Professional Documents
Culture Documents
R
ABSTRACT adiological practice includes classification of illnesses with similar
A radiological sign can sometimes resemble a particular object characteristics through recognizable signs. Knowledge of and abil-
or pattern and is often highly suggestive of a group of similar
pathologies. Awareness of such similarities can shorten the dif- ity to recognize these signs can aid the physician in shortening
ferential diagnosis list. Many such signs have been described the differential diagnosis list and deciding on the ultimate diagnosis for
for X-ray and computed tomography (CT) images. In this ar-
ticle, we present the most frequently encountered plain film a patient. In this report, 23 important and frequently seen radiological
and CT signs in chest imaging. These signs include for plain signs are presented and described using chest X-rays, computed tomog-
films the air bronchogram sign, silhouette sign, deep sulcus raphy (CT) images, illustrations and photographs.
sign, Continuous diaphragm sign, air crescent (“meniscus”)
sign, Golden S sign, cervicothoracic sign, Luftsichel sign, scim-
itar sign, doughnut sign, Hampton hump sign, Westermark Plain films
sign, and juxtaphrenic peak sign, and for CT the gloved finger Air bronchogram sign
sign, CT halo sign, signet ring sign, comet tail sign, CT an-
giogram sign, crazy paving pattern, tree-in-bud sign, feeding Bronchi, which are not normally seen, become visible as a result of
vessel sign, split pleura sign, and reversed halo sign.
opacification of the lung parenchyma. Branching, tubular lucencies of
Key words: • X-ray • computed tomography, X-ray • thorax bronchi are seen in an opacified lung (Fig. 1a). This sign shows that
the pathology is in the lung parenchyma itself (1). This sign is most
frequently encountered in pneumonia and pulmonary edema. Its gen-
eralized form can be seen in respiratory distress syndrome (2). The air
bronchogram sign shows that the central bronchi are not obstructed;
however, it can also be seen when a mass causes half-obstruction. Bron-
chioalveolar carcinoma, lymphoma, interstitial fibrosis, alveolar hemor-
rhage, fibrosis due to radiation and sarcoidosis can also present with this
sign (1–3). This sign can also be seen on CT images (Fig. 1b).
Silhouette sign
In a chest x-ray, non-visualization of the border of an anatomical
structure that is normally visualized shows that the area neighboring
this margin is filled with tissue or material of the same density (Fig. 2).
The silhouette sign is an important sign indicating the localization of a
lesion (4). A well-known example is obliteration of the right heart border
due to middle lobe atelectasis. This rule can also be applied to the arch of
the aorta, the hemidiaphragms and the left border of the heart.
A silhouette sign of the hila is called the “hilum overlay sign”. It is
used to determine the localization of a lesion in the hilar region in chest
X-rays. If hilar vessels can clearly be seen inside the lesion, the lesion
is either anterior or posterior to the hilus. If the hilar vessels cannot be
discriminated from the lesion, the lesion is at the hilus (Fig. 3) (5–7).
18
a b
Figure 1. a–c. Air bronchogram sign. a. Chest X-ray of a patient who had
c radiotherapy for breast cancer. Consolidation with air bronchograms (arrows) due
to radiation pneumonitis at the upper lobe of the right lung. b. Air bronchogram
sign on CT. c. Illustration of air bronchogram sign.
Figure 3. a, b. Hilum overlay sign. a. Chest X-ray of a patient with hemoptysis demonstrating enlarged right hilus. Hilar vessels can be seen
inside the lesion, which shows that the lesion is not at the hilus (arrow). b. Lung CT, mass at the right upper lobe (arrows) and lymph nodes at
the right hilus.
