion
of upper left c o m m o n iliac vein as it passes between
the right c o m m o n iliac artery and spine
• Rectal c a r c i n o m a
Hematogenous spread of metastases depends on
location of primary tumor
I ower two thirds-* internal iliac veins— lungs
« Upper third— inferior mesenteric vein— liver
Lymphatic
• Testicular c a r c i n o m a drains according to site of
primary tumor
1 ymphatics follow venous drainage
Right-sided tumors first spread to infrarenal,
prccaval and aortocaval nodes
o Left-sided tumors initially spread to left para-aortic
nodes near renal hilum
• Ovarian lymphatics follow same course, howe\er,
ovarian cancer more often spreads bv direct peritoneal
seeding
Nerves
• Piriformis s y n d r o m e
Piriformis muscle may irritate sciatic nerve, causing
pain in buttocks and referred pain along course of
sciatic nerve
• P u d e n d a l nerve block
Not as frequently utilized secondary to increased use
of epidurals
Pertormed either transvaginallv or perineally
Needle directed toward ischial spine where pudendal
nerve curves around into pudendal canal
 VESSELS, LYMPHATIC SYSTEM AND NERVES
PEi VIC ARTERIES

Superior meseriteric
artery

Ovari jn (gouadal)
artery
Abdominal m >rta
Inferior vena cava
[ni-normeseisteric
artery

Common iliac artery

' "
Middle sacral artery
fliofci.'irtw artery
Fallopian tube Ir-t^nal iliac artery
Anterior trunk of
Ovarian artery internal iliac artery

External iliac artery

Lateral sacial artery
Uterine artery
Deep iliac drr»raJWx
artery

Medial umbilical
ligament

Frontal graphic of the abdominal aorta, inferior vena cava, and the iliac vessels in a female. The inferior mese iteric
artery is the smallest of the anterior mesenteric branches of the aorta and continues in the pelvis as the superior
rectal artery. The paired ovarian arteries arise from the aorta below the renal arteries and pass inferioriy on the
posterior abdominal wall to enter the pelvis. The ureters cross anterior to the bifurcation of the common Ulac arteries
on their way to the urinary bladder. The common iliac artery divides into the evtemal iliac artery, which supplies the
lower extremity and the internal iliac (hypogastric) artery, which supplies the pelvis. The internal iliac artery divides
Into an anterior trunk for the pelvic viscera and a posterior trunk for the muscles of the pelvis.
 VESSELS, LYMPHATIC SYSTEM AND NERVES
PELVIC ARTERIES
<p_
<
55"
<
CD
C/>
(f>
CD_
C/5

Abdominal aorta
3
a>
i—i-

o'
Common Iliac artery CD
in
CD
Hiolumbar artery
3
Lumbosacral nerve 0)
Internal iliac artery trunk
Posterior division of z
External iliac artery Internal iliac artery
CD
Anterior division of SI nerve root
internal iliac artery CD
Superior gluteal artery
Obturator artery Lateral sacral artery
Umbilical artery
Medial umbilical Inferior gluteal artery
ligament

Superior vesicle Middle rectal artery

arteries
Inferior vesicle artery Internal pudenda!
artery
Uterine artery

Graphic of the pelvic arteries and their relation to the sacral nerves. The superior gluteal artery passes posteriorly and
runs between the lumbosacral trunk and the anterior ramus of the SI nerve, whereas the inferior gluteal artery
usually runs between the Sl-2 or S2-3 nerve roots to leave the pelvis through the infenor part of the greater sdatic
foramen. Only the proximal portion of the umbilical arteries remains patent after birth, while the distal portion
obliterates forming the medial umbilical ligaments. Arteries to the deep pelvic viscera include the superior and
inferior vesicle, uterine, middle rectal and internal pudenda!. The individual branching pattern is quite variable.
 VESSELS, LYMPHATIC SYSTEM AND NERVES
V) PCtVIC VEINS
CD
£
CD
2
"O
c
CO
E
0)
"to
5^
C/3 L*ft penal vein
o
V-*
CO *
xz
CL
E
>.
i
c/f Right orarlan vein
CD Ua#t ovarian vein
</)
C/3 ir • ■ ■ T v*na cava
CD
>
w ^C- t
> 4 "*V
CD l^^^^^^^^^^^^fc^^
0-
V J > ? M.-i >n sacral vein

Illolumbar TiJn

External iliac vein

internal iliac vein

Lateral sacral vein
Round ligament

Uteri-ie vein Mid^errrtalveln

Inguinal ligament S»pe«>or vesWJe vein

Common femoral vein

Graphic of the veins of the pelvis. The left ovarian vein drr.tr; into the left rt-nal vein, whi reas the right ov.'.-im vein
drains directly into the inferior vena cava. Multiple inteai.-.n.nn.riicatri g pelvic venous plerus*> (recta!, vehicle,
prostatic, uterine and v ginal) draii rn ilnly to the iniemal Ulac vein?. There i* a communica*ion between the pelvic
veins and the intrasiiinal sMdwal p i o u s at vetns rhn-uuh the sacral \ r n . m pfcxns.

Ill
56
 VESSELS, LYMPHATIC SYSTEM AND NERVES
AXIAL CECT, PELVIC VESSELS

Branches of superior mesenteric

artery

Inferior mesenteric arlery

AlxJominai aorta

Superior mesenteric artery

Aortic bifurcation
Interior mesenteric arterv
Interior vena cava —
— I umhar artery

- 1.4 vertebral body

I— Mesenteric branches of superior

mesenteric artery
Si;;;, iu i nuscntcrk artery —

— In Icrior mesenteric artery

•— Ix'ft common iliac artery

Confluence of left £c right common

iliac veins

(Top) First of twelve CECT images of the pelvic vessels. The inferior inesenteric arterv. the smallest of the mesenteric
arteries, is an anterior branch of the abdominal aorta. It continues in the pelvis as the superior rectal artery. It
supplies the distal transverse colon, splenic flexure, descending a n d sigmoid colon, and the upper part of the rectum.
(Middle) The aorta bifurcates at the level of L4 into the two c o m m o n iliac arteries. (Bottom) The inferior vena cava
is formed below the aortic bifurcation by the joining of the c o m m o n iliac veins. The left iliac vein passes between the
left c o m m o n iliac artery and the L5 vertebral body. Chronic iliac vein compression syndrome, or May-Thurner
syndrome, is deep vein thrombosis resulting from the chronic compression ol the left c o m m o n iliac vein by the
overlying right c o m m o n iliac artery, l'atients frequently present with lett lower extremity swelling or pain.
 VESSELS, LYMPHATIC SYSTEM AND NERVES
CO AXIAL CECT, PELVIC VESSELS

-o
c Interior mesenteric artery
TO
Left common iliac artery
E Middle (median) sacral artery
£
to
— 1 eft common iliac vein

—
CO 1.5 vertebral bodv

i2
CD
in

■ ■

to
j>
0.
Right common iliac artery —|
Common iliac artery
bifurcation
Right common iliac vein
Left common iliac vein

1'xtcrnal iliac artery - External iliac artcrj

Internal iliac artery - — Internal iliac artery

—
Common iliac vein
lliotumbar artery -

(Top) The middle or median sacral artery is a small unpaired vessel, which comes off the posterior aorta and
descends in the midline to the coccyx. The common iliac arteries usually give off no visceral branches. They may,
however, give origin to accessory renal arteries. (Middle) The common iliac arteries divide, at the level of 1.5-51, into
two branches, the external and internal iliac (hypogastric) arteries. The external iliac artery supplies the lower
extremity, while the hypogastric artery supplies the pelvic viscera and muscles of the pelvis. (Bottom) The iliolumbar
artery, usually a branch of the posterior tnink of the internal iliac artery, arises in this subject from the main internal
iliac artery.
III
r
»8
 VESSELS, LYMPHATIC SYSTEM AND NERVES
AXIAL CECT, PELVIC VESSELS
2.
<
Inferior epigastric artery
■ ■

if
GO
00
External iliac artery
GO
Interior mesenteric vein ■
Internal iliac artery *<
Inferior mesenteric artery - 3
■o
ZT

o
if)

CD
3
CD
Interior epigastric artery Q.

Fxternal iliac artery

I
CD
GO

Anterior division, internal iliac -

artery Internal iliac artery

Posterior division, internal iliac Inferior mesenteric artery

artery

Inferior epigastric artery

External iliac artery

- External iliac vein

Anterior division internal iliac —

artery — Internal iliac vein
Posterior division internal iliac —
artery

(lop) The inferior mesenteric vein, a continuation of the superior rectal vein, accompanies the inferior mesenteric
artery and usually drains into the splenic vein. The rectum is an important site of porto-systemic anastomoses. In
patients with portal hypertension, blood is shunted from the high pressure portal venous system through the inferior
mesenteric vein to the middle and inferior rectal veins, which drain into the internal iliac vein. (Middle) The
internal iliac artery divides into an anterior and posterior trunk. The anterior trunk mainly supplies the pelvic
viscera, whereas the posterior trunk supplies the pelvic musculature. (Bottom) The internal iliac vein receives blood
from multiple pelvic venous plexuses. It unites with the external iliac vein, a continuation of the common femoral
vein, to form the common iliac vein. Ill
>'.)
 VESSELS, LYMPHATIC SYSTEM AND NERVES
to AXIAL CECT, PELVIC VESSELS
I
OJ
- Inferior epigastric artery
Z
■D
C
03
E External iliac artery
Cxtvnial iliac vein

O Anterior division internal iliac

'•4-< artery
TO
-C
Q.
Superior gluteal artery
E
>S

J2
0)
w
Inferior epigastric artery - Inferior epigastric artery

■ •

_ - Deep iliac circumflex artery

■M i Deep iliac circumflex artery
>
— External iliac artery
Q.

Superior gluteal artery

Superior gluteal artery ■

— Inferior epigastric artery

— Deep iliac circumflex artery

—
External iliac, artery

- Internal pudcndal artery

- Inferior gluteal artery

(lop) The superior gluteal artery runs posteriorly between the lumbosacral trunk and the first sacral nerve. It exits
the pelvis through the greater sciatic foramen, above the piriformis muscle. (Middle) The inferior epigastric and deep
iliac circumflex arteries arise from the external iliac artery just above the inguinal ligament. These are important
landmarks on angiography to determine the point where the external iliac artery becomes the common femoral
artery. (Bottom) The internal pudendal artery and inferior gluteal arteries are the terminal branches of the anterior
trunk of the internal iliac artery. They exit the pelvis through the greater sciatic foramen beneath the piriformis
muscle. The internal pudendal artery then curves around the sacrospinous ligament to enter the perineum through
III the lesser sciatic foramen.
00
 VESSELS, LYMPHATIC SYSTEM AND NERVES
PELVIC ANCIOGRAM, ARTERIES ■v
<
w'
■ ■
— Aortic bifurcation
<
CD

Common iliac arteries — u>

CD.
— External iliac artery

— Iliolumbar artery 3
-o
=3"

Lateral sacral artery —

— Superior gluteal artery o"
C/)
Anterior division
internal iliac artery
CD
3
13
Q.
Common femoral
artery CD

CD

Lumbar artery — Aortic bifurcation

Common iliac arteries — Internal iliac artery

Iliolumbar artery

lateral sacral artery — Superior gluteal artery

Anterior division
internal iliac artery External iliac artery

Obturator artery

— Profunda femoris artery

— Superficial femoral
artery

flop) Conventional angiogram of the pelvic arteries. Note t h e overlap between the various visceral branches of the
internal iliac artery, making it difficult to identify individual arteries. Oblique views are commonly obtained for
better visualization of the individual branches. Note that the internal and external iliac arteries are almost in the
same sagittal plane. (Bottom) Digital subtraction angiography allows better visualization of the pelvic arteries.

Ill
61
 VESSELS, LYMPHATIC SYSTEM AND NERVES
3D CT, ARTERIES

Common iliac arteries

Middle sacral artery J External iliac artery

Internal iliac artery

Superior giuteal artery

Internal pudendal
artery
Inferior giuteal artery External lilac artery

Common femoral
artery
Superficial femoral
artery
Profunda femorls artery

Sacrum Superior giuteal artery

Inferior giuteal artery

Internal pudendal
artery

Ischium

(Top) 3D volume rendering frontal image of the iliac arteries. The aorta bifurcates at the level of L4 into the common
iliac arteries and the common iliac arteries bifurcate at the level of L5-S1 into the external and internal iliac arteries.
(Bottom) 3D volume rendering posterior image of the pelvis showing the superior giuteal artery, the continuation of
the posterior trunk of the the internal iliac artery, and the inferior giuteal artery, a branch of the anterior trunk. Note
the proximity of the superior giuteal artery to the iliac bone making it vulnerable to injury in cases of pelvic
fractures.
 VESSELS, LYMPHATIC SYSTEM AND NERVES
3 D CT, ARTERIES

<

Inferior mesenteric <

CD
artery (/)
C/>
Internal iliac artery CD_
C/3
External lilac artery

Deep circumflex iliac 3

artery ■D
Superior gluteal artery IT

til
Inferior epigastric CD
artery o'
Inferior gluteal artery C/)
*<
Obturator artery C/>
CD
Common femoral
artery
3
CO
Internal pudendal
artery
CD
Superficial femoral
artery CD

Prorunda femoris artery

Internal iliac artery

External Iliac artery
Posterior trunk internal
Inferior epigastric Iliac artery
artery
Deep circumflex iliac Anterior trunk internal
artery Iliac artery

Superior gluteal artery

Obturator artery Uterine artery

Internal pudendal
artery

(Top) 3D volume rendered side view of the iliac arteries. The deep lilac circumflex artery arises opposite the inferior
epigastric artery just above the level of the inguinal ligament. They demarcate the external iliac artery above, from
the common femoral artery below. (Bottom) 3D volume rendered oblique side view of the iliac arteries in a female
shows a large uterine artery. The obturator artery, a branch of the anterior trunk of the internal Iliac artery, runs
along the pelvic side wall and leaves the pelvis through the obturator canal. Occasionally, an aberrant obturator
artery can come from the Inferior epigastric artery. Note the tortuous course of the internal pudendal artery, as it
curves around the sacrospinous ligament to enter the perineum through the lesser sciatic foramen.
Ill
63
 VESSELS, LYMPHATIC SYSTEM AND NERVES
MRA M I P

Lumbar artery — Aorta

Common iliac artery

Middle sacral artery

External iliac artery

I — Superior glutcal artery

Urinary bladder

Interior glutcal artery

I'rofunda femoris artery

Superficial femoral
artery

Aorta

Common iliac artery

Middle sacral artery

Internal iliac artery External iliac artery

Superior glutcal artery

External iliac artery

Interior gluteal artery

Urinary bladder

Obturator artery

I'rofunda femoris artery

Superficial femoral
artery

(Top) The first of four maximum intensity projection (Mil') images obtained from a gadolinium-enhanced MRA of
the pelvis. This is a thick Mil' image and the small visceral branches are not well seen. (Bottom) Oblique thick MIP
image of the pelvic arteries again shows the large branches of the iliac arteries. The obturator artery is seen running
anterolaterally along the lateral wall of the pelvis. It exits the pelvis through the obturator foramen to supply the
medial thigh muscles.
 VESSELS, LYMPHATIC SYSTEM AND NERVES
MRA MIP TJ
O
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^ ™ »

W
Aorta
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CD
U)
t omnion iliac artery in
CD
Middle sacral artery 03

External iliac artery

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Superior gluteal artery
• - * ■

o"
Visceral branches of
CO
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the anterior trunk Inferior gluteal artery
CD

Urinary bladder 3
0)
3
Q.

External iliac artery

z
2
CD
CD
I'rofunda femoris artery C/>

Superficial femoral
artery

Internal iliac artery

Middle sacral artery

Posterior trunk of
internal iliac artery
Superior gluteal artery —
Anterior trunk of
internal iliac artery
Superior vesicle artery

( l o p ) A steeper obliquity shows the superior and inferior gluteal arteries. (Bottom) A t h i n M i r image of the internal
iliac arteries shows the b r a n c h i n g vessels in much greater detail.

(,,
 VESSELS, LYMPHATIC SYSTEM AND NERVES
UTERINE ARTERIES
CD

CD
- Common ilia artery

C
CO - Internal iliac artery
E
Superior gluteal artery —
& Ascending segment of the right
in
uterine artery
co Interior gluteal artery
o
- Left uterine artery
CD Right uterine artery
-C
Q.

to
CD
C/>
(/>
CD
>
■ •
tn
>
Q.

Internal iliac artery ■

■ Ascending segment of the right
uterine artery
Left uterine artery
Right uterine artery -

Transverse segment of the right

uterine artery

Ascending segment of the right

uterine artery

Descending segment of the right -

uterine artery

Transverse (ligamentous)
segment of right uterine artery

( l o p ) O b l i q u e v i e w d u r i n g c o n v e n t i o n a l pelvic angiography shows dilated uterine arteries bilaterally (right > left) i n
a patient w i t h m u l t i p l e uterine I c i o m v o m a s . ( M i d d l e ) l i r s t o f t w o m a x i m u m intensity p r o j e c t i o n images f r o m a
g a d o l i n i u m - e n h a n c e d MRA i n t h e same patient as previous image. This closely resembles the appearance o n
c o n v e n t i o n a l angiography. MRA a n d CTA have essentially replaced diagnostic c o n v e n t i o n a l angiography for
evaluation o f pelvic vascular structures a n d d e l i n e a t i o n o f vascular anatomy, p r i o r t o surgical a n d i n t e r v e n t i o n a l
procedures. (Bottom) The uterine artery has a characteristic U-shaped course, w h i c h consists o f a descending
segment r u n n i n g d o w n w a r d a n d medially, a transverse segment w h i c h courses m e d i a l l y t h r o u g h t h e cardinal
III ligament, and the marginal o r ascending segment r u n n i n g along the side o f the uterus.
 VESSELS, LYMPHATIC SYSTEM AND NERVES
OVARIAN VEINS "0

<

« ■

Left renal vein

V)
- Left kidney

Aorta

3
Dilated left ovarian vein
:x

o"
CO
Aclnexal varitosities

3
( chut" axis 0)
z»
Q.
Z
Si;pi iKir mosenteric artery —
- I eft renal vein
1
- Dilated lelt ovarian vein

Right ovarian vein

Sacral venous plexus

Canula —
Uterine vein

(Top) First o l t w o images in a patient w i t h pelvic congestion syndrome. O n this o b l i q u e M i l ' l l image the dilated,
tortuous, left ovarian vein is seen d r a i n i n g i n t o t h e left renal v e i n . T h e left ovarian v e i n shows early, dense
opaclflcation w h e n compared t o the o t h e r pelvic venous structures, w h i c h are not opacified. This is secondary t o
reflux of contrast f r o m the left renal vein i n t o the left ovarian v e i n . ( M i d d l e ) The 3 D v o l u m e rendered image shows
compression o f t h e left renal vein b v the superior mesenteric artery. This compression contributes t o venous reflux
d o w n the ovarian vein a n d has l>een called t h e "nutcracker syndrome". ( B o t t o m ) Pelvic v e n o g i a i n i n a different
patient, obtained atter i n s e r t i o n o f a canula i n t o the m y o m e t r i u m , shows f i l l i n g o f a normal-si?ed right ovarian v e i n .
The right ovarian v e i n flows directly i n t o the I V C , a n d therefore, is at less risk for reflux. Ill
f>7
 VESSELS, LYMPHATIC SYSTEM AND NERVES
AXIAL CECT, T H R O M B O S E D R I G H T O V A R I A N V E I N

Superior mesenteric arterv

Inferior vena cava - - Left renal vein

Aorta
Right ovarian vein/IVC junction ■

Right kidney -

Inferior vena cava — |

Aorta
Right ovarian vein —

— Left common iliac artery

Right ovarian vein —

Right common iliac vein

(Top) hirst of three axial CFCT images in a postpartum woman with fever and right-sided ovarian vein thrombosis.
On this most cephalad image, the thrombus is seen extending to the entrance of the right ovarian vein into the
inferior vena cava. (Middle) The right ovarian vein is dilated and filled with thrombus (Bottom) Thrombosis usually
occurs secondary to pelvic infection. In addition to the thrombus itself, the vessel wall is thickened and there is a
surrounding inflammatory reaction. Following the normal course of the vein up towards the IVC allows
differentiation from other pelvic pathologies, such as appendicitis.
 VESSELS, LYMPHATIC SYSTEM AND NERVES
AXIAL CECT, THROMBOSED LEFT OVARIAN VEIN

Thrombus extending into the

left renal vein

Hydronephrosis

— Left ovarian vein

Hydronephrosis

- - Left ovarian vein

(Top) First of three axial CECT images in a woman with postpartum thrombosis of the left ovarian vein. This image
shows the thrombus extending into the non-opacified left renal vein. (Middle) Clot is present within the left ovarian
vein and the wall is thickened, with surrounding inflammatory changes. (Bottom) The ovarian veins ascend along
the psoas muscle and cross anterior to the ureters, near the confluence of the common iliac veins. Inflammation
from ovarian vein thrombosis may also affect the ureter and result in hydronephrosis, as is seen in this case.
 VESSELS, LYMPHATIC SYSTEM AND NERVES
en PELVIC LYMPH NODES
CD

CD
"a
c Paraorrtc lymph nodes
CD
E
CD
-•—< Common iliac lymph
nodes
CO
o
'■*-<

CD
.c External lilac lymph
a. nodes
E
Internal Iliac lymph
nodes
CD
Co Superficial inguinal
to lymph nodes Deep Inguinal nodes
CD
>
(0
>
Q.

Paraortic lymph nodes

Common iliac lymph

nodes
m Internal lilac lymph

A'
nodes

External lilac lymph

nodes Lymph nodes along
branches of the
internal iliac vessels

(Top) Graphic of the lymph nodes of the pelvis. Generally the lymph nodes are located along, and named after, the
Iliac vessels. Two groups of inguinal lymph nodes are described: The superficial and deep group. The superficial
inguinal nodes lie along the saphenous vein, superficial to the cribriform fascia which overlies the femoral vessels.
There are approximately 10 superficial lymph nodes. The deep inguinal lymph nodes are located medial to the
femoral vein and under the cribriform fascia. There are approximately 3-5 deep nodes. The most superior inguinal
node is located under the Inguinal ligament and is called the gland or node of Cloquet. (Bottom) Graphic of the side
wall of the pelvis shows the lymph nodes along the corresponding iliac vessels.
III
70
 VESSELS, LYMPHATIC SYSTEM AND NERVES
CORONAL MR, PELVIC LYMPH NODES

Fxternal iliac vessels -

ubLil Inguinal lymph nodes

Inguinal ligament

Internal iliac vessels

Left external iliac vein

Lxtcrnal iliac node -
External iliac node

Cervical cancer

Inferior vena cava - - Aorta

*— Common iliac Ivmph nodes

Confluence of internal and external

iliac vein

l-'xternal iliac arter\ -

Lxtcrnal iliac lymph node -

(Top) Coronal Tl MR image shows the distribution of normal-sized inguinal lymph nodes along the inguinal
ligament. (Middle) Coronal oblique T2 MR image of woman with cervical cancer shows enlarged external iliac
lymph nodes from metastattc disease. (Bottom) Coronal Tl MR shows multiple enlarged pelvic lymph nodes in a
patient with lymphoma.
 VESSELS, LYMPHATIC SYSTEM AND NERVES
PET CT, PELVIC LYMPH NODES

■o
C
CO
- Paraortic lymph nodes
E
£ Aorta
to
>. i irctcr
(/)
o
'to
-C
Q.
E
w
CD
</5
</>

* ■

v>
■ —

>
©
Q.
— Common iliac lymph node

Kxternal iliac lymph nodes -

Internal iliac lymph nodes - Ascitcs

flop) First of six axial I'F.T CT images, after injection of 18-F FDCi, shows increased metabolic activity in multiple
enlarged groups of lymph nodes in a young patient diagnosed with non-Hodgkin lymphoma. Image shows
involvement of the para-aortic lymph nodes. Increased activity is seen in the right ureter due to excretion of 18-F
FIXi in urine. (Middle) Increased metabolic activity in the common iliac lymph nodes. (Bottom) Increased
metabolic activity in the internal and external iliac lymph nodes on both sides.
 VESSELS, LYMPHATIC SYSTEM AND NERVES
PET CT, PELVIC LYMPH NODES
XL
<
*-

w
—
External iliac lymph nodes w
<L
w
r-
1
_
Internal iliac lymph nodes

— Ascitcs DJ
S3:
O

m
3
OJ
Q.

z
Inguinal node CD
CD

Ohtiirator lymph nodes

— Internal iliac lymph node

~ Left inguinal lymph nodes

■ Urinary bladder

(Top) The nodal chains are named for the vessels they accompany. ( M i d d l e ) Obturator nodes lie adjacent t o the
obturator internus muscle and are a frequent site o f metastases for pelvic malignancies. ( B o t t o m ) The superficial
i n g u i n a l nodes drain the skin of the penis, lower a b d o m e n , perineum, scrotum a n d part o f t h e b u t t o c k area. The
deep i n g u i n a l nodes located under the fascia lata are the m a i n l y m p h a t i c drainage f r o m the lower extremities, but
they also receive small branches f r o m the penis a n d efferent vessels f r o m t h e superficial i n g u i n a l nodes.

Ill
 VESSELS, LYMPHATIC SYSTEM AND NERVES
PET CT, PELVIC L Y M P H N O D E S
£
(D

z
C
CD
E
2
tf>
>>
C/)
o
to
a. - I .eft inguinal lymph nodes
E Right inguinal lymph nodes

w
<D
to
to
>
■ •

a.

- External iliac lymph nodes

Inguinal lymph nodes

Para-aortic lymph nodes — Left common iliac artery

Left common iliac nodes

Common iliac lymph nodes —

Internal iliac lymph nodes —

(Top) First of six coronal PET CT images in the same patient diagnosed with lyinphoina shows enlarged
metabolically active inguinal lymph nodes. (Middle) The external iliar nodes are above the inguinal ligament and
are the primary drainage for the inguinal nodes. (Bottom) More posteriorly, metabolic activity is seen in internal
iliac, c o m m o n iliac and para-aortic lymph nodes.

Ill
 VESSELS, LYMPHATIC SYSTEM AND NERVES
PET CT, PELVIC L Y M P H NODES

Para-aortic lymph nodes

Para-aortic lymph nodes

Common iliac lymph nodis

Common iliac lymph nodes -

Internal iliac lymph nodes

(Top) This image shows the para-aortic lymph nodes. These nodes receive lymphatic drainage from the common
iliac lymph nodes. In addition the para-aortic nodes receive drainage from the gonads. Typical patterns of spread in
testicular cancer patients occur according to the side of the primary tumor. Right-sided testicular tumors spread
initially to the aortocaval nodes, the right para-aortic nodes and the precaval nodes. Left-sided primaries metastasize
to preaortic nodes and left para-aortic nodes just below the level of the renal vein. (Middle) The common iliac nodes
receive lymphatic drainage from the internal and external groups of lymph nodes, and drain into the para-aortic
lymph nodes. (Bottom) The internal iliac lymph nodes receive lymphatic drainage from Ihe pelvic viscera and drain
into the common iliac lymph nodes.
 VESSELS, LYMPHATIC SYSTEM AND NERVES
PELVIC NERVES

"O
c:
to
£
B
To
L2-4, anterior division

CO
O
TO Upper band of sacral
x: plexus Obturator nerve
E
>>

w
<D Lower band of sacral
C/>
U) Sciatic nerve plexus
(D
>
id Pudendal nerve
'>
o
Q.

Sciatic nerve

Pudendal nerve

(Top) The ventral rami of L2-4 split into two divisions: A larger posterior division, which forms the femoral nerve
(not shown) and a smaller anterior division, which forms the obturator nerve. The obturator nerve follows the
obturator vessels, leaving the pelvis through the obturator foramen. The sacral plexus has a larger upper band (L4, L5,
Sl-3), which becomes the sciatic nerve and a lower band (S2-4), which becomes the pudendal nerve. (Bottom) The
upper band of the sacral plexus coalesces into the sciatic nerve on the ventral surface of the piriformls muscle. The
lower band forms the pudendal nerve, which exits the pelvis through the greater sciatic foramen. It then curves
around the sacrospinous ligament to enter the perineum through the lesser sciatic foramen. The pudendal nerve is
III the primary lnnervation for the perineum and external anal sphincter.
7fi
 VESSELS, LYMPHATIC SYSTEM AND NERVES
PELVIC NERVES

L2-4, posterior
division

Pirlformls

Sciatic nerve

Femoral nerve

The femoral nerve Is formed from the posterior division of the L2-4 ventral raml. It descends through the psoas
major muscle and into the iliopsoas groove. It exits the pelvis beneath the inguinal ligament through the femoral
canal. The well known aaonym "NAVL" (nerve, artery, vein, lymphatic) describes the order of the femoral canal
contents from lateral to medial. The femoral nerve innervates the anteromedial thigh. The sciatic nerve exits the
pelvis through the greater sciatic foramen below the plriformis muscle to innervate the posterior thigh and leg.
 VESSELS, LYMPHATIC SYSTEM AND NERVES
CO SCIATIC NERVE
CD

CD

C
CD
E
2in
>,
C/)
o
ro
si
Q.
E Sciatic nerve — Sciatic nerve

jo
CD
CO
CO
CD
>

■ ■

>
o
Q.

Piriformis Piriformis

Sciatic nerve — Sciatic nerve

(lop) Coronal TI MR shows the nerves from the sacral plexus coalescing to form the sciatic nerve. The long fascicles
composing this large nerve can be easily recognized. (Bottom) Coronal Tl MR shows the sciatic nerve passing
beneath the piriformis muscle into the posterior thigh.

Ill
78
 VESSELS, LYMPHATIC SYSTEM AND NERVES
SCIATIC NERVE

<
</>

if
w
07

Femur -
Quadratus femoris muscle
3
■D
Sciatic nerve - Sciatic nerve 3"
Q)
Ischial tuberosity
o'
■•— Ciluteus maximus muscle if)

3
00
Q.

z
CD
CD
01

Sciatic nerve

Inferior glutcal artery

Sciatic nerve

(Top) lirst of three axial proton density, fat-saturated images shows the sciatic nerve. After it has lefl the pelvis, the
sciatic nerve can be seen near the ischial tuberosities, between the glutens maximus a n d quadratus femoris muscles.
(Middle) As the sciatic nerve passes beneath the gluteus maximus muscle, it is accompanied by the inferior gluteal
artery. (Bottom) The fascicular architecture of the nerve is very distinctive and permits differentiation from other
soft tissues and vessels.

HI
 VESSELS, LYMPHATIC SYSTEM AND NERVES
SCIATIC, FEMORAL NERVE

Sacral nerves —

Iliopsons muscle ~

I'iriformis muscle

— Sciatic nerve
R'rvKiral nerve

(Top) Axial CECTT in a patient with neurofibromatosis type I. The sacral nerves, which form the sciatic nerve, are
dramatically enlarged. (Bottom) Sagittal T2 image in a different patient, also with neurofibromatosis type 1. The
sciatic nerve is dramatically enlarged, as it passes through the greater sciatic foramen, beneath the piriformis muscle.
The femoral nerve is also grossly enlarged.
 VESSELS, LYMPHATIC SYSTEM AND NERVES
FEMORAL NERVE
O
<
55'
■ ■

<
CD
C/>
2.
CO

Psoas muscle —
Psoas muscle
3
-o
rr
Femoral nerve &
— Femoral nerve
o
in
CD
3
0)
=>
Q-
Z
CD

Psoas muscle — Psoas muscle CD

CO

Femoral nerve —
— Femoral nerve

Femoral nerve — — Femoral nerve

Iliopsoas groove U"" Iliopsoas groove

T2 fat-saturated MR in a patient with bilateral femoral nerve inflammation shows the course of the pelvic portion of
this nerve. The femoral nerve is formed from the posterior division of the L2-4 ventral rami. It descends through the
psoas muscle into the groove created between the psoas and iliacus muscles (iliopsoas groove). It maintains this
position until it exits the pelvis beneath the inguinal ligament.

hi
 VESSELS, LYMPHATIC SYSTEM AND NERVES
FEMORAL, OBTURATOR NERVES
CD

CD

T3
CD
E
~w
>.
CO
o
"■♦-'
CD
-C
Q.
E Femoral artery
I — Femoral nerve
_C0
CD Femoral vein —
CO
Cfl
CD
>

CD
Q.

— Femoral vein

Femoral nerve

Femoral artery

O b t u r a t o r nerve

Obturator vessels

Obturator interims
muscle

(Top) Coronal Tl MR of the femoral nerve. The femoral nerve exits the pelvis beneath the inguinal ligament where it
is the most lateral component within the femoral canal. Branches of the femoral nerve innervate the anteromedial
thigh. (Bottom) Axial T2 MR shows the obturator nerve, which runs anterosuperior to the obturator vessels to enter
the upper part of the obturator foramen. Here it divides into an anterior and posterior division as it enters the thigh.

Ill
112
 VESSELS, LYMPHATIC SYSTEM AND NERVES
STIR M R , FEMORAL NERVE "0
o
<
■ ■

•<
3
■o
zr
Femoral nerve - Femoral nerve
o
if)

CD
3
Q.

CD

CD
C/>

Inflamed femoral nerve —

lliacus portion of —
iliopsoas muscle

Psoas portion of
iliopsoas muscle

(lop) Coronal STIR MR in a patient with neurofibromatosis type 1 shows involvement of both femoral nerves (left >
right). (Bottom) Axial STIR MR image shows an abnormal, inflamed, hyperintense right fcnioral nerve traveling in
the iliopsoas grove. The characteristic fascicular architecture of peripheral nerves is well shown. The femoral nerve
had been inadvertently sutured during herniorrhaphy.

