Chest x-ray INTERPRETATION AND signs.pptx

X Rays PICTURES WITH EXPLANATION OF CLINICAL SIGNS, EXPLANATION OF REASON AND PATHOLOGIACL REASONS

1. Signs in the Chest X-ray Dr. Kaleemullah Pulmonologist

2. Normal Chest X-Ray

3. Key facts about the Chest X-Ray

4. Key facts about the Chest X-Ray

5. Consolidation

6. Air bronchogram sign Air bronchogram refers to the phenomenon of air-filled bronchi (dark) being made visible by the opacification of surrounding alveoli (grey/white) It is almost always pathologic It is most frequently seen in pneumonia, pulmonary edema and also in respiratory distress syndrome. Bronchioalveolar carcinoma, lymphoma, interstitial fibrosis, alveolar hemorrhage, fibrosis due to radiation and sarcoidosis can also present with this sign.

7. Air bronchogram sign Branching and tubular lucencies of bronchi. Seen in an opacified lung

8. Silhouette Sign It refers to the loss of normal borders between thoracic structures. Non-visualization of the border of an anatomical structure that is normally visualized, due to the area neighbouring this margin is filled with tissue or material of the same density. The silhouette sign is an important sign indicating the localization of a lesion.

9. Silhouette Signs in Frontal X-ray Loss of Silhouette Sit e of Pathology Chest X-ray Right paratracheal stripe Right upper lobe Right heart border Right middle lobe Right hemidiaphragm Right lower lobe Aortic knuckle Left upper lobe Left heart border Lingular segments of the left upper lobe Left hemidiaphragm Left lower lobe

10. Silhouette sign Non-visualization of the border of an anatomical structure that is normally visualized, due to the area neighbouring this margin is filled with tissue or material of the same density

11. Bulging Fissure Sign Bulging fissure sign is seen classically in consolidation caused by  Klebsiella pneumoniae  infection in the right upper lobe. It occurs due to large exudates produced by the  Klebsiella  organism which expands the lobe and causes a bulge in the fissure, and can be seen in plain X-ray and CT scan.  Main causative organism responsible for this sign is K. pneumoniae Other causes are tuberculosis, pneumococcal pneumonia,  Hemophilus influenzae , lung abscesses, and tumors like bronchoalveolar carcinoma.

12. Bulging Fissure Sign Frontal chest radiograph reveals opacified right upper lobe with bulge in the minor fissure (white arrow) representing the radiologic sign, bulging fissure sign.

13. Deep Sulcus Sign It describes the radiolucency extending from the lateral costophrenic angle to the hypochondrium . It is an important clue indicating possible pneumothorax in chest x-rays obtained in the supine position. When plain films are taken with the subject in an upright position, the free air in the pleural space gathers at the apicolateral space. In the supine position, the air accumulating at the anterior space forms a triangular radiolucency that makes the inferior borders of the lateral costophrenic angle conspicuous.

14. Deep sulcus sign The deep sulcus sign on a supine chest radiograph is an indication of a pneumothorax

15. More Black Sign It is a normal finding in lateral chest x-ray, and refers to the gradual increased apparent radiolucency (blackness) of the vertebral bodies, when proceeding from upper to lower chest. This is due to the increased proportion of the chest comprised of air containing lungs over distal dorsal spine compared to the upper parts. When the air is displaced by higher attenuation material, such as consolidation, fluid or a mass (e.g. bronchogenic carcinoma, paraspinal neurogenic tumour ) then the lower dorsal vertebral bodies become more radiodense ; This is referred to as the loss of the more back sign and is also known as the spine sign.

16. More Black sign Normal finding in lateral chest x-ray, and Refers to the gradual increased apparent radiolucency (blackness) of the vertebral bodies, when proceeding from upper to lower chest.

17. More Black sign Normal finding in PA chest x-ray, and refers to the gradual increased apparent radiolucency (blackness) of the vertebral bodies, when proceeding from upper to lower chest.

