radiological signs (shënja radiologjike )-1

8/11/2019 Radiological Signs (Shënja Radiologjike )-1

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1

Sllavko K. Kallfa

Radiological Signs

Shënja Radiologjike)

Përmbledhje Artikujsh nga

Radiopaedia.org

❶



2

chest x-ray

air bronchogram…………….f. 3

big rib sign............................f. 7

Chang's sign..........................f. 8

coin lesion..............................f. 9

dense hilum sign....................f. 16

double contour sign................f.20

extrapleural sign....................f.25

hilum overlay sign..................f.26

hilum convergence sign...........f.39

holly leaf sign..........................f.42

finger in glove sign..................f.47

flat waist sign..........................f.54

Fleishner's sign.......................f.55

ginkgo leaf sign.......................f.57

Golden S sign..........................f.61

incomplete border sign............f.70

juxtaphrenic peak sign............f.72 medial stripe sign....................f.76

more black sign.......................f.78

Naclerio's V sign.....................f.89

Shmoo sign..............................f.90

silhouette sign[+] ……………...f.91

steeple sign...............................f.103

spinnaker sign..........................f.108

water bottle sign.......................f.114 wave sign..................................f.118

Westermark's sign....................f.121

http://radiopaedia.org/articles/chest-radiograph

http://radiopaedia.org/articles/big-rib-sign


http://radiopaedia.org/articles/changs-sign-1


http://radiopaedia.org/articles/coin-lesion


http://radiopaedia.org/articles/dense-hilum-sign-2


http://radiopaedia.org/articles/double-density-sign-of-left-atrial-enlargement


http://radiopaedia.org/articles/extrapleural-sign-1


http://radiopaedia.org/articles/hilum-overlay-sign


http://radiopaedia.org/articles/hilum-convergence-sign


http://radiopaedia.org/articles/holly-leaf-sign


http://radiopaedia.org/articles/finger-in-glove-sign


http://radiopaedia.org/articles/flat-waist-sign-2


http://radiopaedia.org/articles/fleishners-sign


http://radiopaedia.org/articles/ginkgo-leaf-sign


http://radiopaedia.org/articles/golden-s-sign


http://radiopaedia.org/articles/incomplete-border-sign


http://radiopaedia.org/articles/juxtaphrenic-peak-sign


http://radiopaedia.org/articles/medial-stripe-sign


http://radiopaedia.org/articles/more-black-sign


http://radiopaedia.org/articles/naclerios-v-sign-2


http://radiopaedia.org/articles/shmoo-sign


http://radiopaedia.org/articles/silhouette-sign


http://radiopaedia.org/articles/steeple-sign


http://radiopaedia.org/articles/spinnaker-sign


http://radiopaedia.org/articles/water-bottle-sign


http://radiopaedia.org/articles/wave-sign-2


http://radiopaedia.org/articles/westermarks-sign





























http://radiopaedia.org/articles/chest-radiograph



3

Air bronchogram

Dr Henry Knipe and Dr Behrang Amini et al.

Air bronchogram refers to the phenomenon of air-filled bronchi (dark ) being made visible bythe opacification of surrounding alveoli ( grey - white). It is almost always caused by a pathologicairspace (alveolar) process, in which something other than air fills the alveoli. Air bronchograms

will not be visible if the bronchi themselves are opacified (e.g. by fluid).

Air bronchograms can be seen with several processes, including the following :

pulmonary consolidation

pulmonary oedema

non-obstructive atelectasis

severe interstitial lung disease

neoplasms - bronchioloalveolar carcinoma; pulmonary lymphoma pulmonary infarct

normal expiration

The air bronchogram indicates patent proximal airways.

Air bronchogams that persist for weeks despite appropriate antimicrobial therapy should raise the

suspicion of a neoplastic process. CT or guided biopsy may be planned in such cases.

References

1. Reed JC. Chest radiology, plain film patterns and differential diagnoses. Mosby.(1997) ISBN:0815171226. Read it at Google Books - Find it at Amazon

2. Wong JS, Weisbrod GL, Chamberlain D et-al. Bronchioloalveolar carcinoma and the

air bronchogram sign: a new pathologic explanation. J Thorac Imaging. 1994;9 (3): 141-

4. - Pubmed citation

Synonyms & Alternative Spellings

Synonyms or Alternative Spelling Include in Listings?

Air bronchograms

http://radiopaedia.org/users/henryknipe


http://radiopaedia.org/users/behrang%20amini



http://radiopaedia.org/articles/air-space-opacification-1

http://radiopaedia.org/articles/pulmonary-oedema

http://radiopaedia.org/articles/atelectasis



http://radiopaedia.org/articles/interstitial-lung-disease


http://radiopaedia.org/articles/broncholoalveolar-carcinoma


http://radiopaedia.org/articles/pulmonary-lymphoma



http://radiopaedia.org/articles/pulmonary-infarct


http://books.google.com/books?vid=ISBN0815171226



http://www.amazon.com/gp/product/0815171226?ie=UTF8&tag=radiopaediaor-20&linkCode=as2&camp=1789&creative=9325&creativeASIN=0815171226



http://www.ncbi.nlm.nih.gov/pubmed/8083927











http://radiopaedia.org/articles/pulmonary-oedema






4

This 68 year-old male

patient presented with cough and dyspnoea. The PA chest xray above shows a veil-like opacity

in the left upper zone, and silhouetting of the left heart border, typical of left upper lobe collapse.

