Pleural Effusion Radiography Imaging: L/O/G/O

L/O/G/O
Pleural Effusion
Radiography Imaging
By : Putri Harmen
Preceptor : dr. Dessy Wimelda, SpRad
Overview
Many benign and malignant diseases can

cause pleural effusion. The characteristics of
the fluid depend on the underlying
pathophysiologic mechanism. The fluid can
be transudate, nonpurulent exudate, pus, or
blood, or chyle.
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Imaging studies are valuable in
detecting and managing pleural effusions
but not in accurately characterizing the
biochemical nature of the fluid.
Lateral aspect,
shows a small effusion
accumulating in the
posterior costophrenic
(CP) sulcus.
Depiction of upright posteroanterior and
lateral views of the chest.
Can be detected on
both lateral and frontal
radiographic views. This
effusion produces blunting
of the lateral costophrenic
angle on the frontal view.
Moderate Effusion
Views as a dependent
density with meniscal-shaped
margin. The actual fluid upper
margin is horizontal. However,
there is more fluid posteriorly
and laterally because the
shape of the chest and recoil
characteristics of the lung
Moderate left effusion
Supine Position, Show
moderate effusion.
Accumulating in the
posterior aspect of the
chest. This layering effusion
on the frontal view as an
increased haziness
vascular structures seen.
Right lateral decubitus, a
42-year-old woman with breast
cancer confirms a right pleural
effusion by demonstrating
dependent layering of the fluid.
Radiography
1. Typical pleural effusion
Many factors influence the radiographic

findings of pleural effusion, including the
nature of the fluid (free vs loculated), the
amount of fluid, the patient's position, the
radiographic projection, and the presence of
underlying lung abnormalities.
In the absence of clinically significant lung
parenchymal changes, free pleural fluid tends
to accumulate in the most dependent portion
of the chest because of a difference in
density compared with the air-filled lung.
The pressure of the fluid causes atelectasis of
the adjacent (dependent) lung tissue. Lung
elasticity tends to preserve the shape of the
collapsed lung. As a consequence, the lung
collapses from the periphery toward the hilum,
with a higher degree of collapse in the dependent
portion of the lung.
These factors force some of the fluid to
rise against gravity and surround the
dependent portion of the lung.
A. Upright frontal view
A small amount of effusion accumulates in a

subpulmonic location, causing slight elevation of
the hemidiaphragm. As the fluid increases, the
fluid starts to spill over into the most dependent
costophrenic sulci.
Small effusions may not be visualized on
frontal views due to the orientation of the
diaphragm, because the posterior costophrenic
sulcus is inferior to the lateral costophrenic sulcus.
Fluid accumulating posteriorly can be seen on the
lateral view before it becomes visible on the
frontalview.
When the fluid is slightly above the level of the upper
portion of the diaphragm, blunting of the lateral
costophrenic angle is seen. This is the earliest sign of
pleural effusion on the frontal view. A minimal amount of
fluid (approximately 175 mL) is required to produce
detectable blunting.
`
A very large pleural effusion appears as

an opaque hemithorax with a mediastinal
shift to the contralateral side. The
mediastinal shift can be less prominent or
even absent in the presence of underlying
lung pathology (eg, atelectasis).
Posteroanterior chest, 42-year-
old woman, breast cancer
shows blunting of the right
cardiophrenic angle with slight
elevation of the right
hemidiaphragm.
Posteroanterior chest, 50-
year-old man with non-
Hodgkin lymphoma shows an
opacity (E) in the lower left
hemithorax & obliteration of
the left hemidiaphragm and a
curvilinear upper margin and a
mediastinal shift to the right.
These findings are typical of a pleural
effusion. In addition, minimal blunting of
the right costophrenic angle is present.
Cardiomegaly and a possible
mediastinal mass are noted.
Loculated effusion
in the minor fissure.
The opacity is
smoothly marginated
and biconvex
year-old man, right pleural
effusion. No other definite
abnormalities are seen.
year-old man, hemoptysis
demonstrates opacification of
the right hemithorax with
mediastinal shift to the right.
B. Upright Lateral view
A small amount of effusion accumulates in a