Ill
Hi
 FEMALE PELVIC LIGAMENTS AND SPACES
CD
o
CO
Q. Imaging Anatomy
C/)
All contents lie above levator ani except the vagina,
"O which passes through it
c Reproductive organs
CO Uterus, cervix and fallopian tubes
I
£3
co
Ovaries
Vagina
Other pelvic organs (all exlraperitoneal)
Distal ureters, bladder and urethra
o Rectum
Sup|)orting u t e r i n e l i g a m e n t s
o I hese are visceral l i g a m e n t s and contain vessels,
> nerves a n d lymphatics, as well as connective tissue
<D ■ Similar function as bowel mesentery
Q_
■ Supportive role, connects viscera to pelvic wall
Peritoneum extends over bladder d o m e to anterior
CD
uterus
E ■ Reflects over uterus at lower uterine segment
CD
■ Creates a n t e r i o r cul-de-sac (vesico-uterine pouch)
o Peritoneum sweeps over fundus, extends over
posterior uterine surface to upper vagina, abutting
posterior vaginal fornix
■ Creates posterior cul-de-sac (pouch of Douglas or
rectouterine pouch)
■ Most dependent portion of female pelvis
Broad ligament created from the two sheets of
covering |>eritoneum
o Extends laterally to pelvic siilewall
o Very thin in superior portion and offers little
support
Thickens at base t o form major sup|x>rting ligaments
Nerves and vessels pass through broad ligament
Ovarian ligaments
Suspensory l i g a m e n t of ovary attaches ovary to
pelvic wall and contains ovarian artery and vein
Proper ovarian ligament attaches ovary to uterine
corpus
Mesosalpinx between fallopian tube a n d proper
ovarian ligament
Round l i g a m e n t s
Arise from uterine eornu near fallopian tubes
o Course anteriorly, through inguinal canal to insert
on labia majora
Offer little support t o uterus
I mbryologk homologue to gubcrnaculum in male
Canal of Nuck is a peritoneal diverliculum
(persistent processus vaginalis) created where round
ligament enteis inguinal canal
Cardinal ligaments
. Thickening of endopelvic fascia at base ot broad
ligament
Composed predominately of connective tissue and
transmits neuri>\ ascular structures
Extend from cervix and vagina to lateral pelvic wall
Widen as they attach to pelvic wall
Important support function
Uterosacral ligaments
u Extend from cervix and vagina to sacrum
Extend around rectum and form lateral borders of
pouch of Douglas
Composed predominately of smooth muscle and
t r a n s m i t s a u t o n o m i c nerves
HI
84
luipi Ttiiul support function
Vesicouterine l i g a m e n t s course anteriorly
Vaginal s u p p o r t
Multiple important attachments, which give support
to all pelvic viscera
■ Cardinal ligaments, perineal body, levator ani,
arcus tendineus, vesicovaginal and rcctovaginal
fascia
■ failure of these supports results in cystocele,
rectocele, cnterocele and uterine prolapse
Spaces
a Many of these spaces are filled with loose connective
tissue, and therefore serve as surgical dissection
planes
Space of Ret/ius
■ Retropuhic, prevesical space
■ Separated from anterior abdominal wall by
transversalis fascia
Vesicovagiiial/vesieocervical space
■ Between lower urinary tract and vagina/cervix
■ Distal portion of urethra fused with anterior
vagina
Rcctovaginal space
■ Rcctovaginal fascia provides support lor rectum
and helps prevent rectoccles
Paravesicle a n d pararectal spaces
Presacral (retrorectal) space
■ Between rectum and sacrum/coccyx
■ Extends cephalad to aortic bifurcation
■ Contains autonomic (s> mpathetic and
parasympathetic) nerves for pelvic viscera
Parametrium
■ Pelvic visceral fascia and contents adjacent to
cervix (both uterosacral a n d cardinal ligaments)
Blood supply
Fxtcnsive collateral supply
a Ovarian arteries arise from aorta below renal arteries
Uterine, vaginal and pudendal arteries all arise from
internal iliac arterv
o Right ovarian vein drains to inferior vein cava, while
left drains to left renal vein
Remainder of veins drain into internal iliac veins
Lymphatic d r a i n a g e
Upper 2/3 of vagina and uterus drain into obturator,
internal iliac and external iliac nodes
■ Uterine fundus may drain via lymphatic channels
along round ligament to sii|X'rficial inguinal
nodes
o Lower vagina drains to vulvar and inguinal nodes
Ovarian lymphatics tollow ovarian veins and drain
into aorto-caval a n d periaortic nodes
Clinical Implications
F'oslerior cul-de-sac is most de|>endeiit portion of
abdominal cavity
-■ C o m m o n location for drop metastases from
abdominal neoplasms
Peritoneum over bladder is loose, and is used as an
Dxtmpcritoncal surgical cleavage plane for ccsarean
section
 FEMALE PELVIC LIGAMENTS AND SPACES

■i
i1

I ■ *• » ■\
m

Round ligament Mesosalplnx

Broad ligament

Uterine artery in
cardinal ligament
Suspensory ligament
of ovary
Uterosaaal ligament

Posterior cul-de-sac

Inferior vena cava

I
1 I
Uterus viewed from above and behind shows its positioning and major ligaments. The uterus is covered by a sheet of
peritoneum, creating a double layer (the broad ligament), which sweeps laterally to attach to the pelvic wall. Areas of
thickening at its base are the cardinal ligament, which attaches to the lateral pelvic wall, and the uterosacral
ligament, which attaches to the sacrum. The uterosaaal ligaments form the lateral borders of the posterior cul-de-sac
(redouterine pouch or pouch of Douglas). The round ligaments arise from the cornu of the uterus and course
anteriorly to pass through the inguinal canal and insert on the labia majora. They offer little support for the uterus.
With a portion of the broad ligament removed (on the right), the uterine artery can be seen passing over the ureter
to enter the uterus near the cervix.
 FEMALE PELVIC LIGAMENTS AND SPACES
UTERINE LIGAMENTS

m _*--

Proper ovarian
ligament
Fallopian tube
Suspensory ligament of
ovary Mesosaipinx

■
A Broad ligament

Uterosacral ligament

Prevesicle space (space

of Retzlus)

Paravesicle space

Vesicocervical/vesicovaginal
space
Cardinal ligament

Rectovaginal space
Uterosacral ligament
Pararectal space

Presacral space

(Top) Illustration of the posterior aspect of the uterus and ovaries. The uterus and fallopian tubes are invested by
peritoneum, which creates the broad ligament. The ovary is suspended from the pelvic side wall by the suspensory
ligament of the ovary and from the uterus by the proper ovarian ligament. These ligaments separate the mesosaipinx
above, from the broad ligament below. (Bottom) Schematic representation of the ligaments and spaces at the
cervical/vaginal junction. The ligaments are visceral ligaments, which are composed of specialized endopelvic fascia
and contain vessels, nerves and lymphatics. The main supporting ligaments for the uterus are the cardinal and
uterosacral ligaments. The spaces are largely filled with loose connective tissue and are used as dissection planes
during surgery.
 FEMALE PELVIC LIGAMENTS AND SPACES
CUL-DE-SACS

Posterior vaginal fomix

Space of Retaus Rectum
Bladder
Vagina

» f»F
^ ,

nn t e n o r cm-ae-sac
1 M

V^-X ryH Posterior cul-de-sac

Posterior cul-de-sac

Cesarean section scar

Anterior cul-de-sac

(Top) Sagittal graphic of the female pelvis shows the bladder, uterus and rectum, all of which are extraperitoneal.
(Middle) The peritoneum has been highlighted to show the cul-de-sacs. Posteriorly, the peritoneum extends along
the posterior vaginal fornix, creating the posterior cul-de-sac (pouch of Douglas), the most dependent portion of the
pelvis. Anteriorly, at the level of the lower uterine segment, the peritoneum is reflected over the dome of the bladder,
creating the anterior cul-de-sac. (Bottom) Sagittal T2 MR image with the peritoneum outlined. Note that the scar
from the prior cesarean section is actually extraperitoneal, lying below the anterior peritoneal reflection. The
peritoneum over the bladder is loosely applied, allowing for filling of the bladder. This also allows it to be lifted,
creating a surgical plane for a cesarean section.
 FEMALE PELVIC LIGAMENTS AND SPACES
BROAD LIGAMENT
s
CO
Q.
in
■o
c
03
Uterus
Broail ligament —
E
CO­
CO

o
>
Rectum
Q_

TO
E
■ ■

>
a)
Lower uterine segment/cervix
Broad ligament —

- Cervix

Cardinal ligament — Cardinal ligament

• Posterior tul-de-sac

(Top) First of three (TT images in a woman with ascites showing the uterine ligaments. The brnad ligaments represent
peritoneal reflections that cover the uterus and adnexa, and extend laterally to the pelvic wall. They offer little
structural support to the uterus. (Middle) Just caudal to the uterine arteries, the broad ligament begins to thicken, as
it attaches to the cervix. (Bottom) The cardinal ligament attaches to the lateral margin of the cervix and vagina. It
widens laterally to attach to the pelvic wall. Uterine ligaments are composed of specialized endopelvic fascia that
provide support and transmit the neurovascular supply.
 FEMALE PELVIC LIGAMENTS AND SPACES
B R O A D LIGAMENT
<p_
<.
55"
■ ■

Tl
CD
3
CD
Broad ligaments —
"D

<
o"
r-
CQ'
DJ
3
CD
— Uterus Cfl
03

(f>
Posterior cul-de-sac
O
CD
CO

— Bladder

— Anterior cul-de-sac

Bowel —
— lower uterine segment

■ — Cervix

Posterior cul-de-sai

( l o p ) Axial transahdominal ultrasound in a patient with ascites shows the hroad ligaments, attaching to the pelvic
wall and suspending the uterus within the fluid. The uterine ligaments are analogous in function to the small bowel
mesentery. (Bottom) In the longitudinal plane both the anterior and posterior cul-de-sacs are well demonstrated. The
peritoneum reflects over the lower uterine segment t o create the anterior cul-de-sac. Posteriorly, the peritoneum
extends more inferiorly to the level of the posterior vaginal fornix, creating the posterior cul-de-sac. This is the most
dependent spot in the pelvis.

89
 FEMALE PELVIC LIGAMENTS AND SPACES
R O U N D LIGAMENT
8
Q.
w
■D
C
CD
£
c
E
CO
Round ligament Round ligament

>
0)
D.
J"
ca
E
<D
LL
>>
>
0)
Q-

—
Round ligament

Uterus -

(Top) CECT image of the round ligaments. The round ligaments arise anterior to the fallopian tubes and extend
anteriorly. They pass through the inguinal canal and insert on the labia majora. They are the embryologic
homologue to the gubernaculum in the male and offer little support to the uterus. (Bottom) Axial Tl MK image, also
showing the round ligaments.

Ill
 FEMALE PELVIC LIGAMENTS AND SPACES
UTEROSACRAL LIGAMENT
2.
<
55"
• ■

Tl
IUD in cervix CD
3
£L
CD
Posterior cul-de-sac "D
Utcrosacral ligament Utcrosacral ligament
<
o'
r—
CO

3
Rectum
CD

Q-
Ovary C/)
-o
m
Ovary — o
— Uterus CD
c/>

Cervix

Utcrosacral ligament
Utcrosacral ligament -

— Cervical cancer

thickened iiterosacral ligament

- Normal utcrosacral ligament

(Top) Axial CT with rectal contrast in a patient with ascites. Free fluid is within the posterior cul-de-sac. The
utcrosacral ligaments can be seen forming the lateral borders of this space. (Middle) Normal axial Tl MR shows the
uterosacral ligaments extending from the cervix posteriorly towards the sacrum. They are composed predominately
of smooth muscle and convey the autonomic nerves to the pelvic organs, l'hey, along with the cardinal ligaments
and levator ani, are the main support for the uterus and cervix. (Bottom) An axial T2 MR image shows invasion of
the right uterosacral ligament by cervical carcinoma. Cervical carcinoma commonly invades into the parametrtum,
which includes both the uterosacral and cardinal ligaments. These are very important areas to evaluate when staging
cervical carcinoma. Ill
')l
 FEMALE PELVIC LIGAMENTS AND SPACES
SPACES, PARAVESICLE/PERIRECTAL
8
TO
Q-
U) I — Space of Rctzius (prevesiclc
T3 space)
C
CO

£
CD I'aravesicle space Paravesiclc space
E
03

Bladder

>
CD
CL
i!>
CO
E
CD
■ •

CO
>

Q. - Prcsacral space

Space of Rctzius (prcvcsicle space)

- Bladder

Pararectal space

Rectum

Prcsacral space

( l o p ) CT scan, after the instillation of contrast into the bladder, shows an extraperitoneal bladder rupture with
contrast leaking into the prevesicle and paravesicle spaces. (Middle) Sagittal T2 FS MR in a patient with
neurofibromatosis type I shows large neurofibromas in the prevesiclc and prcsacral spaces. Note how the prcsacral
space extends superiorly u p to the level of the aortic bifurcation. (Bottom) Axial CF.CT in another patient with
neurofibromatosis type I showing the pararectal, as well as the presacral spaces. Normally these pelvic spaces are
filled with fat and connective tissue.

<U
 FEMALE PELVIC LIGAMENTS AND SPACES
SPACES, VAGINA ■D

<
••
■n
CD
3
CD

1
<
Vesicovaginal spate - o'
r-
(Q
3
I
CD
Q.
CO
■D
Q)
O
CD

Vesicovaginal spate

Rectovaginal spate

Rectum

(Top) lirst of three T2 MB images of the vagina in a w o m a n who has had a hysterectomy. This sagittal image shows
high-signal fluid/mucus separating the low-signal muscular walls of the vagina. The vagina is separated from the
bladder by the vesicovaginal space and from the rectum by t h e rectovaginal space. The perivaginal venous plexus lies
within these spaces a n d surrounds the vagina, and partially eniircles the urethra and rectum. (Middle) Axial T2 MR
shows the urethra, vagina and rectum as three separate structures. The high signal within the vesicovaginal and
rectovaginal spaces represents the perivaginal venous plexus. (Bottom) The distal portion ot the urethra is fused with
the anterior wall of the vagina, a n d therefore, n o distinct plane is seen between them.
Ill
'H
 FEMALE PELVIC LIGAMENTS AND SPACES
SPACES, ANTERIOR CUL-DE-SAC

— Uterus

Bladder —

Endometrial implant in Posterior vaginal Fornix

anterior cul-de-sac

Anterior vaginal fornix —

— External cervical os

— Posterior vaginal wall

— Rladder

Fiidoinelrial implant in
anterior cul-de-sac

— Lervix

Rectum

(Top) First of two images of an endometrial implant in the anterior cul-de-sac (vesico-uterine pouch). .Sagittal Tl C+
FS MR image shows an e n h a n c i n g endometrial implant in the anterior cul-de-sac. Gel has been instilled into the
vagina, separating the walls. Note that the posterior vaginal fornix is higher t h a n the anterior vaginal fornix.
(Bottom) Axial T2 image showing the same endometrial implant. In the axial plane, it is often difficult to
differentiate whether a mass is intraperitoneal (lying in t h e anterior cul-de-sac) or extraperitoneal (lying in the
vesicocervical space). The sagittal plane is much better for making this determination.
 FEMALE PELVIC LIGAMENTS AND SPACES
SPACES, POSTERIOR CUL-DE-SAC

Uterus - — Bladder

Endonu In il implants in
posterior cul-de-sac

Uterus

Peritoneal implants
Peritoneal implants

Rectum

Uterus -

Ectopic pregnancy -
j — Blood in |K)Sterior cul-dc-sac

(Top) Midline longitudinal ultrasound on a woman with endometriosis shows multiple, large implants within the
posterior cul-dc-sac. The posterior cul-de-sac is the most dependent spot in the female pelvis. Fluid, blood and
peritoneal implants from both abdominal and pelvic pathologies can accumulate in this region making it a Critical
area to evaluate. (Middle) CECT image in a woman with gastric carcinoma and ascites shows both fluid and multiple
peritoneal implants (drop metastases) within the posterior cul-de-sac. (Bottom) Longitudinal transvaginal ultrasound
of the uterus in a woman with an ectopic pregnancy shows a large a m o u n t of echogenic blood within the posterior
cul-de-sac (pouch of Douglas).
 UTERUS
[Gross A n a t o m y
Overview
• Thick-walled, fibromusculac organ composed of
myomclrium and cndomc'triiim
• I wo major divisions
liodv (corpus) and cervix
■ Fundus alxive ostia of fallopian tubes
• Myometrium
Interwoven layers of smooth muscle
• 1 ndoiiH-lr iiun
Simple, columnar epithelium forming numerous
tubular glands supported by a thick vascular stroina
Composed of two distinct layers
■ Stratum fuiictioiialis: Superficial laver that grows
under hormonal stimulation and sloughs with
menstruation
■ Stratum basalis: Deep supporting layer, densely
adherent to mvometrium
• Cervix
Begins at interior narrowing of uterus (isthmus)
■ Has a supravaginal and vaginal portion (cctocervix
or portio vaginalis)
Internal os: O w n i n g into uterine cavity
external os: Opening into vagina
Stroma is largely fibrous, with a high proportion ot
elastic fibers interwoven with smooth muscle
r.ndocervical canal lined by mucous secreting,
columnar epithelium
■ Epithelium is in a series of small V-shaped folds
(plicae palmatael
Ectocervix lined by stratitied squamous epithelium
Squamocolumnar junction near external os but
exact position is variable, with continuous
remodeling
• Appearance, size, shape and weight vary with estrogen
stimulation and parturition
Prcnienarchc
■ Cervix is larger than corpus (approximately 2/3 of
uterine mass)
Menarche
■ Preferential growth of corpus i n response to
hormonal stimulation
■ Nulliparous women corpus and cervix roughly
equal
■ Parous, non-pregnant women corpus is
approximately 2/.t of uterine mass
Posttnenopa usa 1
■ Corpus decreases back to premenopausal size
• Menstrual cycle
I'roliferative phase
■ End of menstruation to ovulation (- {lay 14)
■ Estrogen induces proliferation of fuiictioiialis layer
■ Corresponds to follicular phase of ovary
Secretory phase
■ Ovulation to l>eginning of menstruation
» Progesterone induces endometrium to secrete
glycogen, mucous and other substances
■ Fndomelrial glands become enlarged and tortuous
■ (orrcsponds to luteal phase of ovary
- Menstrual phase
■ Sloughing of fuiictioiialis layer of endometrium
Anatomic Relationships
• Uterus is extrapcritoneal
- Peritoneum extends over bladder dome to anterior
uterus
■ Creates anterior cul-de-sac (vesico-uterine lxiuch)
Posteriorly, peritoneum extends more inferiorly to
upper portion of vagina
■ Creates posterior i ul-de-sac (pouch of Douglas,
recto-uterine pouch)
■ Most dependent portion of female pelvis
• Supporting ligaments
Broad ligament
■ formed by the two sheets of covering peritoneum
■ Extends laterally to pelvic wall and lornis
sup|x>rting mesentery for uterus
Round ligaments
■ Arise from uterine cornu near fallopian tubes
■ Course anteriorly, through inguinal canal to insert
on labia majora
Ligaments formed from connective tissue thickening
at base of broad ligament
■ Utcrosacral ligaments posteriorly
• Cardinal ligaments laterally
■ Vesicouterine ligaments anteriorly
• Uterine position
flexion is axis of uterine bcxlv relative to cervix
Version is axis of cervix relative to vagina
Most uteri are anteverted and anteflexed
• fallopian tubes connect uterus to peritoneal cavity
" Attached to posterior broad ligament by
mesosalpinx
8-10 cm in length
Composed of four segments: Interstitial, isthmus,
ampulla and i n f u n d i b i i l u i n
Interstitial or intramural portion
■ Portion of tube which traverses uterine wall
■ - I cm in length
■ i Isthmus
■ Narrow portion of tube, immediately adjacent to
uterus
Ampulla
■ Port nous, ectatic portion contiguous with isthmus
■ fertilization usually occurs in this portion of tube
Inftindibuliim
■ 1 unnel-shapcd opening, ringed by finger-like
fimbriae
■ Adjacent to posterior surface of ovary, allowing it
to "capture" ovulated ova
• Uterus has dual blood supply
Uterine artery passes over ureter at level of cervix
("water under the bridge")
■ Courses superiorly, along lateral margin of uterus
and anastomoses w i t h ovarian artery
■ I Herine arteries give rise to arcuate arteries, which
run in outer third of myometrium
Radial arteries extend through myometrium
terminating as spiral arteries in endometrium
• Venous drainage
o Myometrial veins follow same course as arteries
forms complex venous network in parametrium
Eventually drains to either uterine or ovarian vein
 UTERUS
I Imaging Anatomy
Ultrasound
• M v o m c t r i u m .< lavcrs usually discernible
C om patted, thin, hvpoechoic inner layer forms
suheiidonietri.il halo
Thicker, homogeneously echogenic middle layer
lhinner, hvpoechoic outer layer
■ Portion of myometrluni peripheral to arcuate
vessels
• l.ndoiiietricil a p p e a r a n c e varies with phase of
menstrual cycle
Thin, echogenic line early in proliferative phase
Progressive, hvpoechoic thickening (4-K m m i as
proliferative phase progresses
■ I riple laver ('sandwich") appearance: Echogenic
centra! line created where the 2 hypoechoic
endonietrial walls coapt
Alter ov ulation (secretory phase), endometrium
becomes thicker (7-14 mm) and moie echogenic
• Sonohvsterography
Sludv ol choice for evaluating cndometrial
pathology
Balloon catheter inserted into ccrsix
Sterile saline infused while scanning
■ Separates endonietrial walls, allowing lor complete
evaluation of endometrium
• .11) ultrasound
1
Allows multiple views to he reconstructed from
single sweep through uterus
MR
• Uterus and cervix uniform intermediate signal on
IIWl
• Uterus has .i distinct / o n e s on I2WT
• High signal e n d o m e t r i u m
I ow signal iiinciion.il z o n e
■ Inner laver of mvomctrium with low water
content, resulting in decreased signal
■ Normal thickness 2-8 m m
■ > 12 mm abnormal (adenomyosis)
■ 9-11 m m equivocal
Intermediate signal mvometrium
• Uterine appearance varies according to hormonal
stimulation
Preiiieiiopiiiis.il
■ Endometrium thickens in secretorv phase
■ Myometrial signal increases in secretory phase
from increased water content and vascular flow
■ I ow signal uterine contractions, which bulge the
uterine contour may be seen
■ C o n t r a c t i o n s are transient and should not be
confused with libroids or adenomyosis
Oral contraceptives
■ Both endometrium and functional / o n e become
thin
Postmciiopausal
■ I ndometrium atrophies, functional zone is absent
• ( e r v i c a l z o n a l a n a t o m y o n 12VVT
High signal endocervic.il canal
■ Plicae palmalae may be seen as a separate
intermediate signal /one, on high resolution scans
Predominately low signal cervical stroma, secondary
t o large projxxtion of elastic fibrous tissue
■ Contiguous with junctional zone
\ n outer layer of intermediate signal smooth muscle
may be variably present
Nalxithian cysts are c o m m o n h seen
■ Represent obstructed, mucous-secreting glands
■ l o w signal on Tl Wl, high signal on T2W1
Paraiiietrium
1 ow to intermediate signal intensity Tl Wl
Variable signal intensity T2WI
■ Round ligament and uterosacral ligament low
signal intensitv
■ Cardinal ligament and associated venous plexuses
high signal intensity
Embryology
Uterus is formed from paired paramesonephric
(Miillenan ducts)
These paired ducts meet in m i d l i n e a n d fuse
Fusion forms uterovaginal canal (uterus and upper
vagina)
Unlused portions remain as fallopian lubes
Lower vagina formed from nrogenital sinus
jClinical Implications
Miillerian Duct Anomalies
• failure ol Miillerian duct development and/or fusion
leads to s|x.'ctrum of congenital uterine anomalies
c Class I: Agenesis or hypoplasia (1(1% of cases)
o Class II: Unicornuatc uterus (20% of cases)
■ Single uterine horn, may have accessory
rudimentary horn
( lass 111: Uterus didelphys (5% of cases)
■ Two, separate, non-communicating horns
( l a s s IV: Hicornuate uterus (10% of cases)
■ Concave or heart-shaped external uterine contour
Class V: Septate uterus (55% of cases)
■ Normal evternal contour
■ Dividing septum of variable lengths
■ High association with renal a n o m a l i e s
( h e c k kidneys in every patient
Ectopic Pregnancy
• 9 5 % of ectopic pregnancies arc tubal
Ampullarv portion of tube most c o m m o n location
• 2-5% are interstitial
Located in intramural portion of fallopian tulic
Can grow to larger size before rupture
Interstitial line sign: Lchogenic line from
endometrium to ectopic sac
■ Overlying myometrium is thinned
• Rare ectopics: (-ervical, ovary, abdominal,
cesarean-sectinn scar
Hydrosalpinx
• Dilated, Hind-tilled fallopian tube
• "Cogwheel" shape in cross section
Incomplete septae from mucosal folds
 UTERUS
UTERUS

Interstitial (intramural)
portion of fallopian
tube
Fallopian tube

Endometrium
Inner & outer layer of
myometrium
Internal os
Round ligament

Endocervical canal Anterior cul-de-sac

External os

Bladder

Tubal branch of uterine

artery

Ovarian artery

Ascending trunk of
uterine artery

Arcuate artery

Uterine artery
Uterine artery

Descending trunk of Radial arteries

uterine artery
Spiral arteries

(Top) The uterus is composed of a glandular endometrium and muscular myometrium. The smooth muscle within
the Inner portion of the myometrium is more compacted and relatively hypovascular. (Bottom) The uterine artery
arises from the anterior trunk of the internal Iliac artery. It aosses the ureter as It courses medially to the lateral wall
of the uterus. At the level of the cervix It bifurcates Into an ascending and descending trunk. The ascending trunk
forms the major blood supply to the uterus. It courses superiorly along the lateral wall of the uterus where It
anastomoses with the ovarian artery, a branch of the aorta. Arcuate arteries course circumferentially in the outer
third of the myometrium and give rise to the radial arteries and finally the spiral arteries, which supply the
endometrium.
 UTERUS
UTERINE VEINS

Ovarian venous plexus

Radial veins

Arcuate veins

Uterine vein

Fundus
Ovarian vein

Tip of needle

Uterine vein on uterine

Radial veins surface

Uterine vein in
cardinal ligament
Arcuate veins

(Top) Graphic of the uterine venous system. (Bottom) Pelvic venogram with the needle tip within the fundal
myometrium shows very fine radial veins extending from the endometrium and larger arcuate veins, which course
around in a circular fashion in the outer third of the myometrium. Venous drainage may be via the uterine or
ovarian veins. Note the presence of numerous small surrounding veins. These are part of the extensive venous plexus
network within the pelvis. They form a rich collateral venous drainage system. Varices can develop within these
vessels, causing pelvic congestion and chronic pelvic pain.
 UTERUS
A R C U A T E VESSELS

—
Fluid in endomctrial cavity
—
Arcuate artery

Uterine artery

Arcuate vessels

External iliac artery

— Round ligament

Arcuate arterv calcification

- Superior gluteal artery

(Top) Color Doppler u l t r a s o u n d i n a patient w h o has just undergone a d i l a t a t i o n a n d curettage for a failed first
trimester pregnancy. There is v e r y p r o m i n e n t f l o w i n t h e arcuate arteries, w h i c h r u n i n t h e o u t e r t h i r d of t h e
m y o m e t r i u m (Courtesy J. W o n g , M D ) . ( M i d d l e ) 11 MR o f t h e uterus shows h i g h signal w i t h i n t h e arcuate vessels.
This c o u l d represent either t h e arcuate veins o r slow f l o w w i t h i n t h e arcuate arteries. ( B o t t o m ) Unenhanced CT scan
i n a w o m a n w i t h renal failure shows p r o m i n e n t arcuate artery calcifications. The pattern a n d location o f
calcifications is characteristic a n d s h o u l d n o t be confused w i t h a p a t h o l o g i c entity, such as a calcified f i b r o i d . Note
calcifications w i t h i n o t h e r pelvic vessels.
 UTERUS
UTERINE P O S I T I O N

<
Fundus -
55'
• ■

c
CD
F.iulomctrial cavity - I

Endocervkal cavity

Vagina

External cervical m

C*rvix
Fundus

Uterine isthmus

liiiulus

Cervix -

Uterine isthmus ■

(lop) rransabdomlrial ultrasound of an antevertcd uterus. Version refers to the angle the cervix makes with the
vagina. In this case, the cervix is angled anteriorly and the uterus continues in a straight line with the cervix, making
this anteversion. Uterine position can change with the degree of bladder filling. (Middle) Transvaginal ultrasound of
an anteflexed uterus. Flexion refers to the angle the uterine corpus makes with the cervix (a line has been drawn
across the uterine isthmus as a reference point). The uterine corpus is angled forward with respect t o the cervix at this
junction. (Bottom) Transvaginal ultrasound shows the cervix angling posteriorly with respect the probe, which is in
the vagina (retroversion). In addition, the uterus is even more posteriorly angled with respect to the cervix
(retroflexion). Retropositioned can be used generically for either of these positions. Ill
101
 UTERUS
ENDOMETRIUM, CYCLICAL VARIATIONS

Subendomctrial halo -

Kndonielrium, early - — Endocervical canal

proliferalivc phase-

Outer portion ot
myometrium

Lndometrium, late — Endomctrial cavity

proliterative phase
(stratum functionalist

- Stratum basalis

(Top) First of four transvaginal ultrasounds showing the endometrial changes during the menstrual cycle. In the
early proliferalivc phase, the endomelrium is thin and echogenic. This image also nicely demonstrates features of the
myometrium. The smooth muscle within the inner band of myometrium is more compacted a n d relatively
hypovascular, giving it a more hypoechoic appearance (subendometrial halo). The majority of the myometrium has a
homogeneous echogenicity, with the outer portion (peripheral to arcuate vessels) sometimes being slightly less
echogenic. (Bottom) In the late proliferative phase, the functionalis layer of the endometrium thickens a n d becomes
hypoechoic (the basalis layer remains echogenic). A hyperechoic central line is created where the two endometrial
walls coapt. This gives the endometrium a layered, "sandwich" appearance.
 UTERUS
E N D O M E T R I U M , CYCLICAL VARIATIONS
o
<
■ ■

CD
5
en

Endometrium, —
secretory phase
Endoccrvical canal

Fluid in cavity —

F.ndomctrium, onset of -

(Top) During the secretory phase, the endometrium becomes thickened and progressively echogenic. The increased
echogenicity is the result of the endometrial glands becoming enlarged and tortuous, and filled with glycogen,
mucous and other substances necessary to sustain a pregnancy. (Bottom) If no pregnancy occurs, the functionalis
layer of the endometrium begins to involute and slough off (menses). The endometrium becomes progressively
thinner, and a small amount of fluid may be seen within the endometrial cavity.

10
 UTERUS
SONOHYSTEROGRAPHY, ENDOMETR1UM

Fundus

- Saline in endometrial cavity

Balloon catheter —

Saline in endometrial cavity — r

■

Balloon catheter

Saline in endometrial cavity

( l o p ) First of three images from a sonohysterogram in a retroflexed uterus performed just after the cessation of
menses. A balloon catheter is inflated in the lower uterine segment and sterile saline is infused while scanning. As
the cavity distends, the uterine walls begin to separate and the endometrium can be evaluated. This longitudinal
image at the beginning of the infusion shows the inflated balloon in place, and saline beginning t o expand the
endometrial cavity. (Middle) Transverse image through t h e lower uterine segment shows continued distention of the
eiidoiiietrial cavity (Bottom) Near the fundus, the entire endometrium is well seen and has a normal, uniformly
thin appearance. Sonohysterography is the imaging study of choice for evaluating endometrial abnormalities.
 UTERUS
3D ULTRASOUND

Ftindus

Central totalizer -

Endometrium

Central totalizer -

Hindus Endocervical canal

Central totalizer

(Top) First of three simultaneously acquired 3D images. A dedicated Ml probe provides automated acquisition of
ultrasound volume data. This data is displayed in 3 simultaneous orthogonal planes. Multiplanar and rendered
images can be rotated and "sliced through" like CT and MR. A central localizer point on each image allows the
operator to know the precise location in all three planes. In this coronal image the entire endometrial and fundal
contour are displayed. This has particular utility in evaluating Mullerian duct anomalies. (Middle) Same 3D data set
projected in the longitudinal plane. (Bottom) Same 3D data set projected in the transverse plane. The cursors are
measuring the endometrial thickness.

i
 UTERUS
MR, UTERUS

Myometrium -

Endometrtum —

Junctional zone
Bladder

— Rectum
Pubic syniphysis —

Kndometriurn

Junctional zone

(Top) Sagittal T2 MR of the uterus in a woman not on oral contraceptives shows the typical zonal anatomy, with a
high signal endometrium, low signal junctional zone a n d intermediate signal myometrium. The junctional zone
represents the inner most portion of the myometrium, which has a lower water content resulting in the lower signal.
Maximum normal junctional zone thickness is 8 m m , with > 12 m m diagnostic of adenomyosis. Measurements of
9-11 m m are in the equivocal range. (Bottom) Sagittal 12 MR of the uterus in a woman w h o is taking oral
contraceptives shows a much less distinct zonal architecture. Both the endometrium a n d junctional zone have
thinned, and are far less obvious. The endometrium n o longer cycles so remains 1-2 m m in thickness, even before
menses.
 UTERUS
M R , UTERUS "0
2.
Fundus ■ ■

c
Cornua - sr
Kndometrium E
functional rone

—
Cervix

I'arami-tri.il vessels

Myoinctriuin

- Endometrium

uilttional zone

" Myometrium

— Endomcirium

— Junetional zone

(Top) Coronal T2 MR view of the uterus allows simultaneous viewing of the endometrial cavity and uterine fundus.
This view is obtained by angling the scan plane along the long axis of the uterus. (Middle) I'irst of two T2 MR images
taken in an axial plane, with respect to the uterus (oblique coronal to the body). This first image is taken near the
fundus. The uterus and endometrium have an elliptical contour at this level. (Bottom) In the lower uterine segment,
the uterus a n d endometrium become more rounded in appearance.

Ill
10
 UTERUS
CERVIX
2
2
■ •

> Internal os — - Plicae paimatae (lining of

0) endocervlcal canal)
Q.
- Posterior vaginal fornix

Anterior vaginal —
- - External cervical os

Vagina distended with gel —

— Inner cervical stroma

Plicae paimatae — i

- External os

I-ndocervical canal
Inner cervical stroma

- Outer cervical slronia

Vagina distended with gel —

(Top) first of three T2 MR views of the cervix. This sagittal image shows the feathery appearance of the endocervical
canal. The endocervical canal is lined by mucous-secreting, columnar epithelium. This epithelium is arranged in
small V-shaped folds giving a "frond-like'' appearance, and hence the name, plicae paimatae. (Middle) Image plane
taken along the long axis of the cervix. (Bottom) Axial ("donut") view shows the high signal intensity endocervical
canal surrounded by low signal intensity cervical stroma. The cervical stroma is largely fibrous, with a high
proportion of elastic fibers interwoven with smooth muscle. A third intermediate signal outer layer of smooth muscle
is also seen. This layer is of variable thickness and is not seen in all patients.
III
108
 UTERUS
CERVIX
CD

- - I — Ovarian cyst
<
■ ■

c
i-t-
Internal os
CD
Posterior vaginal fornix

Line separating supravaginal

cervix from ectocervix
Anterior vaginal tomix -

Hxternal os

Endocervical canal

Cervical stroma
Coaptcd walls of cervix -
Free fluid in posterior Cul-dc-sat

— Bowel

Nabothian cysts

(Top) Sagittal 12 MR image of the cervix, with a line connecting the vaginal fornices. The supravaginal portion of
the cervix is above this line and the ectocervix, or portio vaginalis, is below it. (Middle) Iransvaginal ultrasound of
the cervix shows a hypoeclioic band within the central portion of the cervix, which is formed by glands and mucous
secretions of the endocervical canal. An echogenic central line is created where the two cervical walls coapt.
(Bottom) Iransvaginal ultrasound of the cervix shows multiple small Nabothian cysts lining the endocervical canal.
Nabothian cysts result from obstructed, mucous-secreting glands of the cervix. They are generally anechoic but can
be hypoechoic or contain obvious debris. Most are small, measuring < 1.5 cm. They appear as well-defined, high
signal cysts on T2-weighted MR images. Ill
1(H)
 UTERUS
FALLOPIAN TUBE

Isthmus

Interstitial (intramural)
portion of tube
Ampulla
Mucosal folds

Infundibulum

Flmbriae

Interstitial portion of
Isthmus

Ampulla Tubal ostlum

Infundibulum Endometrial cavity

Free lntraperitoneal
spill of contrast
Internal cervical os

Endocervtcal canal

External cervical os

(Top) A graphic of the fallopian tube shows t h e four segments including t h e interstitial (intramural) portion,
isthmus, ampulla a n d infundibulum, which is ringed by the flmbriae. (Bottom) A hysterosalplngogram shows the
endocervical canal with a feathered appearance created by the endocervical glands (plicae palmatae) The uterine
cavity has a triangular configuration. The interstitial portion of the tube traverses the myometrial wall at the comua
(approximately 1 cm in length). An acute angulation can often be seen between it and the isthmus- The fallopian
tube widens at the ampulla and Infundibulum, before opening Into the peritoneal cavity adjacent to the posterior
surface of the ovary.
 UTERUS
ECTOPIC PREGNANCY "0
O
<
- ■
Fallopian tube -

?
c
Empty endometrial cavity
Ampullary ectopic pregnancy

Ovary

— Interstitial line sign

Interstitial ectopic pregnancy

Empty endometrial cavity

Empty endometrial cavity - Bladder

Cervical ectopic pregnancy

Fndocervical canal

(Top) First nf three different examples of ectopic pregnancy showing the relative position of the gestational sac to
the fallopian tube and endometrial cavity. In this case, an ectopic gestation (thick echogenic ring) is seen in the
ampullary portion of the fallopian tube. This is the most c o m m o n ectopic location, although precise tribal
localization is usually not possible. (Middle) Color Doppler image of an interstitial ectopic pregnancy. The
endometrial cavity is empty. At the cornua, the proximal interstitial portion of the tube can be followed to the
ectopic sac. This has been called the interstitial line sign. The ectopic pregnancy has dramatically enlarged the
portion of the tube traveling through the uterine wall (interstitial portion) and there is essentially n o surrounding
myometrium. ( b o t t o m ) Transabdominal ultrasound of a cervical ectopic pregnancy. Ill
111
 UTERUS
HYDROSALPINX

Hydrosalpinx Hydrosalpinx

F.ndomeirial cavity —

Cervix

Hydrosalpinx

Mucosal folds

(Top) I lysterosalpingogram shows bilateral hydrosalpinges. The ampullary portion expands dramatically and there is
no free intraperitoneal spill of contrast. (Middle) First of two transvaginal ultrasound images of a left-sided
hydrosalpinx. During real-time scanning it is important to try to elongate the tube as in this image. This allows
differentiation from a cystic ovarian mass. (Bottom) In the cross-sectional plane, a hydrosalpinx will often display a
"cogwheel" appearance. The mucosal folds of the fallopian tube project into the lumen. As the hydrosalpinx becomes
more chronic, these folds will become thick and nodular.
 UTERUS

Bladder MUUerian ducts

Genital tubercle
Urogenltal sinus Urorectal fold
Rectum

Metanephros

Bladder
Ulero-vaginal canal (fused
MOllerlan ducts)
Genital tubercle
Urogenltal sinus Urorectal fold
Rectum

Kidney
Urachus

Bladder Fallopian tube

Vagina
Clitoris

(Top) The fallopian tubes, uterus and upper vagina form from the paired MUUerian (paramesonephilc) ducts, which
develop on either side of the mldline. (Middle) These ducts must meet in the mldllne and fuse to form the uterus
and upper portion of the vagina (uterovaglnal canal). The unfused portions wiU form the fallopian tubes. The
development of the kidney (metanephros) is closely related to uterine development, and coexistent renal and
MUUerian duct anomaUes are common. (Bottom) The distal portion of the vagina is formed from the urogenltal
sinus, which spUts to form the bladder and urethra anteriorly, and the vagina posteriorly.
 UTERUS
UNICORNUATE UTERUS

Fallopian tube —

- F.ndometrial cavity

Fallopian lnl»c
Fndometrial cavity

- Ovary
Unicornuate uterus —

(Top) Graphic of a unicornate uterus, which occurs if only one paramesonephric duct forms. (Middle) A
hysterosalpingogram shows the characteristic "banana" or "cigar-shaped" endometrial cavity, with a single fallopian
tube at the apex. (Bottom) T2 MR of a unicornuate uterus. Note the presence of a normal left ovary. The ovaries form
independently from the uterus, and Miillerian duct anomalies are not associated with ovarian anomalies. They are,
however, associated with congenital renal anomalies, particularly renal agenesis. Every patient with a Miillerian duct
anomaly should have their kidneys evaluated.