The trachea is shifted to the left and there is a small juxtaphrenic peak. The luftsichel sign is

present due to the superior segment of the left lower lobe insinuating itself between the collapsed

upper lobe and the mediastinum. This patient had a hilar bronchogenic carcinoma causing

obstruction of the left upper lobe bronchus. Around 50% of all lung cancers exhibit some degree

of atelectasis or consolidation as a result of obstruction of main, lobar or segmental bronchi. Air

bronchograms may be absent due to filling of the bronchi with secretions. Reference Webb WR,

Higgins CB. Thoracic Imaging: Pulmonary and Cardiovascular Radiology. Lippincott, Williams

& Wilkins 2005 {Template: Contibuted Blocko}} Case 1: with left upper lobe collapse



5

This 25 year-old female

patient’s PA chest xray shows evidence of right middle lobe consolidation. There is an opacity in

the right mid-to-lower zone medially, which silhouettes the right heart border. The opacity has a

straight upper border suggesting margination along the horizontal fissure. There is little evidence

of volume loss. The most common cause of lobar consolidation is Streptococcal pneumonia.

Other causes include infection with other bacteria (eg Klebsiella, TB); bronchial obstruction with

postobstructive pneumonia; or consolidation associated with neoplasm, particularly lymphoma or

bronchioloalveolar carcinoma. Reference Webb WR, Higgins CB. Thoracic Imaging: Pulmonary

and Cardiovascular Radiology. Lippincott, Williams & Wilkins. Image contributed by: Dr

Laughlin Dawes center center center This image is made available under a Creative Commons

Licence. If you wish to use this image outside of this licence, then please contact the author

above. Case 2: with right middle lobe consolidation



6

From the case: Right upper lobe pneumonia

Modality: X-ray

http://radiopaedia.org/cases/right-upper-lobe-pneumonia-1






7

Big rib sign

Dr Henry Knipe and Dr M Venkatesh et al.

The big rib sign is a sign to differentiate right and left ribs on lateral chest radiographs.

It exploits a technique of magnification differences on lateral projections between right and leftribs. For example, on right lateral projections the left ribs appear larger than right ribs.

This sign can be useful but may be difficult to appreciate as the difference in size between ribs is

~10% and is not applicable when the posterior ribs are superimposed.

References

1. Kurihara Y, Yakushiji YK, Matsumoto J et-al. The ribs: anatomic and radiologic considerations.

Radiographics. 1999;19 (1): 105-19. Radiographics (full text) - Pubmed citation



http://radiopaedia.org/users/mvenkatesh



http://radiopaedia.org/articles/missing?article%5Btitle%5D=ribs



http://radiographics.rsna.org/content/19/1/105.full













8

Chang's sign

Dr Yuranga Weerakkody and Dr Henry Knipe et al.

Chang’s sign refers to a dilatation and abrupt change in calibre of a main pulmonary artery dueto pulmonary embolism

1.

References

1. Plain Film Signs in Pulmonary Embolism (with CT correlate), Kirwadi A, Bickle IC.

http://www.eurorad.org/eurorad/case.php?id=7735 Eurorad case 7735



Chang sign ✗

Changs sign

http://radiopaedia.org/users/weer06





http://radiopaedia.org/articles/missing?article%5Btitle%5D=pulmonary-artery



http://radiopaedia.org/articles/pulmonary-embolism



http://www.eurorad.org/eurorad/case.php?id=7735









9

Coin lesion

Dr Henry Knipe et al.

Coin lesion refers to a round or oval, well-circumscribed solitary pulmonary lesion. It istypically 1-5 cm in diameter and calcification may or may not be present

1,3. Typically but not

always the patient is asymptomatic1.

Differential diagnosis

The differential diagnosis for such lesions is1-3

:

primary lung malignancy - e.g. squamous cell carcinoma

metastases

infection

o

pulmonary tuberculosis; o

Streptococcus sp., Staphlycoccus sp., or Klebisialla sp. infection

o hydatid cyst

o abscess

benign disease processes

o

Wegener's granulomatosis

o pulmonary hamartoma

o

pulmonary arteriovenous malformation

o

rheumatoid nodule

o bronchogenic cyst

o bronchial adenoma

Take care not to call a "pseudo-coin lesion", which are caused by artifacts (e.g. button on

patient's clothing, unilateral nipple shadow, etc).

References

1. The pulmonary "coin" lesion [editorial]. Radiology. 1950; 54(1):116-117.

2. Chowdhury R. Radiology at a glance. John Wiley (2013).

3. Parr LH. Coin lesions of the lung. J Natl Med Assoc. 1969;61 (2): 153-7. Free text at pubmed -

Pubmed citation

Synonyms & Alternative SpellingsSynonyms or Alternative Spelling Include in Listings?

Coin lesions ✗

Pulmonary coin lesion



http://radiopaedia.org/articles/solitary-pulmonary-nodules



http://radiopaedia.org/articles/lung-cancer-3


http://radiopaedia.org/articles/pulmonary-metastases


http://radiopaedia.org/articles/pulmonary-manifestations-of-tuberculosis


http://radiopaedia.org/articles/hydatid-disease


http://radiopaedia.org/articles/lung-abscess


http://radiopaedia.org/articles/pulmonary-manifestations-of-granulomatosis-with-polyangitis-1


http://radiopaedia.org/articles/pulmonary-hamartoma-1


http://radiopaedia.org/articles/pulmonary-arteriovenous-malformation


http://radiopaedia.org/articles/rheumatoid-nodules


http://radiopaedia.org/articles/bronchogenic-cyst


http://radiopaedia.org/articles/bronchial-carcinoid-tumour


http://radiopaedia.org/articles/x-ray-artifacts



http://radiopaedia.org/articles/nipple-shadows



http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2611684
























10

From the case: Pulmonary coin lesion

Modality: X-ray

http://radiopaedia.org/cases/pulmonary-coin-lesion






11

From the case: Coin lesion (lung adenocarcinoma)

Modality: X-ray

http://radiopaedia.org/cases/coin-lesion-lung-adenocarcinoma






12

From the case: Coin lesion - breast cancer metastasis

Modality: X-ray

http://radiopaedia.org/cases/coin-lesion-breast-cancer-metastasis






13

From the case: Coin lesion - colorectal carcinoma metastasis

Modality: X-ray

http://radiopaedia.org/cases/coin-lesion-colorectal-carcinoma-metastasis






14

Imaging Differential Diagnosis

From the

case: Pseudo-coin lesion due to button

Modality: X-ray

http://radiopaedia.org/cases/pseudo-coin-lesion-due-to-button






15

From the case: Pseudo-

coin lesion due to button

Modality: X-ray









16

Dense hilum sign

Dr Henry Knipe and Dr Paresh K Desai et al.