Figure 4. Deep sulcus sign and continuous diaphragm sign. Chest X-ray
obtained in the supine position from a patient with trauma history. Pleural
free air accumulating at the right costodiaphragmatic sinus and extending
to the hypochondrium is depicted (arrowhead). Mediastinal air neighboring
the lower border of the heart causes the continuous diaphragm sign by
combining the hemidiaphragms (arrow).
a b Figure 7. a, b. Cervicothoracic
sign. a. Frontal radiograph of the
chest demonstrating a mass with
a distinct cranial border projecting
above the level of the clavicles,
supporting a posterior mediastinal
location (arrows). b. T1-weighted
coronal magnetic resonance
image of the same patient. The
left posterior mediastinal mass is a
biopsy-proven ganglioneuroma.
an immunocompromised patient, this and the long period, often years, re- placed, lateral and concave portion of
sign is highly suggestive of invasive quired for the formation of the ball the “S” is formed by the minor fissure,
aspergillosis. Other causes of the air can aid in distinguishing this condi- while the inferiorly and medially locat-
crescent sign are intracavitary fungus tion from invasive aspergillosis. The ed convex part is formed by the margin
ball (mycetoma), hydatid cyst with ball’s movement with the movements of the mass. This sign is an important
bronchial involvement, hematoma, of the patient helps in differentiating clue indicating a central mass obstruct-
abscess, necrotizing pneumonia, cystic it from a malignant mass attached to ing the bronchus. It can be seen in eve-
bronchiectasis filled with mucus plugs the wall (2). ry lobe, though it has been described
and papillomatosis (2, 9). Saprophytic for the right upper lobe (10).
colonization of aspergillus species Golden‘s sign
within the cavities previously formed The golden‘s sign is encountered Cervicothoracic sign
due to sarcoidosis and tuberculosis when there is right upper lobe atelecta- The cervicothoracic sign is used to
causes intracavitary fungus ball forma- sis due to a centrally located mass. The describe the location of a lesion at the
tion. Air between the cavity wall and minor fissure migrates superiorly, and inlet of the thoracic cavity. In this ana-
the fungus ball can also cause the air a ”reversed S” shape containing the tomical space, the posterior portions of
crescent sign. Normal host immunity mass forms (Fig. 6). The superiorly dis- the lung apices are located more supe-
Scimitar sign
The scimitar sign indicates anomalous
venous return of the right inferior pul-
monary vein (total or segmental) directly
to the hepatic vein, portal vein or infe-
rior vena cava. A tubular-shaped opacity
extending towards the diaphragm along
the right side of the heart is seen (Fig. 9).
The abnormal pulmonary vein resem-
bles a Turkish sword called a “pala”. The
scimitar sign is associated with congeni-
tal hypogenetic lung syndrome (scimi-
tar syndrome) (12).
Figure 8. Luftsichel sign. A patient with a centrally located mass at the left lung. Frontal chest
radiograph demonstrates volume loss due to left upper lobe atelectasis and crescent-shaped Doughnut sign
radiolucency around the aortic arch, formed by the upper segment of the left lower lobe (arrows). The doughnut sign occurs when me-
diastinal lymphadenomegaly occurs
a b behind the bronchus intermedius in
the subcarinal region (7, 12, 13). Lym-
phadenopathy is seen as lobulated
densities on lateral radiographs (Fig.
10) (12, 14).
Westermark sign
The Westermark sign describes a de-
Figure 9. a, b. Scimitar sign. a. Frontal radiograph of a patient with hypogenetic lung crease of vascularization at the periph-
syndrome. The abnormal inferior pulmonary vein is seen as a tubular opacity paralleling the ery of the lungs due to mechanical ob-
right border of the heart (arrows). b. Scimitar. struction or reflex vasoconstriction in
pulmonary embolism (oligemia). It was
first described by Neil Westermark (7).
An increase in translucency on frontal
riorly than the anterior portions (Fig. filled lung and there are cervical soft radiographs is depicted (Fig. 12) (7).
7). For this reason, a lesion clearly vis- tissues at this level (7).
ible above the clavicles on the frontal Juxtaphrenic peak sign
view must lie posteriorly and be en- Luftsichel sign The juxtaphrenic peak sign, which
tirely within the thorax. If the cranial The word “Luftsichel” in German occurs in upper lobe atelectasis, de-
border of the lesion is obscured at or means “air crescent”. This sign is seen scribes the triangular opacity project-
below the level of the clavicles, it is lo- in severe left upper lobe collapse. Due ing superiorly at the medial half of
cated at the anterior mediastinum (7). to the lack of a minor fissure on the left the diaphragm (Fig. 13). It is most
The borders are not clearly delineated side, upper lobe collapse causes vertical commonly related to the presence of
because the lesion is far from the air- positioning and anterior and medial dis- an inferior accessory fissure (7). The
a b
Figure 11. a, b. Hampton hump sign. a. Chest X-ray of a patient with pulmonary embolism showing a peripherally located, wedge-shaped
homogenous opacity consistent with the infarct area (arrow). b. Hump of a camel.
