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Helpful Radiological Signs
in CXR
A. Almasi MD
Iran University of Medical Sciences
Department of Radiology
Mass vs Infiltrate/ Consolidation
1.
2.
3.
•
•
•

First of all, you should be able to detect an abnormality
Then you shoul...
Silouhette Sign
• By studying the borders of the heart,
diaphragm and the aorta we can determine
the anteroposterior posit...
Silhouette Sign
• For the heart, the silhouette
sign can be caused by an
opacity in the RML, lingula,
anterior segment of ...
Silhouette sign in an anteriorly
located mass
(bronchogenic carcinoma)
Silhuette sign in a posteriorly located lesion (lower
lobe pneumonia); not obscuring the right heart border
Silhouette sign in an anterior lesion
obscuring the PA but not the aortic knob
Air Bronchogram
• Visible air-filled bronchus in a background
of airless parenchyma
• Most commonly seen in pneumonia and
...
Air bronchogram in pneumonia
Air Bronchogram
Causes of an air-bronchogram
Common
• Expiratory film
• Consolidation (air space
disease)
• Cardiogenic pulmonary
edema
• ...
Air-space (acinar/alveolar) pattern or
consolidation or infiltration
• Acinus is the functional unit of the lung and is de...
Air-space pattern characteristics
• Ill-defined nodular shadows 4-8mm in
diameter
• Coalescence of these acinar nodules
• ...
Acinar nodules in a case of diffuse
TB (bronchial spread)
Coalescing acinar nodules in
pulmonary contusion (hemorrhage)
Alveolar filling pattern in a case of
diffuse TB
Sharp border of an alveolar shadow confined to
the minor fissure in RUL pneumonia
Typical air-space pattern in
pneumonia
Common causes of an air-space
pattern (Consolidation)
•
•
•
•

Pulmonary edema: cardiogenic/noncardiogenic
Pneumonia/pneum...
Pulmonary edema
• Two basic types:
– cardogenic edema: increased hydrostatic
pulmonary capillary pressure
– noncardogenic ...
Cardiogenic Pulmonary Edema
• Would you favor pneumonia or CHF in this patient? Why?
What pattern is shown?
Fat Embolism (ARDS)
• Mostly
peripheral
distribution of the
opacities contrasts
with the central bat
wing pattern seen in
...
Pulmonary Hemorrhage
Congestive Heart Failure
• Cardiomegaly: the earliest CXR finding
• Cephalization: when the pulmonary capillary wedge
pres...
Kerley B lines
•
•

These are horizontal lines less than 2cm long, commonly found in the lower
zone periphery. These lines...
PVH grade I
PVH grade II

Peribronchial
cuffing
PVH grade III
Solitary Pulmonary Nodule
•
•
•

•
•

•

•

A solitary nodule in the lung can be totally innocuous or potentially a fatal
...
Solitary Pulmonary Nodule
• This patient clearly has a solitary lung nodule present on chest xray. Can you tell which lobe...
Solitary Pulmonary Nodule
• PA and Lateral of a subtle right lower lobe
cancer. Can you find it in the frontal projection?
Interestitial lung disease
• Correlation between the CXR and severity
of the symptoms is poor
• HRCT can detect interstiti...
Different patterns of interestitial
involvement of the lungs
• Miliary pattern: 2-4mm well-defined nodules most
often seen...
The most common causes of miliary
pattern
1)
2)
3)
4)
5)

TB
Silicosis
Coal worker’s pneumoconiosis
Metastases
Sarcoidosis
Miliary pattern in TB
Ground glass density/opacity in
usual interstitial pneumonitis
Reticulonodular pattern in idiopathic
pulmonary fibrosis
Honeycomb pattern in longstanding
RA with reumatoid nodules
Atelectasis/Collapse/Volume Loss
• Passive collapse: due to pleural effusion or
thickening or pneumothorax
• Cicatrisation...
Anatomy of the Fissures
Radiological Signs of Atelectasis
• Direct signs
– Displacement of interlobar fissures
– Loss of aeration
– Vascular and b...
Adhesive Atelectasis due to RDS
Passive Atelectasis due to
Pneumothorax
Cicatrisation Atelectasis due to TB
RUL Atelectasis
RUL Atelectasis
RUL Atelectasis
RUL Consolidation
• Lobar consolidation
usually indicates
bacterial pneumonia
RUL Consolidation
Thymus Sail Sign
Left Upper Lobe Atelectasis
LUL Atelectasis
LUL Consolidation
LUL Atelectasis
LUL Atelectasis
Middle Lobe Atelectasis
•