-I
 UTERUS
UTERUS DIDELPHYS

2 separate, nan-fused uterine

horns

- Vaginal septum

Right uterus — l.eft uterus

Right vanina - Lett vagina

■ Vaginal septum

(Top) Graphic illustration of a uterus didelphys. If both paramesonephric ducts form but fail to fuse, the result is a
uterus didelphys. This malformation has the appearance of two uiiicornuate uteri side-by-side. A vaginal septum is
seen in approximately 75% of cases. If the septum is transverse, it can cause an obstruction with blood products
accumulating within the obstructed uterine cavity. (Middle) first of two 12 MR images of a uterus didelphys.
Oblique image of the pelvis shows two separate uterine horns, each of which has a similar configuration to a
uiiicornuate uterus. (Bottom) Axial image lower in the pelvis shows a thick vaginal septum, which is creating two
separate vaginas.
 UTERUS
BICORNUATE UTERUS
v_
£
5■ • - Concave fundal contour

>
o
a.

Concave lundal contour

Right endometrial cavity — Left endometrial cavity

- Unicollis (1 cervix)

—■ Concave fundal contour

Right endometrial cavity — I eft endometrial cavity

Ovarian cyst — - Bicollis (2 cervices)

( l o p ) G r a p h i c illustration o f a bicorniiate uterus. If t h e paramesonephric ducts o n l y partially fuse, t h e external

c o n t o u r o f the uterus w i l l be concave or "heart-shaped", w h i c h is diagnostic o f a bicorniiate uterus. There m a y either
be a single cervix (unicollis) or t w o cervices (bicollis). ( M i d d l e ) C o r o n a l T 2 M R of t h e uterus shows the classic
concave appearance o f a bicornuate uterus. T h e t w o e n d o m e t r i a l cavities c o m m u n i c a t e i n f e r i o r l y a n d there is a single
cervix (unicollis). ( B o t t o m ) C o r o n a l 12 MR o f t h e uterus also shows the classic concave appearance o f a bicornuate
uterus. I n this particular case, t h e t w o e n d o m e t r i a l cavities d o n o t c o m m u n i c a t e a n d there are t w o separate cervices
(bicollis).
III
I If.
 UTERUS
SEPTATE UTERUS

Normal fundal contour

Normal fundal contour

Septum "

Cervix

— Normal fundal contour

Septum ■

Cervix

(Top) Graphic illustration of a septate uterus. If the paramesoiiephric ducts fuse appropriately but the wall between
them is incompletely resorbed, the result is a septate uterus, the hallmark of which is a normal fundal contour. The
septum itself can be quite variable, and extend only partially into the endonietrial cavity or all the way to the cervix,
and even into the vagina. (Middle) Coronal 12 MR of the uterus shows a normal fundal contour, with the septum
ending before reaching the cervix. (Bottom) Coronal T2 MR of the uterus shows a normal fundal contour. In this
case, there is a complete septum which extend all the way down to the cervix. It is imperative when evaluating
Miillcrian duct anomalies to angle the scanning plane along the long axis of the uterus to simultaneously evaluate
fundal contour and the endometrial cavities.
 OVARIES
[Gross A n a t o m y
Overview
• Ovaries located in true pelvis, although exait position
variable
c I ax it) in ligaments allows some mobility
c Location affected b j parity, ovarian size and uterine
size/position
I ocated within ovarian fossa in nulliparous women
■ Lateral pelvic wall below bifurcation of c o m m o n
Iliac vessels
■ Anterior to ureter
■ Posterior to broad ligament
Position more variable in parous women
■ Ovaries pushed out of pelvis with pregnancy
■ Seldom return to same s|>ot
• I allopian tube drapes over much of surface
Partially covered bv fimbriated e n d
• Composed of a medulla and cortex
c Vessels enter and exit ovary through medulla
Cortex contains follicles in varying stages ot
development
c Surface covered by specialized peritoneum called
germinal epithelium
• 1 igamentous supports
Suspensory l i g a m e n t of ovary (infuudibulopelvic
ligament)
• Attaches ovarv to pelvic wall
■ C o n t a i n s ovarian artery a n d vein
■ Positions ovarv in craniocaudal orientation
Mesovarium
■ Attaches ovary to posterior surlacc ol broad
ligament
■ Transmits nerves and vessels to ovary
Proper ovarian ligament (ulero-ovarian ligament)
■ I ii imiius< iii.H hand extending Irom ovary to
uterine cornu
Mesosalpinx
■ Extends between fallopian tube a n d proper
ovarian ligament
Broad l i g a m e n t
■ Below proper ovarian ligament
• Dual blood supply
Ovarian a r t e r y is branch of aorta
■ Descends to pelvis and enters suspensory ligament
of ov arv
■ Continues through mesovarium to enter ovarv
■ Anastomoses with uterine arterv
Drainage via v e n o u s plexus into ovarian veins
■ Right ovarian drains to inferior vena cava
■ Left ovarian vein drains t«i left renal vein
c Both arteries and veins maikedlv enlarge in
pregnancy
• Lymphatic drainage follows venous drainage
Physiology
• 4(K),(MK) follicles present at birth but only 0 . 1 % (400>
mature to ovulation
• Menstrual cvelc
I'ollicular phase (days 0-14)
■ Several follicles (range 1-11, mean 5) begin t o
develop
■ By davs 8-12 a d o m i n a n t follicle develops, while
remainder start to regress
Ovulation (day 14)
■ rgg extruded from ovary
■ Dominate follicle typically 2.0-2.5 cm at ovulation
I uteal p h a s e (days 14-28)
■ I uteini/ing h o r m o n e induces formation of corpus
luteum
Imaging Anatomy
Ultrasound
• Scan between uterus and pelvic sidewall
Often seen by internal iliac vessels
• Medulla mildly h y p e r e c h o i c in comparison to
hvixiechoic cortex
• Developing follicles anechoic
• Corpus luteum may have thick, cchogcnic ring
I lemorrhdge c o m m o n
■ Variable appearance, with classic appearances of
lace-like scptations, fluid-fluid level and retracting
clot
■ No flow on Doppler ultrasound
• I'ciiogenic foci common
( Non-shadowing, 1-3 m m
Represent specular reflectors from walls ot tiny
unresolved cysts
More c o m m o n in periphery
• Focal calcification may also be seen
" Doppler shows a low-velocity, low-resistance arterial
wave form
• Volume (0.523 x length x width x height) more
accurate than individual measurements
Premcnopausal: Mean - H) +/- 6 c c , max 22 cc
Postmenopausal: Mean - 2-6 cc. max 8 cc
MR
• IIVVI: Uniform intermediate signal with low-signal
follicles (unless hemorrhage)
• T2WL Multiple high-signal follicles of varying sizes
I ow-signal intensity capsule
Medulla higher signal intensity than cortex
• Postmenopausal ovaries usually homogeneous low
signal on n Wl and T2VVI
Clinical I m p l i c a t i o n s
Clinical Importance
• Hemorrhagic cysts c o m m o n & mav be confused with
an endometrioma, dermoid or epithelial neoplasm
Short term follow-up (- o vsks) if diagnosis not clear
• Polvcvstic ovarian s y n d r o m e
failure of ovarian follicles to mature
Large ovaries with m u l t i p l e , small, peripheral
follicles
• I heca luteiu cysts
Response to excessive h u m a n chorionic
gonadotropic
Multiple, large Cysts replace parenchyma and
markedly enlarge ovaries
May be seen with gestational trophoblastic disease,
triploidy, infertility treatment, multiple gestations
 OVARIES
OVARY AND LIGAMENTS "0
<

O
<
Mesosalpinx Suspensory ligament of CD'
ovary

Mesovarium

Proper ovarian
ligament

Broad ligament

Developing follicles

Corpus albicans

Corpus luteum

(Top) Posterior view of the ligamentous attachment of the ovary. The ovary Is attached to the pelvic sidewall by the
suspensory ligament (infundibulopelvic ligament) of the ovary, which transmits the ovarian artery and vein. These
vessels enter the ovary through the mesovarium, a specialized ligamentous attachment between the ovary and broad
ligament. The ovary is attached to the uterus by the proper ovarian ligament, which divides the mesosalpinx above
from the broad ligament below. (Bottom) During the follicular phase of the menstrual cycle, several follicles begin to
develop but by days 8-12 a dominant follicle has formed, and the remainder begin to regress. On day 14 the follicle
ruptures and the egg is extruded. After ovulation, a corpus luteum forms, and if fertilization does not occur, the
corpus luteum degenerates into a corpus albicans. Ill
II 1 )
 OVARIES
OVARY AND LIGAMENTS

Supper v. «y ligament of
ovary

Extern it ili-ic arttry

and vi-in

Fallopiintube

^fc^^Mk

^T^fc

Internal Ui ic artery
External Itac vein

JC
(Top) Graphic shows ti >e locate n of the ovary In nulliparous w«.n»en. It lies against the lateral pelvic w Tl within the
ovarian f. ■■•a, which is r*ie ar< a below the iti*c bifurcatkf>, posterior to fie external iliac vessels, and anterior to the
UxMar. With pregn.v cy, the ov.rks are pushed out of tlie pelvis and seldom return to tf.ie same spot. (Bottom)
Sagittal T2 MR of the lateral pelvic wall shows the ovary within the ovarian fossa, inferior to the iliac bifurcation.
 OVARIES
OVARY A N D LIGAMENTS
O

••

o
<
Suspensory ligament of the ovary — 0)
3.
CD
</>
Suspensory ligament of the
Ovary — ovarv

— Ovary

Uterus Suspensory ligament of ovary

Ri^lit ovary — 1 eft ovary

Cervix — 1

Proper ovarian ligament

Ovary

timbriae

Fallopian tube

(Top) C o r o n a l T 2 MR of the ovaries. The suspensory ligament of t h e ovary attaches the ovary t o the pelvic w a l l a n d
transmits the ovarian artery, vein a n d lymphatics. It is a n elongated, n a r r o w b a n d o f tissue (best s h o w o n t h e left),
w h i c h widens as it attaches t o the ovary (best s h o w n o n the right). ( M i d d l e ) Axial T 2 M R s h o w i n g the triangular
c o n f i g u r a t i o n of t h e suspensory ligament as it attaches t o t h e left ovary. ( B o t t o m ) Transvaginal ultrasound i n a
patient w i t h ascites shows the fallopian tube arching a r o u n d the superior aspect of t h e ovary. The fallopian tube
"cradles" t h e ovary a n d t h e f i m b r i a t e d e n d is i n i n t i m a t e contact w i t h it, a l l o w i n g t h e fallopian tube t o "capture" t h e
ova. The proper, or utero-ovarian ligament attaches t h e ovary t o the uterine c o n i u . The proper ovarian ligament is
inferior t o t h e fallopian tube. Ill
I '1
 OVARIES
ULTRASOUND, NORMAL OVARY

>
o■ ■
- Bladder
.12
>
Q.

Ovary —■ — Ovary

- Uterus

Ilndornetrium —

Ovary

Ovary —

Ovary

- Internal iliac vein

(Top) Transabdominal ultrasound shows the mildly hyperechoic ovarian medulla, compared to the hypoechoic
cortex. The vessels and lymphatics enter and exit the ovary through the medulla. This complex series of acoustic
interfaces results in increased echogenicity. (Middle) Transvaginal ultrasound showing both ovaries adjacent to the
uterus. Ovarian ligaments can be lax, especially after childbirth, making ovarian position quite variable. Ovaries can
be located from above the fundus to the posterior cul-de-sac. When looking for the ovaries it is best to start near the
uterine fundus and follow the ligaments laterally to the pelvic sidewall. They can often be located by the iliac vessels.
(Bottom) Transvaginal color Doppler ultrasound shows the ovary adjacent to the internal iliac vein. Color Doppler
III ultrasound is also helpful in differentiating pelvic vessels from ovarian follicles.
122
 OVARIES
U I T R A S O U N D , N O R M A L OVARY 13
O
<
■ •

(D'
—
Dominant tollicle

Corpus lulcum cyst -

- Peak systole
End diastole —

—
Vt'rious flow

( l o p ) Transvaginal ultrasound o f a w o m a n o n day 13 o f the menstrual cycle. At this p o i n t , a d o m i n a n t follicle has

f o r m e d w i t h m u l t i p l e , smaller s u r r o u n d i n g follicles. ( M i d d l e ) Transvaginal color Doppler ultrasound of a different
w o m a n o n day 20 o f t h e menstrual cycle shows n o r m a l ovarian arterial b l o o d flow. The ovary n o r m a l l y has a
low-resistance, low-velocity wave f o r m . Increased f l o w can be seen a r o u n d a corpus l u t e u m cyst, w h i c h can appear as
a "ring o f fire" o n color Doppler. T h i s s h o u l d not be confused w i t h a similarly-appearing " r i n g of fire", as seen i n an
ectopic pregnancy, ( l i o t t o m ) Transvaginal power Doppler u l t r a s o u n d shows n o r m a l venous flow. Venous flow is the
first t o IK - c o m p r o m i s e d i n ovarian torsion, a n d therefore s h o u l d be d o c u m e n t e d i n all cases where torsion is
suspected. Ill
121
 OVARIES
ECHOGENIC FOCI

I
■ ■

0)
>
0) Echogenic foci
0. Echogcnlc foci -

Echogcnic loci

Echogenic foci

— Calcification

(lop) Transvaginal ultrasound showing multiple, peripheral echogenic foci. These arc typically 1-3 mm and are
non-shadowing, specular reflectors from unresolved cysts. They are of no malignant potential and should be
considered a normal variant. (Middle) Transvaginal ultrasound in another example of echogenic ovarian foci.
(Bottom) Ovarian calcification in a pcrimenopausal woman. Note the larger size and posterior shadowing when
compared to the small echogenic foci. These too, may be seen in an otherwise normal ovary and are likely due to
previous hemorrhage or infection. Care should be taken, however, as neoplasms may have calcifications. Iollow-up
scans should be done if there is any suspicion of a mass.
III
124
 OVARIES
MR, NORMAL OVARY "0
2.
<
■ •

O
12.
I eft ovary
a

I — Uterus
Follicle in rij;ht ovary-

Uterus

Ovary

Ovary

Bladder

Ovary

Dominant follicle

Medullary portion of ovary -

(Top) Axial IT MR of normal ovaries and uterus. Both the ovaries and uterus are of intermediate-signal intensity,
similar to skeletal muscles. Fluid-containing ovarian follicles will be low-signal intensity. Lack of soft tissue contrast
makes it difficult to differentiate the borders between the uterus and ovaries. On the right, it is difficult to
differentiate the right ovary from surrounding bowel. (Middle) I'.oronal T2 MR shows the superior delineation of
pelvic viscera using this sequence. The ovary is surrounded by a low-signal intensity capsule, aiding in differentiation
from surrounding structures. The fluid-containing follicles are high-signal intensity and of variable size. (Bottom)
Axial MR shows higher signal in the medullary portion of the right ovary. This is a common finding and represents
the vessels, which enter and exit through this area. Ill
125
 OVARIES
CD
HEMORRHAGIC CYST

O
■ ■

to
'>
o
Q-

I k-morrhagic cyst —

Hemorriiagic cyst
Retracting Clot

Right ovary

Hcmorrhagic cyst
Retracting clot

Normal follicles —

(Top) Transvaginal ultrasound shows the typical appearance of a hemorrhagic ovarian cyst. The cyst is filled with
thin, fibrinous septations, which have no flow on Doppler imaging. (Middle) First of two axial MR images of a
hemorrhagic cyst. Tl MR shows a moderately-high signal intensity cyst in the right ovary. A lower-signal area within
it represents a retracting clot. There was no enhancement with gadolinium. (Bottom) On T2 MR, the organized clot
is seen to letter advantage. There are overlapping features with endometriomas, but the low signal seen in
endometriomas (T2 shading), generally does not appear as organized as a retracting clot. Additionally,
endometriomas arc typically brighter on Tl than a hemorrhagic cyst. A follow-up ultrasound will show resolution of
III a hemorrhagic cyst.
126
 OVARIES
RESOLVING HEMORRHAGIC CYST

<
55"
••
O

— Acute hemorrhage

- Involuting hcmnrrhagic cyst

Resolved hemorrhaglc cyst

(Top) First of three transvaginal ultrasound images in a woman with acute lefl lower quadrant pain. The initial color
Doppler image shows a large cyst, filled with low-level echoes. There is flow around the cyst but not within it. When
cysts are large or atypical, a follow-up scan should be done to ensure resolution. (Middle) At 6 weeks, there has been
marked involution of the cyst. (Bottom) At 10 weeks, it has essentially resolved with only a vague hypoechoic area
where the cyst had been.

I.'
 OVARIES
POLYCYSTIC OVARIAN SYNDROME
3
o
■ ■

w
'>
o
0. Ovarian sttoma

Small, peripheral cysts ("string of —

pearls")

— Uterus

Right ovary -
Lett ovary

Right ovary- — Left ovary

Uterine fibroid

(Top) First of three different patients with polycystic ovarian syndrome (PCOS). Transvaginal ultrasound shows the
classic appearance of small, peripherally-placed cysts, creating a "string of pearls" appearance. The ovarian size is
increased and there is prominent ovarian strorna. (Middle) Axial T2 MR shows the high signal, peripheral cysts.
These are primordial follicles, with failure of a dominant follicle to develop. Failure of follicular development results
in anovulatory cycles. (Bottom) Axial Tl C+ FS MR image shows scattered small cysts within the ovarian stoma.
Once again, no dominant follicle is present. This is another potential appearance of PCOS. Symptoms of PCOS vary,
with the classic Stein-l.eventhal syndrome (amenorrhea, hirsutism, sterility and obesity) being a severe form.
III
128
 OVARIES
THECA LUTEIN CYSTS ■D

<
55"
■ •

CD
TO"
V)

Scptations

Right ovary Left ovary

— Uterus with hydatidiform mole

Right ovary - — Left ovary

(Top) First of three images in a woman with theca lutein cysts and a hydatidiform mole. The ultrasound shows
multiple, simple-appearing cysts, essentially replacing the ovarian parenchyma. Multiple prominent septae are seen
separating these cysts. These have sometimes been described as having a "spoke-wheel" appearance. (Middle)
Contrast-enhanced CT shows enhancement of the septae. Both ovaries are enlarged, which is typical. Occasionally
there may be only unilateral enlargement. (Bottom) Interiorly, the fundus ot the enlarged uterus is seen. Theca
lutein cysts are the result of increased stimulation from excessive h u m a n chorionic gonadotropin. This can be seen
with gestational trophoblastic disease (hydatiform mole, invasive mole, choriocarcinoma), triploidy, infertility
treatments and multiple gestations. Ill
I.")
 TESTES AND SCROTUM
[Embryology and Histology
• lestes form from gcnil.il ridges, which extend frnin
T6-S2 in embryo
• Composed of .1 cell lines
c Germ cells
• Sertoli cells
t- Levdig cells
• Germ cells
Form in wall of yolk sac and migrate along hindgut
to genital ridges
- form spermatogenic cells in mature testes
■ Mature Irom basement m e m b r a n e to lumen ol
seminiferous tubule (spermatogonia =»
spermatoevtes =» spermatids => spermatozoa)
• Sertoli cells
Supporting network for developing spermatozoa
I orm tight junctions i blood-test is barrier)
c Secrete Miillcrian inhibiting factor
■ ( auses paramesoiiephric (Miillcrian) d u c t s to
regress
■ I'mbrvologic remnant mav remain as a p p e n d i x
tcstis
• ley dig cells
Principal source of testosterone production
c I ie within interstitium
C auses differentiation of mcsoncpliric (Wolffian)
ducts
■ Each duct forms epidiclymis, vas deferens. seminal
vesicle, and ejaculatorv duct
■ An embryologic remnant mav remain as
ap|H'iidix e p i d i d y m i s
• Scrotum derived Irom labioscrotal folds
<- folds swell under influence of testosterone to form
t w i n scrota I sacs
■ Point of fusion is median raphc, which extends
from anus, along perineum to ventral surface of
penis
I'rocessus vaginalis, a sock-like evagination oi
peritoneum, elongates through abdominal wall into
twin sacs
■ forms anterior to developing testes
■ Aids in descent ol testes, along with
giibernaciiluiii (ligamenlous cord extending from
testis to labioscrot.il fold)
■ Results in component layers of adult scrotum
• Icsticular descent
o Between 7-12th week of gestation, testes descend
into pelvis
■ Remain near internal inguinal ring until 7th
m o u t h , when they begin descent through
inguinal canal into twin scrota! sacs
■ lestes remain retroperitoneal t h r o u g h o u t
descent
■ lestes intimately associated with posterior wall of
proccssus vaginalis
C o m p o n e n t layers of spermatic cord and scrotum
formed during descent through abdominal wall
Transvcrsalis fascia =» i n t e r n a l spermatic fascia
■ I ransversus ahdominis muscle is discontinuous
interiorly and does not contribute to formation ol
scrotum
Internal oblique muscle => creiiuislcric muscle a n d
fascia
c External oblique muscle =» external spermatic
fascia
Dartos muscle a n d fascia embedded in loose
areolar tissue below skin
c I'rocessus vaginalis closes a n d forms tunica
vaginalis
■ Mesolhelial-lined sac around anterior and lateral
sides of testis
■ Visceral laverof tunica vaginalis blends
imperceptibly with tunica albuginea
Cross Anatomy
Testis
• Tunica a l b u g i n e a forms thick fibrous capsule around
teslis
• Densely packed seminiferous tubules separated by thin
fibrous septae
200-300 lobules in adult testis
■ Each has 400-600 seminiferous tubules
■ l a c b tubule 30-80 cm long
■ lotal length of seminiferous tubules 300-980
meters
• Seminiferous tubules converge posteriorly t o form
larger ducts itubuli recli)
Drain into rete testis at testicular hilum
• Rele testis converges posteriorly to form 15-20
efferent dut tides
< Penetrate posterior tunica albuginea .it mediastinum
to form head of epididymis
• M e d i a s t i n u m testis thickened area of tunica
albuginea where ducts, nerves, and vessels enter and
exit lest is
Epididymis
• Crescent-shaped structure running along posterior
border of testis
• Efferent cluctules lorm head i g l o b u s major)
Unite t o form single, long, highly convoluted tubule
in bodv of epididymis
• lubulc continues interiorly to form epididymal tail
(glohus m i n o r )
Attached to lower pole of lestis bv loose areolar
tissue
• Tubule emerges at acute angle from tail as vas
delervns- (also know as ductus deferens)
( oiuinues cephalad within spermatic cord
c Iventuallv merges with duct of seminal vesicle to
form ejaculatorv duel
Spermatic Cord
• Contains vas deferens. nerves, lymphatics, a n d
connective tissue
• Begins at internal (deep) inguinal ring and exits
through external (superficial! inguinal ring into
scrotum
• Arteries
Texiicular artery
■ Itranch of aorta
■ Primary blood supplv to testis
Deferential a r t e r y
 TESTES AND SCROTUM

Paraplnlform plexus

Testlcular artery

Head of epididymis

Vas deferens
Efferent ductules

V
Deferential artery
Rete testis

Mediastinum testis

Body of epldldymls

Seminiferous tubules
Cremasteric artery

|
^ ^ y
m
Tunica albuglnea tail of epididymis

"W>^

The testis is composed of densely packed seminiferous tubules, which axe separated by thin fibrous septae. These
tubules converge posteriorly, eventually draining into the rete testis. The rete testis continues to converge to form the
efferent ductules, which pierce through the tunica albuglnea at the mediastinum testis and form the head of the
epldldymls. Within the epididymis these tubules unite to form a single, highly-convoluted tubule in the body, which
finally emerges from the tail as the vas deferens. In addition to the vas deferens, other components of the spennatic
cord include the testlcular artery, deferential artery, cremasteric artery, pampiniform plexus, lymphatics and nerves.
 TESTES AND SCROTUM

Se-nii ilve-icle

Vas deferens

Prrwtate

Corpus spongiotum

Head of epididymis

Tall of epldldymls

External oblique
muscle

1tansven.-">s fas<Ja
Oevel of internal
inguinal ring)
Into j.al oblique muscle

Ex i lal obbque f*'Cia

Superficial (external)
inguinal ring

External spennatic Oemastenc musfie

fascia

(Top) The tall of the epididymis is loosely attached to the lower pole of the testis by areolar tissue. The vas defer., ns
(also r< fered to as duct»s defer- is) emerges from the tail at an acute angle and continues cephalad as part of the
spennatic cord. After pas. lg through the inguinal canal, the vas deferens courses posteriorly to unite with the duct
of the seminal vesicle to form the ejacnlatory duct. These narrow ducts have thkk, muscular walls composed of
smooth muscle, which ri-flexry contract during ejaculation and propel sperm forward. (Bottom) The muscle layers of
the pelvic wall have been separated to show the spermatic cord as it passes through the inguinal canal. The
cremastenc muscle is derived from the Internal oblique muscle, while the external spermatic fascia is formed by the
fascia of the external oblique muscle.
 TESTES AND SCROTUM
SCROTAL DEVELOPMENT

Peritoneum

Transversalls fascia

Transversus abdomtnus
muscle

Internal oblique muscle

External oblique
K Processus vaginalis

muscle

i
Labloscrotal fold
Gubemaculum

'V ■

Peritoneum

Transversals fascia
Processus vaginalis
Internal oblique muscle
External oblique
muscle

Gubemaculum

(Top) The processus vaginalis is a sock-like evagination of the peritoneum, which elongates caudally through the
abdominal wall. It forms on each side of the lower abdomen just anterior to the developing testes and, along with
the gubemaculum (a ligamentous cord extending from the testis to the labioscrotal fold), aids in their descent.
(Bottom) As the processus vaginalis evaginates, it becomes ensheathed by fascia 1 extensions of the abdominal wall,
which ultimately form the layers of the scrotum and spermatic cord. The transversus abdominis muscle is
discontinuous inferiorly and does not contribute to the formation of the scrotum.
 TESTES AND SCROTUM
SCROTAL DEVELOPMENT ■v
<
(A

CD
(S)

(/>
Q)
Q.
cn
o
Peritoneum
o
ET
3
Transversal Is fascia

Internal oblique
muscle

External oblique
muscle

Internal spermatic
fascia (pink)

Tunica vaglnalis
Cremasteric muscle
and fascia (green)

External spermatic
fascia (blue)
Dartos muscle and
fascia (yellow)

The abdominal wall derivative layers of the scrotum are as follows: Transversals fascia =» internal spermatic fascia,
internal oblique muscle =» cremasteric muscle and fascia, external oblique muscle * external spermatic fascia. The
dartos muscle is embedded in the loose areolai tissue and is closely associated with the skin. Its primary function is to
contract the skin and elevate the testes in response to cold. The various layers of the scrotum cannot usually be
discerned with imaging. The superior portion of the processus vaginalis closes and forms an isolated
mesothelial-llned sac, the tunica vaglnalis. Failure of closure may result in a congenital hydiocele and is a risk factor
for an inguinal hernia.
Ill
135
 TESTES AND SCROTUM
E ULTRASOUND, TESTIS
■ » - •

2
o
CO
"D
C
TO
(/) lest is Testis
</)
CD

O
0.

Mediastinum lestis

Mediastinum lost is -*

(lop) Iransvcrse ultrasound showing both testes. I he testes have a homogeneous, medium-level, granular
echotextuie. (Middle) Longitudinal ultrasound shows the ovoid shape. The tunica albuginea may form an echogenic
linear band where it imaginates at the mediastinum testis. The mediastinum testis has a cranincaudal linear course
and is where the efferent ductules, vessels and lymphatics pierce through the capsule. (Bottom) I ongitudinal
ultrasound of a prominent mediastinuni testis. \ traiiMnediastin.il arterv may also sometimes IJV seen.

Ill
I u>
 TESTES AND SCROTUM
U L T R A S O U N D , EPIDIDYMIS ■D

<
55"
■ ■

Bpididymal tail

F.pkliclymal head 03
=3

a.
- Testis o
Ic
3

I pidiclyrius

Testis

Lpididymis

I pididymal cy*t
- lestis

(Top) longitudinal ultrasound shows both the epididymal head (globus major) and tail (glohus minor). The
cpididvmal head measures approximately 10-12 nun and is iso- to slightly liyperechoie compared to the testis. The
body and tail are more difficult to visualize, and may Ix.- slightly less tchogenic than the head. (Middle) 1 ongitudinal
ultrasound shows the epididymal head, which typically has a triangular or slightlv rounded configuration. (Bottom)
Longitudinal ultrasound of the epididymal head shows a well-defined, anechoic cyst. Epididymal cysts are c o m m o n
incidental findings and either represent true epithelial-lined cysts or s|X'rmatoceles. Differentiation is not clinically
necessary as both are benign.
Ill
137
 TESTES AND SCROTUM
A P P E N D I X TESTIS, A P P E N D I X E P I D I D Y M I S

Appendix testis —

Appendix testis —

Testis

Appendix epididymis —

Epididymis

(lop) Ultrasound of the testis in a patient with a hydroceie shows a small, nodular protuberance from the surface of
the testis. It is isoechoic to normal testicular parenchyma. This is the appendix testis, which is a remnant of the
Mullerian system. (Middle) Ultrasound of a slightly larger appendix testis in a different patient. (Bottom)
Longitudinal ultrasound of the upper testis and epididymis shows a small, cystic "tag" of tissue projecting from the
epididymis. This is an appendix epididymis, which is a remnant of the Wolffian system. Both the appendix testis and
appendix epididymis are usually not visible sonographically, unless there is a hydroceie. They are usually of no
clinical significance; however, they can rarely torse and be a cause of scrotal pain.
 TESTES AND SCROTUM
SCROTAL CALCULI "0

I
••
H
CD
Hydrocclc -
3
03
=3
D-

I— Scrotal calculus S?
O
c
3

- Hydrocele

Testis -

Scrotal calculus

- Hydrocclc
Testls
Scrotal calculus

(Top) Ultrasound of a complex hydrocele (note low-level echoes throughout the fluid) a n d a small scrotal calculus.
Scrotal calculi, also called scrotoliths or scrotal pearls, are free-floating calcifications within the tunica vaginalis. They
may result from torsion of the appendix epididymis or ap|>endix testis, or from inflammatory deposits on the tunica
vaginalis that have separated from the lining. On ultrasound they appear as mobile, echogenic calculi with posterior
shadowing. (Middle) Color LX>ppler ultrasound shows a small scrotal calculus with posterior shadowing. (Bottom)
Longitudinal ultrasound shows a larger scrotal calculus by the inferior pole ot the testis.

I
 TESTES AND SCROTUM
E NORMAL FLOW

Io
(f)
"D
C
ro
w Testis — Testis

a)
I-

>
CD
Q.

Intratesticular vessels —

Upididymis Testis

(Top) Iransverse color Doppler ultrasound of the testes. It is important to compare flow between testes to determine
if the symptomatic side has increased or decreased flow, when compared to the asymptomatic side. (Middle)
Longitudinal color Doppler ultrasound shows prominent, radially-arranged vessels within the testis. (Bottom) Color
Doppler ultrasound of the epididyma! head and testis.

4(1
 TESTES AND SCROTUM
NORMAL FLOW -o
<
■ ■

H
ct>
CO
CD
c/>
03
■3
Q.
O
O
• - * ■

c
3

Systolic flow — Diastolic flow

Venous f l o w -

('lop) 1'ulsed-wave arterial Doppler shows the normal, low-resistance wave form. There should always ho diastolic
flow present. (Bottom) Pulsed-wave venous Doppler shows normal venous flow. In evaluating an acutely painful
testis, both arterial and venous flow should be documented, as incomplete torsion may compromise venous flow but
not arterial flow.
 TESTES AND SCROTUM
E INCREASED FLOW, INFECTION
3
£o
if)
-o
c
to
(f)

• ■

F.pklidymis —
Q-
— Testis

— Testis

KpiOiilymis —

(Top) Color Doppler ultrasound of a patient with acute epididymitis. The epididymal head is enlarged and
hvperemic, with a marked increase in color flow. The testis is normal and flow was symmetric with the other testis.
Most infections occur from direct extension of pathogens retrograde, via the vas deferens, from a lower urinary tract
source. Thus, the epididymis becomes infected before the testis. (Bottom) Color Doppler ultrasound of a different
patient with acute epididymo-orchitis. There is dramatic increased flow in both the epididymis and testis.
Approximately 20% of cpididymitis cases are complicated by a coexistent orchitis. This is a potentially more serious
condition, which can lead to vascular compromise with testicular ischemia, infarction and/or abscess.
III
I4_>
 TESTES AND SCROTUM
DECREASED FLOW, T O R S I O N ■o
<p_
<
■ ■

-\
CD
W
CD
C/)
CD

a.
U)
o
a
c
Normal testis — Torsion with infarction 3

Systolic flow —

Alisent diastolic flow

(Top) Transverse power Doppler ultrasound in a patient with left testicular torsion and infarction. The left testis is
enlarged and hypoechoic compared to the normal side. Flow is seen in the surrounding scrotal skin but none is
present within the testis itself. (Ilottom) < :olor and pulsed-wave Doppler ultrasound in a different patient with
testicular torsion. The grayscale appearance of the testis is normal. Flow was seen on color Doppler but was decreased
when compared ro the asymptomatic side. Pulsed-wave Doppler shows systolic flow but there is absent diastolic flow.
Venous flow was absent as well. Because veins are more compressible, their flow is compromised first. This is
followed by loss of diastolic flow and finally systolic flow. Complete loss of blood flow may not be seen unless the
cord has twisted at least 540 degrees. Ill
m
 TESTES AND SCROTUM
MR, NORMAL SCROTUM

Corpora cavemosa

Spermatic cord
SjKrmatic cord -

- Corpus spongiosum

Corpora cavernosa

— Corpus spongiosum

rampiniform plexus
lest is -

— Mediastinum testis

(Top) First of four coronal T2 MR images, presented from back to front, showing normal scrota! anatomy. (Bottom)
The testes have a moderately-high signal intensity. The mediastinum testis is an invagination of the tunica albuginea
along the posterior aspect of the testis. It is low signal intensity, with thin low signal septae radiating away from it.
 TESTES AND SCROTUM
MR, NORMAL SCROTUM "0
<
55'
Corjxjra cavernosa —
CD
</>
S
V)
Q)
Corpus spongiosum
a.
C/)
o

I Pampiniform plexus
a
Mediastinum testis — c
3
M( -:i,i•-.1111iiin teslis

I pididymal tail

Pampiniform plexus

l.pididymal head
Tunica alhuginea

Epididymal tail —

— Hydrocele

— Median raphe

(Top) The pampiniform plexus is a meshwork of interconnected veins. These generally have slow flow so will appear
as an area of serpiginous high signal above the testis. (Hottom) The epididymis is relatively hypointense when
compared t o the testis. The tunica albuginea forms a distinct low signal capsule around the testis. The median raphe
separates the twin scrotal sacs and extends in a linear fashion from the anus to the ventral surface of the penis.

