Clinical Anatomy 27:757–763 (2014)

REVIEW

Pneumomediastinum and the Aortic Nipple: The

Clinical Relevance of the Left Superior
Intercostal Vein
ANDY WALTERS, LINDSEY CASSIDY, MITCHEL MUHLEMAN, ASHLEY PETERSON,
CHRISTA BLAAK, AND MARIOS LOUKAS*
Department of Anatomical Sciences, St. George’s University, School of Medicine, St. George, Grenada

This article discusses the appearance of the “aortic nipple” in chest radiogra-
phy, and reviews the embryology and anatomy of the left superior intercostal
vein which causes the appearance of an “aortic nipple.” This radiological sign
is useful in differentiating certain thoracic pathologies, such as pneumome-
diastinum, pneumopericardium, and medial pneumothorax. Pneumomediasti-
num is an encompassing term describing the presence of air in the
mediastinum, and may arise from a wide range of pathological conditions.
Despite the well-described imaging of pneumomediastinum, it is sometimes
difficult to differentiate from other conditions such as pneumopericardium and
medial pneumothorax. A separate finding, “aortic nipple” is the radiographic
term used to describe the lateral nipple-like projection from the aortic knob
present in a small number of individuals. The aortic nipple corresponds to the
end-on appearance of the left superior intercostal vein coursing around the
aortic knob, and may be mistaken radiologically for lymphadenopathy or a
neoplasm. Despite their relative independence, the aortic nipple is defined by
new contours in cases of pneumomediastinum, taking on an “inverted aortic
nipple” appearance. In this position, the inverted aortic nipple may facilitate
radiographic discrimination of pneumomediastinum from similar conditions.
This study aims to review the common clinical and radiographic features of
both pneumomediastinum and the aortic nipple. The radiologic appearance of
the aortic nipple occurring in unison with pneumomediastinum, and its poten-
tial role as a tool in the differentiation of pneumomediastinum from similarly
presenting conditions will also be described. Clin. Anat. 27:757–763,
2014. VC 2013 Wiley Periodicals, Inc.

Key words: aortic nipple; pneumomediastinum; radiography; left superior

intercostal vein; mediastinum; medial pneumothorax; pneumo-
pericarditis; lymphadenopathy

INTRODUCTION
The aortic nipple was first described by McDonald
et al. (1970) as a lateral, “nipple-like” projection from
the aortic knob. These authors further identified the
*Correspondence to: Marios Loukas, Department of Anatomical
anatomic structure of the aortic nipple to be the end- Sciences, St. George’s University, School of Medicine, Grenada.
on appearance of the left superior intercostal vein E-mail: mloukas@sgu.edu
(LSIV), traveling anteriorly around the aorta on its
way to the left brachiocephalic vein. The aortic nipple Received 5 March 2013; Accepted 20 May 2013
was subsequently classified as a normal radiographic Published online 27 June 2013 in Wiley Online Library
variant in erect anteroposterior chest radiographs, (wileyonlinelibrary.com). DOI: 10.1002/ca.22279

