Mediastinum

Space between lungs

and pleural surfaces
From sternum anteriorly to
thoracic vertebrae posteriorly
From thoracic inlet superiorly to
diaphragm inferiorly
Does not include paravertebral
regions
 Structures
Organs
Thymus
Heart
Aerodigestive tract
Trachea and central
airways
Esophagus
Vessels
Systemic arteries
Thoracic aorta
Thoracic aortic branches
Systemic veins
Venae cavae
Azygos and hemiazygos veins
Central pulmonary arteries and
veins
 Lymphatics,
thoracic duct,
lymph nodes
Nerves
Vagus nerves (X)
Right vagus nerve
courses inferiorly along
lateral trachea, behind
hilum and along lateral
esophagus with branches
to esophagus, cardiac and
pulmonary plexi
 Left vagus nerve
courses inferiorly along
lateral aortic arch,
behind hilum and along
lateral esophagus with
branches to esophagus,
cardiac and pulmonary
plexi
 Left recurrent laryngeal
nerve, branch of left vagus
nerve at lateral aortic arch,
courses under aortic arch,
continues superiorly in a
groove between the trachea
and esophagus towards the
neck to supply the larynx
Phrenic nerves
Right phrenic nerve is
lateral to vagus nerve,
courses along lateral
aspect of right
brachiocephalic vein,
continues anterior to hilum
along lateral pericardium
Left phrenic nerve is
lateral to vagus nerve and
proximal left
brachiocephalic vein,
courses along lateral
proximal aortic arch,
continues anterior to hilum
along lateral pericardium
Mesenchymal
tissues
Pericardium
Mediastinal fat
General Concepts
No true mediastinal compartments
No defined tissue planes
compartmentalize the mediastinum
Establishment of arbitrary mediastinal
compartments
Description of anatomic abnormalities
Classification of disease processes
based on location
Differential diagnosis of mediastinal
masses
Mediastinal compartments
Anatomic mediastinal
compartments
Surgical mediastinal
compartments
Radiologic mediastinal
compartments
Anatomic Mediastinal
Compartments
Superior mediastinum
Mediastinal contents superior to
a transverse plane extending
from sternal angle to T4-T5 disk
From manubrium sternum
anteriorly to T1-T4 vertebral
bodies posteriorly
Contents
Thymus
Aortic arch
Right brachiocephalic, left common
carotid, left subclavian arteries
Superior vena cava
Left superior intercostal, right and left
brachiocephalic veins
Superior trachea
Superior esophagus
Phrenic, vagus, left recurrent laryngeal
nerves
Superior aspect of thoracic duct
Lymph nodes
Inferior mediastinum
Three compartments
below superior
mediastinum
Anterior mediastinum
Middle mediastinum
Posterior mediastinum
Anterior mediastinum
From sternum anteriorly
to pericardium
posteriorly
Inferior thymus
Fat, nerves, lymph
nodes, vessels
Middle mediastinum
Bound by fibrous
pericardium
Heart
Central systemic and
pulmonary vessels
Nerves, vessels
Posterior mediastinum
From fibrous pericardium
anteriorly to thoracic vertebral
bodies posteriorly
Inferior esophagus
Descending aorta
Portions of azygos system
Thoracic duct, lymph nodes
Sympathetic trunks, nerves
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,
aerodigestive tract and the central
aspects of the thoracic great
vessels.
The mediastinum extends
from the thoracic inlet
superiorly to the
diaphragm inferiorly and
from the sternum
anteriorly to the thoracic
vertebrae posteriorly.
 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.
 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 inferiorly. The mediastinum
contains the heart, thymus, portions of
the aerodigestive tract and the great
vessels of the thorax. Mediastinal fat is
also present in variable quantities.
 Graphic depicts the cross-sectional
anatomy of the mediastinum at the
level of the pulmonary trunk. The
mediastinum is located in the middle
of the thorax between the lungs and
pleural surfaces. It contains several
organs, vascular structures, the
esophagus, the central
tracheobronchial tree, lymph nodes,
nerves and mediastinal fat.
 Graphic depicts a detail of the left
paravertebral region. This area does
not form part of the mediastinum
proper but is often included in
imaging and surgical classifications
of the mediastinum and its
compartments. The paravertebral
region contains vascular structures,
fat, lymph nodes and lymphatics and
nerves.
 The peripheral nerves
course through the
paravertebral region as they
exit the neural foramen.
The sympathetic trunk and
ganglia are oriented along
the length of the
paravertebral region.
 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 right
brachiocephalic vein and
continues inferiorly anterior
to the hilum and along the
pericardium. It enters the
abdomen with the inferior
vena cava.
 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.
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
 First of two graphics
depicting the anatomic
mediastinal 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.
 Graphic depicts the
anatomic mediastinal
compartments. The superior
mediastinum lies above a
line drawn from the
sternomanubrial junction to
the T4-5 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.
 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
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.
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.
 Left lateral chest radiograph
showing the Fraser, Muller,
Colman and Par. 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.
 Graphic shows the anatomic
structures of the mediastinum as
they relate to the mediastinal
compartments of Fraser, Muller,
Colman and Par. 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.
 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
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.
 The anterior contour of the
mediastinum on the left
lateral chest radiograph (from
inferior to superior) is formed
by the right ventricle and
pulmonary trunk. A portion of
the proximal ascending aorta
may be evident superiorly.
 The posterior
contour (from
superior to inferior)
is formed by the
aortic arch, left
atrium, left ventricle
Sagittal contrast-enhanced chest
CT (mediastinal window) shows
the anatomic correlates of the
mediastinal contours seen on
lateral radiography. The anterior
contour is formed (from inferior
to superior) by the right
ventricle, pulmonary trunk and
proximal aortic arch.
The posterior contour
(from superior to
inferior) is formed by
the distal aortic arch,
the left atrium and
the left ventricle.
 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.
 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.
 First of two chest radiographs of
normal infants demonstrate
variations in the appearance of
the normal pediatric thymus. AP
chest radiograph of a 10 month
old infant illustrates the sail sign.
The left thymic lobe manifests as
a triangular opacity that mimics
the morphology of a nautical sail.
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
paratracheal; 4) lower paratracheal;
5) subaortic (aortopulmonary); 6)
para-aortic; 7) subcarinal; 8)
paraesophageal; 9) pulmonary
ligament. Lymph nodes in stations
10-14 are considered
intrapulmonary.
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.