Pleural Effusion Radiography Overview

Imaging
Many benign and malignant
Updated: Oct 27, 2015
diseases can cause pleural effusion.
 Author: Omar Lababede, The characteristics of the fluid
MD; Chief Editor: Kavita depend on the underlying
Garg, MD more... pathophysiologic mechanism. The
fluid can be transudate, nonpurulent
Kavita Garg, MD is a member of the exudate, pus, blood, or chyle.
following medical societies: Imaging studies are valuable in
American College of Radiology, detecting and managing pleural
American Roentgen Ray Society, effusions but not in accurately
Radiological Society of North characterizing the biochemical nature
America, Society of Thoracic of the fluid. Images of pleural
Radiology effusion are shown below.

Judith K Amorosa, MD,
FACR Clinical Professor of
Radiology and Vice Chair for Faculty
Development and Medical
Education, Rutgers Robert Wood
Johnson Medical School

Judith K Amorosa, MD, FACR is a
member of the following medical
societies: American College of
Radiology, American Roentgen Ray Illustration of the chest, depicted in
Society, Association of University an upright position from the lateral
Radiologists, Radiological Society of aspect, shows a small effusion
North America, Society of Thoracic accumulating in the posterior
Radiology costophrenic (CP) sulcus. Such small
effusion cannot be detected on the
Disclosure: Nothing to disclose. frontal view but can be visible on the

demonstrates the radiographic appearance of a larger small left effusion as the one in the previous image. The blue arrows point to the effusions. depicted in an upright position from the lateral aspect. The overlay on actual normal radiograph) blue arrow points to the effusion. shows a larger small effusion . of the posterior CP angle (blue arrow which can be detected on both lateral on the next image).lateral radiographic view as blunting accumulating in the lower chest. This effusion produces blunting of the lateral costophrenic angle on the frontal view. Illustration of the chest. and frontal radiographic views. Depiction of upright posteroanterior and lateral views of the chest (using overlay on actual normal radiograph) demonstrates the radiographic Depiction of upright posteroanterior appearance of small left effusion as and lateral views of the chest (using the one in the previous image.

Note that the actual fluid upper margin is horizontal. This layering effusion can be visible on the frontal view as an increased haziness. shows a moderate effusion accumulating in the posterior aspect of the chest. This image shows a moderate effusions. However. depicted in supine position from the lateral aspect. The vascular . effusion accumulating in the lower chest. an upright position from the lateral The blue arrows point to the aspect. as in the previous image. depicted in effusion. llustration of upright posteroanterior and lateral views of the chest (using overlay on actual normal radiograph) demonstrates the radiographic appearance of a moderate left Illustration of the chest. Illustration of the chest. which can be seen on both the frontal and lateral views as a dependent density with meniscal- shaped margin. there is more fluid posteriorly and laterally due to the shape of the chest and recoil characteristics of the lung.

8. or associated lung parenchymal abnormalities. ultrasonography or computed tomography (CT) scanning can be . density. 7. 10. in evaluating the underlying etiology. 4] underlying etiology. 9. [5. this the fluid (arrows). especially in cases of loculated pleural effusion. Ultrasonography and CT scanning are more accurate than chest radiography in identifying the [2. Findings on chest radiographs frequently confirm the Radiographic studies may not help in presence of pleural effusion. 11. 12] Right lateral decubitus view in a 42- year-old woman with breast cancer Magnetic resonance imaging (MRI) confirms a right pleural effusion by is sometimes used to evaluate demonstrating dependent layering of questionable CT findings. complete opacification of hemithorax. [13] used to diagnose and manage pleural Limitations of techniques disease. 6. Lateral differentiating parenchymal decubitus projections enhance the processes from pleural processes.structures can be seen through this used to confirm a pleural effusion. chest radiography is limited radiography. Both modalities can depict small effusions not visualized radiographically. and they are also used to guide interventional procedures to manage pleural effusions. as in differentiating benign disease Depending on the clinical context. 3. modality has been reported to be more sensitive than CT scanning in Preferred examination differentiating benign from Different imaging modalities can be malignant causes of effusion. In sensitivity of conventional addition. from malignant pleural disease.