C
V 2013 Wiley Periodicals, Inc.
758 Walters et al.
Fig. 1. AP chest radiograph showing the classic
“aortic nipple” in a patient with pneumomediastinum.
Labels are added on the left to more clearly delineate the
nipple-like appearance of the left superior intercostal
found in a small number of individuals (McDonald et al.,
1970; Friedman et al., 1978; Ball and Proto, 1982).
Aside from its presentation as a normal variant in
healthy individuals, the spontaneous appearance of the
aortic nipple may be the cause for concern. In several
cases, the aortic nipple has been shown to precede
pathological conditions such as venous obstruction in
the superior vena cava, inferior vena cava, or left bra-
chiocephalic vein (Carter et al., 1985; Byerly and
Schlesinger, 2010). Furthermore, the aortic nipple has
been identified in conditions where venous flow
through the LSIV is increased, such as portal hyperten-
sion and certain congenital venous anomalies (Carter
et al., 1985; Hatfield et al., 1987; Chen et al., 2008).
In contrast to the aortic nipple, pneumomediasti-
num is an abnormal radiographic finding which
encompasses a broad clinical condition in which air
becomes trapped in the mediastinal space. First
described by Lae € nnac in 1834, pneumomediastinum
most commonly presents with central chest pain,
dyspnea, and retrosternal pleuritic pain radiating to
the back and shoulders (Macia et al., 2007). Following
its initial description, Hamman (1939) demonstrated
that pneumomediastinum might be accompanied by
auscultatory crepitations coinciding with normal heart-
beats (Hamman, 1939).
Similar to the aortic nipple, pneumomediastinum
has well-documented radiographic features (Fig. 1).
Generally, pneumomediastinum is described on ante-
roposterior chest radiographs as the depiction of nor-
mal anatomical structures highlighted by air leaving
the mediastinum (Zylak et al., 2000). Although pneu-
momediastinum often presents a variety of radiologi-
cal features, it is often confused with similarly
appearing conditions such as pneumopericarditis and
medial pneumothorax (Cyrlak et al., 1984; Bejvan
and Godwin, 1996; Zylak et al., 2000). Under these
vein. The left superior intercostal vein is bordered medi-
ally by the aortic arch and laterally by the mediastinal
pleura. [Color figure can be viewed in the online issue,
which is available at wileyonlinelibrary.com.]
circumstances, additional radiographic features unique
to pneumomediastinum have important diagnostic
relevance. As the aortic nipple may be mistaken for
lymphadenopathy or neoplasm (McDonald et al.,
1970), or may have underlying pathological origins
(Friedman et al., 1978; Byerly and Schlesinger, 2010),
accurate identification of an aortic nipple in cases of
pneumomediastinum may have a significant impact
on patient morbidity.
This article will review the anatomy, embryology,
and radiological imaging of the LSIV, which leads to
the appearance of the aortic nipple on radiographs.
Furthermore, unique radiographic characteristics of
the aortic nipple in cases of pneumomediastinum will
be presented in an effort to reduce the misdiagnosis
of lymphadenopathy or neoplasm, and affirm the
potential role of the aortic nipple in the accurate iden-
tification of pneumomediastinum.
EMBRYOLOGY
The embryogenesis of the LSIV is seldom the focus
of developmental reviews, and tends to be present
secondary to the reports of larger embryonic venous
structures. Correspondingly, the LSIV has been
reported to arise from one of the two major cardinal
veins, depending on the study cited (Gladstone, 1912;
Campbell and Duechar, 1954; Lane et al., 1976;
Fasouliotis et al., 2002; Paval and Nayak, 2007).
Nowhere has the embryogenesis of the LSIV been so
thoroughly described as in a case report by Campbell
and Duechar (1950) of left-sided superior vena cava.
The consecutive generation and involution of com-
municating shunts characterize the development of
the embryonic venous system. Under the guidance of
such mechanisms, the LSIV appears to arise from the
 Clinical Relevance of LSIV 759

common intersection of the three left cardinal veins.

