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The Split Pleura Sign1
Guenther J. Kraus, MD Appearance
The split pleura sign is seen on contrast
material– enhanced chest computed to-
mographic (CT) images. There is en-
hancement of the thickened inner vis-
ceral and outer parietal pleura, with
separation by a collection of pleural fluid
(Figure) (1).
Explanation
Thoracic empyema is defined as puru-
lent content in the pleural cavity (1).
Empyema most commonly occurs in
the setting of bacterial pneumonia. It
typically develops from transformation
of a parapneumonic effusion (not in-
fected) into a complicated effusion (fea-
tures of infection but not purulent) and
then into empyema (frank pus) (2,3).
In parapneumonic effusion, fluid
moves in the interpleural space due to
increased capillary vascular perme-
ability. Proinflammatory cytokines fa-
cilitate the fluid entry into the pleural
cavity and cause hyperemia. With in-
creasing fluid accumulation and bacterial
A trainee (resident or fellow) wishing to submit a manuscript for
Signs in Imaging should first write to the Editor for approval of
the sign to be prepared, to avoid duplicate preparation of the
same sign.
Published online
10.1148/radiol.2431041658
Radiology 2007; 243:297–298
1
From the Department of Radiology, General Hospital
Graz-West, Graz, Austria. Received September 30, 2004;
revision requested December 2, 2004; revision received
December 10, 2004; final version accepted January 17,
2005. Address correspondence to the author, Diagnoz-
tikzentrum Urania, Laurenzerberg 2, 1010 Vienna, Austria
Contrast-enhanced transverse CT scan shows
(e-mail: krausgj@hotmail.com).
empyema between thickened parietal (arrow-
Author stated no financial relationship to disclose.
heads) and visceral (arrow) pleural layers: the split
pleura sign.
姝 RSNA, 2007
Radiology: Volume 243: Number 1—April 2007
SIGNS IN IMAGING
invasion through the damaged endothe-
lium, transudative effusion progresses to
empyema (3). As empyema progresses, a
fibrin peel coats the surfaces of the vis-
ceral and parietal pleural layers with in-
growth of capillaries and fibroblasts and
subsequent thickening. This forms the ba-
sis of the split pleura sign: thickened vis-
ceral and parietal pleural layers separated
by empyema (1).
The fibrin peel can organize as early
as 7 days after the onset of the disease
(4).
Discussion
In one major study (1), pleural separa-
tion (“split pleura”) was seen in 68% (39
of 57) of empyema patients. In another
study (5), patients with empyema
showed enhancement of the pleura in
86% (30 of 35) of all cases, predomi-
nantly of the parietal pleura. Thickening
and enhancement can be seen with ex-
sudative effusions in 61% (36 of 59), but
not with transudative effusions (5). Em-
pyema is often accompanied by swelling
of the extrapleural subcostal tissue
(60%, 21 of 35), and increased attenua-
tion of the extrapleural fat can appear
(34%, 12 of 35) (6).
CT has been reported as having a
high accuracy (100%, 70 of 70) in differ-
entiating empyema from a lung abscess
(1).
Pleural changes similar to those of
empyema can be seen with malignant
effusions (especially after talc pleurode-
sis), mesothelioma, and hemothorax
and after lobectomy (2,7).
About half of empyemas are caused
by Gram-positive bacteria (Staphylococ-
cus aureus, Streptococcus pneumoniae);
the remainder are Gram-negative organ-
isms commonly growing together with
other Gram-negative organisms or anaer-
obes (1,3).
In summary, the split pleura sign
refers to thickening and increased con-
297
SIGNS IN IMAGING: The Split Pleura Sign Kraus

trast enhancement of the visceral and exudates and transudates: diagnosis with con-
the parietal pleura separated by empy- trast-enhanced CT. Radiology 1994;192:803–
808.
ema or an exsudative effusion.
3. Davies CW, Gleeson FV, Davies RJ; Pleural
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298 Radiology: Volume 243: Number 1—April 2007