18. Bat Wing Sign Also called as Angel Wing Sign. Seen in pulmonary oedema involving perihilar region sparing the cortex of the lungs.

19. Bat Wing Sign

20. Air Crescent Sign Air crescent ("meniscus") sign is the result of air accumulation between a mass or nodule and normal lung parenchyma. It is most frequently encountered in neutropenic patients with aspergillosis. Air between the cavity wall and the fungus ball ( mycetoma ) is the cause the air crescent sign. Normal host immunity and the long period, often years, required for the formation of the ball can aid in distinguishing this condition from invasive aspergillosis. Other causes of the air crescent sign are hydatid cyst with bronchial involvement, hematoma, abscess, necrotizing pneumonia, cystic bronchiectasis filled with mucus plugs and papillomatosis.

21. Air Crescent Sign Air between the cavity wall and the fungus ball ( mycetoma )

22. Scimitar Sign A tubular-shaped opacity extending towards the diaphragm along the right side of the heart is seen. It indicates anomalous venous return of the right inferior pulmonary vein (total or segmental) directly to the hepatic vein, portal vein or inferior vena cava. The abnormal pulmonary vein resembles a Turkish sword called a " pala ". The scimitar sign is associated with congenital hypogenetic lung syndrome (scimitar syndrome).

23. Scimitar Sign

24. Pulmonary Embolism

25. Hampton Hump Sign It occurs within two days as a result of alveolar wall necrosis accompanying alveolar hemorrhage due to pulmonary infarct. It is a wedge-shaped, pleura-based consolidation with a rounded convex apex directed towards the hilus . This sign was first described by Aubrey Otis Hampton.

26. Hampton Hump Sign A wedge-shaped, pleura-based consolidation with a rounded convex apex directed towards the hilus .

27. Westermark Sign The Westermark sign describes a decrease of vascularization at the periphery of the lungs due to mechanical obstruction or reflex vasoconstriction in pulmonary embolism ( oligemia ). An increase in translucency on frontal radiographs is depicted.

28. Westermark Sign Decrease of vascularization at the periphery of the lungs due to mechanical obstruction or reflex vasoconstriction in pulmonary embolism ( oligemia )

29. Fleischner sign Prominent central artery that can be caused either by pulmonary hypertension that develops or by distension of the vessel by a large pulmonary embolus. It is seen most commonly in the setting of massive pulmonary embolism

30. Fleischner sign Prominent central artery that can be caused either by pulmonary hypertension that develops or by distension of the vessel by a large pulmonary embolus

31. Lung Collapse

32. Golden “S” Sign The golden"S " sign is encountered when there is right upper lobe atelectasis due to a centrally located mass. The minor fissure migrates superiorly, and a "reversed S" shape containing the mass forms. The superiorly displaced, lateral and concave portion of the "S" is formed by the minor fissure, while the inferiorly and medially located convex part is formed by the margin of the mass. This sign is an important clue indicating a central mass obstructing the bronchus. It can be seen in every lobe, though it has been described for the right upper lobe.

33. Golden “S” Sign The superiorly displaced, lateral and concave portion of the "S" is formed by the minor fissure, while the inferiorly and medially located convex part is formed by the margin of the mass

34. Veil Sign The opacification of the left hemithorax that is associated with superior displacement of the left hilum and a horizontal left mainstem bronchus.

35. Veil Sign

36. Luftsichel Sign The word " Luftsichel " in German means "air crescent“ This sign is seen in severe left upper lobe collapse. The crescent-shaped radiolucency around the aortic arch is called the Luftsichel sign Due to the lack of a minor fissure on the left side, upper lobe collapse causes vertical positioning and anterior and medial displacement of the major fissure. The superior segment of the left lower lobe migrates superior and anteriorly between the arch of the aorta and the atelectatic lobe.

