ABNORMAL CHEST X-RAYS

Presenter
Dr. Madan Maharjan
PGY1
MD Radiodiagnosis
• Lung Parenchyma
• Pleura
• Hilum
• Mediastinum
• Diaphragm
• Chest wall and bones
Alveolar Disease
CONSOLIDATION
• Alveolar space filled with
inflammatory exudate.
• Interstitium and architecture remain
intact.
• The airway is patent.
• Radiologically:
• A density corresponding to a segment or
lobe.
• Airbronchogram
• No significant loss of lung volume.
 Air bronchograms

Non-opacified bronchus within a consolidated lobe results in air bronchogram sign.

Hyaline membrane disease. Extensive Acute intra-alveolar pulmonary edema with
homogenous consolidation with a prominent air a bat’s wing appearance
bronchogram.
.
Bulging fissures sign
 Silhouette sign
• The dark shape and
outline of someone or
something visible in
restricted light against
a brighter background.
• Loss of silhouette is
silhouette sign.
Application
Right middle lobe consolidation, demonstrating the silhouette sign
with loss of outline of the right heart border
Pitfalls
Collapse
 Collapse
• Signs of lung collapse
• Direct signs
• Opacity/loss of aeration of the affected lobe
• Crowding of vessels
• Displacement / bowing of fissures

• Indirect signs
• Compensatory hyperinflation of normal lung
• Ipsilateral mediastinal/ tracheal displacement
• Displacement of hilum
• Elevation of hemi-diaphragm
• Crowding of ribs on affected side
The lobes collapse in characteristic fashion:
• 1. The upper lobes collapse upwards, medially and anteriorly
• 2. The middle lobe goes downwards and medially
• 3. The lower lobes collapse posteriorly, medially and downwards.
Right upper lobe collapse

The lesser fissure moves upwards

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Right upper lobe collapse: Lateral view

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 Golden S curve

When there is a mass adjacent to a

fissure, the fissure takes the shape of
an "S". The proximal convexity is due
to a mass, and the distal concavity is
due to atelectasis.
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Left Lung collapse
Left Upper Lobe collapse
• Mediastinal shift to left.
• Opacity of left upper lung
field.
• Loss of aortic knob and left
hilar silhouettes
Luftsichel sign (Luft = air; sichel = crescent )
• With complete collapse, the left upper lobe retracts medially and superiorly.

• Hyperexpanded superior segment of the left lower lobe produces a crescent of

lucency interposed between the atelectatic left upper lobe and the aortic arch.

• This crescent of air is termed the luftsichel sign.

• Other features of left upper lobe collapse are present

Luftsichel sign
Bowing Sign
• In LUL atelectasis or following
resection, the oblique fissure
bows forwards (lateral view).
Juxtaphrenic peak sign
Right middle lobe collapse

Rt. middle lobe collapse. There is

a density next to the heart, below
the R hilum, which is roughly
triangular in shape.
Right lower lobe collapse
• Density in right lower lung field
• Indistinct right diaphragm
• Right heart silhouette retained
• Transverse fissure moved down
• Right hilum moved down
Left Lower Lobe collapse
• Inhomogeneous cardiac density
• Left hilum pulled down
• Non-visualization of left diaphragm
• Triangular retrocardiac atelectatic left
lower lobe.
Interstitial Disease
 Diffuse lung disease
• Non-homogenous and includes various pattern.
• Miliary pattern: 2-4mm in diameter
• Ground-glass shadowing: fine granular pattern obscures anatomical details
• Reticulonodular shadowing: nodule<1cm
• Reticular/ linear shadowing: fine irregular network of lines
• Honeycombing: pulmonary fibrosis with thin walled cysts.
Miliary pattern
Reticular/ linear shadowing- coarse
Reticular/ linear shadowing- fine
Honey combing pattern
 Linear and band shadows
• Linear shadow- less than 5mm
• Band shadows- more than 5mm
• Pulmonary infarcts
• Plate atelectasis
• Mucus- filled bronchi
• Sentinel lines
• Kerley B lines
• Thickening of fissures
• Old pulmonary/ pleural scars
• Curvilinear shadows (bullae, pneumatocele, cystic bronchiectasis).
Sentinel lines
 Kerley’s lines
• Kerley’s A lines (arrows) :
• Linear opacities extending from the
periphery to the hila
• Kerley's B lines (white arrowheads) :
• Short horizontal lines situated
perpendicularly to the pleural surface at
the lung base
• Kerley's C lines (black arrowheads):
• Reticular opacities at the lung base
representing superimposed Kerley's B
lines.
Pulmonary infarcts
Plate atelectasis
Thickened bronchial wall
Bronchiectasis
 Solitary pulmonary nodules
• Discrete, well-marginated, rounded opacity
• Less than or equal to 3 cm in diameter
• Completely surrounded by lung parenchyma,
does not touch the hilum or mediastinum,
• Not associated with adenopathy, atelectasis,
or pleural effusion.
• Lesions larger than 4 cms are treated as
malignancies until proven otherwise.
Multiple pulmonary nodules
Cavitating lesions
Common sites of the Lesion
• Tuberculous cavities : Upper zone and apical segments of the lower
lobes.
• Lung abscesses following aspiration : Rightsided and lower
zone(patient position dependant)
• Traumatic lung cysts : Subpleural
• Amoebic abscesses : Right base ,infection extending from the liver.
• Pulmonary infarcts : Usually in lower lobes
Fluid level
Lung Abscess
Empyema