The dense hilum sign suggests a pathological process at the hilum - hilar malignancy or bronchogenic carcinoma should be suspected.

On a well-centred chest PA radiograph the density of the hilum is comparable on both sides. In

absence of calcification or adenopathy, the hila should appear of equal density and be symmetric.

References

1. Khan MIG. On Call Cardiology: On Call Series. Saunders. ISBN:1416025375. Read it at Google

Books - Find it at Amazon 2. Armstrong P, Wilson AG, Dee P et-al. Imaging of diseases of the chest. Mosby-Year Book.

ISBN:0815100116. Read it at Google Books - Find it at Amazon

3. Desai SR, Copley SJ, Aziz ZA et-al. Thoracic Imaging (Oxford Specialist Handbooks in

Radiology). Oxford University Press, USA. ISBN:0199560471. Read it at Google Books - Find it at

Amazon



http://radiopaedia.org/users/mailpkd


http://radiopaedia.org/articles/missing?article%5Btitle%5D=hilum





http://radiopaedia.org/articles/missing?article%5Btitle%5D=hilar-adenopathy







http://www.amazon.com/gp/product/1416025375































17

From

the case: Lung carcinoma with vertebral metastasis Dense right hilum

Modality: X-ray

http://radiopaedia.org/cases/lung-carcinoma-with-vertebral-metastasis






18

From the case: Lung

carcinoma with vertebral metastasis left psoas bulge

Modality: X-ray









19

Necrotic mass in the right

hilum



20

Double density sign of left atrial enlargement

Dr Jeremy Jones and Dr Frank Gaillard et al.

A double-density sign is seen on frontal chest radiographs in the presence of left atrialenlargement, and occurs when the right side of the left atrium pushes behind the right cardiacshadow, indenting the adjacent lung and forming its own distinct silhouette

1-3.

If large enough it can actually reach beyond the border of the right atrium; this is known as atrial

escape.3 The right superior pulmonary vein can lead to a similar appearance

1

References

1. Higgins CB, Reinke RT, Jones NE et-al. Left atrial dimension on the frontal thoracic radiograph:

a method for assessing left atrial enlargement. AJR Am J Roentgenol. 1978;130 (2): 251-5. AJR

Am J Roentgenol (abstract) - Pubmed citation 2. Webb WR, Higgins CB. Thoracic Imaging. Lippincott Williams & Wilkins. (2010)


3. Brant WE, Helms C. Fundamentals of Diagnostic Radiology. Lippincott Williams & Wilkins.

(2012) ISBN:1608319113. Read it at Google Books - Find it at Amazon



Double contour sign ✗

Double contour sign of left atrial enlargement ✓

Right retrocardiac double density ✓

http://radiopaedia.org/users/drjermy


http://radiopaedia.org/users/frank



http://radiopaedia.org/articles/left-atrial-enlargement




http://radiopaedia.org/articles/atrial-escape




http://www.ajronline.org/content/130/2/251.abstract


































21

From the case: Left atrial enlargement

Modality: X-ray

http://radiopaedia.org/cases/left-atrial-enlargement-5






22


Modality: Annotated image







23



24









26

Hilum overlay sign

Dr Henry Knipe and Dr Frank Gaillard et al.

The hilum overlay sign refers to an appearance on frontal chest radiographs of patients with amass projected at the level of the hilum which is in fact either anterior or posterior to the hilum.

When a mass arises from the hilum, the pulmonary vessels are in contact with the mass and as

such their silhouette is obliterated. The ability to see the edges of the vessels through the mass

implies that the mass is not contacting the hilum, and is therefore either anterior or posterior to it.Most of these masses are found to be in the anterior mediastinum.

The sign was first described by Benjamin Felson 2.

References

1. Coche EE, Ghaye B, Mey JD. Comparative Interpretation of CT and Standard Radiography of

the Chest. Springer Verlag. (2010) ISBN:3540799419. Read it at Google Books - Find it at Amazon

2. George PP, Irodi A, Nidugala Keshava S et-al. 'Felson Signs' revisited. J Med Imaging Radiat

Oncol. 2014;58 (1): 64-74. doi:10.1111/1754-9485.12031 - Pubmed citation






http://radiopaedia.org/articles/anterior-mediastinum



http://radiopaedia.org/articles/benjamin-felson









http://dx.doi.org/10.1111/1754-9485.12031

http://dx.doi.org/10.1111/1754-9485.12031

http://dx.doi.org/10.1111/1754-9485.12031





http://dx.doi.org/10.1111/1754-9485.12031









27

From

the case: Lymphoma - mediastinal

Modality: X-ray

http://radiopaedia.org/cases/lymphoma-mediastinal






28

From the case: Lymphoma - mediastinal








29

From the case: Mediastinal lipoma

Modality: X-ray

http://radiopaedia.org/cases/mediastinal-lipoma-1






30






http://radiopaedia.org/images/3109729







31



32









33

From the case: Mediastinal lymphoma

Modality: X-ray

http://radiopaedia.org/cases/mediastinal-lymphoma-3






34

From the case: Ascending aortic aneurysm Case 4: ascending aortic aneurysm

Modality: X-ray

http://radiopaedia.org/cases/ascending-aortic-aneurysm-3






35

From the case: Lung hilar mass - unknown histology

Modality: X-ray

http://radiopaedia.org/cases/lung-hilar-mass-unknown-histology






36



37

From the case: Lung hilar mass - unknown histology

Modality: X-ray







38

From the case: Hilum overlay and loss of more black signs - colorectal carcinoma metastases

Modality: X-ray

http://radiopaedia.org/cases/hilum-overlay-and-loss-of-more-black-signs-colorectal-carcinoma-metastases






39

Hilum convergence sign

Dr Henry Knipe and Dr Andrew Dixon et al.