37. Luftsichel Sign

38. Sail Sign Sail Sign is defined as “Dense triangular opacity overlying the cardiac shadow with increased lucency of the left upper zone relative to the right upper zone” This is the "sail sign" of left lower lobe collapse with subsequent left upper lobe hyper-expansion. Sail sign is seen in left lower lobe collapse

39. Sail Sign

40. Juxtaphrenic peak sign It occurs in upper lobe atelectasis, describes the triangular opacity projecting superiorly at the medial half of the diaphragm. According to one theory, the negative pressure of upper lobe atelectasis causes upward retraction of the visceral pleura, and protrusion of extrapleural fat into the recess of the fissure is responsible. The juxtaphrenic sign can also be seen in combined right upper and middle lobe volume loss or even with middle lobe collapse only .

41. Juxtaphrenic peak sign Triangular opacity projecting superiorly at the medial half of the diaphragm

42. Pneumo -mediastinum / Subcutaneous Emphysema

43. Naclerio V Sign Seen in patients with pneumomediastinum occurring often secondary to an oesophageal rupture. It is seen as a V-shaped air collection. One limb of the V is produced by mediastinal air outlining the left lower lateral mediastinal border. The other limb is produced by air between the parietal pleura and medial left hemidiaphragm .

44. Naclerio V sign One limv of V represents air along the mediastinal border The other limb of V represents air along the lateral hemidiaphragm

45. Naclerio V sign

46. Thymic Sail Sign Represents the triangular shape inferior margin of the normal thymus seen on neonatal frontal chest radiograph. This indicate pneumomediastinum

47. Thymic Sail Sign triangular shape inferior margin of the normal thymus seen on neonatal frontal chest radiograph

48. Continuous Diaphragm Sign Normally, the ecentral portion of the diaphragm is not discretly visualissed on the chest radiograph, as it merges with the cardiac silhouette If the diaphragm can be seen continuously across the midline, then its highly suggestive of a free gas within the mediastinum, pericardium or peritoneal cavity. If the lucency is above the diaphragm then its pneumomediastinum or pneumopericardium . If the lucency is below the diaphragm ,then its pneumoperitoneum.

49. Continuous Diaphragm Sign If the diaphragm can be seen continuously across the midline, then its highly suggestive of a free gas within the mediastinum, pericardium or peritoneal cavity.

50. Haystack sign Seen in paediatric patients is indicative of pneumomediastinum . The paediatric heart is surrounded above and below with air and giving it an appearance of a haystack from Monet's paintings.

51. Haystack sign The paediatric heart is surrounded above and below with air and giving it an appearance of a haystack from Monet's paintings. Indicative of Pneumomediastinum

52. Gingko leaf Sign Extensive bilateral surgical emphyesema throughout the visualised soft tissues of the chest and neck. It is more pronounced on the left with the air tracking between the fibres of the pectoralis major muscle, giving the appearance of a Gingko leaf.

53. Gingko leaf Sign Air tracking between the fibres of the pectoralis major muscle, giving the appearance of a Gingko leaf.

54. Chiladiti Sign The anterior interposition of the colon to the liver reaching the under-surface of the right hemidiaphragm with associated upper abdominal pain. It is one of the causes of pseudopneumoperitoneum . Pain distinguishes Chilaiditi syndrome from asymptomatic colonic interposition, which is termed as Chilaiditi sign. Gas between liver and diaphragm,rugal folds within the gas suggesting that it is within the bowel and not free

55. Chiladiti Sign The anterior interposition of the colon to the liver reaching the under-surface of the right hemidiaphragm .

56. Water Lily Sign It is seen in hydatid infections when there is detachment of the endocyst membrane which results in floating membranes within the pericyst that mimic the appearance of a water lily.

57. Water Lily Sign It is seen in hydatid infections when there is detachment of the endocyst membrane which results in floating membranes within the pericyst that mimic the appearance of a water lily

58. Water Bottle Sign Refers to the shape of the cardiac silhouette in patients who have a very large pericardial effusion. Typically the effusion has accumulated over many weeks to months (e.g. in patients with malignancy) and the pericardium has gradually stretched. The fluid, often measuring a litre or more, causes the pericardium to sag, mimicking an old-fashioned water bag sitting on the bench.

