Top 30 Signs in Chest X-Ray

Transcription

1 Top 30 Signs in Chest X-Ray Poster No.: C-1788 Congress: ECR 2017 Type: Educational Exhibit Authors: C. Maneesh Ramki, M. Farook, F. Abubacker Sulaiman ; Chennai/IN, Chennai, TN/IN Keywords: Respiratory system, Cardiovascular system, Lung, Digital radiography, Diagnostic procedure, Education and training DOI: /ecr2017/C-1788 Any information contained in this pdf file is automatically generated from digital material submitted to EPOS by third parties in the form of scientific presentations. References to any names, marks, products, or services of third parties or hypertext links to thirdparty sites or information are provided solely as a convenience to you and do not in any way constitute or imply ECR's endorsement, sponsorship or recommendation of the third party, information, product or service. ECR is not responsible for the content of these pages and does not make any representations regarding the content or accuracy of material in this file. As per copyright regulations, any unauthorised use of the material or parts thereof as well as commercial reproduction or multiple distribution by any traditional or electronically based reproduction/publication method ist strictly prohibited. You agree to defend, indemnify, and hold ECR harmless from and against any and all claims, damages, costs, and expenses, including attorneys' fees, arising from or related to your use of these pages. Please note: Links to movies, ppt slideshows and any other multimedia files are not available in the pdf version of presentations. Page 1 of 73

2 Learning objectives To describe 30 classic signs in radiological imaging of chest. To provide illustrations of these signs. To discuss the pertinent features related to each sign with emphasis on the cause of the appearance of these signs, and the differential diagnoses to be considered. Background Classic signs in radiology, when invoked, immediately bring an image to mind and add confidence to the diagnosis of certain conditions. This presentation reviews 30 classic radiological signs of chest. To provide knowledge about the features related to each sign and provide illustrations of these signs using different modalities. Findings and procedure details 1. Airbronchogram sign: In an opacified lung, Branching and tubular lucencies of bronchi are seen. Therefore it indicates that the pathology is in the lung parenchyma itself. The sign shows that the central bronchi are not obstructed; however, it can also be seen when a mass causes half-obstruction. 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. This sign can also be seen on CT images. Page 2 of 73

3 Fig. 1: Air bronchogram sign:in an opacified lung, Branching and tubular lucencies of bronchi are seen. References: Radiology and Imaging Sciences, Chettinad Hospital and Research Institute, Chettinad Hospital and Research Institute - Chennai/IN 2. 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. The silhouette sign is an important sign indicating the localization of a lesion. Page 3 of 73

4 Fig. 2: 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. References: Radiology and Imaging Sciences, Chettinad Hospital and Research Institute, Chettinad Hospital and Research Institute - Chennai/IN 3. 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. Page 4 of 73

5 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. Fig. 33: The deep sulcus sign on a supine chest radiograph is an indication of a pneumothorax. References: Radiology and Imaging Sciences, Chettinad Hospital and Research Institute, Chettinad Hospital and Research Institute - Chennai/IN 4. More Black Sign: Page 5 of 73

6 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. Page 6 of 73

7 Fig. 4: More black sign: showing 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. Page 7 of 73

8 References: Radiology and Imaging Sciences, Chettinad Hospital and Research Institute, Chettinad Hospital and Research Institute - Chennai/IN Fig. 5: More black sign: showing 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. References: Radiology and Imaging Sciences, Chettinad Hospital and Research Institute, Chettinad Hospital and Research Institute - Chennai/IN 5.Bat wing Sign: Also called as Angel Wing Sign. Page 8 of 73

9 Seen in pulmonary oedema involving perihilar region sparing the cortex of the lungs. Fig. 6: Bat wing sign: Seen in pulmonary oedema involving perihilar region sparing the cortex of the lungs. References: Radiology and Imaging Sciences, Chettinad Hospital and Research Institute, Chettinad Hospital and Research Institute - Chennai/IN 6. Air Crescent Sign: Page 9 of 73

10 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 immunityand 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. Page 10 of 73

11 Fig. 7: Air crescent Sign: Air between the cavity wall and the fungus ball (mycetoma). References: Radiology and Imaging Sciences, Chettinad Hospital and Research Institute, Chettinad Hospital and Research Institute - Chennai/IN 7. 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. Page 11 of 73