The hilum convergence sign is a useful chest radiograph sign to help distinguish a bulky hilumdue to pulmonary artery dilatation from a mass/nodal enlargement. In the former, pulmonaryvessels can be seen to converge and join a dilated pulmonary artery.

The sign was first described by Benjamin Felson 2.

References

1. Parker MS, Chasen MH, Paul N. Radiologic signs in thoracic imaging: case-based review and

self-assessment module. AJR Am J Roentgenol. 2009;192 (3): S34-48. doi:10.2214/AJR.07.7081 -Pubmed citation

2. George PP, Irodi A, Nidugala Keshava S et-al. 'Felson Signs' revisited. J Med Imaging Radiat

Oncol. 2014;58 (1): 64-74. doi:10.1111/1754-9485.12031 - Pubmed citation



http://radiopaedia.org/users/dixona



http://radiopaedia.org/articles/differential-of-an-enlarged-pulmonary-trunk-on-chest-radiography






http://dx.doi.org/10.2214/AJR.07.7081





http://dx.doi.org/10.1111/1754-9485.12031

http://dx.doi.org/10.1111/1754-9485.12031

http://dx.doi.org/10.1111/1754-9485.12031





http://dx.doi.org/10.1111/1754-9485.12031









40

From the case: Pulmonary arterial hypertension - primary

Modality: X-ray

http://radiopaedia.org/cases/pulmonary-arterial-hypertension-primary






41

From the case: Pulmonary arterial hypertension - primary

Modality: X-ray







42

Holly leaf sign


The holly leaf sign refers to the appearance of pleural plaques on chest x-rays. Their irregularthickened nodular edges are likened to the appearance of a holly leaf.

References

1. Cugell DW, Kamp DW. Asbestos and the pleura: a review. Chest. 2004;125 (3): 1103-17.

doi:10.1378/chest.125.3.1103 - Pubmed citation



Holly leaf appearance






http://radiopaedia.org/articles/pleural-plaque



http://dx.doi.org/10.1378/chest.125.3.1103












43

Image courtesy of Emilio del Prado. Please see case description page for licence and original file

information. From the case: Holly leaf

Modality: Photo

http://radiopaedia.org/cases/holly-leaf






44

From the case: Pleural plaques

Modality: X-ray

http://radiopaedia.org/cases/pleural-plaques










45

From the case: Calcified pleural plaques

Modality: X-ray

http://radiopaedia.org/cases/calcified-pleural-plaques-1






46

From the case: Calcified pleural plaques

Modality: X-ray







47

Finger in glove sign

Dr Henry Knipe and Dr Jeremy Jones et al.

The finger in glove sign seen on CXR and CT chest and refers to the characteristic sign of a bronchocoele. The same appearance has also been referred to as:

rabbit ear appearance

mickey mouse appearance

toothpaste shaped opacities

Y-shaped opacities

V-shaped opacities

Pathology

Aetiology

Obstructive

In bronchial obstruction, the portion of the bronchus distal to the obstruction is dilated with the

presence of mucous secretions. Causes of bronchial obstruction include :

hamartoma

lipoma

carcinoid

carcinoma

congenital bronchial atresia (rarely)

Non obstructive

Causes include :

asthma

allergic bronchopulmonary aspergillosis (ABPA)

cystic fibrosis

References

1. Collins J, Stern EJ. Chest radiology, the essentials. Lippincott Williams & Wilkins. (2007)


2. Swenson SJ, Aughenbaugh GL, Brown LR. Chest case of the day. AJR Am J Roentgenol 1993;

160:1318-1322.

3. Nguyen ET. The gloved finger sign. Radiology 2003 227:2, 453-454






http://radiopaedia.org/articles/bronchocoele


http://radiopaedia.org/articles/mickey-mouse-appearance


http://radiopaedia.org/articles/bronchial_atresia



http://radiopaedia.org/articles/asthma-1


http://radiopaedia.org/articles/allergic-bronchopulmonary-aspergillosis


http://radiopaedia.org/articles/cystic-fibrosis




















48



Finger in glove appearance ✗

Finger-in-glove sign ✗

Rabbit ear appearance ✓

Y-shaped opacities ✓

V-shaped opacities ✓

Gloved finger sign



49

Glove Image courtesy of Werneuchen. Please see case description page for licence and original file

information. From the case: Glove

Modality: Photo

http://radiopaedia.org/cases/glove






50

From the case: Allergic bronchopulmonary aspergillosis (ABPA)

Modality: X-ray

http://radiopaedia.org/cases/allergic-bronchopulmonary-aspergillosis-abpa-1






51



52

Finger in glove appearance of ABPA From the case: Allergic bronchopulmonary aspergillosis (ABPA)

Modality: CT

http://radiopaedia.org/cases/allergic-bronchopulmonary-aspergillosis-abpa






53

Finger in glove appearance of ABPA From the case: Allergic bronchopulmonary aspergillosis (ABPA)

Modality: CT







54

Flat waist sign

Dr Henry Knipe and Dr Vinod G Maller et al.