1
 TESTES AND SCROTUM
E MR, HYDROCELE

2
o
V)
T3
C Hydrocclc —
CO
(/)
Q) — Median raphe
to
CD
I'ampiniform plexus —

I
8. Testis —
— Testis

Median raphc

Hydrocclc —

Tunica albuginca —

— Mediastinum lestis

(Top) Axial T l MR o f t h e scrotum shows t h e intermediate signal testes a n d low-signal hydrocclc. ( B o t t o m ) Axial I'2
FS MR shows bilateral hydrocvlcs (right > left). A hydrocele is a n a c c u m u l a t i o n o f f l u i d between t h e parietal a n d
visceral layers o f t h e t u n i c a vaginalis. The t u n i c a vaginalis surrounds all but the posterior aspect of t h e testis, w h i c h is
attached t o scrotal s k i n . If t h e t u n i c a vaginalis completely surrounds t h e testis, it w i l l be freely m o b i l e ("bell-clapper"
a n o m a l y ) a n d is predisposed t o t o r s i o n .

Ill
Mb
 TESTES AND SCROTUM
CRYPTORCHIDISM

( nrpnra cavcrnma

Testis

Testis

Cilllx TIWlllllllll Cubcmaculiiiri

Empty scrotal sacs

— Bladder

Inguinal ligament Spermatic cord

Seminoma in
S| icrmaln cord undescended testis

Normally descended
testis iilans penis

(Top) Coronal T2 MR of bilateral cryptorchidism. Most undescended tcstes lie within the inguinal canal, near the
external ring, but can be anywhere along the path of testicular descent. Cryptorchidism is associated with testicular
carcinoma, decreased fertility and other congenital genitourinary abnormalities. (Bottom) Coronal T2 MR shows a
tumor (seminoma) in an undescended left testis, lying within the inguinal canal. It is important to be aware that the
increased risk of carcinoma does not just apply to the undescended side but also to the normally descended testis.
The increased risk may be from a generalized embryogenesis defect that results in bilateral dysgenetic gonads and a
predisposition t o tumor formation.
 TESTES AND SCROTUM
E
Z3
RETE TESTIS
■•-■

£
o
(f)

TO
tn
&
co
CD Rctc tcstis
Rctc tcstis
C/>
">

o.

l.pididymls

lipidklymal cysts

— Rctc tcstis

Rete testis

(Top) First of three ultrasound images in a patient with tubular ectasia of the rete testis. Dilatation of the rctc testis is
thought to occur secondary to obstruction in the epididymis or efferent ductules. Tubular ectasia is located
posteriorly by the mediastinum and is frequently bilateral. It may give an impression of a mass, but careful scanning
shows the "mass" is actually a series of dilated tubules. (Middle) Longitudinal ultrasound of the right side shows two
epididymal cysts. These arc frequently associated with dilatation of the rete testis. (Bottom) Longitudinal color
Doppler ultrasound of the left testis shows no flow within these cystic spaces.

Ill
14R
 TESTES AND SCROTUM
RETE TESTIS

Rete testis —

I'iiinpiniform plexus —

Epiclidymis

Lpididymal cyst

— Rete leslls

llydrocele —

(Top) First of two images in a patient with a dilated rete testis. Longitudinal ultrasound of the left testis shows the
typical appearance with multiple dilated tubules. (Bottom) Coronal T2 I:S MR shows a triangular area of increased
signal within the superior aspect of the left testis. This appearance helps to further differentiate tubular ectasia from a
tumor, which is typically a round, low signal intensity mass on 12 MR.
 TESTES AND SCROTUM
VARICOCELE

