Radiological signs of pneumomediastinum

2. Radiology of Pneumomediastinum:
An old Subject revisited
Gamal Rabie Agmy, MD, FCCP
Professor and Head of Chest Department,
Assiut university

3. Figure 1. Diagram shows the anterior (A), middle (M), and
posterior (P) divisions of the mediastinum proposed in the
Zylak method.

4. TABLE 1. Potential Sources of Mediastinal Air
Intrathoracic
Trachea and major bronchi
Esophagus
Lung
Pleural space
Extrathoracic
Head and neck
Intraperitoneum and retroperitoneum

5. Radiograph clearly depicts air extending into the retroperitoneal
compartment and outlining the kidney and the retroperitoneal
segment of the descending colon..

6. Axial CT scan demonstrates air in the left-sided chest wall and in the
mediastinum outlining the vessels. The esophagus is also seen..

7. Radiographic Signs of Pneumomediastinum
Subcutaneous emphysema
Thymic sail sign
Pneumoprecardium
Ring around the artery sign
Tubular artery sign
Double bronchial wall sign
Continuous diaphragm sign
Naclerio's V sign
Extrapleural sign
Air in the pulmonary ligament

9. Ginkgo leaf sign
• The ginkgo leaf sign is a chest plain radiography
appearance which is seen at extensive subcutaneous
emphysema of the chest wall. Air outlines the fibers of
the pectoralis major muscle and creates a branching
pattern that resembles the branching pattern in the
veins of a ginkgo leaf.

10. Anteroposterior radiograph shows air in the subcutaneous tissues of the
neck, a finding that is consistent with pneumomediastinum. The thymus is
outlined by air (thymic sail sign). However, there is also a well-defined
opaque line paralleling the left border of the heart and extending to the
level of the pulmonary artery that represents the pneumopericardium.

12. Anteroposterior radiograph demonstrates the continuous diaphragm
sign.

13. Lateral radiograph shows air surrounding the right pulmonary artery
(ring around the artery sign). Air is present anterior to the pericardium
(pneumoprecardium).

14. The tubular structure seen arising from the top of the aorta
represents displacement of the left subclavian artery by air in the
mediastinum. The mediastinal air outlines the medial side of the
artery, and the aerated lung marginates its lateral border.

15. Axial CT scan obtained in a different patient helps explain this sign.
Air in the mediastinum outlines the posterior aspect of the inferior
wall of the left mainstem bronchus, whereas air in the bronchus
outlines its anterior surface.

16. Extrapleural sign in a 26-year-old woman with esophageal rupture.
Anteroposterior radiograph demonstrates a linear area of lucency
paralleling the descending aorta (arrow) representing air within the
mediastinum. A collection of air is seen just lateral to the lower
descending aorta (black arrowheads). This air presumably resides
within the pulmonary ligament. Note also the small collection of air in
the left pleural space (white arrowheads).

19. Naclerio's V sign

20. Notice the increased lucency of the cardiophrenic sulci in this patient
with inferior anteromedial pneumothoraces. A CT scan confirms the
diagnosis

21.  a hyperlucent upper
quadrant with
visualization of the
superior surface of the
diaphragm and
visualization of the
inferiorvena cava.
 double-diaphragm
sign

22.  Antero lateral air may
increase the
radiolucency at the
costo phrenicsulcus.
This is called the deep
sulcus sign.

23.  Apicolateral
pneumothorax
(arrows) with right
upper lobe collapse
(arrowheads)

24.  shifting of the heart border,
 the superior vena cava, and
the inferior vena cava.
 The shifting of these
structures can lead to
decreased venous return.

25. Fallen Lung Sign
This sign refers to the appearance
of the collapsed lung occurring
with a fractured bronchus .
The bronchial fracture results in
the lung to fall away from the
hilum, either inferiorly and laterally
in an upright patient or posteriorly,
as seen on CT in a supine patient.
DD:
Pneumothorax causes a lung to
collapse inward toward the hilum.