Right middle lobe atelectasis may cause minimal changes on the frontal chest
film. A loss of de...
RML Atelectasis
• Right middle lobe collapse can be difficult to detect in the PA
film.
• The right heart border is indist...
Middle Lobe Consolidation
RML Consolidation vs Collapse
Left Lower Lobe Collapse
Left Lower Lobe Collapse
Left Lower Lobe Consolidation
Right Lower Lobe Collapse
Right Lower Lobe Collapse
Right Lower Lobe Consolidation
Pleural Diseases
•
•
•
•
•
•

Pleural Effusion
Subpulmonic Effusion
Pleural Thickening
Pleural Calcification
Pneumothorax
...
Normal Pleural Space
• Visceral pleura is adherent to the lung
• Space between visceral and parietal
pleura is a potential...
Appearances of Pleural Effusions
• Blunting of
Costophrenic angle
• Meniscus sign
• Subpulmonic
effusion
• Layering

• Loc...
Blunting of Costophrenic Angle
• Normally there are 2-10cc of fluid in the
pleural space
• When >75cc accumulate, the post...
Blunting of the CP Angle

Normal Rt costophrenic angle

Blunted Lt costophrenic angle

• When 200-300cc of fluid accumulat...
Meniscus Sign
• Pleural fluid tends to rise higher along its
edge producing a meniscus shape medially
and laterally.
• Usu...
Meniscus Sign
• Fluid rises higher
along the edge of a
pleural
effusion
producing an upside
down “U” or meniscus
shape.
Loculated Effusion
• Occurs secondary to adhesions which form
between visceral and parietal pleura.
• Adhesions more commo...
Loculated Effusion
• A loculated effusion
has an unusual shape
(lentiform) or position
in the thoracic cavity
• This is a ...
Laminar Effusion
• A laminar effusion collects in the loose
connective tissue between the lung and the
visceral pleura.
• ...
Laminar Effusion
• A laminar effusion collects
between the lung and the
visceral pleura in the loose
connective tissue of ...
Effect of Position - Layering

Erect
Supine
• In the supine position, the fluid layers out posteriorly and
produces a hazi...
Lateralized Diaphragmatic Dome in
Subpulmonic Effusion

Subpulmonic PE

Normal
Right Lateral Decubitus
Subpulmonic Effusion presenting as
increased distance between stomach gas
and diaphragm
Subpulmonic PE

Previously Normal Film
Deep Sulcus Sign
Pneumothorax
Hydropneumothorax
• If both a pneumothorax and a pleural
effusion occur together, it is called a
hydropneumothorax.
• A hy...
Hydropneumothorax
• A straight edge, indicative of a
fluid interface, in this case an airfluid interface, is seen on the
r...
Y=4.2+[4.7 x (A+B+C)]
Barotrauma
Unilateral White Hemithorax
Helpful radiological signs in cxr25 11-91
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Helpful radiological signs in cxr25 11-91

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Helpful Radiologic Signs in Chest X-ray

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Helpful radiological signs in cxr25 11-91

