Gamal Rabie Agmy, MD, FCCP

Professor of Chest Diseases, Assiut University

Ginkgo leaf sign • The ginkgo leaf sign is a chest plain

radiography appearance which is

seen at extensive subcutaneous

emphysema of the chest wall. Air

outlines the fibers of the pectoralis

major muscle and creates a

branching pattern that resembles

the branching pattern in the veins of

a ginkgo leaf.

Golden S sign

The Golden S sign is seen on both PA chest radiographs and

on CT scans. It is named because this sign resembles a

reverse S shape, and is therefore sometimes referred to as

the reverse S sign of Golden.

Although typically seen with right upper lobe collapse, the S

sign can also be seen with the collapse of other lobes. It is

created by a central mass obstructing the upper lobe

b r o n c h u s a n d s h o u l d r a i s e s u s p i c i o n o f a

primary bronchogenic carcinoma. It can also be caused by

other central masses, such as: metastasis, primary

m e di a st i na l t um our, or e nl ar ge d l ym ph node s .

S Curve of Golden

When there is a mass

adjacent to a fissure, the

fissure takes the shape

of an "S". The proximal convexity is due to a mass,

and the distal concavity is

due to atelectasis. Note the

shape of the transverse

fissure. This example represents a

RUL mass with atelectasis

Incomplete Border Sign

(Pregnant Lady Sign)

• The incomplete border sign is useful to depict an

extrapulmonary mass on chest radiograph.

• An extrapulmonary mass will often have a inner well

defined border and an ill-defined outer margin . This

can be attributed to the inner margin being

tangential to the x-ray beam and has good inherent

contrast with the adjacent lung. On the other hand,

the outer margin is enface or partially enface with

the x-ray beam and merges with the pleural or chest

wall thus the border is obscured.

http://radiopaedia.org/images/3168558

Holly leaf sign

The holly leaf sign refers to the

appearance of pleural plaques on

chest x-rays. Their irregular

thickened nodular edges are

likened to the appearance of a

holly leaf.

Juxtaphrenic peak sign

The juxtaphrenic peak sign refers to the peaked

or tented appearance of a hemidiaphragm which

can occur in the setting of lobar collapse. It is

caused by retraction of the lower end of

diaphragm at an inferior accessory fissure (most

common), major fissure or inferior pulmonary

ligament. It is commonly seen in upper lobe

collapse but may also be seen in middle lobe

collapse.

Chang sign refers to a dilatation

and abrupt change in calibre of a

main pulmonary artery due

to pulmonary embolism

Chang sign

Coin lesion

Coin lesion refers to a round or oval, well-

circumscribed solitary pulmonary lesion. It is

typically 1-5 cm in diameter and calcification

may or may not be present. Typically but not

always the patient is asymptomatic .

Coin lesion The differential diagnosis for such lesions is :

malignancy

e.g. squamous cell carcinoma - primary lung malignancy

metastases

infection

;tuberculosispulmonary

Streptococcus sp., Staphlycoccus sp., or Klebisialla sp. infection

cyst hydatid

abscess

benign disease processes

granulomatosisWegener's

hamartomapulmonary

malformation arteriovenouspulmonary

rheumatoid nodule

bronchogenic cyst adenomabronchial

.

PseudoCoin lesion

pseudo-coin lesion", which are caused

by artifacts (e.g. button on patient's clothing,

unilateral nipple shadow, etc).

PseudoCoin lesion

Dense hilum sign

The dense hilum sign suggests a

pathological process at the hilum - hilar

malignancy or bronchogenic

carcinoma should be suspected.

On a well-centred chest PA radiograph the

density of the hilum is comparable on both

sides. In absence of calcification

or adenopathy, the hila should appear of

equal density and be symmetric. .

CT angiogram Sign

Identification of vessels within an

airless portion of lung on contrast-

enhanced CT .

The vessels are prominently seen

against a background of low-

attenuation material .

Associated with:

bronchoalveolar cell carcinoma

lymphoma

infectious pneumonias.

Fallen Lung Sign

This sign refers to the appearance

of the collapsed lung occurring

with a fractured bronchus .

The bronchial fracture results in

the lung to fall away from the

hilum, either inferiorly and laterally

in an upright patient or posteriorly,

as seen on CT in a supine patient.

