‫بسم هللا الرحمن الرحيم‬

Dr Khalid almass
Radiologist MD
▪ Note: the reference from chest imaging cases –oxford.
 Findings
Initial chest radiograph clearly demonstrates increased
lucency in the right hemothorax with minimal
displacement of the right hemidiaphragm inferiorly and shift of
the mediastinum left ward. Note the increased
distances between the ribs on the right, compared with those
on the left . Th e right lung is partially collapsed.
Visceral pleural surface can be seen as a thin white line,
allowing distinction from a skin
fold. No pulmonary vessels are seen lateral to the pleural line.
Th e anterior junction line is also displaced left ward.
Tension pneumothorax. There should be no differential
diagnosis.
19-year-old man aft er a motor vehicle collision is imaged in
the trauma suite.
▪ Supine radiograph shows increased lucency at the left base, but no
pleural line is seen. Th e left costophrenic sulcus extends more
inferiorly than the right. Wires represent ECG leads overlying the
patient.
▪ DDX Deep sulcus sign of a left pneumothorax and a right pleural
effusion are the two main considerations.
▪ Teaching Points
▪ Because the most nondependent portion of the pleural space is at the
base, a pneumothorax may be largest at the base on a supine
radiograph. Th e base of the affected hemothorax may be more lucent
and the costophrenic angle more apparent (deep sulcus sign).
▪ Care should be made to avoid confusion with blunting of the
contralateral costophrenic angle from a pleural effusion on the other
side.
▪ Management
▪ Upright radiographs and decubitus fi lms (side of suspected pneumothorax
up) can be used to confi rm that the deep
▪ sulcus is secondary to a pneumothorax.
▪ Although placement of a thoracostomy tube depends on clinical status,
communication with the clinical team is
▪ essential because the deep sulcus sign is oft en quite subtle and oft en
overlooked if images are viewed outside of a
▪ reading room.
42-year-old woman with shortness of breath
receives this chest radiograph.
▪ Findings
▪ Two-view chest radiograph shows increased opacification of the lower and lateral left
hemothorax with a meniscus .Th e mediastinum is shift ed rightward and the diaphragm is
shift ed inferiorly.
▪ Differential Diagnosis
▪ Unilateral pleural effusions are usually seen in infection (empyema), malignancy, and trauma
(hemothorax). An abdominal process may present with a large unilateral effusion, such as a
large right effusion in the setting of cirrhosis (hepatic hydrothorax). Other less common causes
of large unilateral effusions include chylothorax, and glucothorax (from an extravascular
placement of a central venous catheter).
▪ Teaching Points
▪ Large unilateral effusions are rare in the setting of congestive heart failure and should
prompt consideration of other potential etiologies.
▪ A large effusion may exert tension on surrounding structures and may have the same
physiologic significance as tension pneumothorax.
▪ A decubitus radiograph (side of effusion down) will show that the effusion is mobile when
the effusion is small or medium. In larger effusions, there may be little appreciable change on
a decubitus fi m.
▪ Management
▪ Effusions under tension require drainage on an urgent/emergent basis.
▪ If the patient is hemodynamically stable, a CT may be performed for further
characterization and thoracostomy tube planning.
21-year-old man with chest pain and shortness of breath aft er being shot
in the back is imaged in the
trauma suite
▪ Findings
▪ Single-view portable radiograph shows multiple bullet fragments on the right with
shift of the heart and mediastinum left ward. Pulmonary contusions and lacerations are
seen near the bullet fragments.
▪ Increased opacification is seen in the right apex and increased lucency in the right
base
▪ Although the tension component may prompt one to consider pneumothorax, the
density of the pleura is somewhat mixed. Th e combination of pleural densities is
indicative of either a tension hydropneumothorax or a tension hemopneumothorax.
▪ Teaching Points
▪ Hemopneumothorax usually follows trauma and can result in tension physiology.
Penetrating trauma is more likely to result in a tension hemopneumothorax than blunt
trauma.
▪ Th e radiographic appearance can be confusing because the presence of blood
increases the attenuation of the pleura space.
▪ When supine, the fluid should collect in the more dependent location (apex) while
the gas component will rise in the east dependent portion (base).
