Pleural effusion Is the commonest abn of pleura Pathogenesis off pleural effusion Inc cap HP – CHF Dec cap OP - hypoalbuminemia. Inc cap perm- inflammation. Obst lymphatics - tumor. Movement of fluid from extrathoracic site

2. PLEURAL EFFUSION n TYPES
PNEUMOTHORAX
PLEURAL THICKENING
PLEURAL CALCIFICATION
PLEURAL TUMORS

5. Is the commonest abn of pleura
Pathogenesis off pleural effusion
1. Inc cap HP – CHF
2. Dec cap OP - hypoalbuminemia.
3. Inc cap perm- inflammation.
4. Obst lymphatics - tumor.
5. Movement of fluid from extrathoracic site

6. • less of protein
◦ Clear, watery fluids
◦ imbalance b/w HP n
OP
◦ Usual b/l
TRANSUDATES VS EXUDATES
•excess protein
•Amber, cloudy
fluid clots on
standing to
frank pus
•Usual u/l
except
PE, RA,SLE,
dressler,myx,
Lymphoma

7. R sided – liver, ascites, CHF
L sided – eso , panc, aorta, pericard
Massive – T n inf
DRUGS – pt also
Uremia – pericarditis
CAPD – sweet hydrothorax

8.  Massive effusion may cause complete
radiolucency of thorax – c/l med shift
 No shift – collapse , ext pleural ca
 Diaphragmatic inv – esp left
SUPINE --Hazziness of hemithorax with
preserved vascular shadows

9.  Lamellar effusion
◦ Reprents interstitial pulm fluid and are not true
pleural effusions
◦ Remains fixed with postural change
 Subpulmonic effusion
◦ Increased separation between stomach gas and
apparent hemidiaphragm (>2cm)

10. Adhesions
b/w Vp – Pp , fissures location

13. TRANSUDATES --anechoic
 Exudates
1. Echoes
2. Septa
3. Strands
4. Pt ( > 1cm)
5. Diaphragmatic nodule - CA

15. Densely echogenic fluid VS mass–
1. Fibrin strands
2. Components move wid respi
PLEURALEFFUSION VS PLEURALTHICKENING
1. USG - colour doppler ( eff gives colour) ( pt little or
no)
2. CT – d/t IV contrast in late venous phase -- pleura
dilineated
3. MRI – T2 ---- EPF (white) , pt ( black), pleural fluid
(white)

16.  Pleural effusion on CT is seen as homogeneous
crescenteric opacity in most dependent part of
pleural cavity
 On CT pleural effusion shows low attenuation
than pleural thickening or consolidated or
fibrotic lung
 Cant diff bw transudate or exudate ( a/w pt)
 Loculated – lenticular – smooth margins- non
dep part

18. PLEURALFLUID VS ASCITES
Displacedcrussign:
DiaphragM sign:
Interfacesign:
Bare areasign

20. Low SI - T1W images and high SI - T2 W (
trans)
Can diff btw transudate n exudate
TRIPLE ECHO PULSE SEQUENCE –
Highest SI – complicated exudate ( pus)
High - exudate
Low – transudate

21.  Milky effusions ---TG/CM
 rupture of thoracic duct and seepage of
collaterals
 neoplastic, traumatic developmental
anomalies
 X ray and CT no diff from non chylous
 MRI : high SI
 Pseudochylothorax --milky effusion cholesterol or
lecithin globulin complexes rather than
chylomicrons
◦ Occurs in pleural disease of many years
◦ Seen in TB, rheumatoid disease

22.  CXR – usual – on clot –loculation , fib strand
 CT – hyperdense
 MRI – subacute /chronic - inc SI T1 , T2 – (
concentric ring sign)
 Trauma , AA rupture , coagulopathies ,
traumatic pneumo

23.  Purulent pleural effusion -infection of
pleural space
 Empyema has a strong tendency to loculate
 Malignant neoplasms may arise in the walls
of chronic long standing empyema cavities
 CXR = usual / loculated

24. CT
• Lenticular shaped collection with an obtuse angle at
the interface with chest wall.
• Thick uniform soft tissue density wall (Vp , Pp)
• Smooth inner and outer edge
• k/a split pleura sign
• Enhancement of pleura is seen after contrast
• Septa, LAP ( Subcarinal , paratracheal i/l)
• Inc attenuation of EPF (>50HU)
• Air bubbles +

25. •Exudate
btw them

27. I/P ABSCESS
Spherical
Thick walled
Abrupt vessel cut off
at margin
Bronchi seen at lung
abscess interface

28.  The most common cause of primary
spontaneous pneumothorax is rupture of an
apical subpleural bleb.
 The etiology is obscure--- Difference in
alveolar pressure in upright human between
the base and the apex.
 Children --cystic fibrosis.
 More common in men (6:1). , smoker
 Typical patient is young, tall, thin man in late
adolescence and early adulthood.