The flat waist sign refers to flattening of the contours of the aortic arch and adjacent main pulmonary artery. It is seen in severe left lower lobe collapse and is caused by leftwarddisplacement and rotation of the heart.



http://radiopaedia.org/users/vinodmaller



http://radiopaedia.org/articles/aortic_arch





http://radiopaedia.org/articles/left-lower-lobe-collapse










55

Fleishner's sign

Dr Yuranga Weerakkody and Dr Ian Bickle et al.

Fleishner's sign is a prominent central artery that can be caused either by pulmonaryhypertension that develops or by distension of the vessel by a large pulmonary embolus.

Radiographic appearance

Plain film

Fleishner's sign is a description given to appearances on plain chest x-ray along with

Westermark's sign and Hampton's hump. These are all rarely seen, and usually in the context of a

large pulmonary embolism.

References

1. Plain Film Signs in Pulmonary Embolism (with CT correlate), Kirwadi A, Bickle IC.

http://www.eurorad.org/eurorad/case.php?id=7735 Eurorad case 7735

2. Worsley DF, Alavi A, Aronchick JM et-al. Chest radiographic findings in patients with acute

pulmonary embolism: observations from the PIOPED Study. Radiology. 1993;189 (1): 133-6.

Radiology (abstract) - Pubmed citation



Fleishner sign



http://radiopaedia.org/users/clonvara



http://radiopaedia.org/articles/pulmonary-hypertension-1









http://radiopaedia.org/articles/hampton-hump








http://radiology.rsna.org/content/189/1/133.abstract


















56

From the case: Pulmonary embolism with right atrial thrombus

Modality: X-ra

http://radiopaedia.org/cases/pulmonary-embolism-with-right-atrial-thrombus






57

Ginkgo leaf sign

Dr Henry Knipe and Dr Bita Abbasi et al.

The ginkgo leaf sign is a chest plain radiography appearance which is seen at extensivesubcutaneous 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.

References

1. Ho ML, Gutierrez FR. Chest radiography in thoracic polytrauma. AJR Am J Roentgenol.

2009;192 (3): 599-612. AJR Am J Roentgenol (full text) - doi:10.2214/AJR.07.3324 - Pubmed

citation

2. Chimutengwende-Gordon M, Khan WS, Sidhu J et-al. Advanced trauma life support

radiographic trauma series: part 2-the chest radiograph. J Perioper Pract. 2011;20 (12): 430-5.

Pubmed citation



Ginkgo leaf appearance



http://radiopaedia.org/users/bita_ab



http://radiopaedia.org/articles/subcutaneous-emphysema


http://radiopaedia.org/articles/pectoralis-major-1



http://en.wikipedia.org/wiki/Ginkgo_biloba



http://www.ajronline.org/content/192/3/599.full
























58

Ginkgo leaf



59

Emphizema 3 day after pneumonectomyFrom the case: Subcutaneous emphysema

Modality: X-ray

http://radiopaedia.org/cases/subcutaneous-emphysema-4






60

From the case: Subcutaneous emphysema (ginkgo leaf sign)

Modality: X-ray

http://radiopaedia.org/cases/subcutaneous-emphysema-ginkgo-leaf-sign






61

Golden S sign

Dr Frank Gaillard et al.

The Golden S sign is seen on both PA chest radiographs and on CT scans. It is named becausethis sign resembles a reverse S shape, and is therefore sometimes referred to as the reverse S

sign of Golden.

Although typically seen with right upper lobe collapse, the S sign can also be seen with the

collapse of other lobes. It is created by a central mass obstructing the upper lobe bronchus andshould raise suspicion of a primary bronchogenic carcinoma. It can also be caused by other

central masses, such as: metastasis, primary mediastinal tumour, or enlarged lymph nodes.

Radiographic features

Chest radiographs

The Golden S sign is seen on frontal radiographs. In the most common situation, the appearance

is that of right upper lobar collapse (the right upper lobe appearing dense and shifting medially

and upwards) with a central mass expanding the hilum. These two changes together form areverse S shape.

Etymology

The sign was first described by R Golden in 19253.

References

1. Gupta P. The Golden S sign. Radiology. 2004;233 (3): 790-1. doi:10.1148/radiol.2333021407 -

Pubmed citation



3. Golden R. The effect of bronchostenosis upon the roentgen ray shadow in carcinoma of the

bronchus. AJR Am J Roentgenol 1925; 13:21.


Reverse S sign of Golden ✓

S sign of Golden



http://radiopaedia.org/articles/right-upper-lobe-collapse









http://dx.doi.org/10.1148/radiol.2333021407





















62

From the case: Golden S sign

Modality: X-ray

http://radiopaedia.org/cases/golden-s-sign






63


Modality: X-ray







64













65


Modality: X-ray

http://radiopaedia.org/cases/golden-s-sign-1






66


Modality: X-ray







67

From the case:

S sign of Golden

http://radiopaedia.org/cases/s-sign-of-golden





68

From the case: S sign of

Golden









69

From the case: Pleural effusion with right lower lobe atelectasis

Modality: X-ray Case 4: inverted Golden S sign

http://radiopaedia.org/cases/pleural-effusion-with-right-lower-lobe-atelectasis






70

Incomplete border sign

Dr Yuranga Weerakkody and Dr Charlie Chia-Tsong Hsu et al.

The incomplete border sign is useful to depict an extrapulmonary mass on chest radiograph.

An extrapulmonary mass will often have a inner well defined border and an ill-defined outermargin

1-3. This can be attributed to the inner margin being tangential to the x-ray beam and has

good inherent contrast with the adjacent lung. On the other hand, the outer margin is enface or

partially enface with the x-ray beam and merges with the pleural or chest wall thus the border isobscured.


Differential diagnosis for extrapulmonary mass can be further divided into pleural or

extrapleural.