  1. 1. Helpful Radiological Signs in CXR A. Almasi MD Iran University of Medical Sciences Department of Radiology
  2. 2. Mass vs Infiltrate/ Consolidation 1. 2. 3. • • • First of all, you should be able to detect an abnormality Then you should describe your findings Putting together your different findings you can come to a diagnosis In each of the cases below, there is an abnormal opacity in the left upper lobe (1) In the case on the left, the opacity would best be described as well-defined. The case on the right has an opacity that is poorly defined (2) Therefore the left radiograph depicts a mass and the one on the right is an air space disease (3)
  3. 3. Silouhette Sign • By studying the borders of the heart, diaphragm and the aorta we can determine the anteroposterior position of a lesion on a frontal CXR. • The border of the anatomic organ is obscured only if it is in contact with the lesion (i.e. in the same anteroposterior position).
  4. 4. Silhouette Sign • For the heart, the silhouette sign can be caused by an opacity in the RML, lingula, anterior segment of the upper lobe, anterior mediastinum, and anterior portion of the pleural cavity • This contrasts with an opacity in the posterior pleural cavity, posterior mediastinum, of lower lobes which cause an overlap and not an obliteration of the heart border
  5. 5. Silhouette sign in an anteriorly located mass (bronchogenic carcinoma)
  6. 6. Silhuette sign in a posteriorly located lesion (lower lobe pneumonia); not obscuring the right heart border
  7. 7. Silhouette sign in an anterior lesion obscuring the PA but not the aortic knob
  8. 8. Air Bronchogram • Visible air-filled bronchus in a background of airless parenchyma • Most commonly seen in pneumonia and pulmonary edema • Its presence confirms the intrapulmonary location of the lesion
  9. 9. Air bronchogram in pneumonia
  10. 10. Air Bronchogram
  11. 11. Causes of an air-bronchogram Common • Expiratory film • Consolidation (air space disease) • Cardiogenic pulmonary edema • Hyaline membrane disease Rare • • • • • • • Lymphoma Alveolar cell carcinoma Sarcoidosis Fibrosing alveolitis Alveolar proteinosis ARDS Radiation fibrosis
  12. 12. Air-space (acinar/alveolar) pattern or consolidation or infiltration • Acinus is the functional unit of the lung and is defined as all the airways located distal to a terminal bronchiole. • Acinar pattern appears when the distal airways and the alveoli are filled with fluid (transudate, exudate or blood). • Fluid-filled acini form nodular shadows 4-8mm in diameter (acinar shadows). • An air-filled acinus surrounded by fluid-filled acini produces air-acinogram • These acinar shadows can coalesce into larger illdefined homogenous or patchy opacities which are well-defined adjacent to the fissures. • Vascular markings are usually obscured. • Air-bronchogram is characteristic
  13. 13. Air-space pattern characteristics • Ill-defined nodular shadows 4-8mm in diameter • Coalescence of these acinar nodules • Ill-defined borders of larger opacities except where limited to a fissure • Air-bronchogram • Air-acinogram
  14. 14. Acinar nodules in a case of diffuse TB (bronchial spread)
  15. 15. Coalescing acinar nodules in pulmonary contusion (hemorrhage)
  16. 16. Alveolar filling pattern in a case of diffuse TB
  17. 17. Sharp border of an alveolar shadow confined to the minor fissure in RUL pneumonia
  18. 18. Typical air-space pattern in pneumonia
  19. 19. Common causes of an air-space pattern (Consolidation) • • • • Pulmonary edema: cardiogenic/noncardiogenic Pneumonia/pneumonitis Aspiration Hemorrhage
  20. 20. Pulmonary edema • Two basic types: – cardogenic edema: increased hydrostatic pulmonary capillary pressure – noncardogenic edema: either altered capillary membrane permeability or decreased plasma oncotic pressure.
  21. 21. Cardiogenic Pulmonary Edema • Would you favor pneumonia or CHF in this patient? Why? What pattern is shown?
  22. 22. Fat Embolism (ARDS) • Mostly peripheral distribution of the opacities contrasts with the central bat wing pattern seen in cardiogenic pulmonary edema • Normal heart size is another suggestive evidence
  23. 23. Pulmonary Hemorrhage
