102

	1		2
			3	4	1
39	10	8	5
					14
	9			6		13
	38	7
					17
				18		15
		11
40			12			16
					19		25
				20		22
		36				23	26
41	37			21		24	27
				34
	35
						29	28
				33

32

30

31

1	Platysma	12	Inferior constrictor muscle		within foramen	30	Splenius		uncovertebral synovial
2	Anterior jugular vein		of pharynx		transversarium	31	Ligamentum nuchae		joint (of Lushka)
3	Sternohyoid	13	Sternocleidomastoid	22	Phrenic nerve	32	Spine of fifth cervical	38	Lateral lobe of thyroid
4	Omohyoid	14	Common facial vein	23	Scalenus anterior		vertebra		gland
5	Sternothyroid	15	Internal jugular vein	24	Scalenus medius and	33	Erector spinae	39	Accessory anterior jugular
6	Thyroid cartilage	16	Common carotid artery		posterior	34	Root of sixth cervical nerve		vein
7	Cricoid cartilage	17	Vagus nerve (X)	25	External jugular vein	35	Spinal cord within dural	40	Lymph node of internal
8	Rima glottidis	18	Sympathetic chain	26	Fat of posterior triangle		sheath		jugular chain
9	Arytenoid cartilage	19	Longus capitis	27	Accessory nerve (XI)	36	Body of fifth cervical	41	Cervical lymph node
10 Thyro-arytenoid		20	Longus colli	28	Trapezius		vertebra
11 Pharynx		21	Vertebral artery and vein	29	Levator scapulae	37	Neurocentral or

THORAX

Male – 1 section Axial

8	3/4
7	6
		13
11	16	15
21		19/20
26		23/24
		29

	Axial computed tomogram (CT)
■ Notes
This section passes through the body of the fifth cervical	rima glottidis (8) are adducted.
vertebra (36), immediately above the level of the shoulder	The posterior triangle of the neck has, at its boundaries,
joint. Here the fibres of the trapezius (28) arch over the	the posterior border of sternocleidomastoid (13) anteriorly,
posterior extremity of the posterior triangle. Just below this	the anterior border of trapezius (28) posteriorly and the
level, at C6, lies the junction between the pharynx (11) and	middle third of the clavicle below. Its floor comprises, from
oesophagus, and the larynx (6, 7, 9) and the trachea. In	above downwards, splenius capitis (30), levator scapulae
both the section and the CT image, the pharynx (11) has a	(29) and scalenus medius and posterior (24).
narrow anteroposterior diameter; it distends considerably	Not unusually, as in this case, the external jugular vein
during deglutition. On the CT image, the vocal cords of the	(39) is double.

■ Section level

C5

View

■ Orientation

Anterior

Right Left

Posterior

Male – 1 section Axial

THORAX

103

104

			2
		10	3		5
							1
		12
				11	4	6
1					8	7
	28		14	13		15
29					9			30
	27	25			17	16	35	32
						18
		24 26						31
					19
	23			20				30
	22	21
				39		38	33	34
					37			30
						36

1	Platysma	13	Recurrent laryngeal nerve		vertebra prominens	32	Capsule of shoulder joint
2	Anterior jugular vein	14	Oesophagus	22	Spinal cord within dural sheath	33	Supraspinatus
3	Sternohyoid	15	Lymph node	23	Inferior articular facet of seventh	34	Spine of scapula
4	Sternothyroid	16	Ventral ramus of sixth cervical		cervical vertebra	35	Coracoid process of scapula
5	Sternocleidomastoid		nerve	24	Body of seventh cervical vertebra	36	Trapezius
6	Omohyoid	17	Scalenus anterior	25	Longus colli	37	Rhomboideus minor
7	Internal jugular vein	18	Scalenus medius	26	Vertebral artery and vein	38	Levator scapulae
8	Vagus nerve (X)	19	Ventral ramus of seventh cervical	27	Ascending cervical artery and vein	39	Erector spinae
9	Common carotid artery		nerve	28	Inferior thyroid artery
10 Isthmus of thyroid gland		20	Dorsal root ganglion of eighth	29	Phrenic nerve	40	External jugular vein
11 Lateral lobe of thyroid gland			cervical nerve	30	Deltoid
12 Trachea		21	Spine of seventh cervical vertebra –	31	Head of humerus

THORAX

Male – 2 section Axial

3/4

12		5
	11	7
	9
14			17
40	25
			18
	39		38
			34
			36
			Axial computed tomogram (CT)

■ Notes

This section traverses the body of the seventh cervical	the trachea (12) and the oesophagus (14). The phrenic
vertebra, which bears the longest spine of the cervical	nerve (29) hugs the anterior aspect of scalenus anterior
series, the vertebra prominens (21). This is shorter,	(17) deep to the prevertebral fascia; three structures – the
however, than the spine of T1, as can be ascertained easily	common carotid artery (9), the internal jugular vein (7) and
by feeling the back of your own neck.	the vagus nerve (8) – lie together within the fascial carotid
Three important relationships are demonstrated well. The	sheath. The deep cervical chain of lymph nodes (15) lies
recurrent laryngeal nerve (13) lies in the groove between	lateral to the carotid sheath.

■ Section level

C7

View

■ Orientation

Anterior

Right Left

Posterior

Male – 2 section Axial

THORAX

105

106

	2		1
	3		5
30						32
	28	4			7		33
			6
29		22
27	26		21		8		34
31			20			37	36
25			8	9		38	35
24
	23	19	13		10		33
		18
						39	40
	17				11
			14			45	41
				12
	16
					46	44	42
					47	43	33
		15	51
			50	48		43
				49