30.  Secondary spontaneous pneumothorax
◦ predisposing lung disease
◦ COPD -commonest
◦ The most common sarcoma - osteosarcoma and
synovial sarcoma.
◦ Catamenial pneumothorax, -first three days of menses,
 Tension pneumothorax
◦ gross mediastinal shift.
◦ depression of i/l hemidiaphragm ( more reliable)

31.  avascular space ------
visceral pleural line.
 Expiratory film or decubitus
view with suspected side
uppermost
 subsequent collapse of
ipsilateral lung
 Tension pneumothorax
 White visceral pleura line
mimics
1. Skin folds ( wider)

32.  Deep sulcus sign
 I/l transradiancy
 DOUBLE DIAPHRAGM
SIGN
( ant CP recess)

34. Complications of pneumothorax
• Loculated or encysted pneumothorax
• Haemopneumothorax
• Pyopneumothorax
• Presence of pleural fluid- hydropneumothorax-
there is horizontal air fluid level
• Tension pnumothorax
• Adhesions
• Re expansion edema

35.  LUNG SLIDING SIGN –nt ( large probe – dec
depth)
 BARCODE ( M MODE)
 Lung point
 False positive – COPD

38. IOC
No false positive
Can diff btw pneumo n bullae

40. Connection btw airway and pleura
Persistent pneumo , hydropneumo despite
continuous drainage
Seen in necrotising infections ,partial or
complete lung resection

41. Pt ---
1. Benign – a) diffuse /fibrothorax
b) focal / plaques
2. Malignant --- a) primary / MPM
( can b diffuse) b) secondary /mets (MC)
Calcifications = // to chest wall, diaphragm,
cardiac border ( cxr)

42. CXR -- Soft tissue shadowing --dependent
lateral and posterior parts of chest
 USG -- homogeneous dense layer adjacent to
chest wall.
CT-layer of soft tisssue opacity at chest wall
and lung inteface/ INNER TO RIBS
MRI – use to see tumor ext

43. 1. CIRCUMFERENTIAL THICKENING / RIND
PLEURAL THICKNESS (>1 cm) – in max
width
NODULAR / IRREG PLEURAL THICKENING
MEDIASTINAL PLEURAL INV

46. Cause = empyema, hemothorax, asbestos ,
TB,
 MPM , mets ( adenoCA) = malig pt,U/L
/asym
Can cause ventilatory restriction
Calcification inf>>>>>>>> asbestos
Hemo – a/w rib #
Empyema -- primary cause
Post talc sandwich = thick vp n pp with talc
in btw ( inc attenuation)
Asbestos ? b/l inv

47. CXR ---
soft tissue density along chest wall/ pleural
space ( extent > plaque) ( ¼ chest wall)
Blunting of CP angle -- common

49. CC =8cm
LATERALLY = 5cm
THICKNESS = 3mm

50.  Can occur in the cupula / apical cap
 Apical cap – TB n radiation, pancoast tumor ,
thoracic aorta injury , pt, age
 d/d on cxr - companion rib shadow ( scallop)
 EPF (u/l)
 Large = seen on cxr

52. Pleural plaques -- asbestos exposure ( MC)
 asymptomatic ( vs lung path = symp)
Marker of asbestos exposure
Multifocal , b/l
Always on parietal pleura ( may involve
fiss)
in posterolateral location along chest wall
and on diaphragmatic pleura ( never at
apex/ cp)
Calcify , ossify,
Inc risk of MPM n BAC

53. Can inc in size , thickness
In paravertertebral area – mimic I/C veins
If a/w interstitial lines k.a HAIRY PLAQUES
CLASSIFICATION
THICKNESS LENGTH
MINIMUM
(few )
< 1mm 1-3Cm
MODERATE
( multiple)
1 – 3 mm 3-5cm
SEVERE
( indent lung)
> 3 mm 8cm CC ,
> 5cm lat