  24. 24. Congestive Heart Failure • Cardiomegaly: the earliest CXR finding • Cephalization: when the pulmonary capillary wedge pressure (PCWP) 12-18 mmHg pulmonary venous hypertension (PVH) grade I • Interstitial edema: PCWP 18-24 mmHg, Kerley lines and peribronchial cuffing (thickening), PVH grade II • Alveolar edema: PCWP > 24 mmHg, PVH grade III often in a classic perihilar bat wing pattern of density. Pleural effusions also often occur. • CXR is important in evaluating patients with CHF for development of pulmonary edema and evaluating response to therapy as well.
  25. 25. Kerley B lines • • These are horizontal lines less than 2cm long, commonly found in the lower zone periphery. These lines are the thickened, edematous interlobular septa. They are found in interstitial pulmonary edema, but are also seen in lymphangitis carcinomatosa, lymphoma and other diseases too.
  26. 26. PVH grade I
  27. 27. PVH grade II Peribronchial cuffing
  28. 28. PVH grade III
  29. 29. Solitary Pulmonary Nodule • • • • • • • A solitary nodule in the lung can be totally innocuous or potentially a fatal lung cancer Rule out presence of multiple nodules first After detection, the initial step in analysis is to compare the film with prior films if available. A nodule that is unchanged for two years is almost certainly benign If the nodule is completely calcified or has central or stippled calcium it is benign If the nodule is indeterminate after considering old films and calcification, subsequent steps in the work-up include ordering a CT to find subtle calcification Nodules with irregular calcifications or those that are off center should be considered suspicious, and need to be worked up further with a PET scan or biopsy The patient may choose to have an indeterminate nodule removed if there is no evidence of spread on CT as this would diagnose and treat a cancer if present
  30. 30. Solitary Pulmonary Nodule • This patient clearly has a solitary lung nodule present on chest xray. Can you tell which lobe it's in?
  31. 31. Solitary Pulmonary Nodule • PA and Lateral of a subtle right lower lobe cancer. Can you find it in the frontal projection?
  32. 32. Interestitial lung disease • Correlation between the CXR and severity of the symptoms is poor • HRCT can detect interstitial changes in earlier stages • Different patterns on CXR: – – – – – Miliary Ground-glass Reticular Reticulonodular Honeycomb
  33. 33. Different patterns of interestitial involvement of the lungs • Miliary pattern: 2-4mm well-defined nodules most often seen with TB • Ground-glass opacity: low density opacity which does not obscure the vascular pattern of the lungs. It may be due to either an interestitial disease or mild alveolar filling • Reticular pattern: fine irregular network of lines unlike vessels which bifurcate • Reticulonodular pattern: presenting as reticulations plus nodules <1cm in between • Honey combing: a network made of thin-walled cysts measuring less than one centimeter in diameter and implying end-stage lung fibrosis
  34. 34. The most common causes of miliary pattern 1) 2) 3) 4) 5) TB Silicosis Coal worker’s pneumoconiosis Metastases Sarcoidosis
  35. 35. Miliary pattern in TB
  36. 36. Ground glass density/opacity in usual interstitial pneumonitis
  37. 37. Reticulonodular pattern in idiopathic pulmonary fibrosis
  38. 38. Honeycomb pattern in longstanding RA with reumatoid nodules
  39. 39. Atelectasis/Collapse/Volume Loss • Passive collapse: due to pleural effusion or thickening or pneumothorax • Cicatrisation collapse: due to fibrosis (e.g. IPF, TB) • Adhesive collapse: due to lack of surfactant • Resorption collapse: due to bronchial obstruction. This has a lobar pattern
  40. 40. Anatomy of the Fissures
  41. 41. Radiological Signs of Atelectasis • Direct signs – Displacement of interlobar fissures – Loss of aeration – Vascular and bronchial signs (crowding of vascular markings, airbronchogram) • Indirect signs – – – – Elevation of a hemidiaphragm Mediastinal displacement Hilar displacement Compensatory hyperinflation
  42. 42. Adhesive Atelectasis due to RDS
  43. 43. Passive Atelectasis due to Pneumothorax
  44. 44. Cicatrisation Atelectasis due to TB
  45. 45. RUL Atelectasis
  46. 46. RUL Atelectasis
  47. 47. RUL Atelectasis
  48. 48. RUL Consolidation • Lobar consolidation usually indicates bacterial pneumonia
  49. 49. RUL Consolidation
  50. 50. Thymus Sail Sign
  51. 51. Left Upper Lobe Atelectasis
  52. 52. LUL Atelectasis
  53. 53. LUL Consolidation
  54. 54. LUL Atelectasis
  55. 55. LUL Atelectasis