- Testis

- Varicocele

Testis —
- Varicocele

Hydrocele —

Spermatic curd with varicocele —

- Normal spermatic cord

(Top) I ongitudinal grayscale ultrasound of the left testis shows a large varicocele. Varicoceles are often idiopathic,
particularly on the left side. Several anatomic factors predispose the left side: A) The left testicular vein has a longer
course than the right. B) It has a perpendicular insertion into the left renal vein, while the right flows obliquely into
the inferior vena cava. C) The left renal vein passes beneath the superior mesenteric artery creating a "nutcracker"
effect. (Middle) Coronal T2 MR of a left-sided varicocele. The signal intensity may vary according to bkx>d flow
velocity. last-flowing varicoceles have a signal void, while slow-flowing ones will be intermediate to high signal.
(Bottom) CECT of a right-sided varicocele in a patient with a right renal tumor. Varicoceles may be caused by
compression or invasion of the renal vein or inferior vena cava.
 INDEX
Abdomen. See also specific structures
abdominal wall, 11:40-67
adrenal glands, 11:424-445
biliary system, 11:342-369
colon, 11:238-271
diaphragm, 11:69-91
embryology of, 11:2-39
esophagus, 11:158-173
gastroduodenal, 11:174-205
kidneys, 11:446-483
liver, 11:298-341
lymphatic system, 11:118-157
nerves, 11:118-157
pancreas, 11:370-399
peritoneal cavity, 11:92-117
retroperitoneum, 11:400-423
small intestine, 11:206-237
spleen, 11:272-297
ureter, 11:484-509
urinary bladder, 11:484-509
vessels, 11:118-157
Abdominal aorta, 11:118. 111:52, 54, 57
Abdominal aortic aneurysm, 11:174, 201
Abdominal cavity, 11:5, 7, 92
Abdominal fat, 11:88, 172
Abdominal retroperitoneum, 11:3
Abdominal veins, 11:132
Abdominal viscera, embryology, 11:3
Abdominal wall, 11:40-67
anterior, 11:40, 42, 43
aponeurosis, 111:8
clinical implications, 11:40
graphic, 11:41
gross anatomy, 11:40
incisional hernia, 11:62
inguinal hernia, 11:63
lumbar hernia, 11:66, 67
muscles of, 11:45-57
pannus, 11:60
posterior, 11:40,41, 118
rectus hemorrhage, 11:58-59
skin. 11:504
spigelian hernia, 11:64-65
terminology, 11:40
thoracolumbar fascia, 11:44
ventral hernia, incarcerated, 11:61
Abdominopelvic splanchnic nerves, 11:118
Accessory hemiazygos vein, 1:340, 341, 349, 352
Accessory pancreatic duct (of Santorini), 11:370, 398
Accessory spleen
after splenectomy, 11:292
embryology, 11:272
enlarged. 11:294
incidence, 11:277
intrapancreatic, 11:293
Acetabula
female anatomy, 111:46
normal, 11:124,111:25, 26
root of, 11:102
Achalasia, cricopharyngeal, 11:169
Acinar cells, 11:370
Acinar emphysema, 1:83
Acinar nodules, 1:66, 86
Acini, 1:65. 66, 68
Acquired immunodeficiency syndrome, 11:216, 217
Acromioclavicular joints, 1:464
Acute cholecystitis, 11:342, 3 5 2 , 3 5 3
Acute marginal artery, 1:423, 424, 429, 430, 431, 435
Acute pancreatitis, 11:26-28, 370, 388-389
Addison syndrome, 11:424
Adductor brevis muscle, 111:16, 20, 27, 28, 29
Adductor lonRus muscle, 111:16, 19,20, 2 7 , 2 8 , 29
Adductor magnus muscle, 111:16, 21, 2 7 , 2 8
Adenocarcinoma, lung, 1:37
Adnexal variocosities, 111:67
Adrenal arteries
anterior, 11:425
inferior, 11:119, 424, 448, 462, 463
middle, 11:119,424,425
superior, 11:119, 424,425
Adrenal capsules, 11:426
Adrenal corticotrophic h o r m o n e (ACTH), 11:424
Adrenal glands, 11:52, 378, 404,11:424-445,
11:457,458
accessory spleen and, 11:293
adenomas, 11:434, 436
anatomy, 11:182, 372, 424-431, 454
carcinoma, 11:444
clinical implications, 11:424
congenital anomalies, 111:187
 INDEX
cortex, 11:424,426 endobronchial tumors, 1:226
diaphragm and, 11:85 endoluminal tumors, 1:204
gastric diverticula and, 11:202 during expiration, 1:73
hemorrhage, 11:442,443 function, 1:2, 5, 64
hepatic a t t a c h m e n t s and, 11:300 imaging, 1:203-204
hyperplasia, 11:437 during inspiration, 1:72
imaging issues, 11:424 left lung, 1:215-217
insufficiency, 11:441 microscopic structure, 1:78
kidneys and, 11:433,448 nomenclature, 1:202
left, 11:71,248 overview, 1:5,67,205
medulla, 11:424,426 primitive epithelium, 1:42
metastases, 11:440 pseudoglandular stage, 1:48
neonatal, 11:432,433 right lung, 1:210,211-213
in pancreatitis, 11:407 segmental anatomy, 1:206,207,214
pheochromocytoma, 11:438,439 structure of, 1:64-87
spleen and, 11:277 AJCC/UICC lymph n o d e stations, 1:298,1:322
terminology, 11:424 Alcoholic cirrhosis, 11:173
venogram, 11:428 Alimentary tube, embryology of, 11:3
Adrenal plexus, right, 11:156 Allantoic stalk, embryology of, 11:8,9
Adrenal veins, 0 : 1 1 8 , 1 3 2 , 4 2 4 , 4 2 5 , 4 2 8 , 4 4 7 Allantois (urachus), embryology of, 11:3, 6, 8, 33
Age/aging Alveolar-capillary interfaces, 1:39,98,99,374
aortic, 11:54 Alveolar ducts, 1:64, 65, 67, 76, 77
diaphragmatic defects and, 11:68 Alveolar epithelium, 1:114
pancreas, senescent change, 11:386 Alveolar macrophages, 1:78
Air Alveolar pores, 1:65
bowel, 1:18,11:60 Alveolar sacs, 1:64, 65, 67
extraluminal gas bubbles, 11:190-193,111:201 Alveoli
intrathoracic, 11:90 alveolar stage, 1:49
radiographic density, 1:18 anatomy, 1:64
Air bronchograms, 1:53 capillaries, 1:102
Air-fluid levels, 1:286 development of, 1:39
Airspace disease n u m b e r of, 1:89
lobar p n e u m o n i a , 1:154 structure, 1:65, 77, 78, 79
lower lobe, 1:24,309,421 Ambiguous genitalia, 11:3
segmental, 1:158-161 Amniotic cavity, 11:5, 6, 32
silhouette sign, 1:20,25,131-132 Amniotic fluid, 11:4
upper lobe, 1:192 Ampulla, fallopean tube, 111:96
Air trapping, 1:66, 85 Ampullary carcinomas, 11:361,362,363
Airway generations, 1:67 Anal canal, 111:29, 42, 4 3 , 48, 49
Airways, 1:64-87, 2 0 2 - 2 2 7 Anal triangle, 111:3, 40
abnormalities, 1:40,204 Anemia, hemolytic, 1:486
anatomy, 1:6,202, 218-219 Angiocentric nodules, 1:106
atretic, 1:62 Angiographic catheters, 11:184,250,374
branches, 1:64 Angiography, 1:4,230
bronchial anatomy, 1:202-203,203 Angioscopy, virtual, 1:4
bronchiectasis, 1:222,223 Annular pancreas, 11:370, 399
bronchoarterial (B/A) ratio, 1:221 Anococcygeal ligament, 111:3,38
canal if ular stage, 1:48 Anomalous pulmonary venous drainage, 1:230
cartilage calcification, 1:74, 75 Anomalous vertical vein drainage, 1:230
central, 1:208,209 Anterior adrenal arteries, 11:425
chest overview, 1:5 Anterior cul-de-sac, 111:84
components, 1:2 Anterior cul-de-sac (vesico-uterine pouch), 111:84,
cross-sectional anatomy, 1:26,27 87, 8 9 , 9 4 , 9 8
development of, 1:38 Anterior inferior iliac spine, 111:4, 5, 6 , 1 3
embryonic stage, 1:54 Anterior inferior pancreaticoduodenal artery, 11:185
 INDEX
Anterior intercostal arteries, 1:462 aberrant right subclavian artery and, 1:365
Anterior interventricular sulcus, 1:374, 377 anatomy, 1:302, 307, 313, 315, 316, 317,334, 345
Anterior junction line, 1:308, 312 anomalies, 1:336
Anterior labrum, 111:26 anomalous left vertebral artery and, 1:363
Anterior midline plane, 11:118 aortic enlargement and, 1:360, 361
Anterior pancreaticoduodenal artery, 11:371 cross-sectional anatomy, 1:34
Anterior papillary muscle, 1:375, 383, 387, 406 double, 1:336. 367
Anterior pararenal space, 11:402 double SVC and, 1:440
Anterior perirenal fascia, 11:30 esophagus and, 11:158
Anterior sacrococcogeal ligament, 111:9, 41 frontal view, 11:159
Anterior scalene muscle, 1:229,474 imaging, 1:336
Anterior superior iliac spine, 111:4, 5, 6, 9, 18 impressions on esophagus, 11:162
Anterior vagal trunk, 11:156
indentation, 1:135
Anterior vaginal fornix, 111:94
interface, 1:335, 3 4 2 , 3 4 3
Anterior ventricular vein, 1:441
left, 1:415
Anteroposterior radiographs, 1:2, 12
mass effect on, 1:343
Antrum, 11:175
nieiliastjn.il lymph nodes and, 1:322
Anulus fibrosus, 1:375
Anus, 11:10, 244,111:38, 39 mediastinum and, 1:299, 300, 306
prominent, 1:414
Aorta, 1:6, 433, 4 3 4 , 4 3 5 , 436, 437,11:46, 52, 74, 188, right, 1:336, 354, 366, 415
229, 309,400,111:64, 65, 71, 72, 85, 152,153. sagittal relations, 11:160
See also Abdominal aorta; Ascending aorta; Aortic hiatus, 1:335, 339,11:68, 118
Descending aorta; Thoracic aorta Aortic (intermesenteric) plexus, 11:156
aging, 11:54, 55 Aortic nodes, 11:424, 446
with aneurysm, 11:30 Aorticorenal ganglia, 11:446
anterior view, 1:423 Aorticorenal ganglion, left, 11:156
atherosclerotic, 1:421 Aorticorenal plexus, 11:446
bifurcation, 111:57, 61 Aortic stenosis. 1:376, 420
bifurcation of, 11:47 Aortic tortuosity, 1:19, 360
branches, 11:120, 121 Aortic valve, 1:32, 376, 390, 392, 393, 408, 409,
calcification, 1:19 411,413
diaphragmatic opening, 11:72, 73 abnormal cusps, 1:411
dissection, type B, 1:454 calcification, 1:420
duodenal compression and, 11:200 coronary sinus, 1:405, 409
embryology, 11:5, 7, 32 fibrous ring of, 1:402
enlargement, 1:361 noncoronary sinus, 1:405
in eventration of diaphragm, 11:87 prosthetic, 1:403
frontal view, 11:159, 111:62 Aortocaval nodes, 11:152, 484,111:152
graft, 111:201 Aorto-enteric fistula, 11:174, 201
IVC duplication and, 11:136-137, 138 Aortography, 1:4
lymphadenopathy and, 11:423 Aortopulmonary window, 1:297, 313, 315, 316, 317
mediastinum and, 1:300 Apical lordotic radiography, 1:3, 17
normal, 11:122, 126, 164, 429 Apical pulmonary artery, left, 1:184, 190
in ovarian vein thrombosis, 111:68 Aponcuroscs, abdominal muscles, 11:42, 45, 4 6 , 6 5 ,
in pelvic congestion syndrome, 111:67 111:8, 13
in polysplenia syndrome, 11:296 Appcndiccal artery, 11:242
prenatal circulation, 11:16 Appendiceal carcinoma, 11:116
in renal cell carcinoma, 11:469,471 Appendicitis, 11:238, 258,259
in SMA stenosis, 11:224 Appendix, 11:12, 238, 245,248, 265
in splenic vein occlusion, 11:285 Appendix epididymis, 111:138
tortuosity, 1:19,360 Appendix testis, 111:138
trachea and, 1:202 Arc of Riolan, 11:240
in transitional cell carcinoma, 11:472 Arcuate arteries, 11:448, 462,111:98, 100
variations, 11:148 Arcuate ligaments, 11:68, 80
Aortic arch, 1:32, 338, 347, 348, 350, 351, 353, 414 Arcuate line, 111:6
 INDEX
Arcuate veins, 111:99
Arcuate vessels, 11:68, 80,111:99, 100
Arcus tendineus, 111:9, 37, 4 1 , 4 5
A ring, esophageal, 11:158, 163
Arteriovenous malformations, 1:230,252, 253
Asbestos exposure, 1:288
Ascending aorta, 1:242, 315, 318,338, 339,347,350,
393,399,401,413,430
aberrant right subclavian artery and, 1:364
in absence of pericardium, 1:456
anatomy, 1:34, 315, 318, 334, 345, 346, 411, 445
aortic enlargement and, 1:360
dilated, 1:411
double aortic arch and, 1:367
enlarged, 1:360, 361
heart and, 1:377
heart valves and, 1:408
hypoplastic right SVC and, 1:369
imaging, 1:336
left d o m i n a n t coronary circulation, 1:432
mediastinal lymph nodes and, 1:322
oblique thoracic aortogram, 1:353
pericardia! effusion and, 1:459
pericardial recesses and, 1:454
pericardium and, 1:444,449
persistent left SVC and, 1:369
right aortic arch and, 1:366
right d o m i n a n t coronary circulation, 1:431
Ascending colon, 11:47, 94, 95,102, 109,229, 248,
249, 252,259,266, 414, 419,450,499
anatomy, 11:238,245
ascitesand, 11:21,24, 210
in C r o h n disease, 11:218
lymphoid nodules, 11:213
in midgut malrotation, 11:232
in perirenal bleed, 11:31
Ascending mesocolon, 11:12
Ascites
axial CT, 11:278-279
in bacterial peritonitis, 11:109
broad ligament and, 111:89
cirrhosis, varices, 11:336
diaphragm and, 11:84-85
in gastric carcinoma, 11:116, 111:95
inferior mesenteric vessels and, 11:254-255,256
loculated, 11:108, 1 0 9 , 1 1 0 , 1 1 2 , 1 1 6
lumbar hernia with, 11:67
lung development and, 1:39
malignant, 11:112, 116
mesenteries and, 11:24-25,103,210,252-253
ovary and, 111:121
pancreatitis and, 11:390
in paracolic gutter, 11:389, 409
peritoneal reflections, 11:20-23
peritoneal spaces and, 11:20-25,96-97,98
I'ETCT, 111:72
septations within, II: 116
umbilical ligaments delineated by, 11:106
uterosacral ligament, 111:91
Asplenia, embryology, 11:272
Atelectasis, 1:25, 55, 123, 155, 156,157,223, 226,
285,418,479,11:81,84,166
Atheromatous plaque, 11:270
Atherosclerosis, 1:421,11:222-223
Atria
in congenital absence of pericardium, 1:456
constrictive pericardium and, 1:461
double SVC and, 1:440
enlargement, 1:417
in eventration of diaphragm, 11:87
four-chambered view, 1:398, 410
imaging, 1:376
left, 1:32, 92, 100, 101, 182, 184, 189, 237,239,
240,312,316, 317, 375,386, 388-389,392,
393, 395,399,400-401, 404, 409,412-413,
433,436,439,454
mass effect on, 1:61
pericardium and, 1:451
right, 1:35, 242, 312, 346, 375, 382, 385, 391, 393,
394, 398,399, 400-401, 407, 412,430,431,
439
thrombus, 1:421
two-chambered view, 1:397,410
Atrial appendages
enlarged, 1:421
left, 1:377,388-389, 395, 397,421
right, 1:384, 390
Atrial septal defects, 1:191
Atrioventicular groove. See Coronary sulcus
Atrioventricular bundle, 1:374
Atrioventricular node, 1:374
Atrioventricular ring, 1:404
Atrioventricular valve. See Mitral valve
Automatic implantable cardioverter defibrillator,
1:19
Autonomic nervous system, II: 156
Axial interstitium, 1:113, 125
Axilla, 1:463, 466
Axillary arteries, 1:466, 468
Axillary bundle, 1:468
Axillary veins, 1:468
Azygoesophageal recess, 1:297, 308, 309, 312, 314,
343, 346, 348
Azygousarch, 1:153, 342, 347, 348, 349, 351
anatomy, 1:239,340, 341, 345, 349
enlarged, 1:371
imaging of, 1:335
mediastinal lymph nodes and, 1:322
pericardial effusion and, 1:458
in polysplenia syndrome, 11:144
 INDEX
right aortic arch and, 1:366 acute cholecystitis, 11:352,353
Azygous fissure, 1:130,152, 153,268, 277 ampullary carcinoma, 11:361, 362, 363
anatomy, 1:263 anatomy, 11:342-369, 347
fluid in. 1:281 bile ducts, 11:346
imaging of, 1:263 in Caroli disease, 11:367
pneumothorax in, 1:281 choledochal cysts, 11:368, 369
Azygous lobe, 1:130,152, 153 cystic artery, 11:348
Azygous system, 1:334-335 gallstones, 11:351
Azygous vein, 1:152,312, 314, 334-335,340, 341, hamartomas, 11:366
345,346,349,351,11:118, 151 in pancreatic head carcinoma, 11:364-365
adrenals and, 11:431 Biliary tree, 11:345
anastomoses, 1:349 Biventricular pacemaker, 1:19
azygos fissure and, 1:281 Bladder. See Urinary bladder
drainage into, 1:463 Bleeding, intra|)eritoneal, 11:411
enlarged, 1:336,371 Blood, in perirenal space, 11:411
hypoplastic right SVC and, 1:369 Bochdalek hernia, 11:68, 88
imaging of, 1:336 Body stalk, embryology, 11:4, 32
medial lung surface, 1:135 Bone, radiographic density, 1:18
persistent left SVC and, 1:369 Bovine arch, 1:336,362
in polysplenia syndrome, 11:142, 145,146, Bowel. See also Small intestine
147,296 air in, 1:18, 11:60
thoracic duct and, 1:359 broad ligament and, 111:89
herniated, 11:63
incarcerated loop, 111:31
B loculated ascites and, 11:108
Balloon catheter, 111:104 transvaginal ultrasound, 111:109
Barium aspiration, 1:86 Bowel ischemia, 11:222-223
Bartholin glands, 111:3 Bowel obstruction, 11:61, 63
Basal opacities, 1:128 Boyden nomenclature, 1:228
Basement membrane, 1:69,89 Brachial plexus, 1:463, 466, 474, 475
Basivertebral foramen, 11:150 Brachiocephalic arteries, 1:334, 337,344, 347,
Batson plexus, 111:170 350,353
Battery packs, radiographic density, 1:19 anomalous left vertebral artery and, 1:363
Bedside radiography, 1:13 bovine arch and, 1:362
Benign prostatic hypertrophy (BPH), 111:171, 180, imaging of, 1:336
181,182-183 right, 1:322, 344
Bifid ureter, 11:484, 488 trachea and, 1:202
Bile ducts, 11:314, 342, 345. See also C o m m o n bile Brachiocephalic veins
duct anatomy, 1:335
dilated, 11:340, 356, 361, 364, 365, 367 anomalous left vertebral artery and, 1:363
extravasated bile, 11:357 catheter in, 1:370
gas in, 11:278-279 in chest wall infection, 1:487
hepatic failure and, 11:356 double aortic arch and, 1:367
hepatic vessels and, 11:301 imaging, 1:336
iatrogenic, 11:356, 357 left, 1:337, 344, 345, 347, 350, 352
pancreatic duct and, 11:384 right, 1:337, 338, 341, 344, 345, 347, 352
in polysplenia syndrome, 11:143 Branchial arches, 1:41
stones in, 11:360, 367 Breast cancer
variations, 11:342, 344 metastatic, 1:489, 490, 491,11:334
Biliary artery variations, 11:342 primary, 11:334
Biliary drainage catheter, 11:143 B ring, esophageal, 11:158, 163, 167, 168
Biliary hamartomas, 11:342 Broad ligaments, 111:41, 84, 85, 86, 88, 89, 118, 119
Biliary stents, 11:392, 393 Bronchi. See also Bronchus intermedius
Biliary system, 11:342-369. See also Bile ducts; accessory, 1:203
C o m m o n bile duct; Gallbladder anatomy, 1:64
 INDEX
anomalous, 1:203,225 right main, 1:167, 168, 1 8 2 , 1 9 7 , 2 0 2 , 2 0 5 , 208,
anterior basilar, 1:206 209, 211, 215,220,243, 301,351
anterior segmental, 1:176,202, 2 0 3 , 2 0 6 , 2 0 7 , right upper lobe, 1:172, 174, 175, 176, 177,182,
208, 2 0 9 , 2 1 1 , 2 1 3 , 2 1 5 , 2 1 8 188,189, 190, 191, 193,200, 202, 208,209,
anteromedial basilar, 1:206, 207,216 211,218,220,243
apical segmental, 1:202,206,207, 2 0 9 , 2 1 1 , segmental, 1:71,202, 211-213
219,243 situs abnormalities, 1:203
apicoposterior segmental, 1:202, 203, 206, 207 structure, 1:64, 68
CT, 1:176, 1 7 8 , 2 0 9 , 2 1 5 , 2 1 9 superior lingular, 1:178, 206, 207, 226, 247
axillary, 1:203 superior segmental, 1:202,203,207,212,216,
basilar segmental, 1:202,220 219,220,244, 247, 248
capillaries, graphic, 1:102 supernumary, 1:203
cartilage calcification, 1:74, 75 tracheal atresia, 1:57
cross-section, 1:70,97 truncus basalis, 1:203, 212
CT pulmonary angiogram, 1:94 Wegener granulomatosis, 1:227
development of, 1:38 Bronchial arteries, 1:354
embryonic stage, 1:54 anatomy, 1:354
endoluminal tumor, 1:197 angiography, 1:4
during expiration, 1:73 course of, 1:90
hyparterial (See Bronchi, left main) left, 1:89
imaging-anatomic correlations, 1:65 microscopic anatomy, 1:90, 96
inferior lingutar, 1:206, 207, 218, 247 right, 1:89, 354
inferior segmental, 1:202, 203 structure, 1:88
during inspiration, 1:72 variants, 1:355
lateral basilar, 1:207,219 vascular structure, 1:91
lateral segmental, 1:202,203,206,207,212,213, Bronchial atresia, 1:40, 62, 63
216,220 Bronchial branches, 1:29, 45
left apicoposterior segmental, 1:185, 246 Bronchial buds, 1:38, 42, 43, 44, 58, 60
left cparterial, 1:415 Bronchial veins, 1:88, 90
left lower lobe, 1:71,157,174, 175, 189,202, Bronchiectasis, 1:204, 222,223
203,220 Bronchioles, 1:38, 64, 65, 68, 69, 76, 9 1 , 96, 115
left main, 1:167, 169, 173, 184, 185, 187, 189, Bronchiolitis, 1:80, 84, 85
197,203,205, 209, 2 1 1 , 2 1 2 , 2 1 5 , 2 2 0 , 2 4 1 , Bronchoarterial (B/A) ratio, 1:204, 221
242, 246, 247, 417,11:158,159, 160, 162 Bronchoarterial bundle, 1:88, 124
left upper lobe, 1:174, 175, 178, 183, 188,189, Bronchoarterial pairs, 1:221
190, 193, 196, 200, 202,203, 208,215,220, Bronchogenic carcinoma, 1:157,166,196,197,264
226,247,417 Bronchogenic cysts, 1:40, 60, 6 1 , 331
left upper lobe segmental, 1:183 Broncholithiasis, 1:194
lingular, 1:202, 2 1 5 , 2 1 6 Bronchomediastinal lymphatic trunk, 1:335, 356
lobar, 1:72, 73, 202 Bronchopleural fistula, 1:264, 286
medial basilar, 1:206, 207 Bronchopneumonia, 1:86
medial segmental, 1:202,203, 206,207, 212,213, Bronchoscopy, virtual, 1:4
218,220 Bronchovascular bundle, 1:119, 127
microscopic structure, 1:69 Bronchus-associated lymphoid tissue (BALT), 1:88
middle lobe, 1:181, 182, 183, 202, 203,212, Bronchus intermedius, 1:172, 202-203, 209,218
220,245 in bronchogenic carcinoma, 1:197
normal, 1:119 bronchogenic cyst and, 1:61, 331
posterior basilar, 1:206, 207, 2 1 6 , 2 1 9 cross-section, 1:71
|X)sterior segmental, 1:202, 203, 206, 207, during expiration, 1:73
211,213 during inspiration, 1:72
primitive, 1:38 left lung, 1:215,216
right, 1:168, 186 in lymphadenopathy, 1:198
right anterior segmental, 1:183 normal. 1:167, 176. 178.184,185.188, 189,244
right apical segmental, 1:176, 183, 188 right lung, 1:212
right lower lobe, 1:180, 202, 209, 212 thick, 1:195
right lower lobe basilar segmental, 1:185 virtual bronchoscopic images, 1:220
Brunner gland hyperplasia, 11:189
 INDEX
Buck fascia, 111:154, 156, 159, 160 splenic vessels, 11:280
Bulbar cone, 111:166 in superior vena cava, 1:370
Bulbarsump, 111:166 suprapubic, 111:168
Bulb of vestibule, 111:38 umbilical vein, 1:13
Bulbomembranous junction, 111:166, 168, 172 urinary, 11:418, 5 0 1 , 5 0 8
Bulbospongiosus muscle, 111:38, 39,154, 156, Caval nodes, 11:424, 446
157,164 Cavernosal arteries, 111:154, 155, 159,160, 162
Bulbourethral (Cowper) gland, 111:39 Cavernosal septum, 111:162
Bulbous urethra, 111:154, 165, 166, 168, 169 Cecal tip, 11:248
Bullae, 1:83,280 Cecal volvulus, 11:265
Bullet, on radiograph, 1:21 Cecum, 11:238, 259,265, 266,267
Bullous disease, 1:83 abdominal view, 11:265
embryology, 11:9,10,12
lymphoid nodules, 11:213
c in midgut malrotation, 11:233
Calcium, bone, 1:18 normal, 11:211, 245, 247,111:27
Camper fascia, 11:46 Celiac artery, 11:51, 77, 78, 79, 188,207, 307,
Canal of Nuck, 111:84 308,376
Canals of Lambert, 1:65, 76 arterial phase, 11:318, 382
Canula, pelvic venogram, 111:67 embryology, 11:8
Capillaries frontal view, 11:175
alveolar, 1:89 inferior vena cava and, 11:78
alveolar stage, 1:47, 49 normal, 11:120, 122, 126, 164, 182,215,304
canalicular stage, 1:46 in pancreatic cancer, 11:157
microscopic structure, 1:78 peritoneal cavity, 11:105
pseudoglandular stage, 1:46 renal artery variants, 11:464
saccular stage, 1:47 replaced hepatic arteries, 11:330
structure, 1:79,91 in SMA stenosis, 11:224
Capsular ligament, 111:20 variations, 11:130, 185
Cardiac bronchus, accessory, 1:203 venous phase, 11:383
Cardiac indentation, 1:135 Celiac ganglia, 11:156, 342
Cardiac sulci, 1:374-375 Celiac nodes, 11:118, 152, 174, 177, 342,370
Cardiac veins, 1:422-441, 438, 439 Celiac plexus, 11:342
Cardinal ligaments, 111:84, 85, 86, 8 8 , 9 9 Celiac trunk, 11:73, 80, 119, 186
Cardiomegaly, 1:19, 119,251, 3 7 6 , 4 1 6 , 4 1 7 Central catheters, 1:20, 420
Cardiopericardial enlargement, 1:458 Central line, 1:370, 420
Cardiothoracic ratio, 1:376 Central tendon, 11:41, 68, 69, 111:3
Carina, 1:208, 209,220, 225, 226, 316, 317 Central tracheobronchial tree, 1:40
Caroli disease, 11:342, 367 Centriacinar artery, 1:82, 83
Carotid arteries, 1:472 Centrilobar vessels, 1:122, 123
Cartilage Centrilobular emphysema, 1:66, 82
calcification, 1:74, 75 Centrilobular low attenuation, 1:66
microscopic structure, 1:69 Centrilobular nodules, 1:66
Catecholamines, 11:424,438 Cervical ribs, anatomy, 1:463
Catheters Cervix. See Uterine cervix
angiographic, 11:184, 250, 374 Cesarean section scar, 111:87
balloon-type, 111:104 Chest. See also specific structures
biliary drainage, 11:143 airways, 1:202-227
in brachiocephalic veins, 1:370 airway structure, 1:64-87
central line, 1:20, 420 chest wall, 1:462-493
fractured, pulmonary, 1:260 coronary arteries, 1:422-441
hepatic arteries, 11:127 coronary veins, 1:422-441
in inferior vena cava, 11:141,428 heart, 1:374-421
PICC, 1:53 hila, 1:164-201
in pulmonary arteries, 1:238 interstitial network, 1:110-129
in renal veins, 11:141 lung development, 1:38-63
 INDEX
lungs, 1:130-163 Cirrhosis
mediastinum, 1:296-333 ascites and, 11:98-99
neonatal, 1:50 enlarged accessory spleen in, 11:294
overview, 1:2-37 esophageal varices, 11:336
pericardium, 1:442-461 mesenteries and peritoneal spaces, 11:24-25
pleura, 1:262-295 paraumbilical varices in, 11:323-324
pulmonary vessels, 1:228-261 peritoneal reflections, 11:20-23
systemic vessels, 1:334-373 peritoneal spaces, 11:20-23
vascular structure, 1:88-109 splenic enlargement and, 11:98-99
Chest tubes, 1:55 Cisterna chyli, 11:118, 152
Chest wall, 1:6, 1:462-493 enlarged, 1:359
a n a t o m i c regions of, 1:463 intestinal trunk, 11:152
anatomy, 1:2, 5, 462, 464 lumbar trunks, 11:152
axillary region, 1:466 thoracic duct and, 1:335, 359
cross-sectional anatomy, 1:34, 465 tributaries, 1:359
depressed, 1:479 Clavicles, 1:21
fibrous dysplasia, 1:488 anatomy, 1:462, 468, 470, 474
function, 1:2 fracture, 1:13
graphic, 1:132 frontal view, 1:464
infection, 1:487 impressions on esophagus, 11:162
intercostal region, 1:467 left, 1:9, 171
kyphoscoliosis, 1:481 medial, 1:9, 17
lipoma, 1:488 right, 1:9, 13, 14, 2 3
lymphatics, 1:463 Clitoris, 11:36,111:38, 113
lymphoma, 1:492 Cloaca, 11:3, 8, 33
metastatic disease, 1:493 Cloacal membrane, 11:33
muscles of, 1:462 Coccygeus muscle, 111:3, 9, 4 1 , 47
in neurofibromatosis, 1:485 Coccyx, 11:246,111:29, 36, 47, 48, 49
normal anatomy, 1:468-476 Colic arteries, 11:131,214, 240, 250, 251,252, 380
pectus carinatum, 1:480 Colic veins, 11:179, 207,214, 241, 250, 252,255
Poland syndrome, 1:477 Colitis, ischemic, 11:270
pseudonodule, 1:484 Collateral veins, liver, 11:334-335
skeletal structures, 1:462 Colles fascia, 11:498
skin of, 1:463 Colliculus seminalis. See Vermontanum
soft tissues, 1:463 Collimation
superior aspect, 1:35 anteroposterior chest radiographs, 1:12
supraclavicular region, 1:466 lateral decubitus chest radiography, 1:16
thoracic inlet, 1:466 left lateral chest radiographs, 1:8
traumatic deformity, 1:482 PA radiograph, 1:8
vessels, 1:462-467 Colon, 11:60, 11:238-271, 11:378, 380. See also
Cholecystitis Ascending colon; Descending colon; Sigmoid
acute, 11:352, 353 colon; Transverse colon
ductal stones and, 11:354, 355 adrenals and, 11:431
Choledochal cysts, 11:342, 368, 369 after splcnectomy, 11:292
Choledocholithiasis, 11:354 anatomy, 11:238
Chondrosarcomas, 1:463, 493 appendix, 11:248
Chordae tendineae, 1:375, 387, 404. 406. 408 arteries, 11:240
Chromaffin cells, 11:424 in bacterial peritonitis, 11:109
Chronic obstructive pulmonary disease (COPD), in cirrhosis and ascites, 11:21
1:204 clinical implications, 11:238
Chronic pancreatitis, 11:370 dilated, 11:264
Chronic viral hepatitis, 11:341 diverticulitis, 11:260, 261
Circular muscle, 11:208 hepatic congenital hypoplasia, 11:325
Circumflex vessels, 111:159,160, 167. See also Deep hepatic flexure, 11:89, 232, 245, 270, 343
circumflex artery; Deep iliac circumflex arteries; ileocal region, 11:242
Left circumflex artery (LCX) ileocecal valve, 11:247
 INDEX
incisional herina containing, 11:62
inflamed, 11:220
ischcmic colitis, 11:238, 270
malignant ascites and, II: 112
mesentery and, 11:239
mesentery outlined by ascites, 11:252-253
midgut malrotation, 11:231
mural (wall) anatomy, 11:238
nodular omental metastases and, 11:113
normal anatomy, 11:183,245, 246
in pancreatitis, 11:408
perforated gastric ulcer and, 11:194
polyps, 11:263
in polysplenia syndrome, 11:143, 297
in pseudomyxoma peritonei, 11:116
rectosigmoid, 11:243
retroperitoneal divisions and, 11:402
retroperitoneal planes and, 11:401
spigelian hernia with obstruction of. 11:64-65
superior mesenteric vessels, 11:250
veins, 11:241
Colon cancer, 1:106,11:267
Colonic volvulus, 11:238
Colorectal fistula, 11:260
Columnar epithelium, 1:38, 69
C o m m o n bile duct, 11:316, 318, 346, 382, 384, 398
in ampullary carcinoma, 11:361, 362, 363
anatomy, 11:92, 342, 347
choledochal cysts and, 11:368, 369
frontal view, 11:176
gallbladder and, 11:343
in pancreatic carcinoma, 11:364, 395
stones, 11:354,355, 358-360
variants, 11:344
C o m m o n carotid arteries
double aortic arch and, 1:367
left, 1:334, 336-339, 344, 347,348, 350, 353,
362-365
right, 1:339, 353, 364, 365
C o m m o n femoral arteries, 111:61, 62, 63
C o m m o n femoral veins, 111:56
Common hepatic artery, 11:187,307, 308, 372, 376
celiac angiogram, 11:186
celiac artery variation, II: 130
iatrogenic bile ducts and, 11:357
normal, 11:123, 126, 184
variations, 11:128, 185, 326-327
C o m m o n hepatic duct, 11:315, 343, 346,
358-359,366
C o m m o n iliac arteries, 11:121, 124, 126, 306,111:10,
52,61,64,65,66,74-75
bifurcation, 111:58
frontal view, 11:119,111:54, 62
IVC duplication and, 11:137, 139
lateral view, 111:54
left, 11:47,111:57, 58
nerve sheath tumor and, 11:422
obstruction, 111:53
in ovarian vein thrombosis, 111:68
retrocaval ureter and. 11:493
right, 111:58
C o m m o n iliac nodes, 11:152, 153.111:53, 70, 7 1 , 72,
74-75
C o m m o n iliac veins, 11:48, 118, 258,111:52
confluence of, 111:57
IVC duplication and, 11:137, 139
IVC transposition and, 11:135
left, 111:58
normal, 11:124
in ovarian vein thrombosis, 111:68
right, 111:58
C o m p u t e d tomography, 1:3-4, 4
Congenital absence of kidneys, 11:475
Congenital duplication cyst, 11:236
Congenital hepatic fibrosis, 11:342
Congenital hypoplasia, hepatic, 11:325
Congenital vcnolobar syndrome. See Scimitar
syndrome
Connective tissues, 1:46, 69
C o n n syndrome, 11:424
Constrictive bronchiolitis, 1:66
Constrictive pericarditis, 1:443
Contrast-enhanced computed tomography, 1:3-4
Contrast media
extravasated, 11:502-503
intraperitoneal, 11:501
Conus artery, 1:429, 431, 432, 435
Cornua, 111:107
Coronal abdominal arteries, 11:119
Coronary arteries, 1:422-441
abbreviations, 1:422
anomalies. 1:435
anterior view, 1:423
calcification, 1:418, 419, 421
catheter angiography, 1:428-429
imaging, 1:422
left, 1:409, 437
left d o m i n a n t coronary circulation, 1:432
left main, 1:423, 428, 431, 432, 435, 436
posterior view, 1:424
right {Sec Kight coronary artery (RCA))
right d o m i n a n t coronary circulation, 1:431
right single, 1:437
territories, 1:426,427
Coronary (gastric) vein, 11:179, 207, 394
Coronary ligament, 11:95, 299, 300
Coronary sinuses, 1:422, 439, 441
anterior view, 1:438
biventricular pacing and, 1:441
double SVC and, 1:440
enlarged, 1:369, 373
left, 1:411,433, 435
 INDEX
normal anatomy, 1:393 D
orifice, 1:441
Dartos fascia, 111:130, 135
right, 1:411
Dartos muscle, 111:130, 135
single coronary artery from, 1:436
Decubitus radiography, 1:22
valve of, 1:382, 385
Deep circumflex artery, 11:51,111:63
Coronary sulcus (atrioventricular groove), 1:374,
Deep dorsal vessels, 111:159, 160, 167
377,381,384,385,390
Deep iliac circumflex arteries, 111:52,54,60
four-chambered view, 1:398 Deep inguinal nodes, 111:52, 70
heart and, 1:379 Deep transverse perineal muscle, 111:39,41
left d o m i n a n t coronary circulation, 1:432 Deep transversospinales muscle, 1:462
normal anatomy, 1:392, 400-401 Deferential artery, 111:130-131, 132
two chamber view, 1:397 Deltoid muscle, 1:468, 470, 474
Coronary veins, 1:422-441. See also specific veins Denonvilliers fascia, 111:170
Corpus albicans, III: 119 Dentate line, 11:244
Corpus cavernosa, 111:16-18,144-145, 147, Dermatomes, 11:118
154-162, 167
Corpus luteum, 111:119,123 Descending aorta, 1:33, 34, 301, 313, 315, 334, 336,
Corpus spongiosum, 111:157, 158 339,342, 346, 348,349, 350,351,354, 430
aortic enlargement and, 1:360, 361
anatomy, 11:498,111:154, 156, 159
axial CT, 1:27
erectile function and, 111:160
extravasation into, 111:169 distal, 1:348
graphic, 111:133 left, 1:415
oblique thoracic aortogram, 1:353
normal, 111:17, 18, 144-145
persistent left SVC and, 1:369
retrograde urethrogram, 111:167
sagittal midlineview, 111:164 proximal, 1:344, 345, 348
retrocardiac, 1:154
in straddle injury, 111:169
Cortical column (of Bertin), 11:448, 480 right, 1:354,415
Costal cartilage, 1:464, 465, 476, 483,11:50, 62, 69 right aortic arch and, 1:366
Costal margins, 1:462,464 sagittal reconstruction, 1:32
Costal pleura, 1:267 thoracic duct and, 1:359
Descending colon, 11:65, 94, 102, 103, 229, 238,245,
Costochondral junction, 1:464, 466, 476
252, 260, 262,266, 270, 388,404, 405, 406, 419,
Costodiaphragmatic recesses, 1:262,266,267,
459,460
282,283
Costodiaphragmatic sulcus, 1:270 in acute pancreatitis, 11:26, 27
Costophrenic angle, 1:10, 11, 16, 21 in ascites, 11:21,210
Cowperduct, 111:164, 166,172 in cirrhosis, 11:21,24
Cowper gland, 111:155, 156, 164, 166, 172 embryology, II: 12, 38
Crcmasteric artery, 111:131,132 Dextrocardia, 1:255, 415
Cremasteric fascia, 111:30,130 Diaphragm, 1:339,11:50, 5 1 , 52,11:68-91,11:171.
Cremasteric muscle, 111:30, 130, 135 See also Hemidiaphragms
Cricopharyngeal achalasia, 11:169 abdominal surface, 11:69
Cricopharyngeus muscle, 11:158, 160 acute splenic infarction and, 11:290
Crista terminalis, 1:376, 382, 384, 385 arcuate ligament and, 11:80
Crohn disease, 11:218-220 Bochdalek hernia, 11:88
Crura. See Diaphragmatic crura clinical implications, 11:68
Crura of corpus cavernosa, 111:154, 155, 157, 158 cortico-medullary phase, 11:452
Cryptorchidism, 111:131, 147 in distended peritoneal cavity, 11:100
Cushing syndrome, 11:424 elderly person, 11:56
Cylindrical bronchiectasis, 1:204 embryology, 11:10
Cystic artery, 11:342, 348 esophagus and, 11:158
Cystic bronchiectasis, 1:204 eventration of, 11:87
frontal view, 11:161
Cystic duct, 11:315, 342, 343, 344, 346, 347, 354, 358
gastroesophageal junction and, 11:76, 77
Cystic fibrosis, 1:222
Cystocele, 111:3, 50 heart and, 1:377
hepatic visceral surface, 11:299
hiatal hernia, 11:81, 89
 INDEX
imaging issues, 11:68
indentation, 11:163
insertion, 11:160
loose cms and, 11:81
mediastinum and, 1:299, 300
openings, 11:72, 73, 78, 79
pericardium and, 1:444, 445, 450
peritoneal spaces and, 11:98
right anterior defect, 1:333
sagittal relations, 11:160
separating fluid collections, 11:84-85
slips, 11:82, 83, 88
traumatic rupture, 11:68,90-91
Diaphragmatic crura, 1:58, 339,11:52, 54, 55, 56,
72,161
adrenal adenomas and, 11:436
adrenal hemorrhage and, 11:442
adrenal insufficiency and, 11.441
adrenals and, 11:426, 430, 431
gastroesophageal junction and, 11:76
left, 11:41,68,69,74
loose, 11:81
normal anatomy, 11:70-71, 75, 164, 429
patulous diaphragmatic hiatus and, 11:166
right, 11:41,68,69,73, 165
sagittal relations, 11:160
Diaphragmatic hiatus, II: 166
Diaphragmatic insertions, 11:68
Diaphragmatic motion, 1:4
Diaphragmatic nodes, 11:161
Diverticula, 11:253, 256,260
Diverticulitis, 11:260,261
Diverticulosis, 11:238
Dorsal mesogastrium, 11:2
Dorsal pancreatic artery, 11:375
Dorsal penile arteries, 111:154
Ductus deferens, 11:35
Ductus venosus, 11:2, 15, 16
Duodenal bulb. 11:174. 175, 180, 181, 183, 196,
211,376
gastric diverticulum and, 11:204
perforated duodenal ulcer and, 11:190, 192
peritoneal cavity, 11:105
polypoid filling defects, 11:189
Duodenal diverticula, 11:174, 205
Duodenojejunal flexure, 11:12, 28
Duodenojejunal junction, 11:371
Duodenum, 11:254. 255, 316. 377, 379-381, 389,
398,414,419
in acute cholecystitis, 11:353
in acute pancreatitis, 11:26
in AIDS, 11:216
in ampullary carcinoma, 11:362
anatomy, 11:174, 347, 371, 373
arterial phase, 11:318, 382
arteries of, 11:178
ascending, 11:174
in ascites, 11:21
choledochal cysts and, 11:368
in cirrhosis, 11:21, 22, 24
compression, 11:200
descending, 11:174
development of, 11:19
in disseminated M. aviuin complex, 11:217
diverticula, 11:386
embryology of, 11:2, 7, 12
with feeding tube, 11:403, 409
fold patterns, 11:176
gallbladder and, 11:343
in midgul malrotation, 11:232
mural anatomy, 11:174
normal anatomy, 11:305
in pancreatic cancer, 11:157, 395
perforated ulcer of, 11:190-193
in perirenal bleed, 11:29
perirenal planes, 11:460
retroperitoneal divisions and, 11:402
retroperitoneal planes and, 11:401
second portion, 11:105, 180, 181, 183, 189, 190,
192, 193, 200, 205, 372, 399
third portion, 11:80, 93, 99, 154, 176, 180, 181,
200, 205, 252, 387,388, 399,409, 414,
111:201
transverse, 11:174
venous phase, 11:383
Dyspnea, 1:30,83
E
Echogenic foci, 111:124
Ectopic kidney, 11:476, 477
Ectopic pregnancy, 111:95,97,111
Ectopic ureter, 11:484, 490, 491
Edema
in extralobar sequestration, 1:59
interstitial, 1:111, 122, 123, 166
pulmonary, 1:119, 121
Efferent ductules. III: 132
Egg-shell calcification, 1:166
Ejaculatory ducts, 111:171, 172, 173
Emissary veins, 111:159
Emphysema, 1:66, 82, 83
Empyema, 1:22,264, 286. 287
Endocardium, 1:374
Endocervical canal, 111:102, 103,105,108, 109
ectopic pregnancy, III: 111
graphic, 111:98
hysterosalpingogran, 111:110
Nabothian cysts, 111:109
Endometrial cavity, 111:116
Endometrial implants, 111:94
Endometriosis, 111:95
 INDEX
Endometrium impressions on, 11:162
cyclical variations, 111:102-103 indentation, 1:135
effect of oral contraceptives, 111:106 lymphatics, 11:161
ovarian, 111:122 mediastinal lymph nodes and, 1:322
uterine, 111:96, 9 7 , 9 8 , 102-103, 104, 105,107 mediastinal nerves and, 1:302
Endorectal coils, 111:176, 177,182-183 mediastinum and, 1:300
Endoscopes, 11:398 normal anatomy, 1:313, 314,11:164
Endothoracic cartilage, 1:465 paraesophageal hernia (PF.H), 11:171, 172
Endothoracic fascia, 1:467 posterior abdominal wall, 11:41
Endotrachial tubes, 1:13, 52, 53 right lung and, 1:211
Enterocele, 111:3,51 sagittal relations, 11:160
Eparterial, definition, 1:202 segmental bronchi and, 1:215
Epicardial fat, 1:28 terminology, 11:158
Epicardial fat pad sign, 1:443 thoracic duct and, 1:359
Epicardium, 1:374 trachea and, 1:202
Epididymis, 111:130-133,137-138,140-142, tracheal atresia, 1:57
144-145,148-149 External abdominal muscles, 11:51
Epididymitis, 111:142 External anal sphincter, 11:243,111:3, 37, 38, 3 9 , 4 5
Epididymo-orchitis, 111:142 External cervical os, 111:94, 110
Epidural venous plexus, II: 150 External hemorrhoidal plexus, 11:244
Epigastric veins, 11:118 External iliac arteries, 11:48, 51,111:58, 59, 60, 64,
Epiploic appendages, 11:23, 24, 2 3 8 , 2 3 9 , 2 5 3 , 2 5 6 , 65,71,100,120
257,262 anatomy, 11:485,111:52
Epiploic appendagitis, 11:238 arteriogram, 111:61
Epiploic foramen of Winslow, 11:11, 92, 95 frontal view, 11:119, 111:54, 62
Epithelium lateral view, 111:54,63
alveolar, 1:114 left, 11:215
embryology, 1:43, 46,47, 48 normal, 11:120, 121
microscopic structure, 1:69 obstruction, 111:53
Erectile dysfunction, III: 154 External iliac nodes, 11:152, 153, 155, 484,111:52,
Erector spinae muscles, 1:462, 465,470, 473,11:45, 70-75
46,47,57,111:10, 11,12 External iliac veins, 11:132, 485,111:52, 56, 59, 60,
Esophageal atresia, 1:40, 56, 365 71,120
Esophageal branch, 11:119 External iliac vessels, 11:25, 155, 423,111:13, 14, 71
Esophageal catheter, 1:56, 57 External inguinal ring, 111:31
Esophageal hiatus, 11:68, 69, 70, 75, 77, 8 1 , 158, External intercostal muscle, 1:465
159,160 External jugular veins, 1:470
Esophageal varices, II: 158, 173,336 External oblique fascia, 111:133, 134-135
Esophagus, 11:158-173 External oblique muscles, 1:474,11:40, 42, 46, 64, 65,
A ring, 11:158, 163 111:10, 1 1 , 1 7 , 1 8 , 2 4 , 2 5 , 1 3 3
aberrant right subclavian artery and, 1:364 anterior pelvic wall, 111:2
air in, 1:224 aponeuroses, 11:45, 65
axial anatomy, 1:312 frontal view, 111:8, 30
Bring, 11:158,163, 167, 168 internal view, 111:8
clinical implications, 11:158 posterior pelvic wall, 111:9
coronal CT, 11:77 External os, 111:96, 98, 109
cross-sectional anatomy, 1:27 External pudendal vein, 111:167
development, 1:41 External spermatic fascia, 111:130,133, 135
diaphragmatic opening, 11:72, 73 External (superficial) ring, 111:2
double aortic arch and, 1:367 Extra-embryonic celom, 11:4, 5, 6, 7
embryology, 11:8 Extralobar sequestration, 1:58, 59
"feline," 11:170 Extraperitoneal bladder rupture, 11:484
frontal view, 11:159, 161 Extraperitoneal fat, 11:40,111:8, 176
gastric diverticula and, 11:202 Extraperitoneal spaces, 11:3, 29-31, 412-413,
gross anatomy, 11:158 416-418
imaging issues, 11:158
 INDEX
F Femoral veins, 11:124,111:18, 19, 82
Femoral vessels, 111:14, 15, 16, 26, 2 7 , 4 2
Facet joints, 1:465 Femurs, 111:16, 20, 2 4 , 2 5 , 5 1 , 79. See also Femoral
Falciform ligament, 11:43,92, 165, 182, 304, 305, entries
316,322 Fetal lobation, 11:481
in ascites, 11:20 Fetal urachus, 11:484
in cirrhosis, 11:20 Fibrosing peritonitis, 11:110, 111
cleft, 11:318,320 Fibrosis
embryology of, 11:2, 9, 11 idiopathic pulmonary, 1:128, 129
fissure for, 11:100-103,317 left upper lobe, 1:193
frontal view, 11:175 reticular opacities, 1:111
hepatic attachments and, 11:300 Fibrothorax, 1:291
hepatic visceral surface, 11:299 Fibrous dysplasia, 1:488
peritoneal spaces and, 11:97, 98 Fibrous pericardium, 1:442,445
Fallopian tubes, 111:86, 110, 120 Fibrous trigone, 1:375, 402
ampulla, 111:110 Fimbrae, 111:121
anatomic relationships, 111:96 Focal thoracic scoliosis, 1:456
coronal view, 111:41 Folds of Kerckring, 11:206
ectopic pregnancy, III: 111 Foley catheter, 111:169
embryology, 11:36,111:113 Foramen ovale, 1:375,404,11:16,17
endometrial cavity, 111:110 Foregut, embryology, 1:40, 42, 43, 44, 58, 60,
fetal development, 11:3
11:3, 206
fimbrae, 111:110
Foreign bodies
frontal view, 111:54
inhalation of, 1:204
herniated, 111:36 pulmonary emboli and, 1:260,261
infundibulum, 111:110 Fossa navicularis, 111:154, 155
interstitial portion, 111:98, 110 Fossa ovalis, 1:375, 376, 382, 394,111:30
isthmus, 111:110 Fractures
mucosal folds, 111:110
clavicle, 1:13, 171
transvaginal ultrasound, 111:121 rib, 1:482, 483
tubalostium, 111:110 Frasier, Muller, Colman and Tare classification, '
False (major) pelvis, 111:2, 6
1:297, 305
False ribs, 1:464
Fundiform ligament, 111:8
Fat
Fundus, 11:175,111:104, 105, 107
abdominal, 11:88,172 Funnel chest. See Pectus excavatum
epicardial, 1:28
extraperitoneal, 11:40,111:8, 176
i n f l a m e d , 11:26, 406 G
mediastinal, 1:445, 448-450, 458,459
Gallbladder, 11:51,183,305,315,316,322,342,343,
omental, 11:89
346, 347, 380, 384. See also Bile ducts; Biliary
peripancreatic, 11:406
system; C o m m o n bile duct
perirenal, 11:456
acute cholecystitis, 11:352, 353
perivesical, 11:25
in acute pancreatitis, 11:26
properitoneal, 11:405
in ampullary carcinoma, 11:361
radiographic density, 1:18
arterial phase, 11:318
renal sinus, 11:454, 480
in biliary h a m a r t o m a , 11:366
subcutaneous, 1:27, 34, 465, 467, 468,11:46, 50
carcinoma, 11:342
subepicardial, 1:445,448, 449, 450,458,459
Feeding tubes, 11:230, 231, 409 choledochal cysts and, 11:368,369
Felson classification, 1:296-297, 304 distended, 11:348
Femoral arteries, 11:63, 124,111:18, 34, 82 embryology, 11:8
Femoral canal, 111:53 fossa, 11:298,321
Femoral head, 11:49, 124, 111:6, 2 1 , 42, 44 frontal view, 11:175
Femoral hernias, 111:3, 34 gallstones, 11:351-355, 358-359
Femoral neck, 11:49 hepatic visceral surface, 11:299
Femoral nerves, 111:12, 53, 77, 80, 82, 83 in pancreatic carcinoma, 11:364, 392
peritoneal spaces and, 11:97
 INDEX
sagittal view, 11:451 peritoneal spaces a n d , 11:96, 98
variant extrahepatic ducts, 11:344 spleen and, 11:273, 276
Gallstones, 11:351-355 Genital ridges, 111:130
Gastric antrum, 11:183, 189, 190, 192,198, 204, 399 Genital tract, 11:3
Gastric arteries, 11:174,182, 184,308,372 Genital tubercle, 11:10,34, III: 113
branches of, 11:178 Genitourinary (GU) system, embryology, 11:3, 32-36
left, 11:80, 122, 126,127,128, 130, 175, 178,186, Germ cells, 111:130
187,188,280 Glands of Littre, 111:154, 155, 167
right, 11:178 Glans penis, 111:147,154,156,163
variations, 11:185, 326-327 Glenohumeral joints, 1:464
Gastric bubble, 1:415 Glenoid of scapula, 1:468, 470, 475
Gastric carcinoma, 11:116, 196-198,111:95 Globus major, 111:130
Gastric cardia, 11:81, 168,171,174 Globus minor, 111:130
Gastric diverticula, 11:174, 202-204, 445 Glomerulus, 11:32
Gastric folds (rugae), 11:167, 174,181 Gluteal muscles, U:48, 52
Gastric fundus, 11:171, 174, 204, 445 Gluteus maximus muscle, 11:20,111:11-16,22-29,36,
Gastric mucosa, 11:175 3 8 , 3 9 , 4 2 , 4 3 , 4 5 , 79
Gastric nerves, 11:68 Gluteus medius muscle, 111:11-15,19-22,24-26
Gastric nodes, 11:161 Gluteus minimus muscle, 111:13, 14, 19-22,
Gastric nodules, II: 177 24-26,44
Gastric pylorus, 11:376 Goblet cells, 1:69
Gastric ulcer, 11:194-195 Goiter, 1:224, 332
Gastric veins, 11:174, 179, 241,284-285, 373 Gonadal arteries, 11:118, 119, 447, 485
Gastrocolic ligament, 11:2, 2 2 , 9 3 , 1 1 6 , 1 7 4 , 1 7 5 , 1 9 9 Gonadal veins, 11:118, 132, 447,111:52