The cardinal veins appear in the fourth week of gesta-
tion as symmetrically paired anterior and posterior
cardinal veins connected by two short common cardi-
nal veins, also referred to as the ducts of Cuvier. The
anterior and posterior cardinal veins drain the cranial
and caudal portions of the embryo, respectively, and
communicate centrally through the ducts of Cuvier.
Traveling inward, the ducts of Cuvier converge upon
the sinus venosus as it receives maternal blood from
the developing heart (Campbell and Duechar, 1954).
As the embryonic heart descends caudally into the
thorax, the adjoining ducts of Cuvier descend from
either side of the developing heart. As the anterior
and posterior cardinal veins remain stationary
throughout this process of development, the lateral
portions of the ducts of Cuvier are stretched to lie in
the vertical planes of the embryo. By the eighth week
of gestation, the left and right anterior cardinal veins
form an oblique anastomosis, establishing a left-to-
right venous shunt, which corresponds to the adult
left brachiocephalic vein (Campbell and Duechar,
1954).
At this point in development, the vertically elon-
gated left duct of Cuvier sits immediately below the Fig. 2. Schematic representation of the tributaries of
intersection of the left anterior cardinal and brachioce- the left superior intercostal vein and its course with
phalic veins. To approach this intersection, the left respect to the aorta. After passing lateral to the aorta, the
duct of Cuvier travels laterally away from the sinus LSIV drains into the left brachiocephalic vein.[Color figure
venosus before ascending cranially. At its vertex, the can be viewed in the online issue, which is available at
left duct of Cuvier bends caudally again as the left wileyonlinelibrary.com.]
posterior cardinal vein. In this position, the anterior
cardinal vein, caudal to its juncture with the left bra-
chiocephalic vein, receives the apical bend of the left hemiazygos and left superior intercostal veins (Lane
duct of Cuvier (Campbell and Duechar, 1954). et al., 1976; Carter et al., 1985; Godwin and Chen,
The left brachiocephalic vein diverts venous blood 1986; Byerly and Schlesinger, 2010). As diverted flow
from the left posterior cardinal vein, allowing its produces venous dilation, obstruction to either vena
simultaneous degeneration with the left ascending cava has been demonstrated to manifest radiologically
duct of Cuvier. The persisting apical bend composed of as the spontaneous appearance of an aortic nipple.
the left duct of Cuvier and posterior cardinal vein After receiving intercostal and hemiazygos tributa-
remains connected to the receiving portion of the left ries, the LSIV courses ventrally to round the arch of
anterior cardinal vein, constituting the embryonic the aorta. Traveling anteriorly in the horizontal plane,
components of the adult LSIV (Campbell and Duechar, the LSIV is bordered along its lateral surface by the
1954). mediastinal pleura. This portion of the route is some-
times seen in anteroposterior chest radiographs as
the aortic nipple, and is also clearly demonstrated in
LEFT SUPERIOR INTERCOSTAL VEIN: horizontal plane computed tomography (CT) scans
(Godwin and Chen, 1986; Byerly and Schlesinger,
THE AORTIC NIPPLE 2010). Other notable structures surrounding the LSIV
The LSIV is a dorsal venous structure in the supe- include the left vagus nerve medially and the left
rior mediastinum draining the second, third, and phrenic nerve laterally (Standring, 2008). After round-
sometimes the fourth intercostal spaces (Ozdemir ing the aortic arch, the LSIV continues medially and
et al., 2002; Standring, 2008). It originates immedi- gradually ascends to the dorsum of the left brachioce-
ately posterior and medial to the dorsal aorta at the phalic vein. It is worth mentioning that along its route
level of the third and fourth thoracic vertebrae, and the LSIV may receive the left pericardiophrenic and
has been shown to communicate with the accessory bronchial veins, draining the left pericardium and left