  56. 56. Middle Lobe Atelectasis • Right middle lobe atelectasis may cause minimal changes on the frontal chest film. A loss of definition of the right heart border is the key finding. Right middle lobe collapse is usually more easily seen in the lateral view. The horizontal and lower portion of the major fissures start to approximate with increasing opacity leading to a wedge of opacity pointing to the hilum. Like other cases of atelectasis, this collapse may by confused with right middle lobe pneumonia.
  57. 57. RML Atelectasis • Right middle lobe collapse can be difficult to detect in the PA film. • The right heart border is indistinct on the PA film. • The lateral CXR shows a marked decrease in the distance between the horizontal and oblique fissures.
  58. 58. Middle Lobe Consolidation
  59. 59. RML Consolidation vs Collapse
  60. 60. Left Lower Lobe Collapse
  61. 61. Left Lower Lobe Collapse
  62. 62. Left Lower Lobe Consolidation
  63. 63. Right Lower Lobe Collapse
  64. 64. Right Lower Lobe Collapse
  65. 65. Right Lower Lobe Consolidation
  66. 66. Pleural Diseases • • • • • • Pleural Effusion Subpulmonic Effusion Pleural Thickening Pleural Calcification Pneumothorax bronchopleural fistula
  67. 67. Normal Pleural Space • Visceral pleura is adherent to the lung • Space between visceral and parietal pleura is a potential space • Infoldings of visceral pleura form fissures. • Normally there are 2-10 cc of fluid in the pleural space.
  68. 68. Appearances of Pleural Effusions • Blunting of Costophrenic angle • Meniscus sign • Subpulmonic effusion • Layering • Loculated • Laminar effusion • Opacified hemithorax • Air-fluid levels
  69. 69. Blunting of Costophrenic Angle • Normally there are 2-10cc of fluid in the pleural space • When >75cc accumulate, the posterior costophrenic (CP) sulci, seen on the lateral film, become blunted • When 200-300cc accumulate, the CP sulci on the frontal film become blunted
  70. 70. Blunting of the CP Angle Normal Rt costophrenic angle Blunted Lt costophrenic angle • When 200-300cc of fluid accumulate in pleural space, the usually acute costophrenic angle becomes blunted
  71. 71. Meniscus Sign • Pleural fluid tends to rise higher along its edge producing a meniscus shape medially and laterally. • Usually only lateral meniscus can be seen • The meniscus is a good indicator of the presence of a pleural effusion.
  72. 72. Meniscus Sign • Fluid rises higher along the edge of a pleural effusion producing an upside down “U” or meniscus shape.
  73. 73. Loculated Effusion • Occurs secondary to adhesions which form between visceral and parietal pleura. • Adhesions more common with blood (hemothorax) and pus (empyema). • Loculated effusions have unusual shapes or positions in thorax e.g. remain at apex on erect films.
  74. 74. Loculated Effusion • A loculated effusion has an unusual shape (lentiform) or position in the thoracic cavity • This is a loculated empyema
  75. 75. Laminar Effusion • A laminar effusion collects in the loose connective tissue between the lung and the visceral pleura. • It is not usually free-flowing. • It usually occurs with CHF or lymphangitic spread of malignancy
  76. 76. Laminar Effusion • A laminar effusion collects between the lung and the visceral pleura in the loose connective tissue of the subpleural space • Laminar effusions are usually seen with CHF or lymphangitic spread of tumor
  77. 77. Effect of Position - Layering Erect Supine • In the supine position, the fluid layers out posteriorly and produces a haziness, especially near the bases. • In the erect position, the fluid falls to the bases.
  78. 78. Lateralized Diaphragmatic Dome in Subpulmonic Effusion Subpulmonic PE Normal
  79. 79. Right Lateral Decubitus
  80. 80. Subpulmonic Effusion presenting as increased distance between stomach gas and diaphragm
  81. 81. Subpulmonic PE Previously Normal Film
  82. 82. Deep Sulcus Sign
  83. 83. Pneumothorax
  84. 84. Hydropneumothorax • If both a pneumothorax and a pleural effusion occur together, it is called a hydropneumothorax. • A hydropneumothorax is usually due to trauma, surgery or bronchopleural fistula • It is characterized by an air-fluid level in the hemithorax.
  85. 85. Hydropneumothorax • A straight edge, indicative of a fluid interface, in this case an airfluid interface, is seen on the right. • In order to have an air-fluid level in the pleural space, there must be a pneumothorax present.
  86. 86. Y=4.2+[4.7 x (A+B+C)]
  87. 87. Barotrauma
  88. 88. Unilateral White Hemithorax

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