12 Fig. 8: 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. References: Radiology and Imaging Sciences, Chettinad Hospital and Research Institute, Chettinad Hospital and Research Institute - Chennai/IN 8. Scimitar sign: 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. Page 12 of 73

13 A tubular-shaped opacity extending towards the diaphragm along the right side of the heart is seen. The abnormal pulmonary vein resembles a Turkish sword called a "pala". The scimitar sign is associated with congenital hypogenetic lung syndrome (scimitar syndrome). Fig. 9: Schimitar Sign:A tubular-shaped opacity extending towards the diaphragm along the right side of the heart is seen. References: Radiology and Imaging Sciences, Chettinad Hospital and Research Institute, Chettinad Hospital and Research Institute - Chennai/IN 9. Doughnut sign: Page 13 of 73

14 The doughnut sign occurs when mediastinal lymphadenopathy occurs behind the bronchus intermedius in the subcarinal region. Lymphadenopathy is seen as lobulated densities on lateral radiographs. Page 14 of 73

15 Fig. 10: Doughnut Sign: when mediastinal lymphadenopathy occurs behind the bronchus intermedius in the subcarinal region. Lymphadenopathy is seen as lobulated densities on lateral radiographs References: Radiology and Imaging Sciences, Chettinad Hospital and Research Institute, Chettinad Hospital and Research Institute - Chennai/IN 10. 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. Page 15 of 73

16 Fig. 11: Hampton Hump sign: A wedge-shaped, pleura-based consolidation with a rounded convex apex directed towards the hilus. References: Radiology and Imaging Sciences, Chettinad Hospital and Research Institute, Chettinad Hospital and Research Institute - Chennai/IN 11. 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. Page 16 of 73

17 Fig. 12: Westermark sign: Decrease of vascularization at the periphery of the lungs due to mechanical obstruction or reflex vasoconstriction in pulmonary embolism (oligemia). References: Radiology and Imaging Sciences, Chettinad Hospital and Research Institute, Chettinad Hospital and Research Institute - Chennai/IN 12. Luftsichel sign: The word "Luftsichel" in German means "air crescent". This sign is seen in severe left upper lobe collapse. Page 17 of 73

18 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 dis placement 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. Fig. 13: Luftsichel sign: The crescent-shaped radiolucency around the aortic arch. References: Radiology and Imaging Sciences, Chettinad Hospital and Research Institute, Chettinad Hospital and Research Institute - Chennai/IN 13. Juxtaphrenic peak sign: It occurs in upper lobe atelectasis, describes the triangular opacity projecting superiorly at the medial half of the diaphragm. It is most commonly related to the presence of an inferior accessory fissure. 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. Page 18 of 73

19 The juxtaphrenic sign can also be seen in combined right upper and middle lobe volume loss or even with middle lobe collapse only. Fig. 14: Juxtaphrenic Peak sign:describes the triangular opacity projecting superiorly at the medial half of the diaphragm. References: Radiology and Imaging Sciences, Chettinad Hospital and Research Institute, Chettinad Hospital and Research Institute - Chennai/IN 14.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. Page 19 of 73

20 Fig. 15: 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. References: Radiology and Imaging Sciences, Chettinad Hospital and Research Institute, Chettinad Hospital and Research Institute - Chennai/IN 15. Chilaiditi 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. Page 20 of 73

21 Fig. 16: The anterior interposition of the colon to the liver reaching the under-surface of the right hemidiaphragm with associated upper abdominal pain. References: Radiology and Imaging Sciences, Chettinad Hospital and Research Institute, Chettinad Hospital and Research Institute - Chennai/IN 16.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. Page 21 of 73

22 Fig. 17: Chest PA view: 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. References: Radiology and Imaging Sciences, Chettinad Hospital and Research Institute, Chettinad Hospital and Research Institute - Chennai/IN Page 22 of 73

23 Fig. 18: Chest lateral view: 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. References: Radiology and Imaging Sciences, Chettinad Hospital and Research Institute, Chettinad Hospital and Research Institute - Chennai/IN 17. Water Bag Sign: Refers to the shape of the cardiac silhouette in patients who have a very large pericardial effusion. Page 23 of 73

24 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. Fig. 19: Water bag sign:the fluid, often measuring a litre or more, causes the pericardium to sag, mimicking an old-fashioned water bag sitting on the bench. References: Radiology and Imaging Sciences, Chettinad Hospital and Research Institute, Chettinad Hospital and Research Institute - Chennai/IN 18.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. Page 24 of 73