hemiazygos vein in 75% of patients (McDonald et al., bronchioles, respectively (Godwin and Chen, 1986;
1970; Ball and Proto, 1982). This common anatomic Standring, 2008).
communication has important radiographic relevance
(Fig. 2). As the azygos vein receives the accessory
hemiazygos vein, an increase in azygos blood flow will RADIOLOGY
have collateral implications for the accessory hemia-
zygos and left superior intercostal veins. Indeed, flow The radiology of the LSIV was first described by
impedance to both the superior and the inferior vena McDonald (1970) as a lateral or superior “nipple-like”
cavae has been shown to divert flow to the accessory structure projecting from the aortic knob in erect
760 Walters et al.
Fig. 3. CT scan showing the left superior intercostal
vein travelling lateral to the aortic arch before draining
into the brachiocephalic vein. Asterisk shows the course
of left superior intercostal vein. Arrow shows the drainage
point. An AP radiograph in this patient would reveal a
anteroposterior chest radiograms. In the same study,
McDonald estimated a 4% incidence of the aortic nip-
ple in healthy patients, with a corresponding fre-
quency of 7% in diseased individuals (McDonald,
1970). Further evaluation of aortic nipple frequencies
revealed similar ranges for healthy individuals, vary-
ing from 0.9 to 9.5% depending on the study cited
(Friedman et al., 1978; Ball and Proto, 1982; Abiru
et al., 2005). In their review of 469 posteroanterior
chest radiographs, Ball and Proto (1982) observed the
aortic nipple in 9.5% of cases, with the appearance
“varying from a subtle undulation along the aortic
knob to a prominent protuberance.”
The diameter of the aortic nipple has been demon-
strated to range from 1 to 4 mm (mean, 2.2 mm; SD,
1.1 mm), with a maximum diameter of 4.5 mm in
healthy subjects (Friedman et al., 1978). It is also
notable that the aortic nipple has continuous radiopac-
ity with the aortic knob, accentuating the polarity of its
lateral apex. Diameters of >4.5 mm have been shown
to correlate with certain vascular disease (Friedman
et al., 1978). Although congenital or impending venous
disease can be roughly extrapolated from aortic nipple
diameter, this finding is complicated by the fact that
the aortic nipple has an increased diameter in supine
chest roentgenograms, regardless of individual health
(Friedman et al., 1978).
readily visible aortic nipple. (Used with permission from
Harry’s Chest Radiology Atlas at http://chestatlas.com).
[Color figure can be viewed in the online issue, which is
available at wileyonlinelibrary.com.]
As the aortic nipple bears radiographic resemblance
to other pathologies of the superior mediastinum,
accurate identification of the aortic nipple is vital in
reducing patient morbidity. Specifically, the aortic nip-
ple has been shown to imitate aortic aneurysm,
lymphadenopathy, and neoplasm (Hatfield et al.,
1987). In such cases, it is prudent to undertake sec-
ondary radiological evaluation to confirm the presence
of an aortic nipple (Hatfield et al., 1987). To an extent,
statistical limitations confining plain chest radiographic
identification of the aortic nipple have been overcome
by CT scans and magnetic resonance imaging (MRI).
The LSIV is readily appreciated on horizontal tho-
racic CT scans at the levels of the aortic arch and left
brachiocephalic vein (Dudiak et al., 1991) (Fig. 3). At
the level of the aortic arch, the LSIV may be seen pro-
jecting laterally from the paravertebral space, adher-
ing closely to the outer border of the aorta before
bending superiorly out of the horizontal plane. As it
rounds the aortic arch the LSIV is bordered laterally
by the mediastinal pleura, which is itself bordered by
a region of radiolucency corresponding to the superior
lobe of the left lung. In the plane of the left brachioce-
phalic vein, the LSIV continues ventrally until it inter-
sects with the dorsum of the left brachiocephalic vein
(Dudiak et al., 1991). As the LSIV adheres so closely
to the lateral border of the aortic arch, it may been