1	Sternocleidomastoid sternal head	15	Spine of first thoracic vertebra	27	Phrenic nerve	42	Infraspinatus
2	Anterior jugular vein	16	Spinal cord within dural sheath	28	Vagus nerve (X)	43	Scapula
3	Sternohyoid	17	Part of body of second thoracic	29	Subclavius	44	Subscapularis
4	Sternothyroid		vertebra	30	Right subclavian vein	45	Serratus anterior
5	Clavicle	18	Part of intervertebral disc between	31	Tendon of right biceps long head	46	Serratus posterior superior
6	Internal jugular vein – junction		first and second thoracic vertebrae	32	Pectoralis major	47	Superficial (transverse) cervical
	with left subclavian vein	19	Part of body of first thoracic	33	Deltoid		artery and vein
7	Left subclavian vein		vertebra	34	Subdeltoid bursa	48	Rhomboideus minor
8	Subclavian artery	20	Oesophagus	35	Head of humerus	49	Trapezius
9	First rib	21	Common carotid artery	36	Tendon of left biceps long head	50	Rhomboideus major
10 Intercostal muscles		22	Trachea	37	Coracoid process of scapula	51	Erector spinae
11 Second rib		23	Right lung apex	38	Nerve to serratus anterior
12 Intercostal neurovascular bundle		24	Scalenus medius	39	Tendon of subscapularis	52	Supraspinatus
13 Apex of left lung		25	Root of first thoracic nerve	40	Glenoid fossa of scapula	53	Pectoralis minor
14 Head of second rib		26	Scalenus anterior	41	Suprascapular artery and vein

THORAX

Male – 3 section Axial

			5	32
	21			53
			6/7
6/7		22					22
	8		21
		20	8		44			13
			13			23	20
23		16
		51			43	42
				52
			49
A						B
A						B
Axial computed tomogram (CT)						Axial computed tomogram (CT)

■ Orientation		■ Section level
Anterior

Right Left

T1–2

Posterior

View

■ Notes

This section, through the intervertebral disc		Here, posterior to the medial end of the clavicle	overlying rib and lies protected within the subcostal
between the first and second thoracic vertebrae		(5), the internal jugular vein (6) joins with the	groove.
(18), enters the apex of the thorax and traverses the		subclavian vein (7) to form the brachiocephalic vein	Only in transverse section is the extreme thinness
apices of the upper lobes of the lungs (13, 23).		(see Axial section 4).	of the blade of the scapula (43) appreciated fully.
There are considerable differences between the		The intercostal neurovascular bundle (12) is	One CT (A) is displayed at soft tissue settings
section and CT images at this level because the CT		seen well. Note that it comprises the intercostal	(window level and width of grey scale), the other
is performed with the arms elevated alongside the		vein, artery and nerve from above downwards;	CT (B) at lung windows.
head in order to reduce artefacts from the humeri.		the nerve corresponds to the number of its
107

Male – 3 section Axial

THORAX

108

						2			1
48			47			3		4	5
				46
						20
									6		22
					17								24
				21		18			7
			45
	43		44			14			19			23
							13		8
					16									25
49	40							12			30
		41	42	15		11				9
											31
							10
											32
						39					33	28
											29	27	26	25
							38
									37
												28

36	35
	28
	34

1	Pectoralis major	15	Upper lobe of right lung	28	Scapula	38	Spinal cord within dural sheath
2	Manubrium of sternum	16	Right vagus nerve (X)	29	Subscapularis	39	Body of third thoracic vertebra
3	Sternothyroid	17	Right brachiocephalic vein	30	Second rib	40	Axillary nerve
4	Sternoclavicular joint	18	Brachiocephalic artery	31	Intercostal artery and vein and	41	Radial nerve
5	First rib	19	Left common carotid artery		nerve	42	Ulnar nerve
6	Internal thoracic artery	20	Left brachiocephalic vein	32	External and internal intercostal	43	Median nerve
7	Left phrenic nerve	21	Right phrenic nerve		muscles	44	Right axillary artery
8	Left vagus nerve (X)	22	Pectoralis minor	33	Third rib	45	Right axillary vein
9	Upper lobe of left lung	23	Coracobrachialis and biceps (short	34	Trapezius	46	Axillary fat
10 Thoracic duct			head)	35	Rhomboideus major	47	Pectoral branch of the
11 Oesophagus		24	Long head of biceps tendon	36	Erector spinae		acromiothoracic artery and vein
12 Left subclavian artery		25	Deltoid	37	Fourth rib with articulation of its	48	Cephalic vein
13 Left recurrent laryngeal nerve		26	Infraspinatus		head with body of third thoracic	49	Shaft of humerus
14 Trachea		27	Suprascapular artery and vein		vertebra transverse process

THORAX

Male – 4 section Axial

							■ Orientation		■ Section level
							Anterior
	2		1
	20		6	22
17	18	19					Right	Left
	14	12				14
15		11	9		15	9
						11
				29			Posterior
				26
35	36		28
34
A				B					T3
									View
A				B					section Axial
									– 4
Axial computed tomogram (CT)				Axial computed tomogram (CT)					Male
■ Notes									THORAX
The contents of the upper mediastinum – including the					This section also shows the walls and contents of the axilla.
oesophagus, trachea and great vessels – are demonstrated						Note that the cephalic vein (48) runs in the deltopectoral
in this section, which traverses the manubrium and the third					groove between the medial edge of deltoid and the lateral
thoracic vertebra; these are also shown in Axial section 5.					edge of pectoralis major.

109

	110
					1
								2	31
							3		4
51				30			25	27		36			31
				29
			49		28		24
														34
							23	26		5
50					20								35
				16			22							33
				18						6	37				32
							21
				19						43			38	39
						16
					15						42			40
									7		44
					14			17						41
													45
				17			13
					12
							11	8			46
							10	9	47	44
								48
	1 Manubriosternal joint (angle of		14	Part of intervertebral disc between		26	Left vagus nerve (X)				41		Circumflex scapular artery and vein
	Louis)			fourth and fifth thoracic vertebrae		27	Left phrenic nerve				42		Subscapularis
	2 Internal thoracic artery and vein		15	Part of body of fourth thoracic		28	Pretracheal lymph node				43		Serratus anterior
	3 Thymic residue within anterior			vertebra		29	Superior vena cava				44		Body of scapula
	mediastinal fat		16	Azygos vein		30	Right phrenic nerve				45		Teres minor
	4 Second rib		17	Apical segment lower lobe lung		31	Pectoralis major				46		Infraspinatus
	5 Intercostal			separated by oblique fissure from		32	Deltoid				47		Rhomboideus
	6 Third rib			(18)		33	Shaft of humerus				48		Trapezius
	7 Fourth rib		18	Upper lobe of lung		34	Biceps – long head				49		Axillary vein
	8 Fifth rib		19	Oesophagus		35	Biceps – short head and				50		Axillary artery
	9 Fifth costotransverse joint		20	Trachea at bifurcation			coracobrachialis				51		Cephalic vein
10 Erector spinae			21	Recurrent laryngeal nerve		36	Pectoralis minor
11 Transverse process of fifth thoracic			22	Left subclavian artery orifice		37	Subscapular artery vein and nerve					52	Oblique fissure
	vertebra		23	Aortic arch		38	Latissimus dorsi
12 Spinal cord within dural sheath			24	Left common carotid artery orifice		39	Triceps – lateral head
13 Sympathetic chain			25	Brachiocephalic artery orifice		40	Triceps – long head