▪ Management
▪ Tension hemopneumothorax requires emergent drainage.
26-year-old woman presents with sudden onset of chest and
shoulder pain.
Chest radiograph shows a crescentic lucency below the right hemidiaphragm
Another lucency is seen above the right kidney .Th is gas within the hepatorenal fossa has been
called the “Doge’s cap” sign, as it is said to resemble the headgear of the former leaders of
Venice.
Differential Diagnosis
Curvilinear lucency at the level of the right hemidiaphragm may represent either a
subpulmonic pneumothorax or
free intraperitoneal gas.
Teaching Points
Because the differential includes both free intraperitoneal gas and pneumothorax, knowledge
of the patient’s position is key. On an upright study, gas in this location is most likely from free
intraperitoneal gas. On a supine radiograph, the gas could be from either. An upright or left lateral
decubitus fi lm might be useful, as the pneumothorax is best
seen at the apex (on the upright) or lateral aspect of the lung (on a contralateral decubitus).
Care must be taken to exclude mimics of free intraperitoneal gas, including colonic
interposition, in which haustra may be seen below the hemidiaphragm.
Signs of pneumoperitoneum on chest radiography include curvilinear lucency beneath the
hemidiaphragm, gas outlining the right border of the liver on a left lateral decubitus, Doge’s cap,
continuous diaphragm sign, and generalized increased lucency overlying the liver.
Other signs, such as the Rigler sign (gas outlining both sides of bowel wall) and the triangle sign
(gas within the mesentery between loops of bowel), may be seen.
Pneumoperitoneum may follow intraperitoneal abdominal surgery or trauma, percutaneous
catheter
▪ Management
▪ Because pneumoperitoneum may be a fi nding of a ruptured viscus, management is
directed towards documenting its
▪ presence and excluding certain benign causes.
▪ When encountered in the reading room, one must look for any antecedent surgery or
intervention. As a general rule,
▪ free gas should resolve by 7 to 10 days aft er surgery and decrease with time.
▪ Increasingly, CT is used to document pneumoperitoneum and reveal a potential source.
28-year-old man with a history of myasthenia
gravis is noted to be hypoxic.
▪ Findings
▪ Initial chest radiograph (Fig. 11.1 ) shows a retrocardiac opacity with air bronchograms and
narrowed distances
▪ between the left ribs. Th e left hemidiaphragm cannot be seen behind the heart and the left
heart border appears
▪ Straightened. Also note the inferior location of the left hilum.
▪ Differential Diagnosis
▪ Left lower lobe collapse and pneumonia are the two main considerations. Th e volume loss
strongly supports the
▪ former.
▪ Teaching Points
▪ Left lower lobe collapse assumes the shape of a left retrocardiac triangle. Th e base of the
triangle will obscure the left hemidiaphragm.
▪ Th e aerated upper lobe will allow the left heart border to be visible. Th e volume loss
results in left ward rotation of the heart. Th e net result is an altered appearance to the
cardiac silhouette more akin to a right anterior oblique projection.
▪ Th e altered left heart border appears straighter than normal. Th is finding has been
referred to as the flat waist sign
▪ Two other findings of left lower lobe collapse include shift of the anterior junction line and
the top of the knob sign. In the latter, shift ed mediastinal soft tissues obscure the top of the
aortic arch .
▪ Management
▪ With simple collapse, management rests on pulmonary toilet and occasional bronchoscopy
to clear the mucus. If no prior studies are available, the collapse should be followed to
resolution to exclude a central mass.
69-year-old woman is admitted for
hemoptysis.
▪ Findings
▪ On the initial radiograph ,the right heart border and hemidiaphragm are obscured.
▪ Associated volume loss is noted, which can best be seen by the rightward shift of the heart
and mediastinum.
▪ CT was performed the next day, which showed the collapsed lobes RML = middle lobe and
RLL = right lower lobe). Reconstructions more clearly delineate the central mass (white arrow
and the collapsed lobes
▪ Differential Diagnosis
▪ Based on the radiograph, right middle lobe and right lower lobe collapse should be the
main consideration.
▪ Teaching Points
▪ Right middle and lower lobe collapse is the result of obstruction of the bronchus
intermedius, from either mucus or an endobronchial lesion.