Common pleural masses include:

loculated pleural collection

haematoma

pleural plaques

fibrous tumour of pleura

Extrapleural causes can arises from component of chest wall, bone/cartilage, nerve, vascular,

fat, muscle and skin. If there is sign of rib/bone involvement on chest radiograph the lesion is

most likely to be extrapleural. In adults, skeletal metastases are the most common malignantchest wall neoplasm while chondrosarcoma is the most common primary malignant tumor.

References

1. Catalano O. The incomplete border sign. Radiology. 2002;225 (1): 129-30.

doi:10.1148/radiol.2251010926 - Pubmed citation

2. Ellis R. Incomplete border sign of extrapleural masses. JAMA. 1977;237 (25): 2748. JAMA (link)

- Pubmed citation

3. Hsu CC, Henry TS, Chung JH et-al. The incomplete border sign. J Thorac Imaging. 2014;29 (4):W48. doi:10.1097/RTI.0000000000000088 - Pubmed citation



Incomplete border sign on a chest x ray ✗



http://radiopaedia.org/users/hsu



http://radiopaedia.org/articles/lung





http://radiopaedia.org/articles/pleural-fibroma


http://radiopaedia.org/articles/skeletal-metastases



http://radiopaedia.org/articles/chondrosarcoma








http://jama.jamanetwork.com/article.aspx?volume=237&page=2748






http://dx.doi.org/10.1097/RTI.0000000000000088





















71


Incomplete border sign on a chest radiograph

From the case: Pleural metastases with the 'incomplete border sign'

http://radiopaedia.org/cases/pleural-metastases-with-the-incomplete-border-sign






72

Juxtaphrenic peak sign

Dr Henry Knipe and Dr Andrew Dixon et al.

The juxtaphrenic peak sign refers to the peaked or tented appearance of a hemidiaphragm

which can occur in the setting of lobar collapse. It is caused by retraction of the lower end of

diaphragm at an inferior accessory fissure (most common1), major fissure or inferior pulmonary

ligament. It is commonly seen in upper lobe collapse but may also be seen in middle lobe

collapse.

References

1. Davis SD, Yankelevitz DF, Wand A et-al. Juxtaphrenic peak in upper and middle lobe volume

loss: assessment with CT. Radiology. 1996;198 (1): 143-9. Radiology (citation) - Pubmed citation

2. Konen E, Rozenman J, Simansky DA et-al. Prevalence of the juxtaphrenic peak after upper

lobectomy. AJR Am J Roentgenol. 2001;177 (4): 869-73. AJR Am J Roentgenol (citation) -

Pubmed citation





Juxtaphrenic peak ✗

Juxtaphrenic peak (JP) ✗

Juxta-phrenic peak sign






http://radiopaedia.org/articles/diaphragm



http://radiopaedia.org/articles/lobar-lung-collapse



http://radiopaedia.org/articles/inferior-accessory-fissure



http://radiopaedia.org/articles/inferior-pulmonary-ligament




http://radiopaedia.org/articles/missing?article%5Btitle%5D=upper-lobe-collapse



http://radiopaedia.org/articles/middle-lobe-collapse




http://radiology.rsna.org/content/198/1/143.citation






http://www.ajronline.org/cgi/content/citation/177/4/869





























73

From the case: Luftsichel sign Case 1: in left upper collapse

Modality: X-ray

http://radiopaedia.org/cases/luftsichel-sign






74

From the case: Luftsichel sign Case 1: in left upper collapse

Modality: X-ray







75

From the case: Juxtaphrenic peak sign Case 2 : on right

Modality: X-ray

http://radiopaedia.org/cases/juxtaphrenic-peak-sign






76

Medial stripe sign

Dr Henry Knipe and Dr Aditya Shetty et al.

Medial stripe sign refers to an area of increased lucency at the interface of the medial lung andthe mediastinum in case of medial pneumothorax. A small volume of pneumothorax generallyaccumulates anteriorly or medially which can be difficult to detect hence this sign holds a certain

significance.

Related pathology

neonatal pneumothorax

References

1. Swischuk LE. Two lesser known but useful signs of neonatal pneumothorax. AJR Am JRoentgenol. 1976;127 (4): 623-7. doi:10.2214/ajr.127.4.623 - Pubmed citation



Medial pneumothorax sign ✓

Medial stripe sign in a pneumothorax



http://radiopaedia.org/users/adityashetty01






http://radiopaedia.org/articles/mediastinum



http://radiopaedia.org/articles/medial-pneumothorax



http://radiopaedia.org/articles/neonatal-pneumothorax


http://dx.doi.org/10.2214/ajr.127.4.623
















77

From the case: Pneumothorax

Modality: X-ray

http://radiopaedia.org/cases/pneumothorax-6






78

More black sign


The more black sign is a normal finding in lateral chest x-ray, and refers to the gradualincreased apparent radiolucency (blackness) of the vertebral bodies, when proceeding from upperto 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 radio-dense; this is referred to as the loss of the more back sign.


Loss of more black sign









http://radiopaedia.org/articles/pleural-effusion






http://radiopaedia.org/articles/missing?article%5Btitle%5D=paraspinal-neurogenic-tumour











79

From the case: Normal chest x-ray

Modality: X-ray

http://radiopaedia.org/cases/normal-chest-x-ray






80

Normal chest x-ray



81

Normal pulmonary artery



82

From the case: Left lower lobe consolidation Case 2: left lower lobe consolidation

Modality: X-ray

http://radiopaedia.org/cases/left-lower-lobe-consolidation






83

Left lower lobe consolidation Case 2: left lower lobe consolidation



84

From the case: Small pleural effusion Case 3: right pleural effusion

Modality: X-ra

http://radiopaedia.org/cases/small-pleural-effusion






85

From the case: Small pleural effusion Case 3: right pleural effusion

Modality: X-ra







86

From the case:

Hilum overlay and loss of more black signs - colorectal carcinoma metastases Case 4: colorectal

metastases

Modality: X-ray






87

From the case:

Hiatus and Bochdalek hernias Case 5: Bochdalek hernia

Modality: X-ray

http://radiopaedia.org/cases/hiatus-and-bochdalek-hernias





88

From the

case: Hiatus and Bochdalek hernias Case 5: Bochdalek hernia

Modality: X-ray







89

Naclerio's V sign


The Naclerio's V sign is a sign described on the plain film in patients witha 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.