THORAX

Male – 5 section Axial

31		1
2			3
36
		29
18		20	23		18
			19
16
		16
17		12		17	42	44
			10		46
A				47			A
				48

18

18

52

52

B	17	17	B

Axial computed tomogram (CT)

Axial computed tomogram (CT)

■ Orientation		■ Section level
Anterior

Right Left

Posterior

T4–5

View

■ Notes

This section passes through the important anatomical	contents, and the posterior mediastinum, behind	are present in the lung parenchyma adjacent to a
level of the manubriosternal joint, the angle of Louis	the pericardium.	fissure.
(1). At this joint articulate the second costal cartilage	The trachea bifurcates at this level (20). In the	Pretracheal nodes (28) may become enlarged due
and rib (4), and it is from here that the ribs can be	living upright subject, however, the bifurcation may	to a wide variety of disease processes. They are
conveniently counted in clinical practice. Posteriorly	be as low as the level of T6, particularly in deep	accessible for biopsy via mediastinoscopy.
this plane passes through the T4/5 intervertebral disc	inspiration.	Subscapularis (42) arises not only from the
(14).	The cranial portions of the oblique fissures of the	periosteum of the medial two-thirds of the
This plane demarcates the junction between the	lungs (17, 52) are traversed on this section. The	subscapular fossa of the scapula but also from
superior and the lower mediastinum, the latter of	normal oblique fissures are often not seen on	tendinous laminae in the muscle itself, which are
which is subdivided into the anterior mediastinum,	conventional CT images of the lung parenchyma.	attached to prominent transverse ridges on the
in front of the pericardium, the middle	The position can be inferred, however (see CT b) by	subscapular fossa. This is shown clearly in this
mediastinum, occupied by the pericardium and its	the paucity of blood vessels; only small terminal vessels	section.

Male – 5 section Axial

THORAX

111

112

51 48

50

46

45

42

41

40

2

		55			1
					3
		54
	53	34	33		32
49	52	16		25		23
					21
47			24
44				20
	43		19		18	17
	39				12	13
					11
38				10
	37					9
		36
		35

3
26	31
	29	4
	30
27	28	16
22		5
	15	6
	14	7
	8

1	Body of sternum	13	Intercostal artery and vein	29	Pulmonary vein tributary	44	Ulnar nerve
2	Internal thoracic artery and vein	14	Lower lobe of lung	30	Segmental bronchus	45	Radial nerve
3	Thymic residue within anterior	15	Oblique fissure	31	Left phrenic nerve with	46	Latissimus dorsi tendon
	mediastinal fat	16	Upper lobe of lung		pericardiacophrenic artery	47	Axillary artery and vein
4	Third rib	17	Descending aorta	32	Ascending aorta	48	Biceps and coracobrachialis
5	Fouth rib	18	Thoracic duct	33	Superior vena cava	49	Median nerve
6	Intercostal muscle	19	Azygos vein	34	Right phrenic nerve	50	Shaft of humerus
7	Fifth rib	20	Oesophagus	35	Trapezius	51	Deltoid
8	Sixth rib	21	Lymph node	36	Rhomboideus major	52	Serratus anterior
9	Transverse process of sixth thoracic	22	Left vagus nerve (X)	37	Infraspinatus	53	Lateral thoracic artery and vein
	vertebra	23	Left main bronchus	38	Scapula	54	Pectoralis minor
10 Spinal cord within dural sheath		24	Right intermediate bronchus	39	Subscapularis	55	Pectoralis major
11 Part of intervertebral disc between		25	Right pulmonary artery	40	Teres major
	fifth and sixth thoracic vertebrae	26	Pulmonary trunk	41	Triceps – long head	56	Superior pulmonary vein
12 Part of body of fifth thoracic		27	Left pulmonary artery	42	Triceps – lateral head	57	Left basal pulmonary artery
	vertebra	28	Pulmonary artery branch	43	Subscapular artery and vein	58	Breast

THORAX

Male – 6 section Axial

58		1
	2		3
16	33	32	26	16
	56
	25	25	56	52
	24 20
			23 57
			17	38
		19
	14			14
		10		37

A	35	A

16

			16
15		24	23
		20	15
		14	14
B				B

Axial computed tomogram (CT)

Axial computed tomogram (CT)

■ Orientation		■ Section level
Anterior

Right Left

Posterior

T5–6

View

■ Notes

This section, traversing the upper body of the	At the left hilum, the superior pulmonary vein	accompany the segmental and subsegmental
sternum (1) and the lower part of the body of the	(56) lies anterior to the bronchus (23), which in turn	bronchi (30) usually lie dorsolaterally to these
fifth thoracic vertebra (12), passes through the great	lies anterior to the left basal pulmonary artery (57).	structures; each pulmonary segment receives an
arterial trunks as these emerge from the heart, the	On the right side, the vein (56) lies anterior to the	independent arterial supply. The bronchi usually
pulmonary trunk (26) and the ascending aorta (32).	right pulmonary artery, which lies anterior to the	separate the dorsolateral pulmonary artery branch
On the CT image, the left main bronchus gives off	right intermediate bronchus (24).	from the ventromedially situated pulmonary vein
its common upper lobe/lingular branch at this level.	In this subject, the right (25) and left (27)	tributary (29). Peripherally, many pulmonary venous
On the right, the upper lobe bronchus has already	pulmonary arteries lie in the same axial plane. In	tributaries run between, and drain adjacent,
originated more cranially (on both CT images and	most subjects, the left pulmonary artery is at a more	pulmonary segments. Thus, an individual
section); hence, the term ‘intermediate bronchus’	cranial level than the right – hence the discrepancy	bronchopulmonary segment will have its own
(24) is applied to that portion of the right bronchus	between the section and CT image appearances.	bronchus and artery but not an individual
between its upper lobe and middle lobe branches.	The branches of the pulmonary artery (28) that	pulmonary venous drainage.

