Radiographs of Pleural Pathologies

1. Radiography of Pleural Pathologies
Presented by:
Anish Dhakal
September 16th, 2018

3. Normal Anatomy & Physiology
• Parietal pleural lines the inside of thoracic cage, visceral pleura
adheres to the lung surface
• Enfolded visceral pleura forms the interlobar fissures
• Potential space: 2 to 5 mL pleural fluid
• Hundreds of milliliters fluid produced and reabsorbed each day
• Fluid produced primarily at the parietal pleura
• Reabsorbed at the visceral pleura and by lymphatic drainage through
the parietal pleura

5. Transudates or Exudates?
Transudate Exudate
Congestive Heart Failure Malignancy
Hypoalbuminemia Empyema
Cirrhosis Hemothorax
Nephrotic syndrome Chylothorax

6. Side specificity:
Usually bilateral Usually unilateral Left sided Right sided
Congestive Heart Failure
(usually same amount on
either side)
Tuberculosis Pancreatitis Meigs syndrome
Lupus Pulmonary
thromboembolic disease
Distal thoracic duct
obstruction
Rheumatoid arthritis
Trauma Dressler syndrome Proximal thoracic duct
obstruction

7. Opacified Hemithorax

8. Decubitus film for Pleural Effusion:
• Confirm the presence of pleural effusion
• Determine whether a pleural effusion flows freely, important factor
before draining the fluid
• “Uncover” a portion of the underlying lung hidden by effusion

10. Patterns of Pleural Effusion on Chest X-Rays:
• Subpulmonic effusion:
Between the parietal pleura lining the superior surface of diaphragm
and visceral pleura under the lower lung lobe

12. The Meniscus Sign:

13. Loculated Pleural Effusions:
• Absence of pleural adhesions: effusions flow freely with change in
patient position
• Adhesions, commonly caused by old infections or hemothorax
causes effusions in the same location irrespective of change in
position
• Unusual shape and unusual location
• Therapeutic importance: collections traversed by multiple adhesions
making it difficult to drain the noncommunicating pockets of fluid in a
single pleural drainage

15. Fissural Pseudotumors:
• Also called vanishing tumors
• Sharply marginated collections of pleural fluid either between the
layers of interlobar fissure or beneath the fissure in subpleural
location
• Transudates, most commonly in CHF patients
• Lenticular in shape, mostly in minor fissure, no free flow, usually with
pointed ends on both sides

17. Laminar effusions:
• Thin, bandlike density along the lateral chest wall near costophrenic
angle but doesn’t obliterate it)
• CHF or lymphangitic spread of malignancy

19. Hydropneumothorax/Hemopneumothorax:

20. Pneumothorax:
• Air in the pleural cavity
• Visceral pleura visible as thin white line, outlined by air on both sides
• Curvature of visceral pleural line is parallel to that of chest wall
• In supine radiograph, pneumothorax air displaces costophrenic
sulcus inferiorly and increases lucency of that costophrenic sulcus
(Deep sulcus sign)
• Decubitus chest x-rays or expiratory chest x-rays might sometimes be useful

22. Deep Sulcus Sign:

23. Conditions Mimicking Pneumothorax:
• Absence of lung markings:
1. Bullous diseases of lung
2. Large cysts of lung
3. Pulmonary embolism (lack of perfusion in particular part of lung:
Westermark’s sign of oligemia)
Paradoxically insertion of chest tube into bulla might cause
pneumothorax
Look for visceral pleural line convex outwards

25. Mistaking a skinfold for pneumothorax:
• Fold of skin between patient’s back and cassette
• Edge of skinfold might be mistaken for visceral pleural line
• Parallel to the chest wall just like pneumothorax
• Usually thick band of density rather than thin pleural line

27. Mistaking medial border of scapula for
pneumothorax
• Supine radiographs: scapula are not retracted to the outer margin of
the rib cage
• Medial border of scapula superimpose on upper lung border and
mimic pleural white line

29. Volume Calculation in Pneumothorax: How
large it is?

32. Example of Calculation: Light’s Equation
• A pneumothorax of 2 cm (distance between visceral plural line and
parietal pleura)
• HT= 10 cm
• L= 8 cm
• Volume of pneumothorax= 1- 83/103
= 1 – 512/1000
= 49% of total hemithorax volume