25 Fig. 20: Holly leaf sign: Irregular thickened nodular edges are likened to the appearance of a holly leaf. References: Radiology and Imaging Sciences, Chettinad Hospital and Research Institute, Chettinad Hospital and Research Institute - Chennai/IN 19.Fleischner sign: Page 25 of 73

26 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. Page 26 of 73

27 Page 27 of 73

28 Fig. 21: 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. References: Radiology and Imaging Sciences, Chettinad Hospital and Research Institute, Chettinad Hospital and Research Institute - Chennai/IN 20. 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. Fig. 22: Naclerio V sign: 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 Page 28 of 73

29 produced by air between the parietal pleura and medial left hemidiaphragm. Seen in oesophagus rupture. References: Radiology and Imaging Sciences, Chettinad Hospital and Research Institute, Chettinad Hospital and Research Institute - Chennai/IN 21.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. Fig. 23: Shmoo Sign: Appearance of a prominent, rounded left ventricle and dilated aorta on a plain AP chest radiograph giving the appearance of Shmoo.Indicative of left ventricular enlargement. References: 22.Extra pleural Sign: Page 29 of 73

30 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. Fig. 24: 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. References: Radiology and Imaging Sciences, Chettinad Hospital and Research Institute, Chettinad Hospital and Research Institute - Chennai/IN Page 30 of 73

31 23.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. Fig. 25: 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. Page 31 of 73

32 References: Radiology and Imaging Sciences, Chettinad Hospital and Research Institute, Chettinad Hospital and Research Institute - Chennai/IN 24. Hilum Overlay Sign: Differentiates from the large pulmonary artery from hilar masses on chest xray. 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 therefore its either anterior or posterior to it. Page 32 of 73

33 Fig. 26: 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. References: Radiology and Imaging Sciences, Chettinad Hospital and Research Institute, Chettinad Hospital and Research Institute - Chennai/IN 25. Hilum Convergence Sign: Page 33 of 73

34 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 convergeand join a dilated pulmonary artery. Fig. 27: Hilum convergence sign. References: Radiology and Imaging Sciences, Chettinad Hospital and Research Institute, Chettinad Hospital and Research Institute - Chennai/IN 26.Double Density Sign: Page 34 of 73

35 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. Fig. 28: 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. References: Radiology and Imaging Sciences, Chettinad Hospital and Research Institute, Chettinad Hospital and Research Institute - Chennai/IN 27.Cottage Loaf Sign: Page 35 of 73

36 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. Fig. 29: Cottage loaf sign: 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. References: Radiology and Imaging Sciences, Chettinad Hospital and Research Institute, Chettinad Hospital and Research Institute - Chennai/IN Page 36 of 73

37 28. Pawnbroker's sign: Also called as sign or Garland triad. It is a lymph node enlargement pattern which has been described in sarcoidosis. The lymph nodes involved are right paratracheal,hilar and left hilar lymph nodes. Page 37 of 73

38 Fig. 30: Pawnbroker's sign:it is a lymph node enlargement pattern which has been described in sarcoidosis. References: Radiology and Imaging Sciences, Chettinad Hospital and Research Institute, Chettinad Hospital and Research Institute - Chennai/IN 29. Thymic Sail Sign: Represents the triangular shape inferior margin of the normal thymus seen on neonatal frontal chest radiograph. This indicate pneumomediastinum. Fig. 31: Thymic sail sign: Represents the triangular shape inferior margin of the normal thymus seen on neonatal frontal chest radiograph. This indicate pneumomediastinum. References: Radiology and Imaging Sciences, Chettinad Hospital and Research Institute, Chettinad Hospital and Research Institute - Chennai/IN 30. Continuous Diaphragmatic Sign: Page 38 of 73

39 Normally,th ecentral portion of the diaphragm is not discretly visualissed on the chest radiograph, as it merges with the cardiac sillhouette. 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. Fig. 32: 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. Page 39 of 73

40 References: Radiology and Imaging Sciences, Chettinad Hospital and Research Institute, Chettinad Hospital and Research Institute - Chennai/IN Images for this section: Fig. 1: Air bronchogram sign:in an opacified lung, Branching and tubular lucencies of bronchi are seen. Page 40 of 73