Male – 6 section Axial

THORAX

113

114

27

		49
61	60	50	51
		54	52
		55	53	26
59
	56	57

25

58

1		2	3	4
					5
48		42		46
					6
					47
			43		45
41
				44	7
		36
34				37
			35	38	26	8
					39
33
			32	40
31					9		11
30		28
29					10
	24			25		16	12
					17
23
							13
22						15
				21	18
		20
						14
				19

1	Third costal cartilage with	15	Scapula	26	Upper lobe of lung	40	Left pulmonary artery	50	Coracobrachialis
	adjacent sternocostal joint	16	Subscapularis	27	Middle lobe of right lung		branch to lingula	51	Axillary artery and vein
	(see Notes)	17	Fifth rib	28	Descending aorta	41	Superior vena cava	52	Medial cutaneous nerves
2	Body of sternum	18	Rhomboideus major	29	Azygos vein	42	Artefactual gap within the		of arm and forearm
3	Internal thoracic artery	19	Trapezius	30	Thoracic duct		pericardial space	53	Basilic vein
	and vein	20	Erector spinae	31	Oesophagus	43	Ascending aorta, with	54	Median nerve
4	Partially calcified third	21	Sixth rib, with adjacent	32	Left vagal plexus		orifice of left coronary	55	Ulnar nerve
	costal cartilage		costotransverse joint to	33	Right vagal plexus		artery (arrowed)	56	Triceps – medial head
5	Pectoralis major		transverse process of sixth	34	Right superior pulmonary	44	Left ventricle wall	57	Radial nerve with
6	Pectoralis minor		thoracic vertebra		vein	45	Coronary artery (left		profunda brachii artery
7	Third rib	22	Spinal cord within dural	35	Left superior pulmonary		anterior interventricular		and vein
8	Intercostal muscle		sheath		vein		branch)	58	Triceps – long head
9	Fourth rib	23	Thoracic sympathetic chain	36	Left atrium	46	Infundibulum of right	59	Triceps – lateral head
10 Serratus anterior		24	Body of sixth thoracic	37	Left auricle (atrial		ventricle with pulmonary	60	Shaft of humerus
11 Subscapular artery vein			vertebra, with part of		appendage)		valves	61	Deltoid
	and nerve		intervertebral disc	38	Left pulmonary vein	47	Fibrous pericardium
12 Teres major			between the sixth and		tributary to lingula	48	Right auricle (atrial	62	Hemiazygos vein
13 Latissimus dorsi			seventh thoracic vertebrae	39	Left bronchus segmental		appendage)	63	Right coronary artery
14 Infraspinatus		25	Lower lobe of lung		branch to lingula	49	Biceps	64	Oblique fissure

THORAX

Male – 7 section Axial

		2
		27	46
			63
		48
			43
	10		36
		31	28
		25	29
	13		62

A

27

25

B

45

26

25

A

26

64

25

B

Axial computed tomogram (CT)

Axial computed tomogram (CT)

■ Orientation					■ Section level
	Anterior
Right			Left
	Posterior
					T6–7
					View

■ Notes

The plane of this section traverses the lower part of	components of the joint. In some or all of these	infundibulum of the right ventricle and demonstrates
the body of the sixth thoracic vertebra (24).	joints, however, an arrangement may be found	the pulmonary valves (46).
Anteriorly, it passes through the body of the	similar to that of the first joint.	On the CT image, both the ascending aorta (43)
sternum (2) at the level of the third costal cartilage	The presence of a pericardial effusion in this	and the region of the pulmonary valves (46) have
(1). Note the adjacent sternocostal joint. These vary;	subject has produced an artefactual gap in the	indistinct outlines due to pulsation (compliance) of
the first lacks a synovial cavity, its costal cartilage	superior reflection of the pericardial space (42). The	their walls during the 1-s data-acquisition time. (See
being attached by fibrocartilage to the manubrium.	aorta at its origin (43) shows the orifice of the left	also the ascending aorta on the left-hand image in
The second to seventh joints are usually synovial (as	coronary artery. The descending aorta (28) is	Axial section 6.)
in this subject), with the fibrocartilaginous articular	normally more circular in outline than in this subject.
surfaces on both the chondral and the sternal	Note that this section passes through the

Male – 7 section Axial

THORAX

115

116

			46
	57		47
		52	49	48
	56	51		50
		53
	55
		54

	1	2	3
	41	39
			38
	40		35
42			34
	36
	31	29	33
			28
	30
		22
43	19	21
			20
	44

45

17

18

18

16

15

14

13

12

4

5

37

32

6

27

26

25

7

24

23

8

9

11

10

1	Internal thoracic artery	16	Spinal cord within dural	29	Interatrial septum	39	Right coronary artery	50	Basilic vein
	and vein		sheath	30	Phrenic nerve with	40	Right auricle (atrial	51	Ulnar nerve
2	Body of sternum	17	Intervertebral disc		pericardiacophrenic artery		appendage)	52	Shaft of humerus
3	Fourth costal cartilage		between seventh and		and vein	41	Fibrous pericardium	53	Triceps – short head
4	Pectoralis major		eighth thoracic vertebrae	31	Middle lobe of right lung	42	Nerve to serratus anterior	54	Triceps – long head
5	Fourth rib	18	Lower lobe of lung	32	Wall of left ventricle	43	Intercostal neurovascular	55	Triceps – lateral head
6	Fifth rib	19	Azygos vein	33	Mitral valve		bundle	56	Radial nerve with
7	Sixth rib	20	Descending aorta	34	Vestibule of left ventricle	44	Innermost intercostal		profunda brachii artery
8	Serratus anterior	21	Thoracic duct		(outflow tract) leading to	45	External and internal		and vein
9	Latissimus dorsi	22	Oesophagus		root of aorta		intercostal muscles	57	Deltoid
10 Scapula inferior angle		23	Pulmonary artery branch	35	Divided cusp of aortic	46	Biceps
11 Seventh rib		24	Branches of left lower lobe		valve	47	Median nerve with
12 Trapezius			bronchus	36	Right atrium		musculocutaneous nerve
13 Erector spinae		25	Pulmonary vein tributaries	37	Anterior interventricular		(lateral to it)
14 Eighth rib		26	Oblique fissure		(descending) branch of left	48	Brachial artery with two
15 Lamina of seventh thoracic		27	Upper lobe of left lung		coronary artery		venae comitantes
	vertebra	28	Left atrium	38	Right ventricle cavity	49	Coracobrachialis