was found between the ultrasonographic appearance of the Radiologic intervention effusion and the success of The advent of percutaneous chest drainage. [14] Ultrasonography or CT scanning can be used to guide thoracocentesis or [15] catheter drainage of effusions. Thoracocentesis is primarily performed under ultrasonographic rather than CT scan guidance.Other problems to be considered Percutaneous thoracocentesis is reportedly most successful in Things to keep in mind when effusions that are viewing a chest radiograph are an ultrasonographically anechoic. have made imaging-guided management of intrathoracic collections a safe and effective alternative to traditional surgical therapy. or complex with movable herniation. as compared with echogenic or fibrothorax. in one study. . pleural thickening and/or septa. The small catheters are also associated with a complication rate lower than that associated with thoracotomy tubes. ultrasonography and CT scanning The success rate of radiologically and the advances in drainage catheter guided drainage procedures is 72- design and interventional techniques 88%. viewing a CT scan. consider ascites However. When complex effusions with fixed septa. elevated hemidiaphragm and/or complex. no correlation and/or a subphrenic abscess. The use of image guidance improves the safety of the procedure and reduces the rate of complications. and subpleural fat.

the lung collapses from visible on the frontal view (see the the periphery toward the hilum. orientation of the diaphragm. a higher degree of collapse in the When the fluid is slightly above the dependent portion of the lung. Fluid elasticity tends to preserve the shape accumulating posteriorly can be seen of the collapsed lung. and the A small amount of effusion presence of underlying lung accumulates in a subpulmonic abnormalities. radiographic findings of pleural effusion. the amount frontal view of fluid. A minimal but the upper limits of the fluid amount of fluid (approximately 175 . The pressure of the fluid causes because the posterior costophrenic atelectasis of the adjacent sulcus is inferior to the lateral (dependent) lung tissue. including the nature of the Typical pleural effusion: upright fluid (free vs loculated). The relation between orientation of the x-ray Typical pleural effusion: overview beam and the fluid surface affects the radiographic appearance of the Many factors influence the effusion. the patient's position. Lung costophrenic sulcus. blunting of the lateral to rise against gravity and surround costophrenic angle is seen. As the fluid parenchymal changes. on the frontal view. This is the dependent portion of the lung. level of the upper portion of the These factors force some of the fluid diaphragm. the earliest sign of pleural effusion The fluid-lung interface is curved. with images below).Radiography remain horizontal. In the absence of location. the radiographic projection. causing slight elevation of clinically significant lung the hemidiaphragm. As a on the lateral view before it becomes consequence. the fluid starts to spill over fluid tends to accumulate in the most into the most dependent costophrenic dependent portion of the chest sulci. free pleural increases. Small effusions may not be because of a difference in density visualized on frontal views due to the compared with the air-filled lung.

depending on the amount of the fluid (silhouette sign). depth of the fluid penetrated anteriorly and posteriorly is small. (The apex of the meniscus can be slightly lower than the actual Posteroanterior chest radiograph in a upper limit. . The diaphragmatic contour abnormality.mL) is required to produce detectable A very large pleural effusion appears blunting. especially in the upper portion of the effusion. side. Differences in the depth to which the x-ray beam traverses the fluid produce the contour of the meniscus.) Because the fluid is 42-year-old woman with breast laterally tangential to the x-ray beam. The attenuation is not sufficient to produce a shadow on the radiograph. Although the true upper limit of the fluid is horizontal. is partially or completely obliterated. The mediastinal shift can be less prominent or even absent in the A large free pleural effusion appears presence of underlying lung as a dependent opacity with lateral pathology (eg. only the lateral aspect of the fluid is visible as the meniscal apex. cancer shows blunting of the right the depth of fluid penetration cardiophrenic angle (arrow) with increases and consequently increases slight elevation of the right attenuation of the radiation. atelectasis) or upward sloping of a meniscus-shaped contralateral hemithorax contour. As much as 500 mL of as an opaque hemithorax with a pleural fluid can be present without mediastinal shift to the contralateral apparent changes on the frontal view. The hemidiaphragm.