Figure 12. Westermark sign. Frontal radiograph of a patient with pulmonary Figure 13. Juxtaphrenic peak sign. Frontal radiograph of a
embolism, showing increased radiolucency in the upper and middle zones of patient with right upper lobe atelectasis (arrowheads), superior
the left lung due to decreased vascularization. displacement of the right diaphragm and a ‘peak’ at the
middle (arrow).
Figure 14. a, b. CT halo sign. a. Invasive aspergillosis in a patient with acute leukemia: CT image shows halo sign (arrows). b. Sunshine.
a b
c Figure 15. a–c. Gloved finger sign. a, b. CT images of a patient with lung
cancer, showing bronchi filled with mucus. c. Gloved hand.
Computed tomography
CT halo sign
The CT halo sign represents an area
of ground-glass attenuation surround-
ing a pulmonary nodule or mass on
CT images (Fig. 14). It is seen most
commonly in the early stage of inva-
sive aspergillosis in immunocompro-
mised patients. The CT halo sign has
also been described in patients with
eosinophilic pneumonia, bronchioli-
tis obliterans organizing pneumonia
(BOOP), candidiasis, Wegener granu-
lomatosis, bronchoalveolar carcinoma,
and lymphoma (16–19). Formation of
mechanism is not known with cer- fissure is responsible (15). The juxta- the halo sign varies according to the
tainty; according to one theory, the phrenic sign can also be seen in com- disease. Alveolar hemorrhage in as-
negative pressure of upper lobe atel- bined right upper and middle lobe pergillosis and/or tumor infiltration on
ectasis causes upward retraction of volume loss or even with middle lobe the bronchial walls in bronchoalveolar
the visceral pleura, and protrusion of collapse only. carcinoma are considered the causes of
extrapleural fat into the recess of the this sign (16–19).
a b
Figure 17. a, b. Comet tail sign. a. Prone CT image of a patient with tuberculosis pleuritis history. Subpleural atelectasis (arrow) and
bronchovascular structures extending toward the hilum (arrowheads) are seen. b. Comet.
Gloved finger sign tion. In asthma and asthma with bronchial dilatation (7). The signet
This sign is characterized by branch- ABPA, there is increased airway hy- ring sign can be seen anywhere in the
ing tubular or finger-like soft tissue persensitivity and mucus production. lung. It is an adjunct finding that can
densities (Fig. 15). This appearance Also, in APBA, the cause of bronchial help in differentiating bronchiectasis
is formed by dilated bronchi filled impaction is saprophytic prolifera- from other cystic lung lesions (22).
with mucus (mucoid impaction). On tion of aspergillus organisms within Accompanying findings such as peri-
CT images, mucus-filled bronchi are the dilated bronchi. In cystic fibrosis, bronchial thickening, lack of bronchi-
seen as Y- or V-shaped densities (20, the cause of mucoid impaction is im- al tapering, and visualization of bron-
21). Any obstructing lesion can lead paired ciliary action and abnormally chi within 1 cm of the pleura are all
to distal bronchiectasis and mucoid thick secretions (20, 21). contributing findings confirming the
impaction. Benign and malignant diagnosis (7).
neoplasms, congenital bronchial Signet ring sign
atresia, broncholithiasis, tuberculous Normally, the diameter of a bron- Comet tail sign
stricture, intralobar sequestration, chus is equal to the diameter of the The comet tail sign refers to curvilin-
intrapulmonary bronchogenic cyst, adjacent pulmonary artery (broncho- ear opacities that extend from a subp-
and foreign body aspiration can cause arterial ratio = 1). The signet ring sign leural “mass” toward the hilum. It con-
mucoid impaction of a bronchus. Al- occurs when the bronchoarterial ratio sists of distortion of vessels and bronchi
lergic bronchopulmonary aspergillo- is increased (7) (Fig. 16). This sign is that lead to an adjacent area of rounded
sis (ABPA), asthma, and cystic fibrosis usually seen in patients with bron- atelectasis. This sign is a characteristic
can cause this sign without obstruc- chiectasis or irreversible abnormal feature of round atelectasis (Fig. 17).