THORAX

Male – 8 section Axial

			2
	31		38	37
		36	39	27
			34	32
			28
8	18	22	20
9		19		18
			13
					A
A		12

		31	27
	26		26
			24
18			18

B		B

■ Orientation		■ Section level
Anterior

Right Left

Axial	Posterior
computed
tomogram
(CT)	T7–8

View

Axial computed tomogram (CT)

■ Notes

This section lies at the level of the intervertebral disc	oesophagus (22), separated by the pericardium. The	mortem thrombus in the right atrium (36). The
between the seventh and eighth thoracic vertebrae	left ventricle (32) forms the bulk of the left border of	septum is normally straighter.
(17) and passes through the body of the sternum (2)	the heart, and the right ventricle (38) constitutes the	The lower four or five digitations of serratus
at the level of the fourth costal cartilage (3). All four	major component of the anterior cardiac surface.	anterior (8) converge to insert on the costal aspect
cardiac chambers can be seen and their relationships	In this subject, the left ventricular wall (32)	of the inferior angle of the scapula. This component
to each other appreciated. Note that the right	becomes thinner in the region of the apex of the left	of the muscle, together with the trapezius,
atrium (36) forms the right border of the heart. The	ventricle, due to a previous myocardial infarction.	powerfully pulls the inferior angle of the scapula
left atrium (28) is the major contribution to the base	The interatrial septum (29) has a rather curious	forwards and upwards in raising the arm above the
of the heart and lies immediately anterior to the	convexity. This has been caused by extensive post-	head.

Male – 8 section Axial

THORAX

117

	118
				1		2
						4				5
					3
				47	17			6
								7
							8		9	12
											19
						16			10
				46							18
				45
				21				14 13		11	20
						43		15		21	22
				44
						42
						41		37		23
						40					24
				23		39		38
												25
						36					27
						35
					34			33				26
										28
						32
								30
						31		29
	1 Fifth costal cartilage		14	Left atrium		27	Serratus anterior					40 Azygos vein
	2 Sternocostal joint		15	Coronary sinus		28	Eighth rib					41 Thoracic duct
	3 Internal thoracic artery and vein		16	Right atrium		29	Trapezius					42 Oesophageal vagal plexus
	4 Body of sternum		17	Fibrous pericardium		30	Erector spinae					43 Oesophagus
	5 Pectoralis major		18	Left phrenic nerve, with		31	Spine of eighth thoracic vertebra					44 Dome of right hemidiaphragm
	6 Papillary muscle			pericardiacophrenic artery and vein		32	Lamina of eighth thoracic vertebra					45 Apex of right lobe liver
	7 Chordae tendinae within right		19	Fifth rib		33	Ninth rib					46 Right phrenic nerve, with
	ventricular cavity		20	Upper lobe of left lung (lingula)		34	Right sympathetic chain					pericardiacophrenic artery and vein
	8 Triscupid valve		21	Oblique fissure		35	Spinal cord within dural sheath					47 Middle lobe of right lung
	9 Interventricular septum		22	Sixth rib		36	Intervertebral disc between eighth
10 Left ventricular cavity			23	Lower lobe of lung			and ninth thoracic vertebrae					48 Inferior vena cava
11 Normal left ventricular wall			24	Seventh rib		37	Aorta					49 Right ventricular cavity
12 Thinned left ventricular wall			25	Lateral thoracic artery and vein		38	Origin of eighth intercostal artery
13 Mitral valve			26	Latissimus dorsi		39	Hemiazygos vein

THORAX

Male – 9 section Axial

■ Orientation

■ Section level

47		17					47		Anterior
			49		21
				20			20
			16	10			21
27			48					Right			Left
			15	43	23
23			37	23
			40				23
									Posterior
			39
26			35	30
A					B

T8–9

	A					View
				B
Axial computed tomogram (CT)			Axial computed tomogram (CT)

■ Notes

This section traverses the intervertebral disc between the	Note how only a tiny portion of the left atrium (14) is
eighth and ninth thoracic vertebrae (36) and slices through	present on this section. This demonstrates that the left
the dome of the right hemidiaphragm (44) and a sliver of	atrium is situated more cranially than the other three
the underlying right lobe of the liver (45).	cardiac chambers.
In this section, there is considerable thinning and	The terminal fibres of the right phrenic nerve (46) usually
discoloration of the left ventricular wall at the apex (12),	pass through the vena caval opening in the diaphragm but
consistent with infarction associated with left anterior	may traverse the muscle itself.
descending (interventricular) coronary arterial disease.

Male – 9 section Axial

THORAX

119

120

1 Pectoralis major

2 Internal thoracic artery and vein

3 External oblique

4 Extrapericardial pad of fat

5 Left ventricle

6 Interventricular septum

7 Right ventricle

8 Tricuspid valve

9 Coronary sinus

10Diaphragm

11Fibrous pericardium

12Line of fusion of diaphragm and

pericardium

	41	42	2
	40		43
39	11
	10		7
	12		8

			9
		33	32
38			30
	34
			29
			31
			28
37			27
			26
			23
	36		22

35

21

1

3

6	5	4

13

	14
	15
25	17
	16
24

18

20

19

13	Upper lobe of left lung (lingula)		between ninth and tenth thoracic	35	Tenth rib
14	Left dome of diaphragm		vertebrae	36	Ninth rib
15	Spleen	24	Left sympathetic chain	37	Eighth rib
16	Lower lobe of lung	25	Hemiazygos vein	38	Seventh rib
17	Serratus anterior	26	Azygos vein	39	Sixth rib
18	Latissimus dorsi	27	Thoracic duct	40	Middle lobe of right lung
19	Trapezius	28	Aorta	41	Sixth costal cartilage
20	Erector spinae	29	Oesophagus	42	Fifth costal cartilage
21	Tip of spine of eighth thoracic	30	Left vagus nerve (X)	43	Sternum
	vertebra	31	Right vagus nerve (X)
22	Spinal cord within dural sheath	32	Inferior vena cava	44	Oblique fissure
23	Body of ninth thoracic vertebra,	33	Right hepatic vein
	with part of intervertebral disc	34	Right lobe of liver