DD:

Pneumothorax causes a lung to

collapse inward toward the hilum.

Ring Around Artery Sign

•Visualized on lateral chest radiographs

•Lucency along or surrounding RPA

•Characteristic of pneumomediastinum

•Usually is accompanied by other ancillary signs:

•continuous diaphragm sign

•Naclerio’s V sign

•thymic sail sign

Thymic Sail Sign Naclerio’s V Sign

Flat waist Sign

This sign refers to flattening of the contours of the aortic knob and adjacent

main pulmonary artery .

It is seen in severe collapse of the left lower lobe and is caused by leftward

displacement and rotation of the heart

Finger in Glove Sign

Visible on chest radiographs or CT

•Indicates mucoid impaction within an obstructed bronchus

•Characterized by branching tubular or fingerlike opacities

Finger in Glove Sign

Originate from the hilum and are directed

peripherally

•Also seen in cases of dilated bronchi with

secretions

•Distal lung remains aerated by collateral

drift through interalveolar pores (pores of

Kohn) and Lambert canal

Hampton Hump Sign

Pulmonary infarction secondary to pulmonary embolism produces

an abnormal area of opacification on the chest radiograph, which

is always in contact with the pleural surface.

Luftsichel Sign

•German for sickle of air (luft: air sichel:

crescent)

•Paramediastinal lucency due to

interposition of lower lobe apex between

mediastinum and shrunken upper lobe

•Occurs more commonly on the left than in

the right

Halo Sign

CT shows nodular consolidation associated with a halo of ground-glass opacity

(GGO) in both apices resulting from invasive pulmonary aspergillosis.

This halo represents hemorrhage.

When seen in leukemic patients, is highly suggestive of the diagnosis of

invasive pulmonary aspergillosis.

Double Density Sign

•Indicates left atrial enlargement

•Occurs when right side of the left atrium

pushes into adjacent lung

•Splaying of the carina

•Superior displacement of left main stem

bronchus on frontal view

Double Density Sign

•Posterior displacement of left main stem

bronchus on lateral view

•Posterior displacement of esophagus on

barium study

Walking Man Sign

Juxtaphrenic Peak Sign

This sign refers to a small triangular shadow that obscures the dome of

the diaphragm secondary to upper lobe atelectasis . The shadow is

caused by traction on the lower end of the major fissure, the inferior

accessory fissure, or the inferior pulmonary ligament.

Luftsischel Sign

In left upper lobe collapse, the superior segment of the left lower lobe, which is

positioned between the aortic arch and the collapsed left upper lobe, is

hyperinflated. This aerated segment of left lower lobe is hyperlucent and

shaped like a sickle, where it outlines the aortic arch on the frontal chest

radiograph.

This peri-aortic lucency has been termed the luftsichel sign, derived from the

German words luft (air) and sichel (sickle).

Doughnut Sign

•Detect mediastinal adenomegaly

•Lateral chest radiograph

•Subcarinal lymphadenopathy

•Mass posterior to bronchus intermedius

and inferior hilar window

•CT primary modality for detecting

mediastinal lymphadenopathy

Pulmonary

hypertension Normal

Lymphadenopathy

Cervicothoracic Sign

•Used to determine location of mediastinal

lesion in the upper chest

•Based on principle that an intrathoracic

lesion in direct contact with soft tissues of

the neck will not outlined by air

•Uppermost border of the anterior

mediastinum ends at level of clavicles

Cervicothoracic Sign

• Middle and posterior mediastinum extends

above the clavicles

•Mediastinal mass projected superior the

level of clavicles must be located either

within middle or posterior mediastinum

•More cephalad the mass extends the most

posterior the location

Thoracoabdominal Sign •Posterior costophrenic sulcus extends

more caudally than anterior basilar lung

•Lesion extends below the dome of

diaphragm must be in posterior chest

whereas lesion terminates at dome must be

anterior

•Cervicothoracic and thoracoabdominal

signs were described by Felson

Tapered Margins Sign

•A lesion in the chest wall, pleura or

mediastinum have smooth tapered

borders and obtuse angles

•While parenchymal lesions usually form

acute angles

Water Bottle Sign

Westermark Sign

•Described by Neils Westermark in 1938

•Chest radiograph and CT show

increased lucency or hypoattenuation

•Typically signifies either occlusion of a

larger lobar/segmental artery or

widespread small vessel occlusion

Fleischner Sign

•Described by Felix Fleischner

•Enlargement proximal pulmonary

arteries on plain film or angiography

•PA enlargement due to embolus

•Commonly in the setting of massive PE

•It has relatively low sensitivity

•Abrupt tapering of an occluded vessel

distally (knuckle sign)

