Radiology

1. THE PLEURA

2. PLEURAL EFFUSION
• CAUSES
1.Increase microvascular pressure in
lungs,CHF
2.Reduce plasma oncotic pressure
3.Increase microvascular permeability
4.Reduced lymphatic draniage
5.Passage of peritoneal fluid across defects
in the diaphragm

3. •Transudate or
exudate

4. • Hemothorax
• Chylothorax

5. • Radiological appearances of
pleural fluid
Free fluid
Loculated fluid
Empyema

6. •Free fluid
• it casts a shadow of water
or soft tissue density

7. • The most dependent part of
pleura is posterior
costophrenic angle first
accumulate here and is seen
on lateral CXR

8. • when more fluid accumulates it fill the
lateral costophrenic angle and becomes
visible on frontal CXR,with increasing
pleural effusion homogenous opacity
spreads upward,obscuring the lung
base,this opacity has a well defined
,concave upper edge is higher laterally
than medially and obscures the
diaphragmatic shadow,frequently track
into pleural fissures.

9. Massive pleural effusion will
cause opaque hemithorax
with contralateral
mediastinal shift.If there is
complete collapse of
underlying lung shift towars
side of collapse may occur.

10. • Illustration of the chest,
depicted in an upright
position from the lateral
aspect, shows a small
effusion accumulating in
the posterior costophrenic
(CP) sulcus. Such small
effusion cannot be
detected on the frontal
view but can be visible on
the lateral radiographic
view as blunting of the
posterior CP angle

11. • Depiction of upright
posteroanterior and
lateral views of the chest
(using overlay on actual
normal radiograph)
demonstrates the
radiographic appearance
of small left effusion as
the one in the previous
image. The blue arrow
points to the effusion.

12. • Illustration of the chest,
depicted in an upright
position from the lateral
aspect, shows a larger
small effusion
accumulating in the lower
chest, which can be
detected on both lateral
and frontal radiographic
views. This effusion
produces blunting of the
lateral costophrenic angle
on the frontal view.

13. • Depiction of upright
posteroanterior and
lateral views of the chest
(using overlay on actual
normal radiograph)
demonstrates the
radiographic appearance
of a larger small left
effusion as the one in the
previous image. The blue
arrows point to the
effusions.

14. • Illustration of the chest, depicted in
an upright position from the lateral
aspect. This image shows a
moderate effusion accumulating in
the lower chest, which can be
seen on both the frontal and
lateral views as a dependent
density with meniscal-shaped
margin. Note that the actual fluid
upper margin is horizontal.
However, there is more fluid
posteriorly and laterally due to the
shape of the chest and recoil
characteristics of the lung.

15. • Illustration of upright
posteroanterior and
lateral views of the chest
(using overlay on actual
normal radiograph)
demonstrates the
radiographic appearance
of a moderate left
effusion, as in the
previous image. The blue
arrows point to the
effusions.

16. • Illustration of the chest,
depicted in supine
position from the lateral
aspect, shows a
moderate effusion
accumulating in the
posterior aspect of the
chest. This layering
effusion can be visible on
the frontal view as an
increased haziness. The
vascular structures can
be seen through this
density.

17. • Posteroanterior supine view of
the chest in a 60-year-old man
with right-sided effusion. The
pleural fluid is layering, given
the position of the patient.
There is asymmetric density
with increased haziness in the
lower right hemithorax (blue
arrow). Note that the
pulmonary vascular structures
are not obscured or silhouetted
by the vague density but,
rather, are still visible through
it (open arrow).

18. • Posteroanterior chest
radiograph in a 42-
year-old woman with
breast cancer shows
blunting of the right
cardiophrenic angle
(arrow) with slight
elevation of the right
hemidiaphragm.

19. • Lateral chest radiograph
of a 42-year-old woman
with breast cancer shows
a crescent-shaped
opacity is present in the
posterior costophrenic
sulcus (arrow). Minimal
amount of fluid can be
seen in the inferior aspect
of the right major fissure.
The findings are
compatible with right
pleural effusion. Some of
the fluid is
infrapulmonary.

20. • Right lateral
decubitus view in a
42-year-old woman
with breast cancer
confirms a right
pleural effusion by
demonstrating
dependent layering of
the fluid (arrows).

21. • Follow-up posteroanterior
chest radiograph in a 42-
year-old woman with
breast cancer shows an
opacity (E) in the lower
left hemithorax with
obliteration of the left
hemidiaphragm and
curvilinear upper margin
consistent with effusion.
Note the extension of the
fluid into the left major
fissure (arrow) and
mediastinal shift to the
right.

23. meniscus

24. • Diffrentiation between
ascites and pleural effusions

29. bilateral pleural effusion with
meniscus sign

31. • The Serratus anterior muscle can produce an opacity
that may resemble pleural tickening. This is sometimes
referred to as a "bowling-pin" silhouette.
• "When the muscle is well developed, the medial edge of
this silhouette may be superimposed upon the air
shadow of the lung in a variety of ways. When it overlies
the apex of the lung, it gives rise to the companion
shadow; when overlying the midlateral lung edge and
costophrenic angle it may mimic pleural and/or
extrapleural disease. Recognition of the various possible
patterns is important to prevent overdiagnosis of
disease, particularly asbestosis."

32. prominent serratus muscles bilaterally. This
apparance can be mistaken for pleural effusion or
pleural thickening (single white arrow).