Although Naclerio’s V sign was originally described in patients with oesophageal rupture, it is not entirely specific to that condition.

References

1. Bejvan SM, Godwin JD. Pneumomediastinum: old signs and new signs. AJR Am J Roentgenol.

1996;166 (5): 1041-8. AJR Am J Roentgenol (citation) - Pubmed citation

2. Sinha R. Naclerio's V sign. Radiology. 2007;245 (1): 296-7. doi:10.1148/radiol.2451042197 -

Pubmed citation



Naclerio v sign ✗

Naclerios v sign



http://radiopaedia.org/articles/pneumomediastinum






















90

Shmoo sign

Dr Henry Knipe and Dr Sahith Reddy et al.

Shmoo sign refers to appearance of prominent, rounded left ventricle and dilated aorta on a plainAP radiograph of chest giving the appearance of Shmoo, a fictional cartoon character in thecomic strip Li'l Abner in the 1940s. This signs indicates left ventricular hypertrophy.



http://radiopaedia.org/users/sahithmdrd



http://radiopaedia.org/articles/left-ventricular-enlargement








91

Silhouette sign

Dr Henry Knipe and Dr Ayush Goel et al.

Silhouette sign was first described by Drs Benjamin Felson and Henry Felson in 19501

. Thename is somewhat of a misnomer and in the true sense actually denotes the loss of a silhouette,thus it is sometimes also known as loss of silhouette sign or loss of outline sign

4.

The differential attenuation of x-ray photons by two adjacent structures defines the silhouette,

e.g. heart borders against the adjacent lung segments and it is the pathological loss of thisdifferentiation, which the silhouette sign refers to.

Radiographic appearance

Plain film

Recognition of this sign is useful in localising areas of airspace opacities, atelectasis or

mass within the lung, with the loss of these normal silhouettes on frontal chest radiographs being

generally indicative of the site of pathology3, 4

:

right paratracheal stripe - right upper lobe

right heart border - right middle lobe or medial right lower lobe

right hemidiaphragm - right lower lobe

aortic knuckle - left upper lobe

left heart border - lingula segments of the left upper lobe

left hemidiaphragm or descending aorta - left lower lobe

Sites of silhouette sign on the lateral chest radiograph include3:

posterior border of the heart +/- posterior left hemidiaphragm - left lower lobe

anterior right hemidiaphragm - right middle lobe

posterior right hemidiaphragm - right lower lobe

The silhouette sign forms the basis of the hilum overlay sign, cerviothoracic sign and thoraco-

abdominal sign 2.


The presence of a silhouette sign may not be due to intra-pulmonary disease. For example3, 4

:

right heart border - pectus excavatum

posterior border of heart (lateral projection) - hiatus hernia



http://radiopaedia.org/users/drayushgoel












http://radiopaedia.org/articles/right-paratracheal-stripe








http://radiopaedia.org/articles/cervicothoracic-sign



http://radiopaedia.org/articles/thoracoabdominal-sign




http://radiopaedia.org/articles/pectus-excavatum



http://radiopaedia.org/articles/hiatus-hernia


















92

References

1. FELSON B, FELSON H. Localization of intrathoracic lesions by means of the postero-anterior

roentgenogram; the silhouette sign. Radiology. 1950;55 (3): 363-74. doi:10.1148/55.3.363 -

Pubmed citation

2. Marshall GB, Farnquist BA, MacGregor JH et-al. Signs in thoracic imaging. J Thorac Imaging.2006;21 (1): 76-90. doi:10.1097/01.rti.0000189192.70442.7a - Pubmed citation

3. Webb WR, Higgins CB. Thoracic Imaging. Lippincott Williams & Wilkins. (2010)


4. Wright FW. Radiology of the chest and related conditions. CRC Press. ISBN:0415281415. Read

it at Google Books - Find it at Amazon



Silhouette sign of Felson ✗

Loss of silhouette sign ✗

Loss of outline sign

http://dx.doi.org/10.1148/55.3.363

http://dx.doi.org/10.1148/55.3.363

http://dx.doi.org/10.1148/55.3.363



http://dx.doi.org/10.1097/01.rti.0000189192.70442.7a



























http://dx.doi.org/10.1148/55.3.363



93

From the case: Cardiomediastinal outlines on chest x-ray


http://radiopaedia.org/cases/cardiomediastinal-outlines-on-chest-x-ray






94

From the case: Cardiomediastinal outlines on chest x-ray








95

From

the case: Silhouette sign of Felson - right middle lobe pneumonia

Modality: X-ray

http://radiopaedia.org/cases/silhouette-sign-of-felson-right-middle-lobe-pneumonia






96

From the case:

Silhouette sign of Felson - right middle lobe pneumonia

Modality: X-ray






97

From the case:

Pneumonia - right lower lobe

Modality: X-ray

http://radiopaedia.org/cases/pneumonia-right-lower-lobe





98

From the case:

Pneumonia - right lower lobe

Modality: X-ray






99

From the case: Right upper lobe pneumonia (paediatric)

Modality: X-ray

http://radiopaedia.org/cases/right-upper-lobe-pneumonia-paediatric






100

Imaging Differential Diagnosis

From the case:

Pectus excavatum

Modality: X-ray

http://radiopaedia.org/cases/pectus-excavatum-7





101

From the case: Hiatus hernia

Modality: X-ray

http://radiopaedia.org/cases/hiatus-hernia-5






102

From the case: Hiatus hernia

Modality: X-ray







103

Steeple sign


The steeple sign (also called wine bottle sign) refers to tapering of the upper trachea on a frontalchest radiograph reminiscent of a church steeple. The appearance is suggestive of croup, whichshould be obvious clinically. A corresponding lateral x-ray would show narrowing of the

subglottic trachea and ballooning of the hypopharynx.