56. PLEURAL PLAQUES ( ASBESTOS) / BENIGN CHR PT
↓
ROUND ATELECTESIS/ MASS ( LUNG)
↓
BVMCONVERGEFROMHILUMONTOMASS
↓
COMETTAIL SIGN

58. s/s +
Infiteration +
Inc in size with time
Pleural effusion
Seen in post lower lobe , middle , lingula
MRI dec SI T1 , inc SI T2

59. Same causes as pleural thickening
Ul/
• Empyema,
• hemorhorax
• Pleurisy
Bilateral
• Asbestos exposure (plaque>>> diffuse)

60.  Are relatively uncommon
 Can be localised or diffuse
 Localised
• Localised fibrous tumor
• Lipoma
• Extrathoracic mets

61. • submesenchymal cells of vp – origin
• MC , Asymtomatic ( benign)
• 6-7 decade , f>m
• Etiology ? Asbestos n radiation exposure
• Complication = hypertrophic osteoarthropathy /
hypoglycemia
• Calcify +
• Pleural effusion ±
• 1/3 malignant , 2/3 benign

62. • CXR =
• well defined ,,
• rounded or slightly lobulated mass –
• -variable size ----
• obtuse angle with chest wall
• Mobile with posture n resp

63. CT
Pleural mass ---- Size can be diff --- small and large
SMALL (<10 cm) LARGE (>10cm)
asymptomatic s/s + - cough, pain
,dysp,pneumo
Homogeneous enhancement heterogeneous ( d/t areas
of necrosis)
Pleural eff +
Atelectasis +
Mediastinal inv +
Invasion of chest wall+
benign malignant

65. Low to int SI on T1 , T2, proton density
If a/w necrosis , h’age – inc SI on T2
Gd – intense homogeneous enhancement

66. LIPOMA v/s LIPOSARCOMA
benign
Origin = fat tissue
Asymptomatic
Incidental finding
•CXR = pleural mass
•CT = uniform , pleural
mass , fat density ( < 50
HU)
•MRI = Inc SI on T1 , T2 (
T1>> T2)
Malignant
s/s +
Large
Infilterates surr
tissue
•CT = fat density +
soft ts. Density
•MRI = dec SI T1 ,
inc SI T2 d/t
myxoid
degeneration

67. Pleural mets’
• Are commonest cause of localised pleural mass with
rib destruction
• Seen in adeno CA ( breast, lung, GIT, ovary)
• Multiple
• Often a/w pleural effusion

68. Diffuse malignant mesothelioma
• Highly malignant progressive neoplasm
• Asbestos exposure ( chrysolite)
• Males
• 40-70 years

69. Irregular , nodular opacity ( peripherally)
Pleural effusion ± → + l/t c/l shift
Vol loss on affected side
Pt ±

70. CT` ( main for staging)
•Nodular soft ts mass with hypodens area ( necrosis)
•Pt = malignant esp in lower zones and diaphragmatic
surface
•effusion + = u/l , vol loss on i/l side
•Calcification may occur
•Fissural inv + / interlobar fissure thickening
•Chest wall inv + = rib displacement , bone destruction
•
•Loss of extrapleural fat and I/C muscles invasion
•ABSENCE OF PT does not rule out a neoplastic process

72. Can extend into chest wall via needle biopsy
tracks , surgical scars, chest tube tracts
VASCULAR invasion – obliteration of surr fat
planes, encasing >50% Circumference
TRANSDIAPHRAGMATIC INV – soft tissue
mass that encases hemidiaphragm
PULMONARY METS = nodules or masses

79. Min inc SI T1
Moderately Inc SI T2
Helpful to determine the soft tissue /chest
wall invasion/ diaphragm/ ETF

81. Uptake seen in both malignancy and
inflamm
Uptake malig>>> inflam
Used in staging and preop assessment
Detect occult extrathoracic mets
Predict prog (uptake i.p prog)
 always Used as adjunct with ct

82. • D/d
 Metastatic pleural deposits ( diff to diff) ( hilar LAP
more)
 Breast Ca
 Malignant thymoma ( drop mets in ant med mass)
 Lymphoma- deposits are more discrete and localised
 TB pleural thickenin
 Empyema- smooth , does not usually extend to
mediastinal pleura

83. RSNA, 2004
AJR 1990
RSNA 1999
RSNA 2012
RSNA 2002
RSNA 2007
GRAINGER
HAAGA