▪ Th e volume loss of both lobes results in inferior displacement of the minor and major fi
ssures. Usually, the minor fissure falls below the level of the major fissure and the major
fissure extends superiorly to the hilum (see coronal ct ).
▪ The net composite is the “S-shaped” opacity as seen above, especially when a central mass is
present.
Right middle and lower lobe collapse displaces the right hilum
inferiorly and obscures the descending right interlobar artery.
Shift of the heart and mediastinum rightward is frequently seen
with this combination of collapse.
To prevent confusion with a right pleural eff usion, one must
remember that an eff usion is higher laterally and
combined right middle and lower lobe collapse is higher medially.
Th e double lesion sign refers to collapse of two segments that are
not in proximity. Because of the anatomic distance,
a single lesion (cancer) is not plausible. An example of the double
lesion sign would include right upper and lower lobe collapse without
middle lobe involvement.
Management
With simple collapse, the management rests on pulmonary toilet
and occasional bronchoscopy to clear the mucus.
Collapse should be compared to a prior study or followed to resolution
to exclude a central mass
 62-year-old woman with a 2-month history of a
nonproductive cough receives this chest radiograph.
Findings
Chest radiograph shows volume loss on the right with an elevated right
hemidiaphragm and right hilum. Right
paratracheal opacity is seen in keeping with right upper lobe collapse. Th e
interface with the lung approximates the
shape of a reverse S and has come to be known as the (reverse) S sign of Golden.
Note the very faint juxtaphrenic peak.
Follow-up CT confirmed the right upper lobe collapse and central mass (arrow .
Th is mass obstructs the right upper lobe bronchus and is hyperenhancing. As
would be expected, this was a carcinoid
tumor.
Differential Diagnosis
Based on the radiograph, the two main concerns would be right upper lobe
collapse from a mass or bland right upper
lobe collapse.
Teaching Points
Right upper lobe collapse may be from mucus plugging, peripheral airways disease
(such as tuberculosis), or an endobronchial lesion.
Th e presence of a central mass creates an inferior bulge that helps create an
inverse S between the collapsed lung and
the aerated lung.
Other findings of right upper lobe collapse include a juxtaphrenic peak in which
either an inferior accessory fissure or the inferior pulmonary ligament pulls on the
hemidiaphragm (akin to marionette strings), an elevated right hilum, and findings of
volume loss.
Rarely, right upper lobe collapse has been associated with a pneumothorax that is
thought to result from a vacuum phenomenon. Akin to a joint vacuum phenomenon,
this type of pneumothorax has come to be known as a pneumothorax ex vacuo . Th is
pneumothorax will dissipate only if the central mass is cleared. It will not resolve with
thoracostomy drainage.
When right upper lobe collapse is combined with right middle lobe collapse,
malignancy should strongly be
considered.
▪ Management
▪ With simple collapse, the management rests on pulmonary toilet and occasional
bronchoscopy to clear the mucus. Th e collapse should be compared with prior images or
followed to resolution to exclude an underlying mass
28-year-old woman with asthma comes to the
Emergency Department with worsening dyspnea.
Findings
Initial frontal radiograph contains a vague triangular opacity that eff aces
the right heart border . Accompanying volume loss is best appreciated by
the effect on the right hemidiaphragm.
On the lateral radiograph, the lobar collapse is seen as a dense triangle
with a central apex and the base against the anterior chest wall. Th e
superior border is made up by the horizontal (minor) fissure
and the inferior edge by the major fissure. Th e orientation of the minor
fissure explains why it is no longer clearly seen on the frontal radiograph.
Differential Diagnosis
Right middle lobe collapse and right middle lobe consolidation from
pneumonia are the two main considerations. Th e
volume loss strongly supports the former.
▪ Teaching Points
▪ Right middle lobe collapse is the lobar collapse least associated with volume loss as it is the
lobe with the least volume.
▪ Early collapse is associated with effacement of the right heart border known as the
silhouette sign.
▪ As the collapse progresses, it pulls the minor fissure inferiorly out of the transverse plane.
Th e net effect is that the minor fissure is no longer well seen on the frontal projection.