Empyema: The CXR demonstrates a large, lenticular shaped air-fluid level in the right pleural space
 Empyema vs Lung abscess
Empyema Lung abscess
• Shape of space Usually lenticular Essentially spherical
• Length of air-fluid levels in different projections Unequal Approximately equal
• Relation to chest wall Obtuse angle Acute angle
• ‘split pleura’ sign Often present Absent
• Vessels and airway Displaced Contact margin
• Surrounding consolidation May be absent Usually present
• Wall uniform, smooth Non-uniform, irregular
• Extension into cp angle Sometimes present absent
• Change in shape with posture Sometimes present absent
Air crescent sign
Calcification
Apical Shadowing
Opaque hemithorax
Unilateral Hypertranslucency
 Pleural abnormalities
• Pleural effusion
•Pleural fibrosis/Thickening.
• Pleural plaques.
• Pleural calcification.
• Pleural tumors.
• Pneumothorax
• Fibrothorax
 Pleural effusion

Approximately 150-200 ml of fluid are needed to detect an effusion

in the frontal film vs. approximately 75ml for the lateral.
 Types of Pleural effusion
• 1.Free-flowing
• 2.Subpulmonic
• 3.Laminar
• 4.Loculated/ Fissural (pseudotumor)
 Free flowing
• Fluid first collects under lower lobes-posterior CP angle- lateral CP

• CXR- concave ,upward sloping interface with lung that causes sharp or indistinct
blunting of CP angle(meniscus).

• Which view best- lateral decubitus(5ml)> lateral (75ml)> PA (200ml).

• Complete opacification(pleural fluid vs atelectasis); mediastinal shift in pleural

effusion).

• Large effusions sometimes cause diaphragmatic inversion, particularly on the

left.
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 Sub pulmonic effusion
• PA radiograph - ‘high hemidiaphragm’ with an unusual contour that peaks more
laterally than usual on right side.
On left side:
• More common
• Normal gap between left hemidiaphragm and gastric bubble: 7mm
• Increased in left sided subpulmonic effusion.
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Lamellar effusion:
soft-tissue density,
approximately parallel to the
chest wall immediately
above the costophrenic
angle.
Encapsulated fluid on (A) PA and (B) lateral chest radiographs. Pleural fluid is encapsulated in the major
fissure and against the anterior chest wall. These encysted fluid collections can mimic a lung tumor.
Fissural pleural effusion
Pleural plaques
Pleural calcification
 Pneumothorax
• Air in the pleural space
Pathophysiology
• Either from disruption of
visceral pleura or trauma to
parietal pleura
Chest x ray findings
• Sharp white line of visceral pleura
separated from chest wall by radiolucent
pleural space devoid of bronchovascular
marking.

• Expiratory film more visible.

• Lateral decubitus with affected part

up(children).