THORAX

Male – 10 section Axial

10

				13
				16
16	34	32		15
			29
		33
		28		14
		26
	16	22		16

20

A

A

Axial computed tomogram (CT)

		■ Orientation
44			Anterior
	13
	44
16		Right				Left
	16
16	16
			Posterior

B

B

Axial computed tomogram (CT)

■ Notes

This section is at the level of the body of the ninth thoracic vertebra (23) and traverses the dome of the left diaphragm (14). The cranial portion of the spleen (15) is, therefore, revealed.

The fusion of the diaphragm (10) with the base of the fibrous pericardium (11) is shown clearly at this point.

The massive size of the hepatic veins as they drain into the inferior vena cava (32) is well demonstrated in this section, which passes through the right hepatic vein at its termination (33).

The aorta (28) at this level has become the immediate posterior relation of the oesophagus (29), just as it is about to pass through its hiatus in the diaphragm (10).

■ Section level

T9–10

View

Male – 10 section Axial

THORAX

121

122

17

1

16

46

24

15

38

14	33
	34
13	32

31

23

12

18 19 20

43

42

39

40

37

36

29

28

25

27 26

11 10

9

8 7

1

46

2

41

3

44

21

45

35

22

30

23

5

4

					6
1	Breast	14	Fifth rib	29	Oesophagus	41	Left ventricle
2	Pectoralis major	15	Fourth rib	30	Mediastinal lymph node	42	Right ventricle
3	Intercostal muscles	16	Third rib	31	Pulmonary arterial branch in lower	43	Right coronary artery
4	Latissimus dorsi	17	Third costal cartilage		lobe	44	Left phrenic nerve
5	Serratus anterior	18	Third sternocostal joint	32	Bronchus – segmental branch in	45	Fibrous pericardium
6	Trapezius	19	Sternum		lower lobe	46	Extrapericardial fat pad
7	Erector spinae	20	Internal thoracic artery and vein	33	Orifice of right inferior pulmonary
8	Spine of seventh thoracic vertebra	21	Upper lobe of left lung (lingula)		vein	47	Ascending aorta
9	Spinal cord within dural sheath	22	Left oblique fissure	34	Right inferior pulmonary vein	48	Descending aorta
10 Part of intervertebral disc between		23	Lower lobe of lung	35	Coronary sinus	49	Pulmonary trunk
	the seventh and eighth thoracic	24	Middle lobe of right lung	36	Left atrium	50	Right pulmonary artery
	vertebrae	25	Aorta	37	Interatrial septum	51	Superior vena cava
11 Body of seventh thoracic vertebra		26	Azygos vein	38	Right atrium	52	Left basal pulmonary artery
12 Seventh rib		27	Right sympathetic chain	39	Tricuspid valve	53	Upper lobe of right lung
13 Sixth rib		28	Thoracic duct	40	Aortic valve	54	Carcinoma right breast

THORAX

Female – 1 section Axial

54
53
	47	49	21
51
	50		52
	29
		48
23		26	23

	Axial computed tomogram (CT)
■ Notes
This section of a female subject passes through the body of	tissue becomes atrophied. The inner wall of the left
the seventh thoracic vertebra (11) and through the third	ventricle, immediately proximal to the aortic valve (40), is
sternocostal joint (18). Note the general smaller	smooth-walled and termed the aortic vestibule.
configuration of the female thorax and the smaller, less	This CT image shows a patient with a large carcinoma of
bulky muscles.	the right breast, which has ulcerated and extended into,
The breast (1) contains the mammary gland. This extends	and infiltrated, a wide area of adjacent skin. The
vertically from the second to the sixth rib and transversely	anatomical level is considerably more cranial than the
from the side of the sternum to near the mid-axillary line.	cadaveric section; it corresponds closely to that shown in
The gland is situated within the superficial fascia and is	Axial section 6 of the male thorax.
separated from the fascia covering pectoralis major,	Note that in this section, the margin of the mass of left
serratus anterior and the external oblique muscle by loose	ventricular muscle (41) has been cut across; there is
areolar tissue. In old age, as in this subject, the glandular	infarction in the anterior free wall.

■ Section level

T7–8

View

■ Orientation

Anterior

Right Left

Posterior

Female – 1 section Axial

THORAX

123

		Selected images – Heart
	THORAX

A				B
Axial computed tomogram (CT)				Axial computed tomogram (CT)
			9
				15	19
8		2
	7	6		18
			4
	1
				1
		12	13
				8
	5
		11
		3		2	4
			10
14
	16				9
		15
A				B
	17

Images A–B		7	Tricuspid valve	10	Left atrioventricular	15	Aorta
		8	Right atrioventricular		groove for circumflex	16	Oesophagus
1	Right atrium		groove for right		branch of left	17	Thoracic vertebra
2	Right ventricle		coronary artery		coronary artery	18	Right coronary artery
3	Left atrium	9	Interventricular	11	Mitral valve	19	Left coronary artery
4	Left ventricle		groove for anterior	12	Anterior leaflet of
5	Interatrial septum		branch of left		mitral valve
6	Interventricular		coronary artery	13	Papillary muscle
	septum			14	Pulmonary vein

■ Notes

		Multidetector CT with rapid data acquisition has
		opened up huge opportunities for imaging the heart
		and great vessels. If the data for a whole revolution of
		the CT gantry can be acquired in less than 400 ms,
		then a considerable amount of information can be
		obtained in the relatively quiescent period of the
		cardiac cycle. If the patient’s heart rate is slow and
		regular, then a succession of images can be obtained
		during one breath-hold at the same phase of the
		cardiac cycle; these can be combined and a three-
		dimensional dataset created. This can provide
		exceptional anatomical (and, increasingly, functional)
124
		information.
		The four-chamber view (A) is a multiplanar two-

dimensional reconstruction so that all four chambers can be seen on one oblique image. This is a standard view used in many imaging investigations, including CT, ultrasound and MRI. It allows direct comparison of the left and right sides of the heart. It elegantly shows the interventricular septum. The close relationship of the oesophagus to the posterior aspect of the left atrium explains the advantages of transoesophageal echocardiography.