▪ Th e lateral radiograph is characteristic for right middle lobe collapse. Th e volume loss
results in approximation of the major and minor fissures with a resultant dense triangle over
the heart.
▪ Rarely, right middle lobe collapse may be longstanding as a result of chronic inflammation,
bronchiectasis, or fibrosis. The term right middle lobe syndrome has been used to refer to
chronic nonobstructive, right middle lobe collapse.
▪ Management
▪ With simple collapse, the management rests on pulmonary toilet and occasional
bronchoscopy to clear the mucus.
▪ With a central mass, the treatment is aimed towards diagnosing the mass, usually by
bronchoscopic biopsy, and then /surgical resection, if possible.
53-year-old woman with increasing shortness of
breath presents with worsening cough.
▪ Findings
▪ Increased lucency around the aortic arch (Luft sichel sign) (superior arrow) with vague area
of increased opacity in the left upper lobe on the frontal radiograph.
▪ Volume loss is seen on the left with mild elevation of the left hemidiaphragm and
questionable juxtaphrenic peak
▪ (inferior arrow in pA view).
▪ On the lateral projection, opacity is seen overlying the ascending aorta with increased
retrosternal clear space representing the hyperexpanded right lung (single arrow ).
▪ CT confirms the findings and shows the endobronchial mass (arrow.
▪ Diff erential Diagnosis
▪ Left upper lobe collapse, probably from a mass. Th ere should be no differential diagnosis.
▪ Teaching Points
▪ Left upper lobe collapse can be the hardest lobar collapse (atelectasis) to diagnose on chest
radiography.
▪ Plain film findings on the frontal radiograph include a vague left upper lobe opacity,
increased lucency around the aortic knob (Luft sichel sign) that represents the hyperexpanded
left lower lobe, left volume loss, and a left juxtaphrenic peak.
▪ On the lateral radiograph one may see an anterior opacity bordered by the oblique fissure
and hyperexpanded lower lobe posteriorly (double arrow in lateral view) and the
hyperexpanded right lung anteriorly (single arrow in lateral view).
▪ Management
▪ Th ough rarely mucus may result in left upper lobe collapse, most causes of pure upper lobe
collapse are from an endobronchial mass. For this reason, when encountered on a chest
radiograph, left upper lobe collapse usually prompts a CT and then bronchoscopy. In this case,
the mass was found to be a squamous cell carcinoma by bronchoscopic biopsy.
46-year-old woman with worsening dyspnea on exertion presents to the
Emergency Department
Findings
Chest radiograph shows small effusions and interstitial opacities that can be followed
to the pleural surface. These horizontal, thickened interlobular septae are referred to as
Kerley B lines (white arrows in ).
CT confirmed the findings of pulmonary edema with small pleural effusions. Note the
smooth interlobular septal
thickening (black arrows in axial ct can and white arrows in corona CT Small pleural
effusions can also be seen (black arrow in PA VIEW
Differential Diagnosis
Before launching into a differential diagnosis of interstitial disease, comparison should be
made to any prior studies.
Once we know this is an acute process, edema versus atypical pneumonia (viral) are favored.
Teaching Points
Pulmonary edema can be classified as hydrostatic (cardiogenic) or from increased vascular
permeability (noncardiogenic).
Hydrostatic edema may be from cardiac causes (decreased left ventricular function,
mitral/aortic valve disease), pulmonary venous obstruction, fluid overload (renal failure), or
hypoalbuminemia.
Noncardiogenic edema or edema from increased permeability is less likely to present with
Kerley B lines.
Edema with increased permeability may be seen in a variety of conditions, including
inhalation injuries, trauma, high altitude, shock, drugs, and neurologic disease.
Edema from a mixed hydrostatic increased permeability pattern may be seen in neurogenic
edema, high-altitude edema, re-expansion edema, post surgery edema, or illicit drugs
(crack, cocaine).
Radiograph findings of cardiogenic pulmonary edema include subpleural edema
(seen as fissural thickening), pleural effusions, and interlobular septal line thickening.
Other findings of cardiogenic edema include pulmonary vascular redistribution,
peribronchial cuffing, and lack of visualization of the hilar vessels. Often, the heart is mildly
enlarged. Occasionally, consolidation may be present.