References

1. Salour M. The steeple sign. Radiology. 2000;216 (2): 428-9. Radiology (full text) - Pubmed

citation

2. Dähnert WF. Radiology Review Manual. Lippincott Williams & Wilkins. (2011)




Wine bottle sign






http://radiopaedia.org/articles/trachea



http://radiopaedia.org/articles/croup



http://radiology.rsna.org/content/216/2/428.full
























104

Steeple of Salisbury Cathedral

This cropped image of the steeple of Salisbury Cathedral, Wiltshire, England, is from the original

photgraph by Andrew Dunn, available at

http://commons.wikimedia.org/wiki/File:Salisbury_Cathedral.jpg which is published under the

following license: This file is licensed under Creative Commons Attribution ShareAlike 2.0 License



105

Croup - Steeple Sign



106

Croup - Steeple SignFrom the case: Croup - steeple sign From the case: Croup - steeple sign

http://radiopaedia.org/cases/croup-steeple-sign

















108

Spinnaker sign


The spinnaker sign (also known as the angel wing sign) is a sign of pneumomediastinum seenon neonatal chest radiographs. It refers to the thymus being outlined by air with each lobedisplaced laterally and appearing like spinnaker sails. This is distinct from the sail sign

appearance of the normal thymus.



Angel wing sign ✓

Spinnaker sail sign









http://radiopaedia.org/articles/thymus



http://radiopaedia.org/articles/missing?article%5Btitle%5D=sail-sign-thymus










109

From the case: Pneumomediastum (neonate)

Modality: X-ray

http://radiopaedia.org/cases/pneumomediastum-neonate






110

From the case: Pneumomediastum (neonate)

Modality: X-ray







111

From the case: Pneumomediastinum

http://radiopaedia.org/cases/pneumomediastinum-2






112



113

From the case: Pneumomediastinum







114

Water bottle sign


The water bottle sign or configuration refers to the shape of the cardiac silhouette on erectfrontal chest x-rays in patients who have a very large pericardial effusion. Typically the effusionhas 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 bottle sitting on the bench.

References

1. Walker HK, Hall WD, Hurst JW. Clinical methods, the history, physical, and laboratory

examinations. Butterworth-Heinemann. (1990) ISBN:040990077X. Read it at Google Books - Find

it at Amazon



Water bottle configuration ✗

Water bottle heart






http://radiopaedia.org/articles/missing?article%5Btitle%5D=cardiac+silhouette



http://radiopaedia.org/articles/pericardial-effusion



http://books.google.com/books?vid=ISBN040990077X



http://www.amazon.com/gp/product/040990077X?ie=UTF8&tag=radiopaediaor-20&linkCode=as2&camp=1789&creative=9325&creativeASIN=040990077X













115

From the case: Pericardial effusion - water bottle sign

Modality: X-ray

http://radiopaedia.org/cases/pericardial-effusion-water-bottle-sign










116

From the case: Pericardial effusion

Modality: X-ray

http://radiopaedia.org/cases/pericardial-effusion-4






117

From the case:

Pericardial effusion

Modality: X-ray






118

Wave sign

Dr Henry Knipe and Radswiki et al.

The wave sign refers to the indentation of the normal thymus in young children by the ribs,resulting in a wavy border.

References

1. Textbook of radiology and imaging. Churchill Livingstone. ISBN:0443071098. Read it at Google

Books - Find it at Amazon

From the case: Normal thymus



http://radiopaedia.org/users/radswiki













http://radiopaedia.org/cases/normal-thymus-1
















120

From the case: Prominent thymus - wavy border

Modality: X-ray

http://radiopaedia.org/cases/prominent-thymus-wavy-border






121

Westermark's sign


Westermark's sign is a sign of pulmonary embolus (PE) seen on chest radiographs.

Pathology

In one study (PIOPED) this sign was present on ~10% of chest x-rays of patients with confirmed

PE2.

The theory behind the sign is either obstruction of the pulmonary artery or distal vasoconstriction

in hypoxic lung3.

Radiographic features

Plain film

focal peripheral hyperlucency secondary to oligaemia 2, 3, 4

central pulmonary vessels may also be dilated 3


emphysema 2

References

1. Sreenivasan S, Bennett S, Parfitt VJ. Images in cardiovascular medicine. Westermark's and

Palla's signs in acute pulmonary embolism. Circulation. 2007;115 (8): e211.

doi:10.1161/CIRCULATIONAHA.106.665422 - Pubmed citation

2. Osborn A, Blaser S, Salzman K. Encyclopedia of Diagnostic Imaging. AMIRSYS. (2008)


3. Webb WR, Higgins CB. Thoracic Imaging. Lippincott Williams & Wilkins. (2010)


4. E.Brant MW, A.Helms MC. The Brant and Helms Solution. Lippincott Williams &Wilkins. (2007)

ISBN:B0011ZYZR2. Read it at Google Books - Find it at Amazon



http://radiopaedia.org/articles/pulmonary_embolism



http://radiopaedia.org/articles/pulmonary-emphysema


http://dx.doi.org/10.1161/CIRCULATIONAHA.106.665422

















http://books.google.com/books?vid=ISBNB0011ZYZR2



http://www.amazon.com/gp/product/B0011ZYZR2














radiological signs (shënja radiologjike )-1

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