Chest > Diagnosis > Overview of Chest Imaging > Chest Radiographic and CT Signs
Hilum Overlay Sign
Selected Images
PA chest radiograph of a patient
with thymoma shows an abnormal
left hilar convexity/mass
through which the left hilar vessels
are still identified, the so-called
hilum overlay sign indicative of a
mass residing anterior or posterior
to the hilum, in this case, the
anterior mediastinum.
Additional Images
PA chest radiograph of a patient
with an incidentally discovered left
anterior mediastinal pericardial cyst
shows an abnormal convexity
projecting over the right hilum
through which the hilar pulmonary
vessels are clearly identified, the so-
called hilum overlay sign.
PA chest radiograph of a patient
with a left anterior mediastinal
thymoma shows a lobulated left
"hilar" convexity or mass
through which the left pulmonary
Axial CECT of the same patient
shows a left prevascular mediastinal
soft tissue mass . right hilar mass
Anterior/prevascular mediastinal
masses are the most common cause
of the hilum overlay sign.
Axial CECT of the same patient
shows a well-defined ovoid water-
attenuation left prevascular
mediastinal mass that
represents a pericardial cyst.
Lateral chest radiograph of the
same patient confirms the presence
of an anterior mediastinal mass
PA chest radiograph of a patient
with mediastinal lymphoma shows a
through
which the right pulmonary artery
is identified, the so-called
hilum overlay sign.
PA chest radiograph of a patient
with a remote history of CABG
complicated by a venous graft
pseudoaneurysm shows an
abnormal convexity or mass
projecting over the left hilum. The
left pulmonary artery and its
branches are still visible
through the lesion.
Composite image with PA chest
radiograph (left) and axial CECT
. (right) of a patient with metastatic
disease shows visualization of the
right pulmonary artery through
Santiago Martínez-Jiménez, MD
Hide Images
PA chest radiograph of a patient
status post CABG complicated by
aneurysm formation shows a left
hilar convexity/mass through
which the hilar vessels remain
visible, consistent with the hilum
overlay sign. Awareness that
vascular lesions may produce this
sign is critical for the formulation of
an appropriate differential
diagnosis.
Axial CECT of the same patient
shows a heterogeneously enhancing
soft tissue mass in the left
prevascular mediastinum
mediastinum, which represented a
thrombosed venous graft
pseudoaneurysm.
Composite image with PA chest
radiograph (left) and axial CECT
(right) of a patient with aortic
dissection shows a descending aorta
aneurysm that demonstrates the
artery is identified, the so-called a large left anterior/prevascular hilum overlay sign with visualization
hilum overlay sign. mediastinal mass that of the left pulmonary artery
represents mediastinal through the enlarged aorta . The
lymphadenopathy. hilum overlay sign may also be seen
in posterior/paravertebral
mediastinal masses.

Composite image with PA chest PA chest radiograph of a patient

radiographs of a patient with
thymoma (left) and a patient with
pulmonic stenosis (right) highlights
the difference between the hilum
overlay and the hilum convergence
signs, respectively. The left
pulmonary artery can be
identified through the contour
abnormality produced by the
thymoma (i.e., hilum overlay sign)
but not in the case of left pulmonary
artery enlargement secondary to
pulmonic stenosis (i.e., hilum
convergence sign).
with an aortic aneurysm shows
visualization of the left pulmonary
artery overlying the
mediastinal contour abnormality
produced by the aneurysm .
The hilum overlay sign must be
differentiated from the hilum
convergence sign seen in pulmonary
hypertension and pulmonic
stenosis.

KEY FACTS

Terminology
Convexity/mass that projects over hilum through which ipsilateral pulmonary arteries are still visible
Imaging
PA chest radiography
Pulmonary artery interface > 1 cm medial to interface of abnormal convexity
Peripheral calcifications common in vascular masses
Pitfall: Rotated PA chest radiograph may simulate abnormal convexity projecting over hilum
Lateral chest radiography
Lesion localization anterior or posterior to hilum, typically in mediastinum
CT
Mass anterior or posterior to hilum
IV contrast useful for establishing vascular etiology
Vascular lesions often enhance with contrast but may manifest as soft tissue masses when thrombosed
Top Differential Diagnoses
Hilum convergence sign
Pulmonary artery branches arise from lateral aspect of hilar convexity
Indicates pulmonary artery enlargement
(e.g., pulmonary hypertension, pulmonic stenosis)
Left atrial appendage enlargement
Abnormal convexity below left mainstem bronchus
Cardiomegaly and pericardial effusion
Pulmonary artery remains lateral to abnormal convexity
Pathology
Classically described for anterior mediastinal masses; also seen in middle and posterior mediastinal masses
Etiology
Neoplasm: Thymic neoplasm, lymphoma, germ cell neoplasm, mediastinal lymphadenopathy
Vascular lesion: Pseudoaneurysm, aneurysm
Mimics: Loculated pleural effusion, parenchymal airspace disease

SELECTED REFERENCES
 1. Chiarenza A et al: Chest imaging using signs, symbols, and naturalistic images: a practical guide for radiologists and non-
radiologists. Insights Imaging. 10(1):114, 2019
2. George PP et al: 'Felson signs' revisited. J Med Imaging Radiat Oncol. 58(1):64-74, 2014
3. Algın O et al: Signs in chest imaging. Diagn Interv Radiol. 17(1):18-29, 2011
4. Parker MS et al: Radiologic signs in thoracic imaging: case-based review and self-assessment module. AJR Am J Roentgenol. 2009
Mar;192(3 Suppl):S34-48. Review. Erratum in: AJR Am J Roentgenol. 193(3 Suppl):S58, 2009
5. Marshall GB et al: Signs in thoracic imaging. J Thorac Imaging. 21(1):76-90, 2006
© 2022, Elsevier, Inc. AmirsysSupport@Elsevier.com