Management
Management is based on severity of the
pulmonary edema.
Unilateral edema may prompt a CT to
exclude an underlying central mass (fi
brosing mediastinitis or lung cancer).
15-month-old boy is admitted for new-onset wheezing.
▪ Findings
▪ Th e admission chest radiographs are deceptively near-normal in their appearance.
▪ Th ere may be minimal hyperlucency to the left lung, which is normal in size.
▪ Th e expiration image clearly demonstrates air-trapping in the left lung (Fig. 19.3 ).
▪ Differential Diagnosis
▪ Th e diff erential diagnosis based on a lucent lung with air-trapping would include Swyer-
James-Macleod syndrome,
▪ endobronchial foreign body, congenital lobar overinfl ation, and aspirated foreign body.
▪ Swyer-James-Macleod usually results in a smaller lung with air-trapping and does not
present with acute wheezing.
▪ Congenital lobar overinfl ation
Teaching Points
Most aspirated foreign bodies are radiolucent on radiography.
Most foreign body aspirations are seen in children younger than 10 years.
Medications, ethanol, and illicit drug use can increase the likelihood of aspiration
in older patients.
Radiographic suggestion of radiolucent aspirated foreign body requires
demonstration of air trapping or collapse.
Air-trapping can be demonstrated by failure of a lung or part of the lung to
collapse during expiration imaging. If
the patient is too young to follow commands, a radiograph or fl uoroscopic image
can be obtained during crying.
Alternatively, decubitus views can be obtained. Th e lung with the endobronchial
foreign body will not collapse when
it is the side placed down.
Most foreign bodies are aspirated into the lower lobes. Because of the vertical
nature of the bronchus intermedius, the
right lower lobe is a more common site than the left lower lobe.
Vegetable matter is one of the more common aspirated materials. Over time, a
radiolucent endobronchial foreign
body may calcify.
Management
Aspirated foreign bodies should be
removed. Th eir presence can elicit
proliferation of granulation tissue, which
predisposes to recurrent or chronic
pneumonias, stenosis, bronchiectasis, or
hemoptysis.
Endobronchial foreign bodies are usually
removed bronchoscopically. Very rarely,
when the foreign body has been
present for a long period of time, lobectomy
is required.
post blunt trauma
Multiple acute displaced fractures of the left
sixth to eighth ribs posterolaterally.
 Status-post
thoracic gunshot
wound.
▪Findings of gunshot wound right chest with bullet fragment
in the right axilla, moderate right hemopneumothorax, small
left pneumothorax, and right axillary subcutaneous
emphysema.
Acute shortness of breath and chest pain.
the patient centrally positioned, there are increased right
lung field lucency, and no pulmonary markings peripheral
to the medially displaced shadow of the lateral/peripheral
margin of the hyperdense smaller (collapsed) right lung
relatively wide ipsilateral/right intercostal spaces
shifting of mediastinal shadows to the contralateral/left
side
no obvious or definite evidence of other lesions
Cough and fever.
Airspace consolidation with air
bronchograms in the right lower zone,
clearly shown in the right middle lobe on
the lateral projection.
50 y Cough, night sweats, mild fever
Patchy airspace opacities and
interstitial thickening
throughout both lungs.
Aspiration event a few hours before
presentation
40y Shortness of breath and cough
productive of green sputum.
35y Acutely unwell.
Extensive consolidation and air
bronchograms with loss of the right
hemidiaphragm in keeping with right
lower lobe consolidation. In this
setting most likely community-
acquired pneumonia. Whether or
not there is an associated small
pleural effusion is uncertain. Minor
patchy airspace opacity is also in the
left midzone.
Complete airspace consolidation with air
bronchograms of the right upper lobe, with
further consolidation within the medial right
middle lobe. Small right parapneumonic
effusion.

Left lung and pleural space are clear.

Cardiomediastinal contour is unremarkable.
75y Presented to ED with respiratory distress
and dyspnea
AP chest radiograph for CVC position
shows the presence of extensive bilateral
ground-glass opacities as demonstrated on
the recent CT. Also right IJV catheter and
ETT noted.