59. Water Bottle Sign The fluid, often measuring a litre or more, causes the pericardium to sag, mimicking an old-fashioned water bag sitting on the bench

60. Water bottle sign The fluid, often measuring a litre or more, causes the pericardium to sag, mimicking an old-fashioned water bag sitting on the bench

61. Pleural meniscus sign The appearance of free pleural fluid as a homogeneous opacity with a concave upper border, higher laterally than medially, on erect frontal and lateral radiographs is called the pleural meniscus. The meniscus appearance can be explained by the configuration of free fluid within the pleural space and its relationship to the x-ray beam

62. Loculated pleural effusion / D shaped or Lentiform effusion Obliteration of left costophrenic angle with a wide pleural based dome shaped opacity projecting into the lung noted tracking along the CP angle and lateral chest wall suggestive of loculated pleural effusion. Suggestive of Empyema thoracis

63. Holly Leaf Sign Refers to the appearance of pleural plaques on chest x-rays. Their irregular thickened nodular edges are likened to the appearance of a holly leaf

64. Holly Leaf Sign Irregular thickened nodular edges are likened to the appearance of a holly leaf.

65. Shmoo sign Appearance of a prominent, rounded left ventricle and dilated aorta on a plain AP chest radiograph giving the appearance of Shmoo , a fictional cartoon character in the comic strip Li'l Abner in the 1940s. This sign is indicative of left ventricular enlargement

66. Shmoo Sign

67. Double Density Sign Presence of left atrial enlargement. Occurs when the right side of the left atrium pushes behind the right cardiac shadow indenting the adjacent lung and forming its own distinct sillhouette .

68. Double Density Sign Presence of left atrial enlargement. Occurs when the right side of the left atrium pushes behind the right cardiac shadow indenting the adjacent lung and forming its own distinct sillhouette

69. Extra Pleural Sign The appearance of a pulmonary opacity with oblique margins that taper slowly to the chest wall when the lesion is viewed tangentially to the x-ray beam. This appearance suggests that the lesion is extrapleural in nature, as opposed to intrapulmonary where an acute angle would be expected as the lesion meets the lung periphery. This term may be confused with extrapleural air sign which refers to a different finding

70. Extra Pleural Sign The appearance of a pulmonary opacity with oblique margins that taper slowly to the chest wall when the lesion is viewed tangentially to the x-ray beam

71. Hilum Overlay Sign Hilum overlay sign is useful in differentiating if an opacity on the frontal chest radiograph in the region of lung hilum, is located within the hilum versus anterior or posterior to it When a mass arises from the hilum, the silhouette of the normal pulmonary vessels is obliterated If the edges are the vessels are appreciated, this implies the cause of opacity is not in contact with the hilum and it is therefore, either anterior or posterior to it.

72. Hilum Overlay Sign The ability to see the edges of the vessels through the mass implies that the mass is not contacting the hilum and therefore its either anterior or posterior to it

73. Hilum Convergence Sign To distinguish the bulky hilum due to pulmonary artery dilation from a mass or nodal enlargement. In the former pulmonary vessels can be seen to converge and join a dilated pulmonary artery.

74. Hilum Convergence Sign

75. Cottage Loaf Sign It occurs as a result of right sided diaphragmatic rupture with partial herniation of the liver through the diaphragmatic defect. The herniated component is separated by a waist or the diaphragm from the larger intra abdominal component. This shape is remniescent of a cottage loaf particular shape of bread in which larger and smaller roughly spherical balls are squashed together forming a cottage shape.

76. Cottage loaf sign

77. Pawnbroker’s Sign Also called as 1-2-3 sign or Garland triad. It is a lymph node enlargement pattern which has been described in sarcoidosis. The lymph nodes involved are right paratracheal , right hilar and left hilar lymph nodes.

78. Pawnbroker’s Sign