Hilum Overlay Sign

•Described by B. Felson

•If hilar vessels are sharply delineated it

can be assumed that the overlying mass

is anterior or posterior

•If mass inseparable pulmonary arteries

structures are adjacent to one another

Hilum Convergence Sign

•Described by B. Felson

•Used to distinguish between a prominent

hilum and an enlarged pulmonary artery

•If branches of PA converge toward central

mass is an enlarged PA

•If branches of PA converge toward heart

rather than mass is a mediastinal tumor

CT Halo Sign

CT Halo Sign

•Ground glass attenuation surrounding a

pulmonary nodule/mass on CT images

•Described by Kuhlman in 1985 in patients

with invasive aspergillosis

•Associated w hemorrhagic nodules and

may be caused neo or inflammatory

•Disease pathologically active with tumor

spread, hemorrhage or inflammation

Reverse Halo Sign

•Central ground-glass opacity surrounded

by denser consolidation of crescentic or

ring shape, at least 2 mm thick

•First described by Voloudaki in 1996

•Kim in 2003 used the term reverse halo

•Found to be relatively specific for crypto-

genic organizing pneumonia (COP)

Reverse Halo Sign

•Seen in other conditions:

•Wegener’s granulomatosis

•lymphomatoid granulomatosis

•paracoccidiodomycosis

•neoplastic (metastasis)

•invasive aspergillosis

•lipoid pneumonia

Split Pleura Sign

•Seen on contrast enhanced CT of

chest

•Thickened visceral and parietal pleura

with separation by a collection

•Empyema or exudative effusion

•Exudative: bacterial pneumonia,

cancer, viral infection, PE

Tree-in-Bud Sign

•Commonly seen at thin-section CT

•Initially described in endobronchial spread

of Tuberculosis

•Recognized in diverse entities

•Small centrilobular nodules soft-tissue

attenuation connected to multiple branching

structures

Tree-in-Bud Sign

•

Crazy Paving Sign

•Scattered or diffuse GG attenuation w

superimposed intralobular and interlobular

septa thickening

•Commonly seen at thin-section CT

•Initially described in PAP

•Recognized in diverse entities

Crazy Paving Sign

Comet Tail Sign

•Seen on CT of the chest

•Consists of curvilinear opacity extending

from subpleural mass toward hilum

•Produced by the distortion vessels and

bronchi that lead to adjacent rounded

atelectasis

Signet Ring Sign

•Seen on CT/HRCT scans of chest

•CT finding in patient with bronchiectasis

•Ring shadow representing dilated thick-

walled bronchus associated a nodular opacity

representing pulmonary artery

•Distinguish from cystic lung lesions

Pearl ring sign

More black sign The more black sign is a normal finding in lateral chest x-

ray, and refers to the gradual increased apparent

radiolucency (blackness) of the vertebral bodies, when

proceeding from upper to lower chest. This is due to the

increased proportion of the chest comprised of air

containing lungs over distal dorsal spine compared to the

upper parts.

When the air is displaced by higher attenuation material,

such as consolidation, fluidor a mass (e.g. bronchogenic

carcinoma, paraspinal neurogenic tumour) then the lower

dorsal vertebral bodies become more radiodense; this is

referred to as the loss of the more back sign and is also

known as the spine sign.

Steeple sign

The steeple sign (also called wine bottle

sign) refers to tapering of the

upper trachea on a frontal chest

radiograph reminiscent of a church

steeple. The appearance is suggestive

of croup, which should be obvious

clinically. A corresponding lateral x-ray

would show narrowing of the subglottic

trachea and ballooning of the

hypopharyn

Shmoo sign

Shmoo sign refers to appearance of

prominent, rounded left ventricle and dilated

aorta on a plain AP radiograph of chest giving

the appearance of Shmoo, a fictional cartoon

character in the comic strip Abner in the

1940s. This signs indicates left ventricular

hypertrophy.