Posteroanterior chest radiograph in a 54-year-old man with hemoptysis demonstrates opacification of the right hemithorax with mediastinal shift to the right. minimal blunting of the right costophrenic angle is present. an . Cardiomegaly and a possible mediastinal mass are noted. Posteroanterior chest radiograph in a 50-year-old man with non-Hodgkin lymphoma shows an opacity (E) in the lower left hemithorax with obliteration of the left Posteroanterior chest radiograph in a hemidiaphragm and a curvilinear 69-year-old man demonstrates right upper margin (arrow) and a pleural effusion. Loculated effusion in the minor fissure (arrow). findings are typical of a pleural effusion. The opacity is smoothly marginated and biconvex. In addition. In addition. These abnormalities are seen. No other definite mediastinal shift to the right.

the amount of fluid spills over into the most dependent (posterior) costophrenic sulci. Typical pleural effusion: upright lateral view A small amount of effusion accumulates in a subpulmonary location. The opacity obliterates the an upright position from the lateral underlying portion of the aspect. As the fluid increases. The images below demonstrate costophrenic (CP) sulcus. causing slight elevation of the ipsilateral hemidiaphragm. . Such small the position and appearance of effusion cannot be detected on the pleural effusions as seen in upright frontal view but can be visible on the lateral views. lateral radiographic view as blunting of the posterior CP angle (blue arrow on the next image). shows a small effusion diaphragmatic contour (silhouette accumulating in the posterior sign). depicted in contour.abrupt cutoff of the right mainstem bronchus is present. Small effusions appear as a dependent opacity with posterior upward sloping of a meniscus-shaped Illustration of the chest.

depicted in effusion produces blunting of the an upright position from the lateral . lateral costophrenic angle on the frontal view. The blue arrows point to the effusions. The overlay on actual normal radiograph) blue arrow points to the effusion. depicted in an upright position from the lateral aspect. demonstrates the radiographic appearance of a larger small left effusion as the one in the previous image. shows a larger small effusion accumulating in the lower chest. This Illustration of the chest. Depiction of upright posteroanterior and lateral views of the chest (using overlay on actual normal radiograph) demonstrates the radiographic Depiction of upright posteroanterior appearance of small left effusion as and lateral views of the chest (using the one in the previous image. which can be detected on both lateral and frontal radiographic views. Illu stration of the chest.

The depth of the penetrated fluid laterally is too small to produce a shadow on the radiograph. views. A very large pleural effusion produces generalized increased Illustration of upright posteroanterior opacity with obliteration of the and lateral views of the chest (using underlying hemidiaphragm. depth of fluid traversed by the x-ray shaped margin. Large free pleural effusion appears as a dependent opacity with a meniscus- shaped contour. Note that the actual beam produces the contour of the fluid upper margin is horizontal. especially in the upper portion of the effusion. because the fluid is tangential to the x-ray beam.aspect. as in the previous image. The highest points of the meniscus are anteriorly and . meniscus. appearance of a moderate left The images below demonstrate the effusion. Only 1 overlay on actual normal radiograph) diaphragm on the lateral view may demonstrates the radiographic be a clue to a large pleural effusion. position and appearance of pleural The blue arrows point to the effusions as seen in upright lateral effusions. As noted. This image shows a moderate posteriorly located at approximately effusion accumulating in the lower the same level. the actual upper However. with increased depth of fluid penetration and attenuation. The posteriorly and laterally due to the anterior and posterior aspects are shape of the chest and recoil visible as the meniscal apices characteristics of the lung. The ipsilateral chest. there is more fluid limit of the fluid is horizontal. Variation in the dependent density with meniscal. which can be seen on both the diaphragmatic contour is obliterated frontal and lateral views as a (silhouette sign).

Note that the pulmonary vascular structures are not obscured or silhouetted by the vague density but. given the position of the patient. the effusion initially causes generalized hazy . This view is the least sensitive for detecting pleural effusions. Illustration of the chest. is layering. This layering effusion radiograph. Subsequently. The pleural fluid images). The vascular hemithorax. oblique (not tangential) to the orientation of the x-ray beam. a minimal volume of aspect. A somewhat large amount of fluid is required to produce detectable Posteroanterior supine view of the radiographic findings. are still visible through it (open arrow). There is asymmetric density with increased haziness in the lower right hemithorax (blue arrow). The lung fluid interface structures can be seen through this is mostly in a plane perpendicular or density.Typical pleural effusion: supine frontal view The normal supine view does not exclude the presence of effusion. especially in chest in a 60-year-old man with bilateral effusions (see the following right-sided effusion. depicted in supine position from the lateral In one study. rather. shows a moderate effusion 175 mL was required to produce accumulating in the posterior aspect notable change on the supine of the chest. [16] The fluid accumulates can be visible on the frontal view as in the posterior aspect of the an increased haziness.