mistaken for a blood-filled double aortic lumen in heli-
cal CT scans, as in a dissecting aortic aneurysm (Batra
et al., 2000). This resemblance may be potentially
resolved by superior axial sections of multidetector
row volume-rendered CT scans (Lawler et al., 2002).
MRI has also been proven effective in the visualiza-
tion of the aortic nipple. On MRI, the aortic nipple has
been described to appear in coronal sections as a
small tubular structure with low signal intensity
(Medrea et al., 1988). In a study of 40 patients,
Medrea et al. (1988) reported the presence of the aor-
tic nipple in six cases where conventional chest X-ray
found only one. Despite increased detection fre-
quency, the aortic nipple was reported in MRIs only in
the presence of anomalous thoracic disturbances, and
is therefore, of limited potential in its detection of nor-
mal aortic nipple variants.
PNEUMOMEDIASTINUM
€ nnac in 1819, pneumome-
First described by Lae
diastinum is the clinical term used to describe the
presence of air in the mediastinum (Lae € nnec and For-
bes, 1834). Pneumomediastinum is usually accompa-
nied by complaints of chest pain, dyspnea, and
retrosternal pain radiating to the back and neck, and
should always be considered when the etiology of
these symptoms is unclear (Newcomb and Clarke,
2005). Furthermore, pneumomediastinum may some-
times present during physical examination as an aus-
cultatory crepitation coinciding with the heart beat,
known as Hamman’s sign, which is accentuated
toward the end of exhalation (Hamman, 1939).
The causes of pneumomediastinum are wide-
ranging, and are often subclassified to facilitate specific
diagnostic criteria. Generally, pneumomediastinum
may be classified as either intra- or extrathoracic, with
respect to the original source of air (Zylak et al., 2000).
Extrathoracic pneumomediastinum can arise from
either above and below the mediastinum through the
retropharyngeal and peritoneal spaces, respectively
(Zylak et al., 2000). The mediastinal space may also be
accessed along the fascicular sheaths of major vessels
traveling between the mediastinum and these areas
(Cyrlak et al., 1984).
As the retropharyngeal space may be accessed via
perforation of multiple anatomical structures, includ-
ing the nasopharynx, esophagus, trachea, and larynx,
extrathoracic pneumomediastinum has been reported
to arise in a wide range of clinical scenarios (Cyrlak
et al., 1984). Owing to the sometimes traumatic
nature of the procedure, endotracheal intubation has
been demonstrated as an iatrogenic cause of extra-
thoracic pneumomediastinum (O’Neill and Symon,
1979). The submandibular region also provides a
route of entry into the mediastinum via communica-
tion with the retropharyngeal space (Tofield, 1977),
implicating seemingly simple procedures such as den-
tal extraction in the development of pneumomediasti-
num (Sandler et al., 1975). Furthermore, fractures to
the mid-face have also been documented as a source
of pneumomediastinum (Tofield, 1977).
To a lesser extent, the mediastinum is also
accessed from air in the peritoneum. Most commonly,
Clinical Relevance of LSIV 761
peritoneal pneumomediastinum originates in the GI
tract, which has been perforated by some mechanism,
such as gastric ulcer (Stahl et al., 1977) or duodenal
gastroscopy (Fierst et al., 1951).
Intrathoracic pneumomediastinum is far more com-
mon and is thought to be the result of alveolar rupture,
followed by the dissection of air into the mediastinum
along vascular fascicular sheaths (Macklin, 1939). This
particular cause of pneumomediastinum has been
documented to arise in cases where air is forced
against a closed or highly resistant glottis (Cyrlak et al.,
1984; Zylak et al., 2000). This results in the creation of
a positive pressure gradient exceeding the maximum
alveolar capacity, followed by subsequent rupture of the
alveoli (Macklin, 1939). Pregnancy, asthma, emesis,
coughing or sneezing, and diabetes mellitus have all
been documented as sources of pneumomediastinum
(Girard et al., 1971; Cyrlak et al., 1984; Zylak et al.,
2000). In hospital settings, respirator therapy has
been demonstrated as an iatrogenic cause of pneumo-
mediastinum owing to the high pressures needed to
sustain ventilation (Cyrlak et al., 1984). Pneumome-
diastinum has also been reported to occur in up to 10%
of thoracic blunt trauma cases (Wintermark and
Schnyder, 2001).
Despite the plethora of known causes of pneumome-
diastinum, spontaneous pneumomediastinum may yet
occur in the absence of a known precedent cause. Such
cases account for a relatively small fraction of pneumo-
mediastinum cases, cited to occur in roughly one out of
every 30,000 emergency room admissions (Newcomb
and Clarke, 2005). Spontaneous pneumomediastinum
occurs most frequently in young adult men, and has
been estimated to be under-diagnosed in as many as
30% of all cases, most likely because of its asymptom-
atic and self-limiting nature (Kaneki et al., 2000).
RADIOLOGY
The radiology of pneumomediastinum is simply
described as the depiction of normal anatomical struc-
tures surrounded by air migrating out of the mediasti-
nal space (Zylak et al., 2000). In this way, mediastinal
structures may acquire new radiographic appearance
with regard to both contour and shape. In anteropos-
terior plain chest radiographs, pneumomediastinum
sharply delineates the major arteries and veins of the