• Skin folds extends beyond margins of

chest cavity, much wider margins than
visceral pleural line, vessels, orientation
of the line inconsistent with collapsed
lung margin
The signs of pneumothorax on a supine chest radiograph
are:

• Abnormally increased lucency in the lower chest or upper abdomen.

• The ‘deep sulcus’ sign—abnormally wide and deep costophrenic
sulcus.
• The ‘double diaphragm’ sign—when air outlines the dome and
anterior insertion of diaphragm.
• Sharply outlined diaphragmatic or cardiac border.
• Depression of hemidiaphragm.
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Hydropneumothorax
Fibrothorax
Hilar enlargement
Mediastinal abnormalities
Cervicothoracic sign
Anterior mediastinal masses: T cell lymphoma and retrosternal goiter
Hilum overlay sign
Hilum convergence sign
Thoracoabdominal sign
 Pneumomediastinum
• ‘Double bronchial wall’ sign—visualization of both sides of bronchial wall due to
air accumulating adjacent to bronchial wall
• ‘Continuous diaphragm’ sign—visualization of entire diaphragm from medial to
lateral due to air trapped posterior to the pericardium at base.
• ‘Tubular artery’ sign—air outlining the medial side of aorta with lung air
outlining the lateral side
• ‘Ring around the artery’ sign—air outlining the pulmonary artery
• Elevation of the thymus especially in children/ Angels wing sign.
 Fig: Pneumomediastinum. Chest radiograph shows air outlining the mediastinum (arrows) on both
sides. The air is seen above the level of aortic arch also (upper left arrow)
‘Continuous diaphragm’ sign ‘Double bronchial wall’ sign
 Naclerio’s V sign

• Pneumomediastinum occurring often

secondary to an esophageal rupture.
• V-shaped air collection.
• One limb of the V - mediastinal gas outlining
the left lower lateral mediastinal border.
• The other limb- gas between the parietal pleura
and medial left hemidiaphragm.
Mach effect
Diaphragmatic hernia
Congenital Bochdalek
• Defect pleuroperitoneal folds
• Appearance d/o hernia contents & whether air present within herniated bowel
• Left posterolateral 90%
• Initially: Hernia contents may be radiodense (prior to air swallowing)
• Hours later: Hernia contents contain cystic air structures from small bowel
loops
• Marked CL shift of mediastinum & compression of CL lung
• Right- liver, omentum & not bowel
• Decreased distension/ bowel gas in abdomen
• Catheter position clue to Diagnosis.
• NG tube descends into abdomen and curves into stomach above
hemidiaphragm
Fig: Diaphragmatic hernia
Chest wall abnormalities (bones and soft
tissue)
Pectus carinatum and Pectus excavatum
Rib notching

• Superior vs inferior rib notching

Cervical rib
Rib fracture
 Flail chest
• Flail chest occurs when there are at least two sites of fractures on
each of three or more consecutive ribs creating a flail segment which
moves paradoxically with respiratory motion.
• It signifies significant chest trauma and is associated with atelectasis
and pneumonia and often requires ventilator support or surgical
intervention.
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Left sided mastectomy
 Pulmonary embolism
CXR: neither sensitive nor specific. R/o pneumonia and pneumothorax.
• Fleischner sign: enlarged pulmonary artery (20%)
• Hampton hump: peripheral wedge of airspace opacity and implies lung infarction
(20%)
• Westermark sign: regional oligaemia and highest positive predictive value (10%)
• Pleural effusion (35%)
• Knuckle sign: abrupt tapering or cutoff of a pulmonary artery.
• Palla sign: enlarged right descending pulmonary artery
Pericardial Effusion
• Enlargement of the cardiac
shadow - water bottle sign.
• Cardiac contour is very clearly
demarcated d/t the static outer
margin of the distended
pericardial sac.
• Oligaemic pulmonary vascular
markings (If large enough the
effusion will lead to an
obstruction of the venous return
to the right heart).
Pericardial effusion

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• Oreo-Cookie sign:
Posterior choclate layer: pericardial
fat
Middle cream layer: pericardial
effusion
Anterior choclate layer: Epicardial fat.
Deep sulcus sign
Golden S sign
Pseudo tumor sign- loculated effusion
Status post mastectomy
Continuous diaphragm sign