Dr Mazen QusaibatyMD, DIS

Head Pulmonary and Internist Department Ibnalnafisse Hospital

Ministry of Syrian healthEmail:

Qusaibaty@gmail.com Figure 3 sign Fleischner sign Fissure sign Headcheese sign Hilar overlay sign The Anterior

Junction Line Bulging fissure

sign

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Topic Outline

Figure 3 sign Fleischner sign Fissure sign Headcheese sign Hilar overlay sign The Anterior Junction Line Bulging fissure sign

Figure 3 signMogul Sign

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Figure 3 sign

• Refers to the abnormal contour of aortic arch in coarctation of aorta.

Figure 3 sign

The upper arc is the dilated arch proximal to the coarctation 3

Figure 3 sign

The lower arc is the post stenotic dilatation 3

Figure 3 sign

The indentation between the 2 arcs is the coarctation 3

Figure 3 sign

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Figure 3 sign

Coarctation

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Figure 3 sign

Spiral CT angiography in an infant with a hypoplastic aortic arch

• 2D reconstruction showing hypoplastic aortic arch (arrowheads) with coarctation of aorta (arrow).

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Spiral CT angiography in an infant with a hypoplastic aortic arch

• 3D reconstruction displays the coarctation of the aorta (arrow).

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Summary

Figure 3 sign

Coarctation

Fleischner sign

Radiographic signs with a relatively high specificity but low sensitivity for PTE

1. Pleura-based areas of increased opacity (Hampton sign)

2. Decreased vascularity in the peripheral lung (Westermarck sign)

3. Enlargement of the central pulmonary artery (Fleischner sign)

4. Hemidiaphragm elevation

15Worsley DF, Alavi A, Aronchick JM, Chen JT, Greenspan RH, Ravin CE.Chest radiographic findings in patients with acute pulmonary embolism: observations from the PIOPED Study. Radiology 1993; 189:

Radiographic signs with a relatively high specificity but low sensitivity for PTE

1. Pleura-based areas of increased opacity (Hampton sign)

2. Decreased vascularity in the peripheral lung (Westermarck sign)

3. Enlargement of the central pulmonary artery (Fleischner sign)

4. Hemidiaphragm elevation

16Worsley DF, Alavi A, Aronchick JM, Chen JT, Greenspan RH, Ravin CE.Chest radiographic findings in patients with acute pulmonary embolism: observations from the PIOPED Study. Radiology 1993; 189:

Fleischner sign

Refers to the prominence of central pulmonary artery

Fleischner sign

•Pulmonary hypertension that develops secondary to :PE Or by distension of

the vessel by a large clot

Fissure sign

A ventilation/perfusion lung scan, also called a V/Q lung scan

•A type of medical imaging using scintigraphy and medical isotopesEvaluate the circulation of:• Air• Blood within a patient's lungs

A ventilation/perfusion lung scan, also called a V/Q lung scan

•A type of medical imaging using scintigraphy and medical isotopesEvaluate the circulation of:• Air• Blood within a patient's lungs

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Gamma Camera

A ventilation/perfusion lung scan, also called a V/Q lung scan

Evaluate the circulation of:• Air: Nebulizer of a gaseous radionuclide such as:

o Xenono TechnetiumoDTPA

A ventilation/perfusion lung scan, also called a V/Q lung scan

Evaluate the circulation of:• Blood within a patient's lungs: the intravenous

injection of radioactive technetium macro aggregated albumin (Tc99m-MAA)

Fissure sign

Normal separation of lobes by fissures is not seen in perfusion scans due to low resolution

Fissure sign

But, increased separation due to pleural thickening or effusion is seen as linear area of reduced uptake along the fissure referred as fissure sign

Headcheese sign

Secondary lobule and pulmonary Acinus

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Radiograph of 1-mm lung slice taken from peripheral lower lobe29

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QuizHow many lobules do you see in this image?

A. One lobuleB. 2 lobulesC. 3 lobules

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QuizHow many lobules do you see in this image?