Gastroduodenal artery, 11:126,184,186, 193,280, Gonadal vessels, 11:465
307,308,328, 342,370, 371,372, 374, 375,385 Gonococcal urethritis, 111:167
iatrogenic bile ducts and, 11:357 Gracilis muscle, 111:20
replaced hepatic arteries, 11:329, 330 Granulomas, 1:108,11:217
variations, 11:127,128, 130, 185,326-327 Granulomatous disease, 1:166, 194, 195
Gastroduodenal ligament, 11:2 Great cardiac vein, 1:436, 438, 439, 441
Gastroduodenum, 11:174-205 Greater o m e n t u m , 11:278-279
Gastroepiploic (gastro-omental) arteries, II: 174, 175, anatomy, 11:92, 94
178, 185, 186,272, 374,376,385 in ascites, 11:21, 103
Gastroepiploic (gastro-omental) vessels, 11:2,99, in cirrhosis, 11:21-24
179,182,274,285,378 development of, 11:19
Gastroepiploic nodes, 11:177 embryology of, 11:2, 11
Gastroesophageal junction, 11:70, 75,158, 164, frontal view, 11:95, 175
165,171 lateral view, 11:93
diaphragm and, 11:76, 77 peritoneal cavity, 11:100-103, 105
frontal view, 11:159 peritoneal spaces and, 11:98
gastric diverticula and, 11:202 Greater sac, 11:92
lymphatics and, 11:161 Greater saphenous veins, 111:30
peritoneal spaces and, 11:98 Greater sciatic foramen, 111:2
Gastroesophageal reflux disease (GERD), 11:158 3D CT, 111:6
Gastroesophageal varices, 11:336 Greater trochanter. 111:21. 24
Gastrohepatic ligament, 11:2,3, 20, 158 Greater vestibular (Bartholin) gland, 111:38
Gastrointestinal tract, embryology, 11:8, 9, 10, Great pancreatic artery, 11:371, 385
12,13 Cireat vessels, 1:2, 5, 26
Gastrophrenic ligament, 11:95 Ground-glass opacities, 1:30,256,273
Gastrosplenic ligaments, 11:92, 272,278-279 Gubcrnaculum, 111:130,134,147
in ascites, 11:20 Gut, embryology, 11:15, 32
in cirrhosis, 11:20
cross-sectional anatomy, 11:94
embryology of, 11:2, 3 H
perforated gastric ulcer and, 11:194 Hamartomas, 11:366
peritoneal cavity, 11:105 Haustra, 11:238, 245, 263
 INDEX
Heart, 1:6, 12, 14, 28,1:374-421,1:390-391, in kyphoscoliosis, 1:481
392-393, 399,400-401, 414. See also specific left, 1:7, 140, 154,270
structures pseudotumor and, 1:283
abnormal situs, 1:415 right, 1:158
anatomy, 1:2, 374 Hemithorax, 1:9,22
anterior surface, 1:382 Hemopericardium, 1:443
biventricular pacing, 1:441 Hemorrhages
boarders, 1:374 adrenal, 11:424, 442, 443
cardiac indentation, 1:135 coagulopathic, 11:416-418
cardiomegaly, 1:19, 119, 251,376,416, 417 into extra|>eritoneal spaces, 11:412—413
chambers, 1:384-385, 388-389 perirenal, 11:414-415
coronal reconstruction, 1:32 retroperitoneal, 11:416-418
development, 1:41 Hemorrhagic cysts
dextrocardia, 1:255 ovarian, 111:126
embryology, 11:4, 6 resolving, 111:127
enlargement, 1:15,11:287 Hepatic arteries, 11:51,92,123, 184, 186,298, 304,
in extralobar sequestration, 1:59 307, 308, 315, 342,372. See also C o m m o n
four chaml)er view, 1:398, 409 hepatic artery; Proper hepatic artery
function, 1:2, 374 accessory right, 11:328
graphic, 1:337 arterial phase, 11:318, 382
interior, 1:382 CT angiography, 11:375
intrathoracic stomach and, 11:89 iatrogenic bile ducts and, 11:357
left lateral chest radiography, 1:7 left, 11:126, 280
medial left, 1:14 in pancreatic carcinoma, 11:395
mediastinum and, 1:299, 300 replaced, 11:127, 128-129, 329, 330
orientation, 1:374 right, 11:126,303
overview, 1:5, 377 right replaced, 11:128-129
paraesophageal hernia and, 11:172 segmental anatomy, 11:320
in pectus excavatum, 1:478 splenic vein occlusion and, 11:284-285
persistent left SVC and, 1:368 variations, 11:127-130,185,326-327
in polysplenia syndrome, 11:296 Hepatic carcinoma, 11:348
posterior surface, 1:386 Hepatic cysts. 11:98, 318, 320, 392,483
right cardiac border, 1:140 Hepatic diverticulum, 11:6, 7
sagittal reconstruction, 1:32 I lepatic ducts, 11:342, 344, 347
short axis view, 1:396 Hepatic flexure, 11:89, 232, 245, 270, 343
skeleton of, 1:402 Hepatic nodes, 11:370
sulci, 1:378-379 Hepaticopancreatic ampulla (of Vater), 11:342, 346
surface anatomy, 1:374, 378-381 Hepatic veins, 11:92, 118, 122, 298, 304, 309, 310,
two chamber view, 1:397 314, 342, 373
valves, 1:402, 407-409, 412-413 (See also specific accessory, 11:148
valves) arterial phase, 11:317
Heitzman classification, 1:297 bile ducts and, 11:301
Helicine arteries, 111:155, 159, 160 confluence, 11:148
Helicubacter pylori, 11:174 coronal view, 11:132
Hematocrit sign, 11:417 embryology of, 11:2, 15
Hematogenous metastases, 1:90 fetal development, 11:14-15
llematomas, 11:411,442 inferior vena cava and, 11:78, 84
Hematopoiesis, 1:486 left, 11:303
Hemiazygous vein, 1:335, 340, 341, 346,349,11:151 in liver steatosis, 11:338
enlarged, 1:372 middle, 11:148, 303, 306, 310, 320
imaging, 1:336 normal vessels, 11:311
in polysplenia syndrome, 11:142 in polysplenia syndrome, 11:142,146
Hemidiaphragms, 1:21, 24,11:171, 310,429. See also segmental anatomy, 11:320, 321
Diaphragm unfavorable for transplantation, 11:332, 333
elevated, 1:36,156,11:68,86 variations, 11:148-149
inverted, 1:59 venous phase, 11:318
 INDEX
Hepatic venous plexus, 11:14 Hilar lymph nodes, 1:104, 168, 169, 177, 249
Hepatitis, 11:341 bilateral calcification, 1:195
Hepatocellular carcinoma, 11:298,341 calcification, 1:193,194
Hepatoduodenal ligament, 11:92, 9 5 , 1 7 5 , 1 7 6 left, 1:187
Hepatoduodenal papilla, 11:345 in lung cancer, 1:327
Hepatogastric ligament, 11:92,95,175 right, 1:182,184, 186
Hepatopancreatic ampulla (of Vater), 11:370 Hilar overlay sign, 1:166,190
Hepatopulmonary syndrome, 1:230,253 Hilar vascular opacity, 1:174, 175, 190,200,232
Hepatorenal fossa, 11:18, 457 Hiler convergence signs, 1:166
Hepatorenal recess, 11:104,116 Hindgut, embryology, 11:3, 6, 8, 9, 206
Hereditary hemorrhagic telangiectasia, 1:252 Hodgkin lymphomas, 11:272
Hernias Honeycomb cyst, 1:129
Bochdalek, 11:88 Honeycomb lung, 1:111
description, 11:40 Horseshoe kidneys, 11:446,478, 479
direct inguinal, 111:33 Humeral head, 1:468,470,475
femoral, 111:3, 34 Humerus, 1:11
hiatal, 11:68, 8 1 , 89, 158, 163, 166-169 Hutch diverticulum, 11:484
Hydatidform mole, III: 129
incisional, containing colon, 11:40, 62
indirect inguinal, 111:31, 32 Hydroceles, 111:31,131,138, 139,144-146,149, 150
infarcted o m e n t u m , 111:33 Hydronephrosis, 11:491,111:69
inguinal, 11:63, 111:3, 3 1 , 32, 33 Hydrosalpinx, 111:97, 112
lumbar, 11:66, 67 Hydrothorax, 1:59
Morgagni, 1:333, 11:68, 89 Hyparterial, definition, 1:203
obturator, 111:3, 35 Hypogastric vein, II: 132
paraesophageal, 11:171, 172 Hypo (laryngopharynx), 11:158
patulous diaphragmatic hiatus with, 11:166
perineal, 111:3
sciatic, 111:36 I
spigelian, 11:64-65 Idiopalhic pulmonary fibrosis (IPH), 1:128, 129
stomach, 11:90, 169,172 Heal arteries, 11:131, 2 0 7 , 2 1 4
umbilical, 11:21 Heal veins, 11:207, 214
ventral, 11:40, 61 Heal vessels, 11:252
Heroin addiction, 1:463 Ileocecal fold, IF:242
Herringbone mucosal pattern, 11:170 Ileocecal valve, 11:211, 218, 239, 247,259,265
Hesselbach triangle, 111:2, 17, 33 Ileococcygeus muscle, 111:45
Hiatal hernias, 11:68,81, 8 9 , 1 5 8 , 1 6 3 , 166-169 Ileocolic artery, 11:120,131, 207, 214, 215, 240, 241,
Hila, 1:11, 17,1:164-201,1:167,174-185, 188,189 242,250
abnormal position, 1:192 Ileocolic veins, 11:179,214, 215,250
anatomy, 1:164 Ileocolic vessels, 11:21,210
bilateral calcification, 1:193 Ileum, 11:206, 211, 229,247
calcification, 1:166 in acute appendicitis, 11:258
definition, 1:164 in C r o h n disease, 11:218, 219
density changes, 1:166 dilated, 111:223
enlargement, 1:166, 196-201 graphic, 11:209
function, 1:164 lymphoid nodules, 11:213
height changes in, 1:166 normal small intestine, 11:212
hilum convergence sign, 1:191 Iliac arteries, 11:37,124,248, 259
imaging, 1:164-165 Iliac bone, 111:4, 5, 6, 11, 19, 27, 37, 44
left, 1:169, 173, 187 Iliac crest, 11:47, 5 1 , 65, 66, 67, 403, 457, 111:4, 5, 9,
lymph nodes, 1:165-166 10, 2 4 , 2 5
mass, 1:166,198 Iliac nodes, 11:423
overlay sign, 1:166, 190 Iliacus muscle, 11:40, 4 1 , 48, 52, 54, 55,111:9, 11, 12,
right, 1:168, 172, 186, 187 19,20,21,27,28,46,77
thick intermediate stem line, 1:196 Iliac vein confluence (IVC), 11:47, 124
Hilar angle, 1:164, 172,251 Iliac vessels, 11:219
Hilar convergence signs, 1:191 Iliac wing, 11:53, 124
 INDEX
Iliococcygeus muscle, 111:3, 37,47 Inferior mesenteric nodes, 11:152
Iliofemoral ligament, 111:20, 26 Inferior mesenteric vein (IMV), 11:179,215,241,
Iliolumbar artery, 111:52, 54, 58, 61 254,309,373
Uiolumbar vein, 111:56 anatomy, 11:272
Iliopsoas compartment, 11:417 angiogram, 11:251
Iliopsoas complex, 111:12 portal vein variations, 11:331
Iliopsoas groove, 111:12, 80 posterior division of, 111:59
Iliopsoas muscle, 11:48, 49,111:9, 13, 14, 15, 16, 18, rectal blood flow, 11:244
19,20, 26, 27, 80 spleen and, 11:273
inflamed, 111:83 Inferior mesenteric vessels, 11:21,24,25, 251-256
insertion, 11:41 Inferior pancreaticoduodenal artery, 11:374
Iliopsoas tendon, 111:20 Inferior phrenic arteries, 11:118, 119, 178,185,
Iliopubic eminence, 111:4, 5, 6 326, 425
Iliotibial band, 111:14, 15 Inferior phrenic veins, 11:132
Ilium, 111:12, 13,44 Inferior phrenic vessels, 11:447
Imperforate anus, 11:3 Inferior polar renal artery, 11:464
Incisional hernias, 11:40 Inferior pubic ramus, 11:63, 111:16
Infants, 1:13, 319 Inferior pulmonary arteries, 1:168
Infections Inferior pulmonary ligaments, 1:169
acinar nodules and, 1:66 Inferior rectal artery, 11:240
bronchopneumonia, 1:80 Inferior rectal vein, 11:244
lymph node calcification, 1:250 Inferior segmental artery, 11:448, 462
osseus destruction in, 1:487 Inferior stemopericardial ligaments, 1:442
Infectious AIDS and disseminated M. avium Inferior vena cava (IVC), 11:309, 373,111:152,153
complex, 11:217 adrenal hemorrhage and, 11:442
Infectious bronchiolitis, 1:66 adrenal insufficiency and, 11:441
Inferior accessory fissure, 1:263,278 anatomy. 1:335, 346,445.11:118. 400
Inferior adrenal arteries, 11:119,424, 4 4 8 , 4 6 2 , 4 6 3 anomalies, 11:118
Inferior adrenal vessels, 11:447 axial view, 1:389,11:46. 79, 314, 379, 427. 450,
Inferior aortic recess, 1:453 111:57
Inferior bronchial artery, 1:354 azygos continuation of, 1:336, 371
Inferior epigastric artery, 11:48, 50, 51,111:52, 59, catheter in, 11:141,428
60,63 collateral flow, 11:335
Inferior epigastric vessels, 11:40,43, 48, 106, 107, coronal view, 1:347, 399,11:52, 77, 78,111:71
124,111:17 duplication and anomalies, 11:133, 136-136,
i n ascites, 11:25 138-139
in cirrhosis, 11:25 elderly person, 11:54
direct inguinal hernia and, 111:33 embryology, 11:15
indirect inguinal hernia and, 111:32 enlarged suprahepatic, 1:371
Inferior gemellus muscle, III: 1 5 , 2 5 , 2 6 , 2 7 , 2 8 filter, 11:466, 468
Inferior gluteal (sciatic) artery, 111:52, 62, 63, 64, 65, frontal view, 111:54, 56
66, 79 graphic. 1:338, 340, 356.111:85
Inferior gluteal vessels, 111:36 heart and, 1:379, 382
Inferior ischiopubic ramus, 111:156 hemiazygos continuation of, 1:372-373
Inferior lumbar triangle of Petit, 11:40 hepatic sulcus for, 11:300
Inferior mesenteric artery (IMA), 11:121,124, 240, hepatic veins and, 11:84
111:57, 58, 59 bepatic visceral surface, 11:299
anatomy, 11:485 hiatus, 11:159
angiogram, 11:251 imaging, 1:336
embryology of, 11:3, 8, 9, 10 interface, 1:342
frontal view. 11:119, 111:54 interrupted, 11:150-151
hepatic artery variations, 11:128-129 intrahepatic, 1:348, 351
horseshoe kidneys, 11:479 left-sided, 11:134, 135
lateral view, 111:63 in lymphoma, 11:154, 423
origin, 11:461 mediastinum and, 1:306
Inferior mesenteric ganglia, II: 156
 INDEX
normal anatomy, 1:307,393,11:122, 124, 215,
303,310,429
opening, 1:385,401,11:69
in ovarian vein thrombosis, 111:68
paraesophageal hernia and, 11:172
in perirenal bleed, 11:29
polysplenia and, 11:142-147
prenatal circulation, 11:16
with pseudothrombus, 11:471
in renal cell carcinoma, 11:469
retrocaval ureter and, 11:492
sagittal view. 1:349, 351, 393, 401.11:73
senescent changes, 11:386
supernumerary renal veins and, 11:465
in transitional cell carcinoma, 11:472
unfavorable for transplantation, 11:333
valve, 1:382, 385
Inferior vesicle artery, 11:485,111:52, 54
lnfrarenal retroperitoneal space, 11:30, 3 1 , 400, 403,
407,484
lnfrarenal spaces, 11:417
Infraspinatus muscle, 1:468,469, 4 7 0 , 4 7 1 , 4 7 3
Infundibulum, 11:453, 111:96
Inguinal canal, 111:2, 30, 31
Inguinal hernias, 11:63, 111:3, 3 1 , 32, 33
Inguinal ligament, 11:40, 4 1 , 42,111:2, 6, 9, 12, 17,
1 8 , 5 6 , 7 1 , 147
Inguinal lymph node, 111:18, 71, 73, 74-75
Innominate bones, pelvic, 111:2
Interatrial septum, 1:375, 376, 394
Intercostal arteries, 1:301, 339, 348, 354, 462, 465,
467,473
Intercostal arteriography, 1:4
Intercostal muscles, 1:462, 465, 467,468, 473
internal, 1:465, 467
Intercostal nerves, 1:262, 463, 465, 467
Intercostal neurovascular bundles, 1:467, 475
Intercostal region, 1:467
Intercostal stripe, 1:263, 269
Intercostal veins, 1:340, 341, 465, 467
left superior (aortic nipple), 1:335, 336, 352
posterior, 1:463,11:151
superior, 1:368, 369, 372, 440
superior left, 1:340
superior right, 1:340, 341, 345, 352
Intercostal vessels, 1:350
Intcrfascial planes, 11:400,402, 403, 408, 414, 416
Interior iliac artery, 111:52, 59
Intcrlobar fissures, 1:121
Interlobarsepta, 1:109, 122, 123
Interlobar vessels. See Pulmonary arteries;
Pulmonary veins
Interlobular septa, 1:91, 119,125,127
Intermediate stem line, 1:166,174,175, 190, 194
Internal cervical os, 111:110
Internal (deep) ring, 111:2
Internal hemorrhoidal plexus, 11:244
Internal iliac (hypogastric) arteries, 11:16, 48,
119-121,111:52-54,58-66, 120
Internal iliac (hypogastric) nodes, 11:152, 484,
111:53, 70, 72, 73, 74-75
Internal iliac (hypogastric) vein, 11:132, 244,111:52,
56,59,122
Internal iliac (hypogastric) vessels, 11:25, 124,111:71
Internal inguinal ring, 111:31, 32
Internal jugular veins, 11:118
Internal mammary artery, 1:339, 353, 465, 476
Internal mammary vein, 1:465
Internal m a m m a r y vessels, 1:34
Internal oblique muscles, 11:40,42, 45, 46, 5 1 , 64,
65, 66,111:2, 8-12, 17, 18, 25, 30, 134-135
Internal os, 111:96, 98, 108, 109
Internal pudendal artery, 111:52, 54, 60, 62, 63
Internal spermatic fascia, 111:130, 135
Internal thoracic (internal mammary) muscles,
1:462
Interpulmonary septum, 1:102
Interstitial edema, 1:111,122, 166
Interstitial fibrosis, 1:112, 223
Interstitial line sign, 111:111
Interstitial network, 1:110-129
Interstitial sheath, 1:113
Interutericfolds, 11:498
Interventricular groove, 1:432
Interventricular septum, 1:28, 376, 385, 387, 389,
396, 398,420,434
Interventricular sulcus, 1:400
Intestinal lymphatic trunks, 11:118
Intestinal villi, 11:206
Intrahepatic ducts, 11:346,368
Intraperitoneal fluid, 11:499
Intrasplenic cysts, 11:272
Intrasplenic pseudocyst, 11:286
Intrathoracic volume, 1:39
Intrinsic parasympathetic ganglia, II: 118
Ischemic colitis, 11:270
Ischial spine, 11:49, 486, 487,111:4, 5, 36, 37, 45
Ischial tuberosity, 111:4, 5, 23, 44, 45, 79
Ischiocavernosus muscles, 111:38,39, 154, 156, 157
Ischiopubic rami, 111:6, 156, 158
Ischiorectal fossa, 111:14, 15, 2 3 , 4 1 , 42, 43, 47
Ischium, 11:49,111:6, 16, 62, 157
lschorectal fossa, 111:3
Islet cell (neuroendocrine) tumor, 11:396
Islet cells, 11:370
Isthmus of parenchyma, 11:478
J
Jackson and Huber systematization, 1:228-229
Jejunal arterial arcade, 11:208
Jejunal arteries, 11:120, 131,207, 2 1 4 , 2 1 5 , 2 5 0
 INDEX
Jejuna! straight artery, 11:208
Jejuna! veins, 11:207,214, 215, 250
Jejuna! vessels, 11:154, 252
Jejunum
acute angulation, 11:220
in AIDS, 11:216
anatomy, 11:206, 208,239
inascites, 11:210
dilated, 11:228,229
duodenal compression and, 11:200
frontal view, 11:176
inflamed, 11:220
midgut malrotation, 11:231, 232
normal, 11:181, 211, 212, 221,247
Jugular veins, 1:302, 340, 470,11:118
Junctional zone, 111:106, 107
Juxta-intestinal nodes, 11:206
K in situ, 11:447
Kerley lines, 1:110-111, 121, 124
Kidneys, 11:72, 316, 403,404,11:446-483. Sec also
Renal entries
adrenal adenoma and, 11:434, 436
adrenal carcinoma and, 11:444
adrenal hemorrhage and, 11:442
adrenals and, 11:426, 4 2 7 , 4 2 9 , 4 3 0 , 431
anatomy, 11:403, 446
arteries, 11:448
ascent and rotation, 11:37, 38, 39
inascites, 11:21, 103
atrophic, 11:100-103, 150
in cirrhosis, 11:21,22
clinical implications, 11:446
congenital absence of, 11:446,475
cortico-medulary phase, 11:452
crossed fused ectopia, 11:446,477
cyst, 11:378,379
dcvascularized, 11:414
duplication of collecting system, 11:482
ectopic, 11:446, 476
embryology, 11:35, 37, 38, 446,111:113
excretory urograms, 11:453
fetal lobation, 11:446,481
frontal view, 11:449
gastric diverticula and, 11:203, 445
graphic, 11:481
hepatic impression, 11:299
high density cyst, 11:483
horseshoe kidney, 11:295
imaging, 11:446
interior anatomy, 11:448
intrasplenic pseudocyst and, 11:286
laceration, 11:411
left, 11:150, 274, 279
in lymphoma, 11:155
neonatal, 11:432, 433
normal, 11:121, 310, 454-455, 456
in ovarian vein thrombosis, 111:68
in pancreatic carcinoma, 11:394
partial duplication, 11:446
pelvic, 11:476
in pelvic congestion syndrome, 111:67
perforated gastric ulcer and, II: 194
perirenal planes, 11:460-461
perirenal spaces, 11:457
peritoneal spaces, 11:97
pheochromocytoma and, 11:439
polycystic, 11:339, 446, 483
in polysplenia syndrome, 11:297
pyelographic phase, 11:452
in renal cell carcinoma, 11:469, 470
renal fascia, 11:388, 457
right, 11:150, 176,215,248
simple cyst, 11:472
spleen and, 11:273, 275
splenic vein occlusion and, 11:285
staghorn calculi, 11:468
transitional cell carcinoma, 11:472-473, 473
transplant. 11:102
Krukenberg metastases, 11:116
Kyphoscoliosis, 1:481
L
Labioscrotal fold, 111:134
lacteals, 11:206
I angerhans cells, 11:370
large intestine. Sec Colon
I aryngeal nerves. 1:302, 322
I aryngotracheal groove, 1:38
Larynx, development of, 1:38
Lateral arcuate ligaments, 11:41, 68, 69
Lateral decubilus radiography, 1:3,16
1 ateral plane, anatomy, 11:118
Lateral pubovesical ligament, 111:43
Lateral sacral artery, 111:52, 54, 61
lateral umbilical folds, 11:17, 107
Lateral umbilical ligaments, 11:25, 43
lateroconal fascia, 11:388, 400, 401, 402, 404, 405,
407, 408, 457, 459,460
Lateroconal plane, 11:27, 400
1 atissimus dorsi muscle, 1:462,465, 469, 470, 471,
472, 473, 475,11:45, 66, 457
I avage fluid, 11:100
Left anterior descending artery (LAD), 1:422, 423,
427-433,436,439
Left bundle branch, 1:374
Left circumflex artery (LCX), 1:422, 423, 424, 427,
428-429, 431, 433,436,439
 INDEX
left common carotid artery, 1:334, 336-339, 347, bare area of, 11:98, 100
348,350,353,362-364 bile ducts, 11:301, 345
Left lateral radiography, 1:2, 7, 10, 11 caudate lobe, 11:93
Left main bronchus. See Bronchi, left main chronic splenic infarction and, 11:287
l.eiomyomas, 111:66 cirrhosis, 11:20, 22, 173,281, 336
I.eriche syndrome, 111:154 clinical implications, 11:298
Lesser o m e n t u m , 11:92,93,94,182 collateral flow through, 11:334-335
embryology, 11:2,9,10 congenital hypoplasia, 11:325
gallbladder and, 11:343 coronal view, 11:51, 72, 74, 248, 450
hepatic attachments and, 11:300 cortico-medulary phase, 11:452
peritoneal spaces and, 11:98 diaphragm and, 11:85
spleen and, 11:273 in diaphragm with slips, 11:83
Lesser sac (omental bursa), 11:93, 94, 272, in distended peritoneal cavity, II: 100
278-279,370 embryology, 11:2, 8 , 9 , 10, 14
in cirrhosis and ascites, 11:20, 22 in eventration of diaphragm, 11:87
development of, 11:19 frontal view, II: 175
embryology of, 11:2, 11, 18 hepatic carcinoma, 11:348
gastric ulcer perforated into, 11:194-195.195 hepatic cyst, 11:483
peritoneal cavity, 11:92,94, 104, 105 hepatic failure, 11:356
peritoneal spaces and, 11:96-97 hepatocellular carcinoma, 11:341
pseudocyst in, 11:390 imaging, 11:298
sagittal relations, 11:160 interrupted IVCand, 11:151
Lesser sciatic foramen, 111:2, 6 intrathoracic stomach and, 11:89
Lesser trochanter, 111:9 lobes, 11:300
Levator ani muscle, 11:239, 243, 244,111:3, 14,15, loculated ascites and, 11:108
23,29,39,179 metastases in, 1:359,11:298, 340
female anatomy, 11:498,111:42, 4 3 , 46, 47, 49 normal anatomy, 11:164, 182-183, 303-305,
male anatomy, 111:45, 48 310,456
in pelvic floor relaxation, 111:50, 51 normal vessels, 11:311, 372-313
posterior abdominal wall, 11:41 paraumbilical varices, 11:323-324
posterior pelvic wall, 111:9 peritoneal spaces and, 11:96-97, 99
post hysterectomy, 111:93 polycystic, 11:339
Levator ani sphincter, 111:38 in polysplenia syndrome, 11:296-297
Levator scapulae muscle, 1:462,470,473 portal venous system, 11:306
Leydig cells, 111:130 in pseudomyxoma peritonei, 11:116
Ligament of Treitz, II: 174 replaced hepatic arteries, 11:330
Ligamentum arteriosum, 1:315, 334 sagittal view, 11:73, 403, 451
Ligamentum teres, 11:2, 43, 322 segmental anatomy, 11:298, 302, 320-321
hepatic visceral surface, 11:299 steatosis, 11:74, 337, 338
post natal circulation, 11:17 unfavorable vessels for transplantation,
Ligamentum venosum, 11:2,17, 20, 70, 75, 165, 166, 11:332, 333
300,317,318 venous phase, 11:318
Light's criteria, 1:263-264 visceral surface, 11:299
Limbus fossa ovalis, 1:375 Lobar arteries, 1:118
Linea alba, 11:40, 42, 45, 46, 61,111:2, 8 , 1 1 , 12, 13 Lobar dysmorphism, 11:446
Linear (septal) opacities, 1:110 Lobar pneumonia, 1:154
Lingula, 1:140 Lobular bronchioles, 1:76
Lipomas, 1:463,488 Lobular low attenuation, 1:66
Lipomatosis, 1:298, 329 Localized fibrous tumors, 1:293
Liposarcomas, 11:400, 419 Loculation, imaging, 1:264
Liver, 11:268-269,11:298-341,11:457. See also Lordotic radiograph, anteroposterior, 1:23
Hepatic entries Lower esophageal sphincter, 11:158, 163
adrenal metastases, 11:440 Lower polar artery, 11:463
ascites, 11:20 Lower thoracic nerves, II: 118
attachments, 11:300 Lumbar arteries, 11:118, 121,126,111:57, 61, 64
axial view, 11:249, 278-279,314-316 Lumbar hernias, 11:40, 66, 67
 INDEX
Lumbar lymphatic trunks, 11:118 middle lobe consolidation, 1:159
Lumbar (para-aortic) nodes, 11:153, 154-155, neonatal, 1:39-40, 50
424,446 normal anatomy, 1:470
Lumbar (para-caval) nodes, 11:153 normal ventilation, 1:162, 163
Lumbar plexus, 11:118 overview, graphic, 1:132
Lumbar (retro-caval) nodes, 11:152 parenchyma, 1:38
Lumbar veins, 11:118, 132,134, 150 perfusion scans, 1:150,151, 162
Lumbar vertebrae. 11:73 pleura I anatomy, 1:265
Lumbosacral nerve trunk, 111:54 postnatal development, 1:40
Lung buds, 1:38,11:6 premature infant, 1:51
Lung cancer, 1:327, 359 primary adenocarcinoma, 1:37
Lung hila, description, 1:164 pseudoglandular stage, 1:38-39, 44, 45, 4 6 , 4 8 , 62
Lungs, 1:6, 29, 1:130-163 relaxation atelectasis, 1:285
abscess, 1:487 retrocardiac lower lobe, 1:7
air, radiographic density, 1:18 retrodiaphragmatic, 1:7
alveolar stage, 1:39, 47, 49 right, 1:144,145, 211-213
anatomy, 1:130 right lower lobe, 1:44
anteromedial basal defects, 1:162 right lower lobe defects, 1:163
aortic indentation, 1:137 right middle lobe, 1:25, 44
apical lesion, 1:23, 36 right posterior border, 1:133
apices, 1:16,133,134, 136,137 right upper lobe, 1:44
atelectasis, 1:25, 55, 123, 155, 156, 157, 223,226, saccular stage, 1:39, 47
285,418,479,11:81,84, 166 segmental airspace disease, 1:158, 159,160,161
azygos lobe, 1:152, 153 segmental anatomy, 1:131,144-149,202,210,
bases, 1:136,137 214-217
bronchial atresia, 1:63 surface anatomy, 1:133,134,135, 136,137
bronchogenic cysts, 1:61 terminology, 1:130
canalicular stage, 1:39, 46, 48 trachea and, 1:202
cardiac indentation, 1:136,137 tracheal atresia, 1:57
cardiac notch, 1:133 transesophageal fistulae, 1:56
coronal reconstruction, 1:31 traumatic injury, 1:55
costal surface, 1:133,134,136, 137 vascular structure, 1:88-109, 91
cross-section, 1:26,27, 34, 70 volume, 1:16
development of, 1:38-63 Lymphadenopathies
dyspnea, 1:30 axillary nodes, 1:492
embryology, 1:38, 41, 43, 44, 54, 58, 60 bilateral hilar enlargement, 1:198
extralobar sequestration, 1:59 chest wall, 1:492
honeycomb, 1:111 due to lymphoma, 11:154-155
hyperlucent parenchyma, 1:63 in lung cancer, 1:327
hypoplastic, 1:59,255 mediastinal enlargement and, 1:298, 328
imaging, 1:131-132 mctastatic, 1:166
immature, 1:52, 53 in non-Hodgkin lymphoma, 1:323-325
inferior borders, 1:133, 134 non-ncoplastic, 1:166
intercostal region, 1:467 paratracheal nodes, 1:492
left, 1:146, 147,214 porta hepatis, 11:157
left anterior border, 1:133 portocaval, 11:157
left lower lobe, 1:44 prevascular, 1:492
left lower lobe defects, 1:163 retroperitoneal, 11:423
left upper lobe, 1:44 Lymphangiograms, 11:153
lingular defects, 1:162 Lymphangitic carcinomatosis, 1:90, 109, 111-112,
lobar pneumonia, 1:154 124,125
lobes, 1:130-131, 138-143,274-275 Lymphatic duct, 1:463
mediastinal surface, 1:137 Lymphatic system
mediastinum and, 1:300 abdominal, 11:118-157
metastases in, 11:268-269 channels, 1:105,356,11:158
conduit, 1:88
 INDEX
course of, 1:90
csophagcal, 11:161
M
normal lymphangiogram, 11:153 Magnetic resonance imaging, 1:4
pelvic, 111:52-83 Main portal vein, 11:126, 214
Major duodenal papilla, 11:342
peribronchial, 1:104
Major (oblique) fissures, 1:221, 274-275
perilobular, visceral, 1:105
anatomy, 1:262-263
perivascular, visceral, 1:105
posterior abdominal wall, 11:118 cross-section, 1:142
pulmonary, 1:88-89, 104 imaging, 1:263
reservoir, 1:88 incomplete, 1:276
saculotubular, 1:88 intrapulmonary lymph nodes and, 1:249
small intestine, 11:177 left, 1:29, 157,270,271
stomach, 11:177 lobar atelectasis and, 1:156
lobar pneumonia, 1:154
suprapleural vessels, 1:105
l y m p h nodes normal, 1:119
pleural effusion and, 1:284
in acute appendicitis, 11:258
p n e u m o t h o r a x and, 1:280
aortopulmonary, 1:315
axillary, 1:35, 491 p s e u d o t u m o r a n d , 1:283
celiac, 11:118 right, 1:29, 266, 270, 271, 278
coronal view, 11:152 segmental airspace disease, 1:159
Major papilla of Vater, 11:176
in Crohn disease, 11:219
Mammary ducts, 1:465
enlarged, 11:193
Mammary glands, 1:465
granulomatous calcification, 1:250 Marfan syndrome, 1:361
hilar, 1:104,165-166, 314 Marginal arteries, 1:428,11:131, 240, 250, 251
internal mammary, 1:465, 491 Marginal veins, 1:438
intrapulmonary, 1:88, 104, 249 May-Thumer syndrome, 111:53, 57
mediastinal, 1:298, 313, 322,323-325 Meckel diverticulum, 11:2, 237
metastases in, 1:491,11:196-198,268-269 Median arcuate ligament arches, 11:41
paracardiac, 1:323-325 Median arcuate ligaments, 11:41, 52, 54, 68-70,
paratracheal, 1:315
pectoral, 1:491 77-79
Median raphe, 111:144-145, 146
peribronchial, 1:88
Mediastinal fat, 1:445, 448-450, 458, 459
pulmonary, 1:230, 250
Mediastinal pleural reflection, 1:168, 169
scapular, 1:491
Mediastinum, 1:296-333
splenic lymphomas, 11:283
subcarinal, 1:301, 312 anatomy, 1:296
anterior junction line, 1:308
sub-clavicular, 1:491
apical lordotic radiography, 1:17
supraclavicular, 1:463,491
l y m p h o i d follicles, 11:238 axial anatomy, 1:301, 312,111:146
Lymphoid nodules. See Peyer patches compartments, 1:296-297, 303
l.ymphomas coronal anatomy, 1:300
chest wall, 1:492 enlargement of, 1:298, 327, 328, 332, 333
Hodgkin, 11:272 expiratory radiograph, 1:15
inferior vena cava, 11:154, 423 graphic, 1:132
kidneys, 11:155 hypoplastic, 1:59
imaging, 1:297
lymphadenopathy in, 1:166,11:154-155
mediastinal T-cell, 1:190 left paratracheal stripes, 1:310
mesenteric nodes, 11:154-155 lines, 1:297
non-Hodgkin, 1:323-325,11:272,111:72-73 lipomatosis, 1:329
obturator nodes, 11:155 lymph nodes, 1:322-325
metastases in, 11:334
pelvic, 111:71, 74-75
portal veins in, 11:154, 423 nerves of, 1:302
portocaval, 11:423 normal anatomy, 1:306, 307, 313-317
overview, 1:299
retrocrural nodes, 11.154
retroperitoneal, 11:400, 423 paravertebral stripes, 1:311
splenic, 11:272, 283 posterior junction line/stripe, 1:309
 INDEX
primary thymic neoplasm, 1:330 Minor (horizontal) fissures, 1:272, 273
sagittal anatomy, 1:300 anatomy, 1:263, 268
spaces, 1:297 avascular zone, 1:272
stripes, 1:297 bronchiectasis, 1:222
structures, 1:296 coronal view, 1:274-275,279
supra-aortic, 1:336 cross-section, 1:142
Mediastinum teslis, 111:130-132,136, 144-145 displaced, 1:279
Medical devices, radiographic densities, 1:19 elevated, 1:155
Medulla, ovarian, 111:118 imaging, 1:263
Membranous urethra, 111:154, 165, 166, 172 incomplete, 1:266,279
Menarche uterus, 111:96 inspiratory, 1:31
Menstrural cycle, 111:96, 118 intrapulmonary lymph nodes and, 1:249
Mesenchyme, 1:43-48, 58, 60 lateral radiograph, 1:270
Mesenteric fat, inflamed, 11:406 left lateral chest radiograph, 1:140
Mesenteric nodes, 11:154-155, 206,216, 217, normal anatomy, 1:269
268-269, 283,423 segmental airspace disease, 1:158
Mesenteric root, 11:234 thick. 1:124
Mesenteric- veins, 11:225, 234, 235, 372 Mitral annulus, 1:376, 408, 419
Mesenteric vessels, 11:109,216,221 Mitral stenosis. 1:376
Mesenteries Mitral valve
adult with cirrhosis and ascites, 11:21, 2 3 , 24 anatomy, 1:376,404, 409
ascitesin, 11:103 anterior cusp, 1:409
colon and, 11:239 axial view, 1:389
dorsal, 11:2, 5, 8, 9, 10 fibrous ring of, 1:402
embryology, 11:19 four chamber view, 1:410
inflamed, 11:220 graphic, 1:387
outlined by ascites, 11:210,252-253 leaflets, 1:397, 398
peritoneal cavity, 11:92 posterior cusp, 1:409, 412, 413
peritoneal spaces and, 11:24-25,98-99 prosthetic, 1:403
tumor, 11:112 two chaml)er view, 1:410
Mesoappendix, 11:238,242,258 Mitral valve stenosis, 1:421
Mesocolon of the hindgut, 11:8 Moderator band, 1:375, 383, 385,413
Mesonephric duct, 11:33, 34 Monitoring devices, 1:13, 53
Mesonephric tubules, 11:32 Monitoring leads, 1:52
Mesonephric (Wolffian) ducts, 111:130 Mononucleosis, 11:290-291
Mesonephron, 11:3, 32, 33 Morgagni hernia, 1:333, 11:68, 89
Mesosalpinx, 111:84, 85, 8 6 , 1 1 8 , 1 1 9 Morrison pouch. See Posterior subhepatic
Mesothelial cells, 1:105 (hepatorenal) recess
Mesothelioma, 1:295 Mosaic attenuation/perfusion, 1:66
Mesothelium, 11:92 Mounier-Kuhn trachea (Iracheobronchomegaly),
Mesovarium, 111:118, 119 1:204
Metal, radiographic density, 1:18 Mucocele, 1:62. 63
Metallic stents, 11:199 Mucoid impaclion, 1:222, 223, 226
Metanephric duct (uteric bud), 11:3 Mullerian ducts, 11:3, 34,111.97,113
Metanephric tissue, 11:32, 37 Multifocal pneumonia, 1:20, 160
Metanephron, 11:34 Multiplanar imaging, 1:4
Metanephros, 111:113 Muscularis mucosa, 11:208
Metanonephric tissue, 11:33 Musculotendinous sling, 111:166
Middle lobe arteries, 1:183 MycabiKteriuni iivimn complex, 11:217
Midgut, embryology, 11:3, 4, 5, 7, 8, 206 \dycobacteriuni avlum intmcellulaie (MAI), 1:223
Midgut volvulus, 11:206, 234, 235 Myelomas, 1:463
Miliary infections, 1:90
Myenteric plexus of Auerbach, 11:118
Miliary tuberclosis, 1:107
Myocardium
Minor calix, 11:453
anatomy, 1:374
Minor duodenal papilla, 11:370
calcification, 1:376,417
left ventricular, 1:389, 404
segmentation, 1:422
 INDEX
thick, 1:420 Obturator internus ligament, 111:22, 26, 27, 28,
Myometrium, 111:96,97,98, 102, 106 41,42
Obturator internus muscle, 11:49, 498,111:3, 14, 15,
20, 2 1 , 22, 29, 35, 37, 44, 45, 46, 82, 176
N Obturator internus t e n d o n , 111:21,22,25,26, 28, 42
Nabothian cysts, 111:109 Obturator membrane, 111:6
Nasoenteric tube, 11:212 Obturator muscles, 111:41
Nasogastric tubes Obturator nerve, 111:41, 5 3 , 76, 82
chest, 1:55 Obturator neurovascular bundle, 111:42
coronal view, 11:54 Obturator nodes, 11:155,111:73
hiatal hernia and, 11:81 Obturator vessels, 111:41, 82
intrathoracic stomach and, 11:89 Obtuse marginal artery, 1:428
patulous diaphragmatic hiatus and, 11:166 Occygeus muscle, 111:45
in stomach, 11:90, 9 1 , 390 Oligohydramnios, 1:39
Nasopharynx, anatomy, 11:158 Omental"cake,"II:112
Neonates, 1:13, 50 Omental fat, 11:89
Nerves, abdominal, 11:118-157 Omental metastases, 11:114-115
Nerves, pelvic, 111:52-83 Omental tumor deposits, II: 113
Nerve sheath tumors, 11:400, 422 O m e n t u m , 11:92,95, 198,210. See also Greater
Neural tube, 11:5, 7 omentum; Lesser o m e n t u m
Neurofibromatosis, 1:485,11:424,111:83,92 Oral contraceptives, 111:106
Neurovascular bundles (NVBs), 111:170, 176, Orogastric tube tips, 1:13, 53
177,182 Oro (mesopharynx), anatomy, 11:158
Neurovascular plane, 11:118 Orthogonal radiographs, 1:21
Nipples, 1:463, 465 Ovarian arteries, 11:118, 485.111:54,96.98.118
Nodular opacities, 1:111 Ovarian carcinoma, 11:113
Non-coronary sinus, 1:411 Ovarian cysts, 111:109, 118
Non-Hodgkin lymphomas, 1:323-325,11:272, Ovarian fossa, 111:118
111:72-73 Ovarian ligaments, 111:84, 119, 120
Non-small cell lung cancer, 1:36 Ovarian veins, 11:132,111:53, 56, 67, 68, 69, 99, 118
Ovarian venous plexus, 111:99
Ovaries, 111:118-129
o in ascites, 111:121
Obdurator canal, 111:6 axial view, 111:90,91, 121
Obdurator foramen, 111:4, 5 broad ligaments and, 111:88
Oblique abdominal muscles. See also External calcification, 111:124
oblique muscles; Internal oblique muscles clinical implications, 111:118
aponeuroses, 111:13 coronal view, 111:41, 47, 121
axial view, 11:66 developing follicles, III: 119
coronal view, 11:50, 54, 55 echogenic foci, 111:124
graphic, 11:43 ectopic pregnancy, 111:111
Oblique fissure graphic, 111:86
right, 1:27 hemorrhagic cyst, 111:126,127
Oblique sinus, 1:442-445,454-455 herniated, 111:36
Oblique vein of left atrium, 1:438 hydatidiform mole, 111:129
Obliterated umbilical arteries, 111:8 imaging, 111:118
Obliterated urachus, 111:8 medulla, 111:118
Obturator artery, 111:52, 54, 6 1 , 63, 64 mestastases in, II: 116
Obturator canal, 111:6, 15, 28, 37 normal anatomy, 111:122, 123, 125
Obturator externus ligament, 111:25, 27 physiology, 111:118
Obturator externus muscle, 111:15, 20, 2 1 , 35, 43, 44, polycystic ovarian syndrome, 111:128
46,176 theca Iutein cysts, III: 129
Obturator fascia, 111:41 unicornuate uterus and, 111:114
Obturator foramen, 111:2 Ovulation, 111:118
Obturator hernias, 111:3, 35
 INDEX
Pacer leads, 1:19
Pampiniform plexus, 111:131, 132, 144-146, 149,151
Pancreas, 11:370-399
accessory spleen and, 11:293
in acute cholecystitis, 11:353
acute pancreatitis, 11:26, 388-389
acute splenic infarction and, 11:291
adrenal adenoma and, 11:434
adrenal hemorrhage and, 11:443
adrenals and, 11:426, 431
after splenectomy, 11:292
anatomy, 11:370,371, 372-373, 380-381
arterial phase, 11:382
arteries, 11:376,377
in ascites, 11:22
axial view, 11:71, 122, 123, 183, 187,231,254,
274, 279, 304,305,316,379, 450
bile duct stones and, 11:359
in cirrhosis, 11:22
clinical implications, 11:370
development of, 11:19
distended peritoneal cavity, 11:100-103
duodenal diverticula and, 11:205
embryology, 11:2, 7, 8, 9, 10, 11, 38
fatty infiltration, 11:386-387
gallbladder and, 11:343
gallstones and, 11:351
gastric diverticula and, 11:203
graphic, 11:241
hepatic arterial phase, 11:318
imaging, 11:370
inflamed, 11:407
intrasplenic pseudocyst and, 11:286
islet cell (neuroendocrine) tumor, 11:396
lateral view, 11:93
in pancreatic cancer, 11:157
perforated duodenal ulcer and, II: 190, 191
perforated gastric ulcer and, II: 194
perirenal planes, 11:460
peritoneal cavity, 11:105
peritoneal spaces and, 11:96-97, 99
retroperitoneal divisions and, 11:402
retroperitoneal planes and, 11:401
sagittal view, 11:451
senescent change, 11:386
spleen and, 11:276,277
unicate process, 11:73
veins, 11:378-379
venous phase, 11:383
vessels, 11:374, 375
Pancreatic arteries, 11:385
Pancreatic carcinoma, 11:157,284-285, 392, 393,
394-395
Pancreatic divisum, 11:370, 398
3
Pancreatic duct O.
in ampullary carcinoma, 11:362 ft
X
anatomy, 11:347
arterial phase, 11:382
bile ducts and, 11:384
in biliary hamartoma, 11:366
choledochal cysts and, 11:368
dilated, 11:361, 363
ductal stones, 11:355
frontal view, 11:176
gallbladder and, 11:343
obstruction, 11:370
in pancreatic carcinoma, 11:393
stones. 11:360
variations in, 11:397
Pancreatic ductal carcinoma, 11:370
Pancreatic duct (of Wirsung), 11:370, 398, 399
Pancreatic head carcinoma, 11:364-365
Pancreatic islet cell tumors, 11:370
Pancreaticoduodenal arcade, 11:370
Pancreaticoduodenal arteries, 11:126,184,185, 371,
374, 375,377,385
Pancreaticoduodenal nodes, 11:177
Pancreaticosplenic nodes, 11:177
Pancreatitis, 11:390-391, 400, 406, 407, 408-409
Pancreatoduodenal artery, 11:174, 342
Pancrcatoduodenal veins, 11:179
Panlobular emphysema, 1:66,82
Pannus, 11:40, 60
Panumbilical venous collateral, 11:20
Paperclip o n perineum, 111:51
Papillary muscles, 1:390, 392, 396,397,398,400,
404.408,410,411,413
anterior, 1:375, 383, 387, 406
posterior, 1:375, 387, 406
septal, 1:375, 406
Para-aortic interface, 1:336, 342, 343, 360, 361, 366,
368,414
Para-aortic lymph nodes, 111:74-75,153
Paracardiac lymph nodes, 1:323-325
Paracolic gutters
in acute pancreatitis, 11:27, 28
ascites in, 11:389, 409
in cirrhosis and ascites, 11:21, 24
distended paretoneal cavity and, 11:102
fluid in, 11:102, 414
left, 11:94, 95
peritoneal reflections, 11:18
right, 11:24, 102
urine in, 11:499
Paracolic recess, 11:21
Paraesophageal hernia (PEHj, 11:171,172
Paragangliomas, 11:400, 424
Parametrial vessels, 111:107
Parametrium, 111:84,97
Paraortic lymph nodes, 111:70, 72
xxv
 INDEX
Pararectal space, 111:84,86 nerves, 111:52-83
Pararenal hemorrhage, 11:410 ovaries, 111:118-129
Pararenal spaces, 11:3.27, 400, 4 0 2 , 4 0 3 . pelvic floor, 111:2-51
405-409, 416 pelvic spaces, female, 111:64-95
Paraseptal emphysema, 1:66 pelvic wall, 111:2-51
Parasympathetic innervation, 11:118 penis, 111:154-169
Paratracheal nodes, 1:323, 324, 452,11:161 prostate, 111:170-187
Paratracheal stripes, 1:203, 310 scrotum, 111:130-153
Paraumbilical collateral veins, 11:85,173 seminal vesicles. 111: 170-187
Paraumbilical varices, 11:294,323-324 testcs, 111:130-153
Paravertebral space, 1:297 urethra, 111:154-169
Paravertebral stripes, 1:311 uterus, 111:96-117
Paravesicle space, 111:84,86,92 vessels, 111:52-83
Parenchyma, 1:85 Penile bulb, 111:3, 154, 155,156, 157
Parenchymal interstitium, 1:113,114 Penile urethra, 11:498, 502,111:154, 165,166, 168
Parietal pericardium, 1:459 Penis, 111:154-169
Parietal peritoneum, 11:7, 18, 40, 43, 400,111:8 clinical implications, III: 154
Parietal pleura, 1:266.267,286.467 cross-section, 111:159
Partial anomalous pulmonary venous return, 1:254 deep fascia of, 111:39
Patient positioning embryology, 11:35
apical lordotic chest radiography, 1:17 graphic, 111:155-156
chest radiographs, 1:2, 8-12 normal erectile function, 111:160, 161, 162
supine, 1:12 perineum and, 111:157
Pectineus muscle, 1:382,111:15,16, 19,35, 4 2 , 4 3 root of, 111:158
Pectoralis major muscle, 1:468-472,477 urethra and, 111:164-165
anatomy, 1:462 Peribronchial cuffing, 1:111,121
cross-sectional anatomy, 1:465 Peribronchial nodules, 1:108
Pectoralis minor muscle, 1:462, 465, 468-472, Pericardial cavity, 1:443
474,477 Pericardial cysts, 1:443,457
Pectoral muscles, 1:462,477 Pericardial effusion, 1:122,443,453,458, 459
Pectus carinatum, 1:463, 480 Pericardial fluid, 1:442, 450
Pectusexcavatum, 1:463, 478, 479 Pericardial recesses, 1:445, 452-455
Pelvic arch, 111:2 Pericardial reflections, 1:442, 4 4 5 , 4 5 4 , 4 5 5
Pelvic brim, 11:486 Pericardial space, 1:442, 445
Pelvic congestion syndrome, 111:67 Pericardial vessels, 1:442
Pelvic diaphragm, 111:2, 3 Pericardiophrenic ligaments, 1:442,445
Pelvic extraperitoneum, 11:3 Pericardium. 1:28, 33,1:442-461
Pelvic fascia, 11:498 anatomy, 1:442,445-447
Pelvic floor calcification, 1:460, 461
anatomy, 111:2 congenital absence of, 1:443, 456
female anatomy, 111:38, 4 1 , 42, 43, 46, 49 constricti ve, 1:461
male anatomy, 111:39, 44-45, 48 innervation, 1:442
muscle laxity, 111:3 mediastinum and, 1:299, 300
pelvic wall and, 111:2-51 normal anatomy, 1:448, 449, 450-451
relaxation of, 111:3, 50, 51 overview, 1:444
Pelvic inlet, 111:2 sagittal view, 1:35
Pelvic kidney, 11:476 superior as|>ect, 1:35
Pelvic outlet, 111:2 thickening, 1:443, 460
Pelvic recess, 11:102 Pericolonic fluid, 11:261
Pelvic splanchnic nerve, 11:118 Peridiaphragmatic fluid collections, 11:68
Pelvic wall, 111:2-51, 3 , 8 , 9, 24-29 Perigastric varices. 11:284-285, 391,394
Pelvis. Sec also specific structures Perigastric vessels, 11:284-285
axial view, 111:10-16 Perihylar haze, 1:111
coronal view, 111:17-23 Perilymphatic nodules, 1:108, 109
ligaments, female, 111:74-95 Pcrineal body, 111:38, 39, 156,157
lymphatics, 111:52-83 Perineal hernia, 111:3
 INDEX
3
Perineal membranes, 111:38, 39 Peritoneal reflections O.
Perineum, 11:34,111:3, 38, 39, 156, 157 anatomy, 11:345 n
x
Peripancreatic fat, 11:406 in cirrhosis a n d ascites, 11:20-23
Peripheral interstitium, 1:113,114, 115, 125 frontal view, 11:95
Peripherally inserted central catheter (PICC), 1:53 gallbladder and, 11:343
Perirectal space, 111:92 lateral view, 11:243
Perirenal bridging septa, 11:400, 404, 405, 410, 460 in paracolic gutters, 11:18
Perirenal fascia, 11:28, 29,30, 193 peritoneal spaces and, 11:96-97
Perirenal fat, 11:456 Peritoneal spaces, 11:2, 3 , 2 0 - 2 5 , 96-99
Perirenal planes, 11:460-461 Peritoneum
Perirenal septa, 11:29, 30, 411, 414, 458, 461 anatomy, 11:92
Perirenal spaces, 11:424 enhancing rim, 11:109
in acute pancreatitis, 11:27, 28 female anatomy, 11:498
anatomy, 11:400 frontal view, 111:30
axial view, 11:405 graphic, 11:457
blood in, 11:414 metastases in, 11:112
coronal reformation, 11:403 scrotal development and, 111:134-135
embryology of, 11:3 thickened, 11:92, 109, 110
graphic, 11:457 t u m o r implant, 11:116
hemorrhage into, 11:411, 414, 416 Peritonitis, bacterial, 11:109
kidneys and, 11:446 Peritonitis, fibrosing, 11:110,111
in pancreatitis, 11:407 Periurethral glands, 111:170
in a perirenal bleed, 11:29, 30 Perivascular lymphatics, 1:104
renal fascia and, 11:458-459 Perivascular nodules, 1:108
sagittal view, 11:403 Perivesical fat, 11:25
ureter in, 11:484 Perivesical space, 11:58-59, 413, 418, 484, 498
urine in, 11:414 Peyer patches, 11:206, 213
Peritoneal cavity, 11:92-117 Peyronie disease, 111:154, 163
bacterial peritonitis, 11:109 Pharynx, 11:6, 169
carcinoma, 11:114-115 Pheochromocytoma, 11:424, 438, 439
clinical implications, 11:92 Phrenic ampulla, 11:158,163
cross-sectional anatomy, 11:94 Phrenic nerves, 1:262, 296, 302,11:86, 342
definition, 11:92 1'hrenicocolic ligament, 11:92,95
distended, 11:100-103 Phrenicoesophageal ligament, 11:158, 161
fibrosing peritonitis, 11:110, 111 Pigeon breast. See Pectus carinatum
frontal view, 11:95 Piriformis muscle
gastric carcinoma, 11:116 axial view, 11:48
gross anatomy, 11:92 coronal view, III: 78
imaging issues, 11:92 female anatomy, 111:41, 47
lateral view, 11:93 frontal view, 111:77
lesser sac (omental bursa), 11:94, 104 male anatomy, 111:45
loculated ascites in, 11:108 normal anatomy, 111:13, 23, 27, 28, 37
malignant ascites, 11:112 posterior abdominal wall, 11:41
mesenteries, 11:19 posterior pelvic wall, 111:9
nodular omental metastases, 11:113 sagittal view, 111:80
peritoneal recesses, 11:104 Piriformis syndrome, 111:53
peritoneal spaces, 11:98-99 Piriformis tendon, 111:21, 22, 25
pseudomyxoma peritonei, 11:116 Placenta, 11:16
right subphrenic space, 11:100 Pleura, 1:262-295
terminology, 11:92 anatomy, 1:2, 262, 265-268
umbilical folds (ligaments), 11:106, 107 calcification, 1:264, 290, 291
Peritoneal dialysis, 11:100-103, 110, 111 costal, 1:266, 267
Peritoneal fluid. See Ascites cross-section, 1:26
Peritoneal implants, 111:95 diaphragmatic, 1:266, 267
Peritoneal recesses, 11:3, 94,104 fissures, 1:268
function, 1:2