mediastinum, as well as the trachea, esophagus, and
thymus (Cyrlak et al., 1984; Zylak et al., 2000). In
cases where the volume of air is large enough, the
thymus may become elevated and take on the
appearance of a sail, commonly known as the “thymic
sail sign” (Moseley, 1960). Similarly, air surrounding
both sides of the aorta functions to highlight its medial
and lateral borders, giving it a tubular shape also
known as the “tubular aorta sign” (Zylak et al., 2000).
This latter feature is of significant relevance to the
presence of an aortic nipple, as it may serve to accen-
tuate the medial border of the LSIV traveling around
the anterior arch of the aorta (Ball and Proto, 1982).
Other common features of pneumomediastinum
include a thin, radiolucent line parallel to the left car-
diac border. This line represents the negative space
762 Walters et al.
between the mediastinal pleura and the left cardiac
border, created by pressurized mediastinal air (Maun-
der et al., 1984).
When discussing the radiologic presentation of
pneumomediastinum, it is important to consider simi-
larly presenting conditions. Most notably, pneumoperi-
cardium and medial pneumothorax provide significant
diagnostic obstacles to the accurate identification of
pneumomediastinum (Ball and Proto, 1982; Cyrlak
et al., 1984; Zylak et al., 2000). Of particular similar-
ity to pneumomediastinum is medial pneumothorax in
the supine patient. Supine chest radiographs of medial
pneumothorax depict a small pleural reflection imme-
diately left of the cardiac border, simulating pneumo-
mediastinum (Bejvan and Godwin, 1996). In these
cases, additional radiographic features specific to
pneumomediastinum are of particular importance.
PNEUMOMEDIASTINUM AND THE
AORTIC NIPPLE: THE INVERTED
NIPPLE
Although both pneumomediastinum and the aortic
nipple are common occurrences in anteroposterior
chest radiographs, they are usually described inde-
pendent of one another. As the aortic nipple is a
mediastinal structure, and most other mediastinal
structures acquire different contours in cases of pneu-
momediastinum, it follows that the aortic nipple
should also appear with newly defined contours in
cases of pneumomediastinum. Indeed, the aortic nip-
ple occurring in tandem with pneumomediastinum
acquires a medial border, clearly delineating it from
the outer wall of the aorta (Ball and Proto, 1982).
More specifically, there is a loss in continuous
radiopacity of the aortic nipple with the aortic knob
owing to the presence of air highlighting the unnatu-
ral rift between the aortic arch and the aortic nipple.
As the aortic nipple is normally adherent to the outer
wall of the aorta, mediastinal air exerting lateral pres-
sure on the pleura separates both the pleura and the
nipple from the outer wall of the aorta, outlining the
medial border of the LSIV. Close inspection of the aor-
tic nipple in these cases reveals that it is continuous
with the mediastinal pleura, projecting inward toward
the aorta. This reversal in nipple polarity assumes a
unique inverted aortic nipple appearance, and sug-
gests that the aortic nipple is more firmly adherent to
the mediastinal pleura than to the wall of the aortic
arch. Conversely, in cases of left-sided pneumo-
thorax, only the lateral aspect of the LSIV will be out-
lined, resulting in a more classic aortic nipple
appearance (Ball and Proto, 1982). Therefore, this
unique inverted appearance allows the aortic nipple
to be used as a valuable tool for the identification of
pneumomediastinum. The inverted aortic nipple
should not be mistaken for lymphadenopathy or neo-
plasm in these cases.
CONCLUSIONS
Although the aortic nipple and pneumomediastinum
are common features of plain chest radiographs, they
are usually presented independently of one another.
The aortic nipple may present as a normal radiographic
variant in healthy individuals, or arise as the result of
an impending venous disease state. Commonly, the
aortic nipple appears as a lateral projection of aorta,
sharing continuous radiopacity with the aortic knob. In
these cases, the aortic nipple may be mistaken for
lymphadenopathy, neoplasm, or aortic aneurysm.
Pneumomediastinum is a broad clinical condition,
describing the presence of air in the mediastinal
space. Although the radiographic features of pneumo-
mediastinum have been well-described, it is com-
monly mistaken for similar conditions such as medial
pneumothorax and pneumopericardium.
The aortic nipple is defined by a new set of con-
tours in cases of pneumomediastinum, thus we
acknowledge its potential role in the discrimination of
pneumomediastinum from medial pneumothorax and
pneumopericardium. Physicians should be aware of
the inverted aortic nipple appearance, and should be
ruled out in cases where lymphadenopathy and neo-
plasm are suspected based on radiology alone. To this
end, the radiographic descriptions of lymphadenopa-
thy and neoplasm in cases of pneumomediastinum
are largely absent in the literature, and the exact radi-
ographic contribution of lymphadenopathy or neo-
plasm to pneumomediastinal radiography remains to
be determined.
ACKNOWLEDGMENTS
The authors wish to thank Sessica Holland, MS, Medi-
cal Illustrator in the Department of Anatomical Scien-
ces, St. George’s University, Grenada, West Indies, for
the creation of her illustrations used in this publication.
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