41 Radiology and Imaging Sciences, Chettinad Hospital and Research Institute, Chettinad Hospital and Research Institute - Chennai/IN Fig. 2: 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. Radiology and Imaging Sciences, Chettinad Hospital and Research Institute, Chettinad Hospital and Research Institute - Chennai/IN Page 41 of 73

42 Fig. 4: More black sign: showing 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. Page 42 of 73

43 Radiology and Imaging Sciences, Chettinad Hospital and Research Institute, Chettinad Hospital and Research Institute - Chennai/IN Fig. 6: Bat wing sign: Seen in pulmonary oedema involving perihilar region sparing the cortex of the lungs. Radiology and Imaging Sciences, Chettinad Hospital and Research Institute, Chettinad Hospital and Research Institute - Chennai/IN Page 43 of 73

44 Fig. 5: More black sign: showing 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. Radiology and Imaging Sciences, Chettinad Hospital and Research Institute, Chettinad Hospital and Research Institute - Chennai/IN Page 44 of 73

45 Fig. 7: Air crescent Sign: Air between the cavity wall and the fungus ball (mycetoma). Radiology and Imaging Sciences, Chettinad Hospital and Research Institute, Chettinad Hospital and Research Institute - Chennai/IN Page 45 of 73

46 Fig. 8: 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. Radiology and Imaging Sciences, Chettinad Hospital and Research Institute, Chettinad Hospital and Research Institute - Chennai/IN Page 46 of 73

47 Fig. 9: Schimitar Sign:A tubular-shaped opacity extending towards the diaphragm along the right side of the heart is seen. Radiology and Imaging Sciences, Chettinad Hospital and Research Institute, Chettinad Hospital and Research Institute - Chennai/IN Page 47 of 73

48 Fig. 10: Doughnut Sign: when mediastinal lymphadenopathy occurs behind the bronchus intermedius in the subcarinal region. Lymphadenopathy is seen as lobulated densities on lateral radiographs Radiology and Imaging Sciences, Chettinad Hospital and Research Institute, Chettinad Hospital and Research Institute - Chennai/IN Page 48 of 73

49 Fig. 11: Hampton Hump sign: A wedge-shaped, pleura-based consolidation with a rounded convex apex directed towards the hilus. Radiology and Imaging Sciences, Chettinad Hospital and Research Institute, Chettinad Hospital and Research Institute - Chennai/IN Page 49 of 73

50 Fig. 12: Westermark sign: Decrease of vascularization at the periphery of the lungs due to mechanical obstruction or reflex vasoconstriction in pulmonary embolism (oligemia). Radiology and Imaging Sciences, Chettinad Hospital and Research Institute, Chettinad Hospital and Research Institute - Chennai/IN Page 50 of 73

51 Fig. 13: Luftsichel sign: The crescent-shaped radiolucency around the aortic arch. Radiology and Imaging Sciences, Chettinad Hospital and Research Institute, Chettinad Hospital and Research Institute - Chennai/IN Page 51 of 73

52 Fig. 14: Juxtaphrenic Peak sign:describes the triangular opacity projecting superiorly at the medial half of the diaphragm. Radiology and Imaging Sciences, Chettinad Hospital and Research Institute, Chettinad Hospital and Research Institute - Chennai/IN Page 52 of 73

53 Fig. 15: 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. Radiology and Imaging Sciences, Chettinad Hospital and Research Institute, Chettinad Hospital and Research Institute - Chennai/IN Page 53 of 73

54 Fig. 16: The anterior interposition of the colon to the liver reaching the under-surface of the right hemidiaphragm with associated upper abdominal pain. Radiology and Imaging Sciences, Chettinad Hospital and Research Institute, Chettinad Hospital and Research Institute - Chennai/IN Page 54 of 73

55 Fig. 17: Chest PA view: 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. Radiology and Imaging Sciences, Chettinad Hospital and Research Institute, Chettinad Hospital and Research Institute - Chennai/IN Page 55 of 73

56 Fig. 18: Chest lateral view: 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. Radiology and Imaging Sciences, Chettinad Hospital and Research Institute, Chettinad Hospital and Research Institute - Chennai/IN Page 56 of 73

57 Fig. 19: Water bag sign:the fluid, often measuring a litre or more, causes the pericardium to sag, mimicking an old-fashioned water bag sitting on the bench. Radiology and Imaging Sciences, Chettinad Hospital and Research Institute, Chettinad Hospital and Research Institute - Chennai/IN Page 57 of 73