33. Unenhanced CT scan of thorax in 79-year-old man shows relatively low density (8.8 HU;
SD, 13.3) 2,549-mm2 right-sided pleural effusion (circle). Patient had pleural exudate
secondary to colon carcinoma with pleural metastasis (white arrows).
Read More: http://www.ajronline.org/doi/full/10.2214/AJR.08.1286

34. Contrast-enhanced axial CT scan of thorax in 80-year-old woman with congestive heart failure
showing bilateral loculated pleural effusion. CT density measurement of right effusion (circle) 691
mm2 in size was 14.5 HU with SD of 19.8. Fluid was proven to be transudate at thoracentesis.
Read More: http://www.ajronline.org/doi/full/10.2214/AJR.08.1286

35. Large right effusion (red arrow)
displacesthe heart to the left
(yellow arrow

36. • Calcinosis in a patient
with CREST
syndrome. Also note
the encapsulated
pleural empyema on
the right side.
• Related Articles:

37. cp

38. hydropneumo

39. • A large left sided pleural
effusion is present with
no fluid seen on the right.
No evidence of
cardiomegaly or
pulmonary venous
congestion. No evidence
of trauma.
• Multiple surgical clips are
seen in the right
supraclavicular fossa.

41. • Atypical distribution
• Lamellar effusions are the
shallow collections between the lung
surface and the visceral pleura sometimes
sparing the costophrenic angle.

43. • Subpulmonic effusions Large
effusions accumulate between the
diaphragm and undersurface of the
lung mimicking elevation of
hemidiaphragm.

44. subpulmonic effusion

48. • The contour of diaphragm is
altered ,its apex being more
lateral,there may be some blunting of
costophrenic angle or tracking of fluid into
the fissures.On the left side increase
distance between the gastric
bubble and lung base seen.

49. • A large right pleural effusion may
collect in azygoesophageal
recess and mimic retrocardiac mass.The
reasons for atypical distribution is not clear
but it may be associated with abnormality
of underlying lung.

50. • LOCULATED FLUID
• Pleural space may be partially obliterated
by pleural disease.causing fusion of
parietal and visceral layers.
• An encysted effusion is often associated
with free pleural fluid or other pleural
shadowing and may extend into the
fissure.

51. loculated effusion

53. • Loculated effusion in
the minor fissure
(arrow). The opacity
is smoothly
marginated and
biconvex.

54. • Frontal and lateral views of an
89 year-old female with an
oval soft tissue density
superimposed on the minor
fissure on both the frontal and
lateral views. The lesion has
slight "points" where it abuts
the minor fissure, a sign of a
"pseudotumor" or "vanishing
tumor" in the minor fissure.
There are usually more signs
associated with congestive
heart failure than are seen in
this patient.

55. • Axial computed tomography
images of the lower chest in
51-year-old patient with acute
lymphoblastic leukemia. A
small, dependent, crescent-
shaped area with attenuation
similar to that of water in the
right hemithorax is consistent
with a tiny right pleural effusion
(arrow). This effusion is most
obvious on the mediastinal
window.

56. • Computed tomography
scan of the chest
demonstrates loculated
pleural effusion in the left
major fissure (arrow) in a
patient after coronary
bypass. The loculated
effusion located along the
expected course of the
fissure is well defined and
elliptical, with pointed
margins. The fluid is
similar to water in its
attenuation.

57. • Computed
tomography scan of
the chest
demonstrates a
loculated pleural
effusion (E) in the left
hemithorax. The
loculated effusion is
well defined and
elliptical and similar to
water in its
attenuation.

58. • These have little depth but considerable
width like biconvex lens.
• Differentiate it from extrapleural opacities
which have much sharper outline with
tapered smooth concave edges where
they meet the chest wall. For
Differentiation CT and USG are
particularly helpful.

59. • Fluid may become loculated in one or
more of the interlobar fissures,This is
uncommon seen in CHF.Appearance
depends on which fissure is involved.Fluid
collecting in horizontal fissure produces a
lenticular,oval or round shadow with well
demarcated margins.

60. • Loculated fluid in oblique fissure is better
seen on lateral CXR and the typical
lenticular configuration is seem.
• Following treatment they may disappear
rapidly and hence known as pseudo or
vanishing tumors,They may recur in
subsequent episode of heart failure

61. •Empyema
• May be suspected on plain film by
spontaneous appearance of fluid level in
pleural effusion but best seen on CT or
USG.
• On CT empyema has a lenticular shape
and may compress underlying lung.Fluid
with or without gas may be present in
pleura,both layers of pleura may be
thickened.

70. • Pleural thickening progress to
pleural rind so rapid Dx and
treatment required,surgical
decortication may be necessary bcz it
cause respiratory function impairment.

71. • Multiple septations may be
broken down by fibrinolytic
agent like urokinase ,100,000 units
instilled in 50ml normal saline,drain
clamped for 1 hour after which free
drainage or low pressure suction
done.treatment may be repeated daily for
5 days.

72. • USG appearance of pleural
fluid
• USG is an excellent method for locating
loculated pleural fluid prior to aspiration.
• Transudate is anechoic
• Exudate may or may not contain reflective
material
• Septations can be seen
• pleural mass can be seen

73. fetal pleural effusion

75. • Ultrasonogram of the
right lower chest in a 60-
year-old man with a right
pleural effusion. This
sagittal study was
performed with the
patient seated and
confirms the presence of
the effusion as slightly
complex but mostly
anechoic (E) in the right
hemithorax. Note the
echogenic curvilinear
diaphragm (arrow).

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