Chest > Diagnosis > Overview of Chest Imaging > Chest Radiographic and CT Signs

Signet Ring Sign

Santiago Martínez-Jiménez, MD

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Graphic shows the signet ring sign
defined as a bronchial
diameter larger than that of the
adjacent pulmonary artery
(bronchoarterial ratio > 1) on cross
section.
Axial CECT of a patient with chronic
obstructive pulmonary disease and
recurrent infection shows left upper
lobe bronchiectasis that exhibits the
so-called signet ring sign: A dilated
bronchus and its adjacent
pulmonary artery . The dilated
airway represents the "ring" and the
adjacent vessel the "stone."
Composite image with axial (left)
and sagittal (right) CECT of a patient
with postinfectious bronchiectasis
shows varicose bronchiectasis
, which exhibits the signet ring sign
when viewed in cross section.
Axial NECT of a 34-year-old man
with ulcerative colitis and
bronchiectasis shows diffuse
cylindrical bronchiectasis and
bronchial wall thickening. The
abnormal bronchoarterial pairs
exhibit the so-called signet ring sign
when viewed in cross section.

Additional Images
KEY FACTS

Terminology
Signet ring sign: Characteristic CT morphology of dilated airway and adjacent pulmonary artery (in cross section)
Dilated airway represents "ring"
Adjacent pulmonary artery represents "stone"
Bronchial dilatation with bronchoarterial ratio > 1
Bronchoarterial ratio = 1.5 may be normal in older asymptomatic individuals and at high altitude
Bronchial dilatation is commonly irreversible
Occasionally reversible (e.g., organizing pneumonia)
Irreversible bronchial dilatation synonymous with bronchiectasis
Imaging
Radiography
Bronchiectasis may be subtle or not visible
Tram-track sign: Visible parallel thick bronchial walls
Air-fluid levels indicate superimposed infection
Finger-in-glove sign: Branching opacities
CT
Dilated bronchus (in cross section) > adjacent artery
Absence of bronchial tapering
Mosaic attenuation and expiratory air-trapping
Pathology
Etiology
Congenital (primary ciliary dyskinesia, cystic fibrosis, Williams-Campbell syndrome)
Immunodeficiency (common variable immunodeficiency)
Infection (pneumonia, nontuberculous mycobacterial infection)
Inflammation (allergic bronchopulmonary aspergillosis)
Proximal airway obstruction (lung cancer)
Interstitial lung disease (traction bronchiectasis)
Inflamed bronchial wall
Luminal mucopurulent exudate: Neutrophils, macrophages
Bronchial wall destruction, loss of fibromuscular tissue, erosion/loss of bronchial wall cartilage
Decreased submucosal glands
Squamous metaplasia of bronchial epithelium
 Thin bronchial wall appears thick due to peribronchial fibrosis that involves adjacent lung parenchyma

SELECTED REFERENCES

1. Tiddens HAWM et al: The radiological diagnosis of bronchiectasis: what's in a name? Eur Respir Rev. 29(156), 2020
2. 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
3. Amaral RH et al: Computed tomography in the diagnosis of bronchiectasis. Eur Respir J. 46(2):576-7, 2015
4. Milliron B et al: Bronchiectasis: mechanisms and imaging clues of associated common and uncommon diseases. Radiographics.
35(4):1011-30, 2015
5. Algın O et al: Signs in chest imaging. Diagn Interv Radiol. 17(1):18-29, 2011
6. Marshall GB et al: Signs in thoracic imaging. J Thorac Imaging. 21(1):76-90, 2006
7. Ouellette H: The signet ring sign. Radiology. 212(1):67-8, 1999
8. Kim JS et al: Bronchoarterial ratio on thin section CT: comparison between high altitude and sea level. J Comput Assist Tomogr.
21(2):306-11, 1997
9. Naidich DP et al: Computed tomography of bronchiectasis. J Comput Assist Tomogr. 6(3):437-44, 1982
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