58 Fig. 20: Holly leaf sign: Irregular thickened nodular edges are likened to the appearance of a holly leaf. Radiology and Imaging Sciences, Chettinad Hospital and Research Institute, Chettinad Hospital and Research Institute - Chennai/IN Page 58 of 73

59 Page 59 of 73

60 Fig. 21: 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. Radiology and Imaging Sciences, Chettinad Hospital and Research Institute, Chettinad Hospital and Research Institute - Chennai/IN Fig. 22: Naclerio V sign: 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. Seen in oesophagus rupture. Radiology and Imaging Sciences, Chettinad Hospital and Research Institute, Chettinad Hospital and Research Institute - Chennai/IN Page 60 of 73

61 Fig. 23: Shmoo Sign: Appearance of a prominent, rounded left ventricle and dilated aorta on a plain AP chest radiograph giving the appearance of Shmoo.Indicative of left ventricular enlargement. Page 61 of 73

62 Fig. 24: 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. Radiology and Imaging Sciences, Chettinad Hospital and Research Institute, Chettinad Hospital and Research Institute - Chennai/IN Page 62 of 73

63 Fig. 25: 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. Radiology and Imaging Sciences, Chettinad Hospital and Research Institute, Chettinad Hospital and Research Institute - Chennai/IN Page 63 of 73

64 Fig. 26: 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. Radiology and Imaging Sciences, Chettinad Hospital and Research Institute, Chettinad Hospital and Research Institute - Chennai/IN Page 64 of 73

65 Fig. 27: Hilum convergence sign. Radiology and Imaging Sciences, Chettinad Hospital and Research Institute, Chettinad Hospital and Research Institute - Chennai/IN Page 65 of 73

66 Fig. 28: 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. Radiology and Imaging Sciences, Chettinad Hospital and Research Institute, Chettinad Hospital and Research Institute - Chennai/IN Page 66 of 73

67 Fig. 29: Cottage loaf sign: 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. Radiology and Imaging Sciences, Chettinad Hospital and Research Institute, Chettinad Hospital and Research Institute - Chennai/IN Page 67 of 73

68 Fig. 30: Pawnbroker's sign:it is a lymph node enlargement pattern which has been described in sarcoidosis. Radiology and Imaging Sciences, Chettinad Hospital and Research Institute, Chettinad Hospital and Research Institute - Chennai/IN Page 68 of 73

69 Fig. 31: Thymic sail sign: Represents the triangular shape inferior margin of the normal thymus seen on neonatal frontal chest radiograph. This indicate pneumomediastinum. Radiology and Imaging Sciences, Chettinad Hospital and Research Institute, Chettinad Hospital and Research Institute - Chennai/IN Page 69 of 73

70 Fig. 32: 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. Radiology and Imaging Sciences, Chettinad Hospital and Research Institute, Chettinad Hospital and Research Institute - Chennai/IN Page 70 of 73

71 Fig. 33: The deep sulcus sign on a supine chest radiograph is an indication of a pneumothorax. Radiology and Imaging Sciences, Chettinad Hospital and Research Institute, Chettinad Hospital and Research Institute - Chennai/IN Page 71 of 73

72 Conclusion Radiology signs play an extremely relevant role in the decision making process, in the identification of differential diagnoses and in the achievement of a more accurate specific diagnosis. In spite their degree of specificity, signs may be useful in the building of a more relevant and to further narrow the differential diagnosis list. Personal information Mr. Maneesh Ramki C.B 3rd year MBBS student Dr.M.Farook Senior Consultant Department of General Medicine Dr.F.Abuabacker Sulaiman, MD.RD Professor Department of Radiology and Imaging Sciences Chettinad Hospital and Research Institute Kelambakkam Kanchipuram District Tamilnadu India. References Page 72 of 73

73 Amirsys, Inc; 2nd Revised edition edition (1 June 2012) 4.Intrathoracic mass with air bronchogramj Garvey; L ParmerChest. 1978;73(2): doi: /chest kong, A. The deep sulcus sign. Radiology. 2003;228: Silouette Sign, 2008, Family Practice Notebook, LLC. Retrieved 9 February Corne; et al. (2002). Chest X-Ray Made Easy. Churchill Livingstone. ISBN Page 73 of 73