The coloured three-dimensional surface rendered view of the ventricles and coronary arteries provides a good general overview but, in practice, the coronary arteries (B) are better displayed and analysed using more selective analysis tools.

Selected images – Heart
	THORAX

C

Axial computed tomogram (CT)

■ Orientation			■ Orientation
	Anterior			Superior
Right		Left	Right	Left
A	Posterior		B C	Inferior

20	6	7	10
			11
	1		8
	2
3			9
4			16
		13
5			15
	12		18

14	17

C

Image C

1 First rib (right)

2 Second rib

3 Third rib

4 Fourth rib

5 Fifth rib

6 Clavicle

7 Sternoclaviclar joint

8 Sternum – manubrium

9 Sternum – body

10Hyoid bone

11Left subclavian vein

12Right atrium

13Right atrial appendage

14Right ventricle

15Right ventricular outflow tract

16Pulmonary trunk

17Left ventricle

18Left anterior descending – branch of left coronary artery

19Right coronary artery

20Right subclavian artery

■ Notes

This edited 3D view of the chest (C) has been	the contrast medium and are well shown. It is just
presented as a collage whereby the skin and	possible to see the right subclavian artery (20)
subcutaneous tissues have been ‘peeled away’ to	between the right first rib (1) and the right clavicle
expose the internal structures of the chest. By using	(6). The coronary vessels are well shown with the left
different window widths and colouring, it has been	anterior descending artery (LAD, 18) seen in the
possible to demonstrate some lung detail in areas,	interventricular groove and the right coronary artery
which have not been obscured by overlying	(19) seen in the right atrioventricular groove. Note the
structures. These images were obtained during a long	way that the 2nd rib (2) leads to the sterno-manubrial
bolus injection of dilute iodinated contrast medium	angle (of Louis). Of course the chondral part of the
via the left arm. Hence the left subclavian vein (11) is	rib, which articulates with the sternomanubrial joint,
well demonstrated but not the right. The heart, great	is not sufficiently calcified to be seen at these
vessels and coronary arteries are rendered opaque by	settings.

125

126

		7		10			8	10
							9
	2	3	4	9	11		21	11
			5
		20
		1	6			13
					17
			16			20	15
					18
						1
		19			22		16
A	A				18		14
					D
Axial computed tomogram (CT)
			7
				9
			4
	2	3
		20
		1	12
			16		D
		19
B
	B				Axial computed tomogram (CT)
Axial computed tomogram (CT)

7

9 21

4

2

20

112

16

19

C C

Axial computed tomogram (CT)

THORAX

CTs Axial – Mediastinum – images Selected

	Images A–D		12	Aortic arch (with fleck of	■ Orientation	■ Section level
				calcification in wall in image C)
	1	Trachea	13	Ascending aorta	Anterior
	2	Right brachiocephalic vein	14	Descending aorta
	3	Brachiocephalic artery	15	Left pulmonary artery
	4	Left brachiocephalic vein	16	Oesophagus
	5	Left common carotid artery	17	Superior vena cava	Right	Left
	6	Left subclavian artery	18	Azygos vein
	7	Manubrium of sternum	19	Right superior intercostal vein
	8	Body of sternum	20	Fat in pretracheal space
	9	Internal thoracic artery and vein	21	Fat in anterior mediastinal	Posterior
	10 Pectoralis major			space (with thymic remnant)
	11 Pectoralis minor		22	Azygos-oesophageal recess
						A
						B
						C
						D
						View

■ Notes

This patient has copious mediastinal fat, which	structure (partial volume effect). The space	the cardinal veins, is of immense importance when
makes the normal structures very conspicuous.	immediately caudal to the aortic arch and cranial to	the vena cava becomes blocked for any reason
Enlarged lymph nodes would show up well in such	the bifurcation of the pulmonary artery is known as	(usually by a tumour). For example, in superior vena
a patient (see Axial section 6). If such nodes lie in	the subaortic fossa or aortopulmonary window. The	cava obstruction caused by mediastinal nodal
the pretracheal space (20), then biopsy material can	ligamentum arteriosum (the obliterated ductus	enlargement secondary to carcinoma of the
be obtained via mediastinoscopy.	arteriosus passing from the left pulmonary artery to	bronchus, the venous return from the head, neck
The trachea (1) is bifurcating on image D; this	the aorta) runs through this space. This fossa may	and arms will go via collateral veins around the
point is known as the carina. The left pulmonary	also contain enlarged lymph nodes.	scapula and retrogradely in the intercostal veins into
artery (15) lies at a more cranial level than the right;	The azygos vein (18) can be seen approaching	the azygos and thence back to the heart, bypassing
it is just entering part of the section shown on	the posterior aspect of the superior vena cava (17)	the obstruction in the superior mediastinum.
image D. It appears indistinct because only part of	on image D. This venous system, which developed
the thickness of the slice is occupied by the	at an early stage of embryological development of

CTs Axial – Mediastinum – images Selected

THORAX

127

128

								1							1
		1													2
								2							3
		5						5								4
		6						6
	12													9		10
									7	12 13	15
							8							19
	8							11		16						7	12
			14	16		17									20		16
				18			19				18			25	21		22
						47							40				18
			29					27		23/24
	26	27													31		39
								29					28
	40		32			40								36
							30 33
	33								39				41	34		35
	41		39			41	34	35
														44
A	42		45		B			45		46		C	43			45
		37	46			38
								37
	38

	A		B		C
Coronal magnetic resonance image (MRI)
			Coronal magnetic resonance image (MRI) Coronal magnetic resonance image (MRI)