XXVII
 INDEX
incomplete fissures, 1:276 multifocal, 1:20, 160
intercostal region, 1:467 recurrent, 1:223
interlobar fissures, 1:262-263 thymic enlargement in, 1:320
irregular interface, 1:129 Pneumopericardium, 1:453
masses, 1:292,294 Pneumothorax, 1:264,280,281
mediastinal, 1:266 Poland syndrome, 1:463, 477
metastatic disease, 1:294 Polar arteries, 11:463
overview, 1:5 Polycystic disease, 11:446
parietal, 1:262, 266,267, 286 Polycystic kidney disease, 11:483
reflections, 1:262 Polycystic liver, 11:339, 342
standard fissures, 1:274-275 Polycystic ovarian syndrome (PCOS), 111:118,128
surface of, 1:116 Polyps, colonic, 11:263
thickening, 1:192, 264, 290, 295 Polysplenia syndrome, 11:142-147,272, 296-297
visceral, 1:22, 105, 262, 266, 267, 286 Pores of Kohn, 1:65, 76
Pleural disease, 1:22 Porta hepatis, 11:299, 337, 357
Pleural effusion, 1:123 Porta hepatis nodes, 11:154, 157, 364
acute splenic infarction and, 11:290 Portal sinus, 11:2, 15, 16
axial view, 1:284 Portal triad, 11:298
bilateral, 1:371,418, 421, 453 Portal veins, 11:214, 308, 309, 372,373, 380-381
bronchopleural fistula and, 1:286 alcoholic cirrhosis, 11:173
chronic heart failure and, 1:119 anatomy, 11:92, 272, 298, 342, 370, 372
collateral flow t h r o u g h liver and, 11:334 angiogram, 11:280
coronal view, 1:284,11:56 arterial phase, 11:317, 318, 382
diaphragm and, 11:84-85 axial view, 11:315, 322,323, 378
frontal view, 1:121, 282, 284 catheter angiography, 11:374
hiatal hernia and, 11:81 celiac angiogram, 11:186
imaging of, 1:263-264 confluence with splenic vein, 11:105
incomplete fissures and, 1:276 coronal view, 11:229, 322
lateral view, 1:282 embryology, 11:15
loculated, 1:281,285,287 frontal view, 11:179
lung development and, 1:39 gas in, 11:225
in mesothelioma, 1:295 hepatic congenital hypoplasia, 11:325
patulous diaphragmatic hiatus and, 11:166 hepatic vein variation a n d , 11:148
in pectus excavatum, 1:479 in hepatocellular carcinoma, 11:341
peridiaphragmatic, 11:68 left, 11:122, 165
peritoneal spaces and, 11:98 in lymphoma, 11:154, 423
right, 1:412 normal, 11:123, 126, 1 8 2 , 2 1 5 , 3 0 3 , 3 0 4 , 3 1 0 , 3 1 1
segmental airspace disease, 1:160 in pancreatic cancer, 11:157,392,394
transient tachypnea of newborn, 1:52 perforated gastric ulcer and, 11:194
ultrasound, 1:4 peritoneal spaces and, 11:96, 98
Pleural fluid, function, 1:2 in polysplenia syndrome, 11:143
Pleural lymphatics, 1:105 prenatal circulation, 11:16
Pleural plaques, 1:264, 288, 289, 295 segmental anatomy, 11:321
Pleural reflections, 1:266 splenic vein occlusion and, 11:284-285
Pleural space, 1:16,262 unfavorable for transplantation, 11:332, 333
Plicae circulares, 11:206 variations, 11:185,331
Plicae palmatae, 111:96, 97, 108 venous phase, 11:318, 383
Pneumoconiosis, 1:166, 193 Portal venous system, 11:2, 179, 306
Pneumocytes Portocaval lymphadenopathy, 11:157,423
type 1, 1:78 Positron-emission tomography, 1:4
type 2,1:38,40, 78 Postcaval recess, 1:445, 455
Pneumomediastinum, 1:298, 326 Posterior cul-de-sac
Pneumonia withascites, 111:89,91
b r o n c h o p n e u m o n i a , 1:80 blood in, 111:95
left lower lobe, 1:161 broad ligaments and, 111:88
lobar, 1:154 female anatomy, 111:84
free fluid in, 111:109
 INDEX
graphic, 111:85 lateral view, 11:243
lateral view, 111:87 with obstructive symptoms. III: 177
spaces, 111:95 posterior view, 111:173
Posterior descending artery (PDA), 1:422,424, 429, seminal vesicles and, 111:170-187
430,434 transurethral resection of, 111:184
Posterior inferior pancreaticoduodenal artery, 11:185 zonal anatomy, 111:170, 174-175
Posterior intervcntricular sulcus, 1:374-375,377, Prostatic sinus, 111:170, 172
379,396 Prostatic urethera, 111:154,165, 166,168, 170, 172
Posterior junction line/stripe, 1:309, 313 Prostatic utricle, 111:170
Posterior papillary muscle, 1:375, 387, 406 Prostatic vesicle plexus, 11:484
Posterior pararenal space, 11:27 Pseudocysts, 11:390-391
Posterior parietal peritoneum, 11:3 Pseudodiaphragm, 1:199
Posterior perirenal fascia, 11:30 Pseudomyxoma peritonei, 11:116
Posterior ribs, 1:11 Pseudonodule, 1:484
Posterior sacroiliac ligament, 111:10 Pseudotumor, 1:264,283
Posterior scalene muscle, 1:474 Psoas compartment, 11:416
Posterior segmental artery, 1:229,11:448, 462 Psoas fascia, 11:461
Posterior spinous process, 1:465,473 Psoas (major) muscle, 11:40, 4 1 , 457,111:9, 10
Posterior subhepatic (hepatorenal) recess, Psoas (minor) muscle, 11:41,111:9, 10
11:104, 116 Psoas muscles, 11:262,111:80
Posterior subphrenie space, 11:20 in acute appendicitis, 11:258
Posterior vagal trunk, 11:156,206 anatomy, 11:118,485
Posterior vaginal fornix, 111:94 axial view, 11:45, 46, 48, 416, 450
Posterior vein of left ventricle, 1:439 coronal view, 11:52, 54, 55, 56, 72, 2 5 9 , 4 5 0
Posteroanterior radiographs, 1:2 cortico-medullary phase, 11:452
Posterolateral artery (PI.A), 1:422, 424, 434 frontal view, 111:77
Posterolateral plane, 11:118 graphic, 11:69
Postmenopausal uterus, 111:96 normal, 11:124,111:11, 12, 19, 20, 27, 28
Pouch of Douglas. See Rectouterine recess retrocaval ureter and, 11:493
Premenarche uterus, 111:96 Pubic arch, 111:4, 5
Prepuce, 111:155 Pubic bone, 111:18, 2 1 , 2 9
Presacral space, 11:3, 418, 501, 503,111:86, 92 female anatomy, 111:5, 6, 42, 43, 49
Pretracheal fascia, 1:442 male anatomy, 111:4, 48
Pretracheal space, 1:297,312,329 Pubic rami, 11:63, [11:4, 5, 20, 35
Prevascular space, 1:297, 312,313,314, 329 Pubic symphysis, 111:106
Prevesical space (of Retzius), 11:3, 400, 412-413, 417, Pubic tubercle, 111:6
418, 484, 502, 503,111:48, 84, 86, 87 Pubis, anatomy, 11:40
Primary gut loop, 11:9 Pubococcygeal line, 111:49,50
Primary pulmonary lobules, 1:65 Pubococcygeus muscle, 111:3, 4 1 , 44
Processus vaginalis, 111:130, 134 Puborectalis muscle, 111:3, 41, 43, 46
Profunda femoris artery, 111:61, 62, 63, 64, 65 Pudendal canal, 111:53
Pronephron, embryology of, 11:3 I'udendal nerve, 111:53, 76
Proper hepatic artery, II: 126, 308, 326, 343, 348 Pudendal nerve block, 111:53
Properitoneal fat, 11:405 Pulmonary angiography, 1:4
Proper ovarian ligament, 111:84, 86, 118, 119, 121 Pulmonary arterial hypertension, 1:166, 199,
Prostate carcinoma, 111:171, 185,186 230,257
Prostate gland, 111:170-187, 111:178 Pulmonary arteries, 1:436
anatomy, 111:29,44,48,172-173,176,179 anatomy, 1:228, 234
benign prostatic hypertrophy, 111:180-183 anterior view, 1:423
calcifications, 111:178, 181 arteriogram, 1:235
congenital anomalies, 111:187 ascending right, 1:172
coronal STIR image, 111:158 basilar segmental, 1:237
coronal view, 11:498 bronchogenic cyst and, 1:331
graphic, 111:133 catheter in, 1:238
gross anatomy, 111:170 computed tomography, 1:28,92,95
imaging, 111:171 cross-sectional anatomy, 1:27,97
 INDEX
CTangiography, 1:94, 100, 315 Pulmonary ligament
enlarged, 1:191,200, 257,259 right, 1:168
in eventration of diaphragm, 11:87 Pulmonary ligament arteries, 1:88
function, 1:88 Pulmonary ligaments, 1:167, 262, 322
heart and, 1:377 Pulmonary lymphatics, 1:88, 90, 104, 230, 335
imaging, 1:229-230 Pulmonary nodules, 1:90
inferior, 1:168 Pulmonary recess, 1:445
interlobar, 1:6, 95, 172, 215, 216,228-230, 253, Pulmonary reflections, 1:167
11:448,454,462 Pulmonary stenosis, 1:166
left, 1:33, 167,173-177, 182, 184, 185,187-191, Pulmonary thromboembolic disease, 1:163, 230,
195, 196, 199, 201,203,232-235,240,242, 258,259
246,313,317 Pulmonary trunk, 1:230,437
left apical, 1:241 3D volume-rendered CT, 1:430
left descending, 1:231,235 in absence of pericardium, 1:456
left interlobar, 1:169, 180, 181,185, 188, 190, anatomy, 1:169,228, 318,445
195, 198,232, 234,241,246, 247 axial view, 1:301
left lower lobe, 1:229,237, 246, 247, 248 computed tomography, 1:95
left main, 1:32,34 coronal view, 1:317, 390, 399
left upper lobe, 1:229, 2 4 7 , 2 4 8 cross-sectional anatomy, 1:34
lobular, 1:90,91, 103 CT angiography, 1:32
middle lobe, 1:234,244,245 | diameter, 1:166
nomenclature, 1:228-229 enlarged, 1:191,199, 201,257
normal interstitium, 1:115 graphic, 1:231,234
photomicrograph, 1:96 I large, 1:191
right, 1:167, 168, 1 7 7 , 1 8 2 , 1 8 3 , 1 8 6 , 1 8 8 , 191, lateral view, 1:232,307
195, 197,198,199, 201,202, 235,236, 240, left d o m i n a n t coronary circulation, 1:432
242,253,316,317,451 mediastinal lymph nodes and, 1:322
right ascending, 1:183, 188, 1 8 9 , 2 3 1 , 2 3 4 , 2 3 5 , mediastinum and, 1:299,300, 306
236,240,243 normal, 1:232, 236, 240, 316
right basal segmental lower lobe, 1:180 origin, 1:89
right descending, 1:189, 231, 234, 235, 236. overview, 1:5
240,241 pericardial effusion and, 1:459
right inferior, 1:168 pericardial recesses and, 1:454
right interlobar, 1:178, 1 7 9 , 1 8 0 , 1 8 1 , 1 8 3 , 184, pericardium and, 1:444, 449, 450
185, 189, 190. 1 9 1 . 2 3 2 , 2 3 3 , 2 3 7 , 2 3 9 , 2 4 1 , in pulmonary thromboembolic disease, 1:258
244,253 radiography of, 1:229
right lower lobe, 1:229, 244, 245 right d o m i n a n t coronary circulation, 1:431
right middle lobe, 1:229 sagittal reconstruction, 1:32
right segmental, 1:243-245 sagittal view, 1:242, 307, 392
right upper lobe, 1:243 variable appearance, 1:233
sagittal relations, 11:160 Pulmonary varix, 1:256
in scimitar syndrome, 1:255 Pulmonary vasculature, 1:33, 88. See also Pulmonary
structure, 1:88,91,93 arteries; Pulmonary lymphatics; Pulmonary
Pulmonary artery hypertension, 1:191 veins
Pulmonary AV malformations and, 1:252 Pulmonary vein recess, 1:455
Pulmonary edema, 1:119, 121 Pulmonary veins, 1:101
Pulmonary emboli, 1:258, 260, 261, 455 anatomy, 1:228,234
Pulmonary hypoplasia, 1:230 central, 1:230
Pulmonary interstitium computed tomography, 1:28,92
anatomy, 1:110 course of, 1:90
chest radiography, 1:110-111 cross-sectional anatomy, 1:97
components, 1:110 CT angiography, 1:94, 100, 439
embryology, 1:110 embryology, 1:228
fiber network, 1:110 heart and, 1:379
imaging, 1:110 imaging of, 1:89, 229-230
normal, 1:115,116, 117, 119
 INDEX
inferior, 1:33, 101, 168,169,172,173, 180, 181, fascia for, 11:44
184, 185, 186, 187, 189, 219, 228,389, 391 graphic, 11:69, 457
interlobular, 1:102 normal anatomy, 111:10
left, 1:101,167, 169, 188, 231,242, 392, 400, 445 perirenal planes, 11:460
left inferior, 1:169, 180,181, 185,187, 189,234, posterior abdominal wall, 11:41
236,237,238,241 posterior pelvic wall, 111:9
left lower lobe, 1:229 sagittal view, 11:451
left superior, 1:169, 173, 176-179, 182, 183, 184,
185,187, 188, 189,197,232,233,236, 238,
240, 241, 246, 395,397, 399 R
left upper lobe, 1:229, 247 Radial arteries, 111:98
middle lobe, 1:238, 239, 245 Radial veins, 111:99
nomenclature, 1:228-229 Radiographic densities, 1:3, 18-19
normal anatomy, 1:238 Radiographic projections, 1:2
partial anomalous return, 1:254 Radionucleotide imaging, 1:4
primitive c o m m o n , 1:228 Ramus intennedius, 1:422
right, 1:32, 101, 167,195 Random nodules, 1:106,107
right inferior, 1:101,168,180,181, 184, 186, 234, Rectal arteries, 11:240,244, 463,111:52, 54
237,239,241 Rectal b a l l o o n , 11:267
right interlobar, 1:184, 185,239 Rectal carcinoma, 11:238, 268-269,111:53
right lower lobe, 1:229,239 Rectal fascia, 11:243
right superior, 1:168, 172, 177, 178, 182, 183, 186, Rectal folds, 11:238
188, 232, 233,234,236-240, 243, 244, Rectal (hemorrhoidal) veins, 11:179
388-389,391,395,399 Rectal plexus, 111:53
right upper lobe, 1:229 Rectal valves, 11:239,246
sagittal relations, 11:160 Recta) wall, 111:176
segmental, 1:221 Rectocele, 111:3, 50
structure, 1:88,93 Rectorenal plane, 11:29
superior, 1:228, 369 Rectosigmoid colon, 11:23
variants, 1:239 Rectosigmoid j u n c t i o n , 11:243, 253
vascular structure, 1:91 Rectouterine pouch, 111:84
Pulmonary vein varix, 1:230 Rectouterinc recess, 11:104. 243, 484,111:84
Pulmonary venous hypertension, 1:230,251 Rectovaginal space, 111:84, 8 6 , 9 3
Pulmonary vessels Rectovesical pouch, 11:418, 484
central, 1:236-237,240-241,242 Rectovesical space, 11:25, 418
coronal reconstruction, 1:32 Rectovesicular septum, 111:176
cross-section, 1:26,27 Rectum
intrapulmonary lymph nodes, 1:249 anatomy, 111:179
normal, 1:116, 117,232-233 axial view, 11:63, 104, 1 1 6 , 2 6 7 , 4 1 3 , 4 1 8 ,
overview, 1:231 111:94, 157
peripheral, 1:232 barium enema, 11:260
rctrodiaphragmatic, 1:9 (See also Pulmonary in bladder cancer, 11:508
arteries; Pulmonary veins) bladder rupture and, 11:503
Pulmonic recesses, 1:452,454,455 broad ligaments and, 111:88
Pulmonic stenosis, 1:200,201 caudal view, 11:261
Pulmonic valve, 1:375-376, 383, 392,402, 406, 407 in cirrhosis and ascites, 11:25
Purkinje fibers, 1:374 collapsed, 11:264
Pyloric sphincter, 11:175 in congenital absence of kidneys, 11:475
Pylorus. 11:175.176, 181, 190 in Crohn disease, 11:219
development of, 11:34
distended peritoneal cavity and, 11:102
Q embryology, 11:10,111:113
Quadratus femoris muscle, 111:16, 22, 45, 79 female anatomy, 111:41, 46, 47, 49
Quadratus lumborum muscle in gastric carcinoma and ascites, 111:95
anatomy, 11:40 gross anatomy, 11:238
axial view, 11:45, 46, 4 7 , 66, 450 inferior view, 111:40
coronal view, 11:53, 57 lateral view, 11:243, 111:87
 INDEX
lumen, 11:268-269 Renal cysts, 11:187, 378, 379, 446
male anatomy, 111:45, 48 Renal fascia, 11:400, 403, 414, 416,424, 457,
normal, 11:124,111:23, 29, 37 458-459,461
in pelvic floor relaxation, 111:50, 51 in pancreatitis, 11:406-409
posterior abdominal wall, 11:41 perirenal bridging septa and, 11:410
posterior pelvic wall, 111:9 retroperitoneal divisions and, 11:402
rectus hemorrhage into perivesical space, 11:59 Renal fascia (of Gerota), 11:446
ruptured bladder and, 11:502 Renal ganglia, 11:446
sagittal view, 11:501,111:106 Renal hilum, 11:446, 452
uterosacral ligament and, 111:91 Renal medulla, 11:446, 452, 454
valves, 11:244 Renal papillae, 11:446,448, 4 5 2 , 4 5 3
veins, 11:244 Renal pelvis
Rectus abdominis muscles anatomy, 11:446
anatomy, 11:40 dilated, 11:494,495
anterior pelvic wall, 111:2 excretory urogram, 11:453
axial view, 11:45, 47, 49 horseshoe kidneys, 11:478
coronal view, 11:50 hypertrophied column of Bertin, 11:480
direct inguinal hernia and, 111:33 normal, 11:454-455, 456, 486
frontal view, 111:8, 30 pyelographic phase, 11:452
incarcerated ventral hernia and, 11:61 in situ, 11:447
incisional hernia containing colon, 11:62 in transitional cell carcinoma, 11:472
internal view, 111:8 axial CT, 11:472
normal, 111:10-15, 17,29 in ureteral cancer, 11:496
Rectus femoris muscles, 111:14, 15,16,18, 19,24, Renal pyramids, 11:448, 4 4 9 , 4 5 1 , 4 5 2 , 456,480
25,26 Renal sinus, 11:456
Rectus muscles, 11:40,42, 43, 46, 58-59, 64, 107,451 Renal sinus fat, 11:454, 480
Rectus sheath, 11:40, 42, 412,111:2, 8, 30 Renal veins
Recurrent laryngeal nerves, 1:322 axial view, 11:377,450, 459
Red pulp, splenic, 11:272 catheter in, 11:141,428
Reid classification, 1:204 circumaortic variation, 11:140, 141, 466
Renal agenesis, 11:3 coronal view, 11:52,132
Renal arteries crossed fused ectopia, 11:477
aberrant, 11:495 left, 11:71, 118, 135, 136, 138, 254,111:56
anatomy, 11:448 normal, 11:120,454
axial view, 11:450 in ovarian vein thrombosis, 111:68
coronal view, 11:52 in pelvic congestion syndrome, 111:67
crossed fused ectopia, 11:477 in pelvic kidney, 11:476
embryology, 11:38 perirenal planes, 11:460
hepatic arteries and, 11:127 in polysplenia syndrome, 11:143, 147
hepatic artery variations, 11:128-129 preaortic, 11:141, 465
horseshoe kidneys, 11:478,479 in renal cell carcinoma, 11:469,470
left, 11:119, 188 retroaortic, II: 141,465, 466
left replaced, 11:128-129 right, 11:52, 118, 136
multiple, 11:464 senescent change in pancreas, 11:386
normal, 11:121,123, 215, 454 in situ, 11:447
in renal cell carcinoma, 11:469 SMA compromise, 11:467
right, 11:128 supernumerary, 11:465
UP) obstruction and, 11:495 variants, 11:465
ureteric branch, 11:485 venous phase, 11:383
variants, 11:463 Respiratory bronchioles, 1:64, 65, 67, 76, 77
Renal calculi, 11:140, 446 Respiratory distress syndrome, 1:40,53
Renal capsule, 11:447 Respiratory diverticuli, 1:38
Renal carcinoma, 11:446 Retetestes, 111:130, 132, 148, 149
Renal cell carcinoma, 1:489,11:469, 470-471 Reticular opacities, 1:111,128,129
Renal colic, 11:446 Reticulonodular opacities, 1:126
Renal cortex, 11:446, 448, 452, 454, 456,480 Retroaortic renal vein, 11:465
 INDEX
Retrobronchial line, 1:175
Retrocardiac lesions, 1:37
Retrocaval ureter, 11:492-493
Retrocrural nodes, 11:154
Retrocrural space, 1:297
Retromesenteric plane, II:4CX)
Retroperitoneal fibrosis, 11:400, 420-421
Retroperitoneal hemorrhage, 11:400
Retroperitoneal (lumbar) nodes, 11:283, 423
Retroperitoneal spaces, 11:26-28, 150
Retroperitoneum, 11:400-423
anatomy, 11:400, 403
clinical implications, 11:400
divisions of, 11:402
embryology of, 11:3
hemorrhage across midline, 11:414-415
liposarcoma, 11:419
lymphoma, 11:423
normal fascial planes, 11:404-405
pancreatitis, 11:405
planes of, 11:401
relationships, 11:400
sagittal view, 11:403
terminology, 11:400
Retropubic extravasation, 111:168
Retropubic venous plexus, 111:167
Retrorenal interfascial plane, 11:29
Retrorenal plane, 11:27, 400
Retrotracheal lymph nodes, 1:323
Retrovaginal fascia, 111:49
Retrovesical recess, 11:501
Retrovesical septum, 111:172
Retrovesical space, 11:243,500
Rheumatic heart disease, 1:376
Rhomboid muscles, 1:462, 465, 468, 469, 470,
471.475
Ribs
1st, 1:17, 23,468, 476, 482
2nd, 1:468
6th, 1:15
8th, 1:15,493
9th, 1:15
10th, 1:15, 11:51
11th, 11:53
12th, 11:449
anatomy, 1:462
articulation, 1:476
cervical, 1:482
costal groove anatomy, 1:462
false, 1:462, 464
fibrous dysplasia, 1:488
floating, 1:462
fractures, 1:482
intercostal region, 1:467
metastatic disease, 1:489
orthogonal radiographs, 1:21
osseus destruction, 1:489
posterior, 1:11
true, 1:462, 464
Right atrioventricular valve. See'l ricuspid valve
Right bundle branch, 1:374
Right coronary artery (RCA), 1:427, 4 3 1 , 4 3 4 , 4 3 7
3D volume-rendered CT, 1:430, 437
anatomy, 1:422
anomalies, 1:435
catheter angiography, 1:429
1R MR image, 1:436
left d o m i n a n t coronary circulation, 1:432
Right sympathetic trunk, 11:156
Rokitansky-Aschoff sinus, 11:345
Root of mesentery, 11:12, 9 2 , 9 5
Round ligament of uterus, 11:298, 111:41, 56, 84, 85,
90,100
Rouviere anatomic classification, 1:298
s
Saber sheath trachea, 1:204, 224
Saccular bronchiectasis, 1:204
Sacral arteries, middle, 11:119, 121,111:54, 58, 62,
64,65
Sacral nerves, 111:80
Sacral plexus, 111:53, 76
Sacral veins, 11:132,111:56
Sacral venous plexus, 111:67
Sacrococcgeal ligament, 111:9, 41
Sacroiliac joints, 111:4, 5, 6, 2 1 , 22, 23, 28, 45
Sacrospinus ligament, 111:6, 14, 36
Sacrotuberous ligament, 111:2, 6
Sacrum
axial view, 11:48, 124
barium enema, 11:246
coronal view, 11:53
female anatomy, 111:5, 6, 41
frontal view, 111:62
lateral view, 11:243
male anatomy, 111:4, 48
sagittal view, 11:501,111:28,29
Sarcoidosis, 1:90, 108, 111,112, 126, 127, 166
Sartorius muscle, 111:13-16, 25-27
Scalene muscles, 1:229,470, 474
Scapulae
anatomy, 1:462
anterior borders, 1:11
axial view, 1:470, 471
cross-sectional anatomy, 1:465
left, 1:9, 12, 14, 17
right, 1:9, 12, 17
Scapular spine, 1:468
Scaipa fascia, 11:45, 46
Schatzki ring, 11:168
Sciatic hernias, 111:36
 INDEX
x ^ — —
-O Sciatic nerves, 111:15, 2 1 , 2 6 , 2 8 , 53, 76, 78, 79, 80 Serratus posterior muscles, 1:462
£ Sciatic notch, 111:2, 6 Sertoli cells, 111:130
Scimitar syndrome, 1:230, 255 Short gastric vessels, 11:2,185, 272,274, 370
Scoliosis, 1:171 Shoulder girdle, 1:462
Scrotal calculi, 111:131,139 Sickle cell disease, 11:287
Scrotal sac, 111:147 Sigmoid arteries, 11:240,251
Scrotal swelling, 11:35 Sigmoid colon
Scrotum, 111:16,111:130-153, 111:169 in ascites, 11:23, 103
Secondary pulmonary lobules, 1:65-66, 67, 76,105 axial view, 11:253,255, 257,260, 267
109,114 barium enema, 11:245, 246, 260
Secuni, 11:258 in cirrhosis, 11:23, 24, 25
Segmental airspace disease, 1:158,159, 160, 161 collapsed, 11:264
Segmental arteries colon carcinoma and. 11:267
inferior, 11:448, 462 coronal view, 111:18
posterior, 1:229,11:448, 462 dilated. 11:264
right apical, 1:177 female anatomy, 111:46, 47, 49
superior, 11:448, 462 frontal view, 11:264
Semilunar folds, 11:238, 239, 245,246, 263 gross anatomy, 11:238
Semilunar valves, 1:405 lumen, 11:268-269
Seminal vesicles, 111:170-187 rectus hemorrhage into perivesical space, 11:59
anatomy, 111:44, 45, 172, 179 Sigmoid mesocolon, 11:12, 23, 24, 95, 103, 106, 239,
benign prostatic hypertrophy, 111:180 243,253
in bladder cancer, 11:508, 509 Sigmoid veins, II: 179, 251,255
in congenital absence of kidneys, 11:475 Sigmoid volvulus, 11:264
congenital anomalies, 111:187 Signet ring sign, 1:204
embryology, 11:35 Silhouette sign, 1:3, 20, 24, 25, 131-132
graphic, 111:133 Silicosis, 1:166,193
gross anatomy, 111:171 Sinoatrial (SA) node, 1:374
imaging, 111:171 Sinuses of Valsalva, 1:411
oblique sagittal view, 111:178 Sinus node artery, 1:423, 429
posterior view, 111:173 Sinus venosus, 11:14
in prostate carcinoma, 111:186 Situs ambiguous (polysplenia), 1:336, 372-373
prostate gland and, 111:170-187 Situs inversus, 1:415
sagittal midlineview, 111:164 Skin
sagittal view, 11:107 abdominal wall, 11:504
small ureterocele and, 11:487 chest, 1:463,467,468
Seminiferous tubules, 111:130, 132 cross-sectional anatomy, 1:465
Seminoma, 111:147,153 scrotal development and, 111:135
Sensory innervation, 11:118 Small bowel. See also Small intestine
Septae, testicular, 111:132 air-fluid levels, 11:228
Scptal nodules, 1:108 ascites in mesenteries, 11:103
Septal papillary muscle, 1:375, 406 axial view, 11:236
Septal thickening, 1:109,111 in bacterial peritonitis, 11:109
Septal veins, 1:89, 90, 103, 118 bladder rupture and, 11:499
Scptomarginal trabecula. See Moderator band coronal view, 111:17
Septum of Bertin, [1:446 dilated, 11:236, 389, 409
Seromuci nous glands, 1:69 female anatomy, 111:47, 49
Serosa, jejunal, 11:208 gas in. 11:225, 234
Serous parietal pericardium, 1:442,445 ischemia, 11:206, 224,111:223
Serous pericardium, 1:442 loop. 111:32
Serous visceral pericardium, 1:445 male anatomy, 111:48
Serratus anterior muscles, 1:462 mesentery, 11:210,252
axial view, 1:468, 470, 471 nodular omental metastases and, II: 113
coronal view, 1:472, 474, 475 obstruction, 11:206,111:35
displaced, 1:488 root of, 11:95
intercostal region, 1:467