which can be seen in more than 50% of large effusions. Depending on the The absence of an air bronchogram amount of the fluid and the degree of also helps in differentiation. With further fluid silhouetted by the vague density but.homogeneous opacity with ill. This finding helps in differentiating opacity is believed to be secondary to opacity secondary to effusion from small capacity of the lung at the apex one caused by lung parenchymal with the extension of the fluid lateral abnormalities. Typical pleural effusion: lateral decubitus view A lateral decubitus view obtained with a horizontal x-ray beam is the Posteroanterior supine view of the most sensitive radiographic chest in a 60-year-old man with projection for detecting an effusion. defined ipsilateral apical opacity vessels) can be seen through this (apical capping) is often produced. airspace disease. opacity (see the image below). such as atelectasis or and superior to the lung tissue. Blunting of the costophrenic angles (meniscus sign). right-sided effusion. obliteration of the diaphragm becomes obvious. and (open arrow). is attributed to accumulation of fluid about the level of the lateral costophrenic sulcus. Well- the lung collapse. are still visible through it entire hemithorax increases. right hemithorax (blue arrow). There is asymmetric density . The pleural fluid [17] A small amount of fluid (10-25 is layering. the opacity of the rather. accumulation. Note that the pulmonary vascular The opacity first projects over the structures are not obscured or lower lung zones. lung markings (eg. given the position of the mL) can be depicted on this patient. This especially with large effusions. with increased haziness in the lower defined margins.

more common on the right side. especially obese easily be detected as a dependent. subpulmonary effusion presents as an elevated diaphragm (pseudodiaphragmatic contour).projection. include the following: . Atypical pleural effusion: large Right lateral decubitus view in a 42. This appearance is pleural and chest wall (see the image easily appreciated. the parietal pleura is slightly sharply defined. because it is below). linear opacity medial to this line because of separating the lung from the parietal subpleural fat. On upright frontal and lateral views. subpulmonary effusion year-old woman with breast cancer A large subpulmonary effusion can confirms a right pleural effusion by be considered an atypical effusion. demonstrating dependent layering of Unilateral subpulmonary effusion is the fluid (arrows). Additional findings. patients. and the parietal pleura–chest bilateral on frontal examination and wall margin can be identified as a because it persists on the line connecting the inner apices of nondependent hemithorax of the the curvature of the ribs. accumulated fluids usually spill into the posterior costophrenic sulcus. The layering fluid can In some patients. contralateral decubitus image. which can help in suggesting the presence of effusion. Atypical pleural effusion: overview Although a small effusion may accumulate first in a subpulmonary location.

Loculation secondary to adhesions is usually secondary to an infected or hemorrhagic effusion. the effusion. The can be seen as well. Loculated effusion in the pulmonary fissures (demonstrated below) appears as a well-defined elliptical opacity with pointed margins. from the pseudodiaphragmatic contour  On the lateral view: in cases of left subpulmonic Frequently. thin triangular pseudodiaphragmatic contour. . with a pleural effusion sharp descent into the anterior An atypical distribution of pleural costophrenic sulcus. pseudodiaphragmatic contour is interrupted anteriorly by Atypical pleural effusion: loculated the major fissure. visualized through the Sometimes. On the posteroanterior (PA)  On both PA and lateral views: view: The peak of the In contrast to the normal pseudodiaphragmatic contour diaphragmatic opacity. upward extension of the fluid The gastric gas lucency is can be seen medially on the widely separated (>2 cm) left side. the is more lateral than the peak pulmonary vessels are poorly of the normal diaphragm. Loculated effusions produce peripheral soft-tissue opacity with smooth obtuse tapering margins when seen tangentially. fluid can be also caused by loculation Extension of a small amount secondary to adhesions or by lung of fluid through the inferior parenchymal changes that alter the aspect of the major fissure recoil characteristics of the lung. second mechanism can occur in atelectasis.

Lateral decubitus . Even large. differentiate from an elevated hemidiaphragm. Small pleural effusions can be difficult to detect radiographically. In addition. Subpulmonic fissure (arrow). lung parenchymal abnormalities may obscure large Degree of Confidence effusions. projections are the most sensitive radiographic images for detecting free pleural effusion. Upright chest radiography is highly sensitive in detecting pleural effusion. The opacity is effusion is sometimes hard to smoothly marginated and biconvex. loculated or atypical effusions may demonstrate substantial gravitational movement to suggest their nature. False Positives/Negatives Pleural thickening and/or fibrothorax and subpleural fat may mimic a small Loculated effusion in the minor pleural effusion.