CT angiogram sign
The CT angiogram sign consists of Figure 18. CT angiogram sign. A patient with bronchoalveolar carcinoma. Enhancing
enhancing pulmonary vessels in a ho- pulmonary vessels in a low-attenuating mass are seen.
mogeneous low-attenuating consoli-
dation of lung parenchyma relative to a
the chest wall musculature at the me-
diastinal window (Fig. 18). This sign
has been described in the lobar form
of bronchoalveolar cell carcinoma (17,
24). Another important cause of the CT
angiogram sign is pneumonia. The low-
attenuating area has been considered
to be the result of mucus production
by tumor cells. The CT angiogram sign
has also been reported in pulmonary
edema, obstructive pneumonitis due to
central lung tumors, lymphoma, and
metastasis from gastrointestinal carci-
nomas (25, 26).
Figure 20. a, b. Tree-in-bud pattern. a. Patient with tuberculosis: small centrilobular nodules connected to multiple branching linear structures
are seen. b. Tree-in-bud.
Figure 21. Feeding vessel sign. A patient with bronchial carcinoma. Figure 22. Split pleura sign. A patient with empyema. Visceral
Pulmonary artery leading directly to the mass is seen. and parietal pleura are thickened and separated because of
fluid.
References
1. Collins J. CT signs and patterns of lung dis-
ease. Radiol Clin North Am 2001; 39:1115–
1134.
2. Hansell DV, Armstrong P, Lynch DA,
McAdams HP. Basic patterns in lung dis-
ease. In: Hansell DV, Armstrong P, Lynch
DA, McAdams HP. Imaging of diseases of
the chest. 4th ed. Philadelphia: Lippincott
Williams & Williams, 2005; 69–142.
3. Webb WR. Sarcoidosis. In: Webb
WR, Higgins CB. Thoracic imaging.
Philadelphia: Lippincott Williams &
Williams, 2005; 439–449.
4. Murfitt J. The normal chest. In: Sutton
D. Textbook of radiology and imaging.
Edinburgh: Churchill Livingstone, 1999;
299–353.
5. Felson B. The mediastinum. Semin
Roentgenol 1969; 4:41.
6. Felson B. Localization of intrathoracic le-
sions. In: Felson B, ed. Chest roentgenol-
It is defined as a central ground glass mation (inflammatory infiltrates in the ogy. Philadelphia: WB Saunders Company,
opacity surrounded by denser consoli- alveolar septum with macrophages, 1973.
dation shaped like a crescent (forming lymphocytes, plasmatic cells and some 7. Geoffrey B. Marshall GB, Farnquist BA,
MacGregor JH, Burrowes PW. Signs in
more than three quarters of a circle) or giant cells, with a relative preservation thoracic imaging. J Thorac Imaging 2006;
ring (forming a complete circle) that of alveolar spaces) and cellular debris 21:76–90.
is at least 2 mm in thickness (38, 39) and that the ring-shaped or crescen- 8. Kong A. The deep sulcus sign. Radiology
(Fig. 23). The reversed halo sign seen tic peripheral air-space consolidation 2003; 228:415–416.
on CT appears to be relatively specific corresponds to the area of organizing 9. Webb WR. Solitary and multiple nod-
ules, masses, cavities, and cysts. In:
to a diagnosis of cryptogenic organiz- pneumonia within the alveolar ducts Webb WR, Higgins CB. Thoracic imag-
ing pneumonia (38). It is also reported (37, 41). ing. Philadelphia: Lippincott Williams &
in lymphomatoid granulomatosis, sar- Williams, 2005; 271–305.
coidosis, pulmonary paracoccidioid- Acknowledgment 10. Hansell DV, Armstrong P, Lynch DA,
McAdams HP. Neoplasms of lungs, airway
omycosis and other pulmonary fungal We gratefully acknowledge Michael
and pleura. Ed. In: Hansell DV, Armstrong
infections (38–42). Voloudaki et al. Armstrong and Aydın Kuran for their contri-
P, Lynch DA, McAdams HP. Imaging of
butions.
reported that the central ground glass diseases of the chest. 4th ed. Philadelphia:
opacity corresponds histopathological- Lippincott Williams & Williams; 2005;
ly to the area of alveolar septal inflam- 785–900.