xxxiv
 INDEX
3
Small bowel mesentery, 11:3,24, 93, 94,99, 102, 176, Spinal canal, 1:34 CL
239,371 Spinal cord, 1:470,475 *
Small cardiac vein, 1:438 Spinal fusion rods, 11:265, 266
Small cell carcinoma, 1:166 Spine, ischial, 11:49
Small intestine, 11:206-237,11:262. See also Small Spinous process, 1:9, 465, 473,11:53
bowel Spiral arteries, 111:98
in acute pancreatitis, 11:26 Splanchnic mesoderm, 11:5
in ascites, 11:21 Splanchnic nerves, 11:206
axial view, 11:60, 253, 255 Spleen, 11:272-297
barium study, 11:211 accessory spleen and, 11:293
bladder rupture and, 11:501 acute infarction, 11:290-291
in cirrhosis, 11:21, 23 in acute pancreatitis, 11:26
clinical implications, 11:206 adrenals and, 11:431
congenital duplication cyst, 11:236 AIDS and disseminated M. avhan complex,
Crohn disease, 11:218-220 11:217
dilated, 11:63 anatomy, 11:272,371
embryology of, 11:2,11, 12, 206 in ascites, 11:20, 108
enteroclysis study, 11:212 axial view, 11:164, 182-183, 274,276,378, 458
in fibrosing peritonitis, 11:110 in bacterial peritonitis, 11:109
in gastric carcinoma, II: 116 in bladder rupture, 11:499
gross anatomy, 11:206 calcified, 11:287
ileum, 11:209 capsule, 11:290
imaging issues, 11:206 chronic infarction, 11:287
incarcerated ventral hernia, 11:61 in cirrhosis, 11:20, 173, 336
infarction, 11:225,226-227 coronal view, 11:52, 54, 56, 72, 74, 248, 275,
ischemia, 11:222-223 396,450
jejunum, 11:208 cortico-medulary phase, 11:452
lymphatics of, 11:177 cyst, 11:288-289
malrotation, 11:230,231,232-233 in distended peritoneal cavity, II: 100
Meckel diverticuium, 11:237 elevated hemidiaphram and, 11:86
mesentery of, 11:19 embryology, 11:2,8,9,10, 272
midgut volvulus with infarction, 11:234, 235 enlarged, 11:323
obstruction of, 11:228, 229 focal lesion, 11:283
peritoneal spaces and, 11:99 gastric diverticula and, 11:202
venous thrombosis, 11:226-227 gastric impression, 11:273
vessels, 11:207 heterogenous enhancement, 11:281
Smoke inhalation injury, 1:84 histology, 11:272
Smooth muscle, structure, 1:69, 96 infarction, 11:272, 288-289, 295
Smooth pressure erosion of bone, 1:463, 485 intrasplenic pseudocyst, 11:286
Soft tissues laceration, 11:282, 411
imaging, 1:35 ligaments, 11:278-279
masses, 1:190 liver steatosis and, 11:337
radiographic density, 1:18 in lymphoma, II: 154-155, 283
Somatic mesoderm, 11:5 in pancreatic carcinoma, 11:394
Spermatic cord, 111:152 in pancreatitis, 11:408
abnormal, 111:152 paraesophageal hernia and, 11:172
anatomy, 111:130-131 perforated gastric ulcer and, 11:194
axial view, 111:15 perisplenic hematoma, 11:282
coronal view, 111:144, 147 peritoneal cavity, 11:105
frontal view, 111:8 peritoneal spaces and, 11:96
graphic, 111:133 in polysplenia syndrome, 11:143, 146, 147,
indirect inguinal hernia and, 111:32 296-297
variocele, 111:150 prominent medial lobulation, 11:273
Sphincter of Boyden, 11:342 in pseudomyxoma peritonei, 11:116
Sphincter of Oddi, 11:342 relations, 11:273
Spigelian hernias, 11:40, 64-65 renal CT, 11:381 •
renal impression, 11:273 '
XXXV
 INDEX
"O right-sided, 1:373 cross-sectional anatomy, 11:94
£ in ruptured diaphragm, 11:91 embryology of, 11:2, 3
sagittal view, 11:451 perforated gastric ulcer a n d , II: 194
traumatic injury, 11:282 peritoneal cavity, 11:105
vessels, 11:278-279, 280 spleen and, 11:273
wandering, 11:295 Splenosis, 11:272
Splenic artery, 11:308 Split pleura sign, 1:287
anatomy, 11:370 Squamocolumnar junction, 111:96
angiogram, 11:126, 186, 188, 280, 328, Squamous cell carcinoma, 1:166
375, 385 Squamous epithelium, 11:92
arterial phase, 11:382 Staghorn calculi, 11:468
axial view, 11:122,187, 279,315, 376 Steatosis, 11:337,338
celiac artery variation, 11:130 Sternal angle, 1:462, 464
completely replaced hepatic artery, 11:329 Sternal notch, 1:464
distended peritoneal cavity, 11:100-103 Sternal wires, 1:417
frontal view, 11:178 Sternochondral joints, 1:463
hepatic artery variations, 11:127, 128-129, 326 Sternoclavicular joints, 1:463, 464, 472, 476
multiplanar CT, 11:372 Sternocleidomastoid muscle, 1:468,470, 474
in pancreatic carcinoma, 11:395 Sternocostal hiatus, 11:68
in pancreatitis, 11:390 Sternohyoid muscle, 1:468,474
Sternotnyroid muscle, 1:468
peritoneal cavity, 11:105
Sternotomy wires, 1:403
replaced hepatic arteries, 11:330
Sternum
spleen and, 11:273,277
Splenic flexure, 11:232,245,270,274, 276, 292 anatomy, 1:318, 462
Splenic nodes, 11:177, 370 axial view, 1:301, 470,471
Splenic-portal confluence, 11:305, 378, 388, 393 cortex, 1:27
Splenic veins, 11:309, 381 cross-sectional anatomy, 1:465
accessory spleen and, 11:293 left lateral view, 1:7
adrenal insufficiency and, 11:441 manubrium of, 1:464, 466, 476
adrenals and, 11:426, 431 marrow, 1:27
anatomy, 11:174, 370 mediastinum and, 1:300
angiogram, 11:186, 215,280, 374 pectus carinatum, 1:480
arterial phase, 11:382 pectus excavatum, 1:478,479
axial view, 11:71, 122, 123, 2 7 4 , 3 7 8 , 4 2 7 , 429 Stomach
confluence, 11:254 acute splenic infarction in, 11:290
confluences, 11:105, 251,372 adrenals and, 11:431
frontal view, 11:179 after splenectomy, 11:292
graphic, 11:207,241 air, radiographic density, 1:18
multiplaner view, 11:311 anatomy, 11:174, 347, 371
obstruction, 11:370 antrum, 11:174
occlusion, 11:284-285 arteries of, 11:178
in pancreatic carcinoma, 11:392 in ascites, 11:20
pancreatitis and, 11:391 axial view, 11:164, 182-183, 274, 278-279, 304,
perforated duodenal ulcer and, 11:190 305,378, 450
peritoneal cavity, II: 105 barium study, 11:180, 181,211
portal vein variations, 11:331 barium upper GI series, 11:171
senescent change in pancreas, 11:386 body, 11:174
spleen and, 11:273,277 cardia, 11:174
venous phase, 11:383 chronic splenic infarction and, 11:287
Splenius muscle, 1:462 in cirrhosis, 11:20, 22, 294
Splenomegaly, 11:217, 272 constricted by tumor, 11:196, 198
Splenorenal ligament coronal view, 11:51, 54, 72, 164, 165, 396, 450
anatomy, 11:92, 370 in diaphragm with slips, 11:82
in ascites, 11:22 duodenal compression and, 11:200
axial view, 11:278-279 duodenal diverticula and, 11:205
in cirrhosis, 11:22 elevated hemidiaphram and, 11:86
I
xxxvi
 INDEX
embryology, 11:6, 8,9, 11 Subcutaneous fat
frontal view, 11:175 abdominal, 11:46, 50
fundus, 11:75,174 chest, 1:467, 468
gallstones and, 11:351 cross-sectional anatomy, 1:27, 34,465
in gastric carcinoma, 11:116, 196-198 intercostal region, 1:467
gastric diverticula, 11:202, 445 Subcutaneous tissues, 1:463,11:504
hepatic impression, 11:299 Subendometrial halo, 111:97, 102
herniated, 11:90, 167, 169,172 Subepicardial fat, 1:445, 448, 449, 450, 458, 459
hiatal hernia and, 11:81 Subperitoneal space, 11:3
intrasplenic pseudocyst and, 11:286 Subphrenic space, 11:100
intrathoracic, 11:89,91 Subpleural nodules, 1:108,127
lateral view, 11:93 Subscapularis muscles, 1:465, 468, 469, 470,471,
lymphatics of, 11:177 473,475
metallic stent in, II: 199 Superficial dorsal veins, 111:159
mucosa, 11:174 Superficial femoral arteries, 111:61,62,63, 64, 65
mural anatomy, 11:174 Superficial inguinal lymph nodes, 111:70
with NG tube, 11:390,391 Superficial inguinal ring, 111:8, 30, 133
nodular omental metastases and, 11:113 Superficial thoracolumbar fascia, 111:10
paraesophageal hernia and, 11:172 Superficial transverse perineal muscle, 111:38,
in patient with AIDS, 11:216 39,40
patulous diaphragmatic hiatus and, 11:166 Superior accessory fissure, 1:263, 268, 279
perforated duodenal ulcer and, II: 193 Superior aortic recess, 1:315,452, 454
perforated gastric ulcer, II: 194-195 Superior bronchial artery, 1:354
peritoneal cavity, II: 105 Superior epigastric vessels, 11:40
peritoneal spaces and, 11:96, 98 Superior gemelius muscle, 111:22,26,27
in polysplenia syndrome, 11:296-297 Superior gluteal arteries, 111:52, 54, 60-66, 100
pylorus, 11:376 Superior hypogastric plexus, II: 156
renal CT, 11:380 Superior inguinal nodes, 111:52
sagittal relations, 11:160 Superior intercostal veins
sagittal view, 11:451 double SVC and, 1:440
spleen and, 11:273,276 enlarged. 1:372
splenic infarction and, 11:288-289 hypoplastic right SVC and, 1:369
upper GI series, 11:196 left, 1:340
venous phase, 11:383 persistent left SVC and, 1:368, 369
Stratum basalis, 111:102 right, 1:340, 341, 345, 352
Stratum functionalis, 111:96 Superior niesenteric artery (SMA), 11:308, 3 7 2 , 3 7 3
Subcarinal space, 1:297,312, 314,316, 317 after AAA repair, 111:201
Subclavian arteries AIDS and disseminated M. avium complex,
axial view, 1:468, 470 11:217
coronal view, 1:472 anatomy, 11:206, 371, 373, 485
interface, 1:342,343 angiogram, 11:120, 126, 188, 215, 250, 328
left, 1:316,334-339,344. 347, 348, 350, 353, aortogram, 11:121
362-365,367 arterial branches, 11:131
right, 1:336, 353, 364, 365 arterial phase, 11:382
right, aberrant, 1:364 axial view, 11:71, 123, 124, 2 2 6 - 2 2 7 , 2 3 1 , 254,
superior view, 1:466 376, 377, 379,111:57
Subclavian catheter, fractured, 1:260 branches of, 111:57
Subclavian lymphatic trunk, 1:356 celiac artery variation, 11:130
Subclavian veins compromised, 11:467
axial view, 1:470 coronal view, 11:51, 164
coronal view, 1:472, 474 ductal stones and, 11:355
left, 1:340,11:118 duodenal compression and, 11:200
right, 1:339, 340 embryology, 11:3, 8, 9, 10
Subclavius muscle, 1:474 frontal view, 11:119, 176,111:54
Subcostal arteries, 11:118 gallbladder and, 11:343
Subcostal muscles, 1:462 graphic, 11:207, 240,242
 INDEX
hepatic artery variations, 11:127, 128-129, 326
jejunal branches, 11:121,126
lateral view, 11:93
in ovarian vein thrombosis, 111:68
in pancreatic cancer, 11:365
in pelvic congestion syndrome, 111:67
perforated duodenal ulcer and, 11:193
renal artery variants, 11:464
renal CT, 11:381
replaced hepatic arteries and, 11:330
sagittal view, 11:73, 77, 78,80, 188
in situ, 11:447
stenosis of, 11:222-223, 224
stent placement, 11:224
Superior mesenteric artery syndrome, 11:200
Superior mesenteric ganglion, II: 156
Superior mesenteric nodes, 11:152,177, 370
Superior mesenteric plexus, 11:156,370
Superior mesenteric vein (SMV), 11:309
AIDS and disseminated M. avium complex,
11:217
anatomy, 11:174, 206, 241,272
angiogram, 11:126,214, 215,250, 280
arterial phase, 11:382
axial view, 11:71, 123, 124, 226, 231, 254, 379,
450
coronal view, 11:306
ductal stones and, 11:355
duodenal diverticula and, 11:205
frontal view, II: 176, 179
gallbladder and, 11:343
narrowed, 11:393
in pancreatic carcinoma, 11:394
portal vein variations, 11:331
renal CT, 11:380-381
senescent change in pancreas, 11:386
splenic vein occlusion and, 11:285
venous phase, 11:383
Superior mesenteric vessels. See also Superior
mesenteric artery (SMA); Superior mesenteric
vein (SMV)
adult with acute pancreatitis, 11:26
angiogram, 11:214,215,250
in ascites, 11:210
in lymphoma, 11:154
in pancreatic cancer, 11:157, 392
perforated duodenal ulcer and, 11:191
peritoneal spaces and, 11:99
Superior pancreatic artery, 11:371, 385
Superior pancreaticoduodenal artery, 11:184, 371,
374, 375, 385
Superior pericardial reflection, 1:33
Superior pubic ramus, 11:63,111:4, 5, 20, 35
Superior pyloric nodes, 11:177
Superior rectal (hemorrhidal) artery, 11:240,251
Superior rectal (hemorrhidal) vein, 11:179, 244, 251
Superior segmental artery, 11:448, 462
Superior sternopericardial ligaments, 1:442
Superior vena cava (SVC), 1:153, 436
anatomy, 1:335,337, 338, 340, 341,345,
346,356,422,445
anterior view, 1:423
axial view, 1:301,313,384
bronchogenic cyst and, 1:331
catheter in, 1:370
coronal view, 1:32, 317, 347, 390, 391
cross-sectional anatomy, 1:34
double, 1:440
graphic, 1:168
heart and, 1:377, 379, 382
imaging, 1:335
interface, 1:342, 343
left, persistent, 1:336
medial lung surface, 1:135
mediastinum and, 1:299, 300, 306
orifice of, 1:382,384
pericardium and, 1:444
persistent left, 1:372-373
persistent left, absent right, 1:369
persistent left, hypoplastic right, 1:369
persistent left, normal right, 1:368
polysplenia syndrome, 11:144
right, 1:440
right aortic arch and, 1:366
sagittal view, 1:349, 351,393, 401
Superior vesicle arteries, 11:16, 484, 485,111:52,
54,65
Superior vesicle veins, 111:56
Supernumery foregut buds, 1:40
Supraclavicular region, 1:466
Suprapubic catheter, 111:168
Supraspinatus muscle, 1:468, 473, 475
Supraspinous ligament, 11:44
Suprasternal (jugular) notch, 1:462
Supravesical space, 11:498
Surface-rendered techniques, 1:4
Surfactants, 1:39
Surgical clips, 1:437,11:325,111:201
Suspensory ligament of ovary, 111:84, 85, 86,
118,119,120,121
Suspensory ligament of penis, 111:154
Suture lines, 11:199
Sympathetic ganglia, 1:301,11:156
Sympathetic innervation, II: 118
Sympathetic trunk, 1:301,11:158
Symphysis pubis, 11:59, 60, 107, 501,111:4, 5, 6,
19,176
Synchondrosis, 1:482
Systemic vessels, 1:334-373,1:337-341,
341-349, 353, 354, 356. See also specific
vessels
 INDEX
T Thymus
anatomy, 1:297-298, 301, 312, 318
T3 spinous process, 1:9
axial view, 1:313, 321
Taeniae coli, 11:238,239,243
enlargement of, 1:320
T-cell lymphoma, 1:190
imaging, 1:298
Tendinous inscription, 11:42, 50
measurement of, 1:320
Tensor fasciae latae muscle, 111:14, 1 5 , 1 6 , 1 8 ,
mediastinum and, 1:299, 300
19,24
pediatric, 1:319
Teres major muscle. 1:465,468,469
primary neoplasm, 1:330
Teres minor muscle, 1:469
Thyroid carcinoma, 1:106
Terminal bronchioles, 1:38, 64, 65, 67, 76, 77,91
Thyroid gland, 1:202, 224, 332
Terminal ileum, 11:218,219,247
Tight cell junctions, 1:78
Terminal saccules, 1:39
Tip of coccyx, 111:5, 38, 39
Testes, 111:130-153
Tooth, aspirated, 1:55
appendix testis, 111:138 Torsion, anatomy, 111:131
axial view, 111:146 Trabeculae, penile, 111:155
bilateral cryptorchidism, 111:147
Trabeculae carneae, 1:375,383, 387, 389, 390, 396
clinical implications, 111:131
Trachea, 1:153
coronal view, 111:144-145
aberrant right subclavian artery and, 1:364,
descent, 111:130
365
embryology, 111:130
anatomy, 1:202
epididymus and, 111:137
aortic enlargement and, 1:360
frontal view, 111:8
axial view, 1:209, 313
gross anatomy, 111:130-131, 132
cartilage calcification, 1:74, 75
imaging, 111:131
cervical deviation, 1:332
increased flow, 111:142
coronal view, 1:317
lymphatic drainage, 111:152, 153
cross-section, 1:70
scrotum and, 111:130-153
development of, 1:38
torsion, 111:143
embryonic stage, 1:42
ultrasound, 111:136, 140-141, 150
during expiration, 1:73
variocele and, 111:151
extrathoracic, 1:224
Testicular arteries, 11:118, 463,111:130. 132
frontal view, 1:45, 208,11:159
Testicular carcinoma, 111:53, 131
imaging-anatomic correlations, 1:65
Testicular veins, 111:131, 151
Thalassemia major, 1:486 during inspiration, 1:72
Theca lutein cysts, 111:118, 129 lateral view, 1:7, 174, 175
Thick intermediate stem line, 1:196 mass effect on, 1:331
Thoracic aorta, 1:334, 337, 350 mediastinum and, 1:300
Thoracic cardiovascular system, 1:5 microscopic structure, 1:69
Thoracic duct, 1:335, 356-359, 463,11:118, 152, narrowing of, 1:204, 224, 227
pericardium and, 1:451
161
posterior wall, 1:174
Thoracic inlet, 1:300, 463, 466
Thoracic kyphosis, 1:481 relationships. 1:202
Thoracic lymphatics, 1:356 right lung and, 1:211
Thoracic nerves, II: 118 segmental bronchi and, 1:215
Thoracic outlet, 1:463 structure, 1:64
Thoracic splanchnic nerves, 11:156 transesophageal fistulae, 1:56
Thoracic vertebrae, 1:7,9, 171, 300, 301, 462, Tracheal aplasia/agenesis, 1:40
Tracheal atresia, 1:57
11:452
Tracheal bronchus, 1:225
Thoracic vessels, 1:7
Tracheal buds, 1:38, 42
Thoracoluinbar fascia, 11:44, 45, 46
Tracheal remnant (median umbilical ligament),
Thorax, anatomy, 1:26
Thymicsail sign, 1:298, 319 11:3
Thymic wave sign, 1:298, 319 Tracheobronchial nodes, 11:161
Thymoma, 1:330 Tracheobronchomegaly (Mounier-Kuhn
trachea), 1:204
 INDEX
Tracheoesophageal fisrulae, 1:40
Tracheoesophageal folds, 1:42
Tracheoesophageal septum, 1:38
Tracheomalacia, 1:204, 224
Traction bronchiectasis, 1:111, 204, 223
Transesophageal fistulae, 1:56
Transient tachypnca of newborn, 1:40, 52
Transitional cell carcinoma, 11:472-473,473
Transplants, 11:102
Transurethral resection of prostate (TURP), III: 184
Transvaginal ultrasound, 111:102
Transversalis fascia, 11:3, 40, 43, 400,111:8, 30,
133-135
Transverse abdominal muscles, 11:40,43,45,46,
50, 5 1 , 54, 55, 64, 65, 66, 459,111:8. See also
Transversus abdominis muscle
Transverse colon, 11:11,94,270
anatomy, 11:238
in ascites, 11:210
axial view, 11:252
barium study, 11:211, 245
in cirrhosis and ascites, 11:21, 22, 24
frontal view, 11:175, 176, 264
gastric carcinoma, 11:116
graphic, 11:457
inflamed pancreas and, 11:406
lateral view, 11:93
malignant ascites and, 11:112
in midgut malrotation, 11:233
peritoneal spaces and, 11:97,99
sagittal view, 11:403
Transverse mesocolon, 11:3, 19,95
anatomy, 11:92,239, 371
embryology, 11:3,12
peritoneal spaces and, 11:99
root of, 11:176, 273
Transverse pancreatic artery, 11:375,385
Transverse process, 11:53
Transverse septum, 11:8,9
Transverse sinus, 1:442^43, 452, 454
Transverse thoracic muscle, 1:465
Transversospinal muscle, 1:468, 471, 473
Transversus abdominis muscle. See also Transverse
abdominal muscles
anterior pelvic wall, 111:2
aponeuroses, 111:13
axial view, 111:10, 11, 12
coronal view, 111:18
discontinuity of, 111:130
frontal view, 111:30
posterior pelvic wall, 111:9
scrotal development and, 111:134
Transversus thoracis muscles, 1:462
Trapezius muscles, 1:462, 465, 468-471,473,475
Trauma board artifacts, 1:13, 55
Tree-in-bud opacities, 1:66, 80
Triangular ligaments, 11:95,299,300
Tricuspid valve, 1:375,382,383, 402,406,407, 412
Trigone, 111:155
Trigone of bladder, 11:484, 498
True (minor) pelvis, 111:2, 6
True ribs, 1:464
Truncus anterior, 1:228, 229
Truncus basalis, 1:180,203, 212, 2 1 6 , 2 1 9 , 2 2 0 , 2 4 5
Tuberculosis, 1:66, 80, 86, 107, 192
Tubulirecti, 111:130
Tunica albuginea, 111:130. 132, 144-145, 146,154,
159, 160
Tunica vaginalis, 111:130, 135
u
Ulcers, 11:190-193,192,194-195
Umbilical arteries, 11:16, 37,38,111:52, 54
Umbilical cord, 11:8, 12, 15, 37
Umbilical folds (ligaments), 11:17, 2 5 , 4 3 , 9 2 , 1 0 6 ,
107,253,484,111:8,54
Umbilical hernia, 11:21
Umbilical vein catheters, 1:13
Umbilical veins, 11:2, 11, 14, 16, 37, 38
Umbilicus, 11:16, 42, 43, 47, 64, 323-324, 504,
111:10
Unicinate process, 11:370, 373, 379, 382, 383,
386, 408
Upper extremities, 1:11
Upper polar artery, 11:463
Urachal cancer, 11:506
Urachal cysts, 11:107,504-505
Urachus, 11:35, 36, 37, 92, 107,111:113
Ureteral duplication, 11:484, 488-489, 490
Ureteral orifices, 11:484,498
Ureteral stent, 11:420-421
Ureteric bud, 11:33,34
Ureterocele, 11:484,487,491
Ureicropelvic junction, 11:484, 486, 494,495
Ureterovesical junction, 11:484, 486, 487
Ureters, 11:484-509
anatomy, 11:484,111:72, 85, 98, 120, 133
bifid, 11:484, 488
bladder and, 11:484-509
blind, 11:482
cancer of, 11:496,497
clinical implications, 11:484
crossed fused ectopia, 11:477
duplicated, 11:482
ectopic, 11:484, 490, 491
embryology, 11:10
excretory urogram, 11:453, 486
frontal view, 11:449,111:54, 56
posterior view, 111:173
 INDEX
pyelographic phase, 11:452
retrocaval, 11:492-493
Urethra, 111:154-169
anatomy, 111:37, 154,166-167
axial view, 111:177
in benign prostatic hypertrophy, 111:180, 182
clinical implications, 111:154
compressed, 111:180
crest, 111:155, 172
cross-section, 111:159
embryology, 11:35, 36
female anatomy, 11:498,111:41, 42, 43, 46
inferior view, 111:40
"jet," 11:509
male anatomy, 11:498
penis and, 111:164-165
posterior abdominal wall, 11:41
posterior pelvic wall, 111:9
post hysterectomy, 111:93
retrograde urethrogram, 111:167
straddle injuries, 111:154
transverseTRUS image, III: 178
traumatic injury, 111:168-169
Urcthral sphincter, 11:498
Urethrovesical junction, 111:50
Urinary bladder, 11:484-509, 111:73
anatomy, 11:484,485,111:166, 172, 176, 179
angiogram, 111:64, 65
in ascites, 11:25
axial view, 11:63, 124, 253, 413, 418,111:94, 177
balloon-tipped catheter in, 11:418
barium enema, 11:260
broad ligament and, 111:89
cancer, 11:509
catheter tip in, 11:501, 508
in cirrhosis, 11:25
clinical implications, 11:484
in congenital absence of kidneys, 11:475
congenital anomalies, 111:187
coronal view, 111:147
in Crohn disease, 11:219
development of, 11:34
diverticula, 11:484, 507, 508
ectopic pregnancy, 111:111
embryology, 11:9, 10, 35, 36, 37, 38,111:113
endometriosis and, 111:95
excretory urogram, 11:486
extrajwritoneal rupture, 11:484, 502-503,111:92
female anatomy, 11:498,111:42, 46, 47, 49
frontal view, 11:449
gas in, 11:261
internal view, 111:8
intramural hematoma, 11:500
intraperitoneal rupture, 11:499-500,501
lateral view, 11:243,111:87
lumen, 11:268-269
male anatomy, 11:498,111:44, 48
in pelvic floor relaxation, 111:50
posterior view, III: 173
postnatal development, 11:17
post-TURP, 111:184
prenatal development, 11:16
retrograde urethrogram, 111:168
sagittal midlineview, 111:165
sagittal view, 11:107,111:29, 94, 106
small ureterocele and, 11:487
stone, 11:507
ultrasound, 111:122
urachal cancer and, 11:506
11 rat ha I cyst and, 11:505
ureter and, 11:484-509
urine within, 11:500
uterus and, 111:98
wall of, 11:106
Urine, 11:414, 472,499, 500, 502
Urogenital arterial rete, 11:38
Urogcnital diaphragm, 11:498, 111:3, 29, 37, 4 1 ,
48, 155, 156, 164, 172
Urogenital sinus, 11:10,34,111:113
Urogenital triangle, 111:3, 40
Urorectal duct, 11:34
Urorectal fold, 111:113
Urorectal septum, II: 10
Uterine arteries, 11:485,111:52, 54, 63, 66, 85,
96,98, 100
Uterine cervix, 111:107, 108
anatomy, 111:96
anteflexed utenis, 111:101
axial view, 111:91,94, 121
broad ligament and, 111:88, 89
cancer of, 111:71,91
coronal view, 111:47, 71
ectopic pregnancy, 111:111
inner stroma, III: 108
l U D i n , 111:91
in pelvic floor relaxation, 111:50
retroversion, 111:101
sagittal view, 111:49, 109
septate uterus, 111:117
ultrasound, 111:109
Uterine prolapse, 111:3
Uterine veins, 111:56, 67, 99
Uterosacral ligaments, 111:84, 85,86, 91
Uterovaginal canal, 11:3
Uterovaginal plexus, 11:484
Uterus, 111:96-117, 111:97, 107
anatomy, 111:98, 105
anteflexed, 111:101
anterior cul-de-sac, 111:94
anteverted, 111:101
 INDEX
arcuate vessels, 111:100 in pelvic floor relaxation, 111:51
axial view, 11:63, 104, 124,111:90, 9 1 , 121 posterior fornix, 111:108, 109
bicornuate, 111:116 post hysterectomy, 111:93
blood supply, 111:84, 96 prolapse, 111:3
broad ligament and, 111:88, 89 sagittal view, 111:49
coronal view, 111:41, 46 spaces, 111:93
in Crohn disease, 11:219 superior view, 111:41
cyclical endometrial variations. III: 102-103 supporting ligaments, 111:84
didelphys, 111:115 Vaginal artery, 11:485,111:52
ectopic pregnancy and, 111:95 Vaginal cuff, 111:50
effect of oral contraceptives, 111:106 Vaginal septum, 111:115
embryology, 11:36,111:113 Vagus (X) nerves, 1:296, 302,11:68, 118, 158
endometriosis and, 111:95 Valvulae conniventes, 11:206
endometrium, 111:104 Varicella pneumonia, 1:66
fibroid, 111:128 Varices, 11:85, 158,173, 284-285, 336, 391, 394
fundus, 111:99, 104 Varicose bronchiectasis, 1:204
in gastric carcinoma and ascites, 111:95 Variocele, 111:131, 150,151
hydrosalpinx, 111:112 Vasa deferentia, 11:498,111:130, 132, 133, 171,
lateral view, 11:243,111:87 173, 179, 180
ligaments, 111:84, 85-86 Vascular equalization, 1:230
lymphatic drainage, 111:84 Vascular imaging, 1:4, 15
menarche, 111:96 Vascular pedicle, 1:335, 343
postmenopausal, 111:96 Vascular structure, 1:88-109
premenarche, 111:96 alveolar-capillary interface, 1:98, 99
rectus hemorrhage, 11:59 lymphangiticcarcinomatosis, 1:109
round ligament and, 111:90 perilymphatic nodules, 1:108
sagittal view, 111:49 pulmonary, 1:92-97, 100, 101, 104, 106
in sciatic hernia, 111:36 random nodules, 1:107
septate, 111:117 secondary pulmonary lobule, 1:102,103, 105
sonohysterography, 111:97 Vastus intermedius muscle, 111:20,24,25
transabdominal ultrasound, 111:122 Vastus lateralis muscle, 111:16, 1 9 , 2 0 , 2 1 , 2 2 , 24
unicornuate, 111:114 Vastus medialis muscle, 111:19, 20, 25
urachal cancer and, 11:506 VATtR acronym, 11:446
veins, 111:99 Vena caval foramen, 11:68
Utricle orifice, 111:172 Venae cavae, 1:384, 385. See also Inferior vena
cava (IVC); Superior vena cava (SVC)
Venous plexus, 111:176
V Ventilation-perfusion imaging, 1:4
Vagal trunk, 11:156, 206 Ventilation-perfusion matching, 1:89
Vagina Ventral hernias, 11:40
anatomy, 111:37 Ventral mesenteries, 11:2, 3, 5, 7, 8
anterior, 111:108 Ventral mesogastrium, 11:2, 8
anterior fornix, 111:109 Ventral pancreas, 11:8, 9
anteverted uterus, 111:101 Ventral rami, 111:76, 77
axial view, 11:63,111:42, 43 Ventricles, cardiac, 1:396
blood supply, 111:84 in congenital absence of pericardium, 1:456
caudal view, 11:261 constrictive pericardium and, 1:461
coronal section, 11:498 four chamber view, 1:410
coronal view, 111:41 hypertrophy, 1:411
dilated, 111:108 left, 1:32, 35, 312, 346, 375-377, 387, 390-392,
embryology, 11:36,111:97, 113 396-400,403, 404, 409, 411-413, 418,
fetal development, 11:3 430,431,434,439
inferior view, 111:40 myocardial segments, 1:425
lateral view, 111:87 right, 1:242,312, 375-377,382,383-385,
lymphatic drainage, 111:84 390-394,398-101, 407, 409, 412-413,430,
431,433
 INDEX
3
two chamber view, 1:410 Q.
Ventricular assist device, 11:289 n>
Ventricular outflow track, 1:384 Xiphoid process, 1:462, 464, 466, 476,11:68, 69
axial view, 1:237
left, 1:389,392,409,411
right, 1:346, 390, 392, 396, 399, 400, 407
Vermontanum, 111:166-167 Yolk sac, 11:4, 5,6, 7
Vertebrae, 1:34,11:169. See also Thoracic Yolk stalk, 11:2, 8, 9, 12, 33
vertebrae
Vertebral arteries, 1:336, 363
Vertebral bodies. 1:301, 465. 466, 482, 111:11,
57,58 Z line, 11:161
Vertebral cortex, 1:27
Vertebral venous plexus, 11:135
Vertebrocostal triangle, 11:68
Verumontanum (colliculus seminalis), 111:155,
170,172
Vcsical fascia, 11:243,498
Vesical venous plexus, 11:484
Vesicocervical space, 111:84, 86
Vesicouterine ligaments, 111:84
Vesicouterine pouch. See Anterior cul-de-sac
Vesicovaginal space, 111:84,86,93
Vessels. See also specific vessels
abdominal, 11:118-157
pelvic, 11:52-83
pulmonary, 1:228-261
Vestibule. 11:36,111:41
Virtual angioscopy, 1:4
Virtual bronchoscopy, 1:4
Viscera, sensory innervation, 11:118
Visceral ligaments, 111:84
Visceral pericardium, 1:459
Visceral peritoneum (serosa), 11:7,92
Visceral pleura, 1:266, 267, 280,286, 467
Visceral pleural lymphatics, 1:105
Vitelline veins, 11:2, 14
Von Hippie Lindau syndrome, 11:424

W
Wandering spleen, 11:272, 295
Water
abdominal, 1:18
attenuation contents, 1:61
soft tissue, 1:18
"Water bottle" morphology, 1:443
Webb and Higgins classification, 1:298
Wegener granulomatosis, 1:227
Weigert-Meyer rule, 11:484
Whipple procedure, 11:174
White pulp, splenic, 11:272
Wolffian ducts, 11:3

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