A. One lobuleB. 2 lobulesC. 3 lobules

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Why do we see two lobules ?

S: Interlobular septa : 0.1 mm V: Pulmonary vein : 0.5 mm A: Pulmonary arteries : : 1 mm

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Headcheese sign

Ground glass opacity

Normal lung

Low attenuation (air trapping)

Headcheese sign

Hypersensitivity pneumonitis

Headcheese sign in hypersensitivity pneumonitis

• Combination of patchy or lobular ground-glass opacity (small arrows) and mosaic perfusion (large arrows)

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Headcheese sign in Chronic hypersensitivity pneumonitis

Ground glass opacity

Normal lung

Low attenuation (air trapping)

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Headcheese sign in Chronic hypersensitivity pneumonitis

Expiration Inspiration

Hilar overlay sign

Hilar overlay sign

Refers to the ability to see the hilar structures through the shadow of a mass superimposed on the hilum

Hilar overlay sign

Indicates that the mass lies either in front or behind the hilum

Hilar overlay sign

•Anterior lymphoma•or posterior neurofibroma

Hilar overlay sign PA chest X-ray

•A large anterior mediastinal mass.

Hilar overlay sign PA chest X-ray

•The hilum overlay sign:

The mediastinal mass overlaps the main pulmonary artery which is seen well within the margins of the mass.

Hilum overlay sign in a patient with lymphoma Posteroanterior chest radiograph

• The ability to see the hilar structures through the shadow of a mass superimposed on the hilum

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Hilum overlay sign in a patient with lymphoma Posteroanterior chest radiograph

• The mass localise in:A. Posterior mediastinumB. Anterior mediastinum

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Hilum overlay sign in a patient with lymphoma Posteroanterior chest radiograph

• The mass localise in: Posterior mediastinum Anterior mediastinum

Why??

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Hilum overlay sign in a patient with lymphoma Posteroanterior chest radiograph

• The descending aorta is clearly seen (black arrow), indicating that the mass is not within the posterior mediastinum

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Hilum Overlay Sign

• Hilar vessels are seen through a mediastinal mass

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Hilum Overlay Sign

• A lymphoma in a HIV-positive patient.

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The Anterior Junction Line

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A transverse section of the thorax

• Showing the contents of the middle and the posterior mediastinum.

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Posteroanterior chest radiograph demonstrates the anterior junction line

(arrow)

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Computed tomographic (CT) scan shows the four layers of pleura that constitute the anterior

junction line (arrow)

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Chest CT scan

• An anterior mediastinal mass.

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The anterior junction line is obliterated

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Bulging fissure sign

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Normal major fissuresLateral chest radiograph demonstrates the two major fissures

http://radiographics.rsna.org/content/21/4/861/F2.expansion.html

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Normal major fissures

Note that both fissures are seen as double lines

http://radiographics.rsna.org/content/21/4/861/F2.expansion.html

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Normal major fissuresThe left fissure: ?? The right fissure: ??

http://radiographics.rsna.org/content/21/4/861/F2.expansion.html

Normal major fissuresThe left fissure (arrows) The right fissure (arrowheads)

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http://radiographics.rsna.org/content/21/4/861/F2.expansion.html

CT scan

CT scan shows the major fissures as lucent bands of relative hypovascularity (arrows)

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http://radiographics.rsna.org/content/21/4/861/F3.expansion.html

Normal major fissures

HRCT scan

Bulging fissure sign

• Consolidation: Spreading rapidly Causing lobar

expansion Bulging of the

adjacent fissure inferiorly

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Bulging Fissure Sign

• Consolidation spreading rapidly, causing lobar expansion and bulging of the adjacent fissure inferiorly

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What do you think the diagnosis?

A. Pneumonia caused by staphylococcus aureus.

B. Pneumonia caused by Klebsiella

C. TBD. Large cell

carcinoma

Bulging Fissure Sign

• Historically: Klebsiella pneumoniae involving the right upper lobe .

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