subpulmonary location, causing slight elevation
of the ipsilateral hemidiaphragm. As the fluid
increases, the amount of fluid spills over into the
most dependent (posterior) costophrenic sulci.
Small effusions appear as a dependent
opacity with posterior upward sloping of a
meniscus-shaped contour. The opacity
obliterates the underlying portion of the
diaphragmatic contour (silhouette sign).
C. Supine Frontal view
The normal supine view does not exclude the

presence of effusion. This view is the least sensitive
for detecting pleural effusions. A somewhat large
amount of fluid is required to produce detectable
radiographic findings, especially in bilateral
effusions.
Lateral aspect, moderate
effusion
Increased haziness
Vascular structures seen.
Posteroanterior supine,
60-year-old man, right-
sided effusion
Asymmetric density
Increased haziness in the
lower right hemithorax.
In one study, a minimal volume of 175 mL was required to
produce notable change on the supine radiograph. The fluid
accumulates in the posterior aspect of the hemithorax.
Subsequently, the effusion initially causes generalized
hazy homogeneous opacity with ill-defined margins.
D. Lateral Decubitus view
A lateral decubitus view obtained with a horizontal x-

ray beam is the most sensitive radiographic projection
for detecting an effusion. A small amount of fluid (10-25
mL) can be depicted on this projection. Can easily be
detected as a dependent, linear opacity separating the
lung from the parietal pleural and chest wal.
Right lateral decubitus, 42-
year-old woman, breast
cancer.
Right pleural effusion by
demonstrating dependent
layering of the fluid.
2. Atypical pleural effusion
Overview
Although a small effusion may accumulate

first in a subpulmonary location, accumulated
fluids usually spill into the posterior costophrenic
sulcus.
A. Large Subpulmonary Effusion
A large subpulmonary effusion can be

considered an atypical effusion. Unilateral
subpulmonary effusion is more common on the right
side. On upright frontal and lateral views,
subpulmonary effusion presents as an elevated
diaphragm (pseudodiaphragmatic contour).
B. Loculated Pleural Effusion
An atypical distribution of pleural fluid can be

also caused by loculation secondary to
adhesions or by lung parenchymal changes that
alter the recoil characteristics of the lung.
The second mechanism can occur in
atelectasis. Loculation secondary to
adhesions is usually secondary to an
infected or hemorrhagic effusion.
Loculated effusion, in
the minor fissure.
Opacity is smoothly
marginated, biconvex.
False Positives/Negatives
Pleural thickening and/or fibrothorax and subpleural fat
may mimic a small pleural effusion. Subpulmonic
effusion is sometimes hard to differentiate from an
elevated hemidiaphragm.
Small pleural effusions can be difficult to detect

radiographically. In addition, lung parenchymal
abnormalities may obscure large effusions.
Conclusion
Pleural Effusion Typical can detected by

posteroanterior radiography position, Lateral,
supine frontal and lateral lecubitus view. Upright
chest radiography is highly sensitive in detecting
pleural effusion. Lateral decubitus projections are
the most sensitive radiographic images for
detecting free pleural effusion.
Even, large effusion, loculated or
atypical effusions may demonstrate
substantial gravitational movement to
suggest their nature.
L/O/G/O
Thank You!

Pleural Effusion Radiography Imaging: L/O/G/O

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L/O/G/O

Many benign and malignant diseases can

Many factors influence the radiographic

A small amount of effusion accumulates in a

A very large pleural effusion appears as

A small amount of effusion accumulates in a

The normal supine view does not exclude the

A lateral decubitus view obtained with a horizontal x-

Although a small effusion may accumulate

A large subpulmonary effusion can be

An atypical distribution of pleural fluid can be

Small pleural effusions can be difficult to detect

Pleural Effusion Typical can detected by

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