THORAX

MRIs Coronal – images Selected

1	Falx cerebri	25	Brachiocephalic vein
2	Lateral ventricle	26	Carina (bifurcation of trachea into
3	Third ventricle		two main bronchi)
4	Lateral sulcus (Sylvian fissure)	27	Aortic arch
5	Tentorium cerebelli	28	Superior vena cava
6	Cerebellum	29	Left pulmonary artery
7	Sternocleidomastoid	30	Right pulmonary artery
8	Spinal cord	31	Main pulmonary artery
9	Second cervical vertebra (axis)	32	Left superior pulmonary vein
10	Parotid gland	33	Left atrium
11	Scalene muscles	34	Right atrium
12	Clavicle	35	Left ventricle
13	Acromioclavicular joint	36	Ascending aorta
14	Glenoid fossa of scapula	37	Descending aorta
15	Acromion process of scapula	38	Inferior vena cava
16	Humeral head	39	Left lung
17	Coracoid process of scapula	40	Right lung
18	Deltoid	41	Liver
19	Trachea	42	Right hepatic vein
20	Thyroid gland	43	Middle hepatic vein
21	Internal jugular vein	44	Left hepatic vein
22	Subclavian vein	45	Stomach
23	Axillary vessels	46	Spleen
24	Brachial plexus and resulting	47	Vertebral artery
	nerves

■ Orientation		■ Section level
Superior		A B C

View

Right Left

Inferior

■ Notes

These three T1-weighted coronal magnetic	depend much on the degree of thoracic spine	cancer, the axilla may be affected both by nodal
resonance images are included to show the overall	kyphosis, body habitus and degree of inspiration.	metastases and by the effects of radiotherapy.
relations of the head, neck, thorax and upper	The relations in this relatively obese subject are fairly	These can cause either neurological symptoms in
abdomen. Only rarely would such a large field of	representative.	the arm or lymphoedema. Coronal images of the
view be used in clinical practice, as the anatomical	A wide field of view is used when trying to	two axillae together can be very helpful in this
spatial resolution is inevitably compromised. Of	compare structures on the two sides. The brachial	differentiation, which can be difficult on clinical
course, the exact relations on the coronal plane	plexus (image B, 24) is a case in point. In breast	grounds.

129

MRIs Coronal – images Selected

THORAX

THORAX Selected images – Chest CT

	A		B
	Coronal computed tomogram (CT)		Coronal computed tomogram (CT)
				20
		1
		17		17
	3	2	2	5	18
		6
	4	5
		7
	A		B	19
	C		D
	Sagittal computed tomogram (CT)		Sagittal computed tomogram (CT)
	Left Lung		Right Lung
		11	11
		15
			16		15
			12		13
	12
		13
	15		15
130	C		D

Selected images – Chest CT
	THORAX

■ Orientation		■ Orientation
Superior		Superior

Right

Left

Anterior

Posterior

						A	B E	Inferior	C	D	Inferior
	E					1	Trachea		12	Lingula (on the left)
	Reconstructed 3D computed					2	Right main bronchus		13	Lower lobe
						3	Right upper lobe bronchus		14	Middle lobe (on the right)
	tomogram (CT)
						4	Bronchus intermedius		15	Oblique fissure
						5	Left main bronchus		16	Horizontal fissure (on the
						6	Left upper lobe/lingular			right)
			1				bronchus		17	Aortic knuckle
						7	Left lower lobe bronchus		18	Left pulmonary artery
						8	Left upper lobe bronchus		19	Oesophagus (containing
						9	Left upper lobe lingular			some swallowed air)
			20				bronchus		20	Carina – the bifurcation of
	3	2	5		8	10 Right lower lobe bronchus				the trachea
				6	9	11 Upper lobe
		4
				7
	10
	E

■ Notes

A spiral CT dataset of the chest at full inspiration has	lowest image is a three-dimensional reconstruction
been obtained on a multidetector CT system. Next,	just extracting out the airways and accentuating the
the individual thin slices have been loaded together to	interface between air and soft tissue – this provides a
form a three-dimensional volume with each voxel	graphic map of the anatomy of the trachea and main
isometric so that the x, y and z resolutions of the	bronchi. These images elegantly show the more
resulting pixels are identical. This three-dimensional	vertical nature of the right main bronchus (2) – hence
dataset can be analysed in a variety of ways.	the peanut and the endotracheal tube tend to enter
The first two images show coronal multiplanar	the right side preferentially. They also show the
reconstructions viewed at lung settings to show the	greater length of the left main bronchus (5); on the
anatomy of the airways in this plane. The middle	right, the takeoff for the upper lobe bronchus can be
images shows sagittal reconstructions to demonstrate	very close to the carina (20, the point of bifurcation
the lobes and fissures of the left and right lungs. The	of the trachea into two main bronchi).

131

		Selected images – Arterial system
	THORAX

A

B

132

Selected images – Arterial system
	THORAX

2
1	9
	3
	11	12
	10
3
8	13	8
		14
	15	14
4	5
	6	4
	4

B

7

A

1	Heart	9 Twelfth thoracic vertebra			■ Orientation
2	Ascending aorta	10	First lumbar vertebra
3	Abdominal aorta	11	Coeliac artery			Superior
4	Common iliac artery	12	Splenic artery
5	External iliac artery	13	Hepatic artery
6	Common femoral artery	14	Superior mesenteric artery
7	Superficial femoral artery		and arcade		Right			Left
8	Kidney and pelvicalyceal	15	Cholecystectomy clips
	system
						Inferior

■ Notes

	These two surface rendered 3D angiograms have	On the right image the patient has had a previous
	been obtained on a modern CT system following the	laproscopic cholecystectomy and the clips (15) can
	injection of standard iodinated contrast medium. The	readily be identified as very dense structures overlying
	CT data were acquired during the aortic phase of the	the right kidney and close to the hepatic artery (13).
	passage of contrast medium through the body and	Note the way the aorta changes in calibre at the L1
	the images subsequently manipulated on the	level; it is smaller inferior to the coeliac artery,
	workstation.	superior mensenteric artery and the two renal
	On the left image the global view allows the	arteries. The superior mensenteric arcade is beautifully
	relationship of the heart, aorta, iliac and femoral	demonstrated (14). The tortuosity of the iliac vessels is
	vessels to be appreciated in relation to the skeletal	normal in middle age and above. The renal and
	structures. A test dose of contrast medium has been	splenic parenchyma are only faintly seen in this early
	given sometime before and this accounts for the	phase.
				133
	dense iodine being excreted from the kidneys and
	pelvicalyceal system (8).