Pleural effusion_03 (Imaging)

Pleural effusion (Imaging)
Detection of pleural effusion(s) and creation of initial differential diagnosis are highly
dependent upon imaging of pleural space. Conventional CXR and CT are primary imaging
modalities that are used for evaluation of all types of pleural disease, but ultrasound and MRI
have role in selected clinical circumstances.
2. The imaging of pleural effusions will be presented here. Imaging of pleural plaques,
thickening, tumors, and pneumothorax are discussed separately.
1. The term pleura is generally meant to encompass parietal pleura (lining inner surface of
chest wall, including diaphragmatic pleura and cervical pleura also called dome of pleura or
pleural cupola that covers lung apex and extends into cervical region), visceral pleura (lining
outer surface of lung), and intervening pleural space. Both visceral and parietal pleural
surfaces consist of mesothelial layer and 3 to 7 connective tissue layers, but visceral pleura is
thicker than parietal pleura. Together, visceral and parietal pleural layers and lubricating
liquid in interposed pleural space have combined thickness of 0.2 to 0.4 mm, while width of
pleural space is 10 to 20 μm.
Normal pleural anatomy can be displayed by CT. A 1 to 2 mm thick line of soft-tissue
attenuation can be seen at point of contact between lung and chest wall, corresponding to
visceral and parietal pleura and minimal amount of lubricating pleural liquid.
Extrapleural fat and endothoracic fascia, each with thickness of 0.25 mm, are visible
between pleural line and ribs (or subcostal and innermost intercostal muscles). The apical
part of endothoracic fascia is thickened and is called Sibson's fascia. Outside this fascia is
space filled with areolar tissue, called Semb's space. The anterior and posterior junction lines
are well outlined by lung and contain 4 layers of pleura: 2 visceral and 2 parietal components
(image 2A-B). The interlobar fissures and most accessory fissures in lungs are formed by 2
layers of visceral pleura, with exception of azygos vein fissure, which contains four layers of
pleura, ie, two visceral and two parietal layers of pleura.
Abnormalities of pleural space can easily be detected by conventional radiographic methods
using frontal, lateral, oblique, and decubitus radiographs. Pleural effusions accumulate in the
most dependent part of thoracic cavity because lung, which is physically less dense than
liquid, floats on effusion. The otherwise normal lung will follow its intrinsic elastic recoil and
decrease in volume while maintaining its shape during collapse.
Because of gravity, initial accumulation of pleural liquid occurs in subpulmonic location, ie,
between inferior surface of lower lobes and diaphragmatic leaflets. Up to 75 mL of pleural
effusion can occupy subpulmonic space without spillover. As it accumulates, pleural liquid
spills over into costophrenic sulcus posteriorly, anteriorly, and laterally. It surrounds lung and
forms cloak, or cylinder, which looks like meniscoid arc in radiographic projections.
The amount of pleural effusion can be estimated based on standard frontal and lateral
radiographs. At least 75 mL are needed to obliterate posterior costophrenic sulcus, and a
minimum of 175 mL is necessary to obscure lateral costophrenic sulcus on upright CXR. A
pleural effusion of 500 mL will obscure diaphragmatic contour on upright CXR; if pleural
effusion reaches level of 4th anterior rib, close to 1000 mL are present. On decubitus
radiographs and CT, less than 10 mL, and possibly as little as 2 mL, can be identified (image 3).
For quantitation on decubitus views, rind of layering pleural effusion is measured: small
effusions are thinner than 1.5 cm, moderate effusions are 1.5 to 4.5 cm thick, and large
effusions exceed 4.5 cm. Effusions thicker than 1 cm are usually large enough for sampling by
thoracentesis, since at least 200 mL of liquid are already present.
On supine radiographs, as little as 175 mL of effusion can be visible, sometimes forming apical
caps which disappear on upright imaging. Mobile effusions also layer along posterior aspect
of thorax in supine position and produce filter effect or pleural veil that overlies aerated lung;
a gradient of decreasing opacity towards apex can be identified. The following features
suggest that this appearance in supine patient is due to effusion, as opposed to parenchymal
lung disease (such as pneumonia or pulmonary edema).
A. Pulmonary vessels are clearly visible through added opacity created by effusion
B. Air bronchograms are absent
Subpulmonic effusion
A. Subpulmonic pleural effusions elevate lung base, mimicking elevated diaphragmatic
leaflet. The apex of curvature at lung base is shifted laterally, and its slope slants sharply
towards lateral costophrenic sulcus. This configuration has been dubbed “Rock of
Gibraltar sign” and is particularly well seen on lateral CXR in patients with subpulmonic
effusion. Large pleural effusions, especially on left side, can produce diaphragmatic
inversion, making normally convex diaphragm appear concave. This configuration can
lead to paradoxical breathing on affected side with inspiratory elevation of
diaphragmatic leaflet and expiratory descent of hemidiaphragm.
On left side, marked separation (> 2 cm) of lung from stomach bubble suggests
subpulmonic effusion. This separation of stomach gas bubble from lung base, especially
when bubble appears displaced inferomedially, is of particular significance on frontal
and lateral views.
Atypical localization of pleural effusion generally results from abnormality in underlying
lung. When lung cannot expand to fill thoracic cavity, relative pleural pressure becomes
more negative relative to atmospheric pressure. The increased negative pleural pressure
enhances pleural liquid formation, leading to accumulation of pleural liquid. Pleural
effusions accumulate in these areas subtended by lung with the greatest elastic recoil.
Loculated pleural effusion
A. Pleural effusions can also loculate as result of adhesions. Loculation is most common
when underlying effusion is due to hemothorax, pyothorax, chylothorax, or TB pleuritis.
A typical configuration of loculation along chest wall, often described as pleural or
extrapleural sign, has the following features.
The angles of interface between pleural “mass” and chest wall are obtuse, and
mass displays tapered borders
The surface of “mass” is usually smooth when seen in tangent, poorly marginated
when seen “en face,” and only partially visualized when displayed in oblique
projection (“incomplete margin sign”) also called “one-edged lesions”
The content is homogeneous
The “mass” droops on upright images owing to its liquid content and effect of
1. CT detects small pleural effusions, ie, < 10 mL and possibly as little as 2 mL of liquid in pleural
space. Thickening of the visceral and parietal pleura as well as enhancement of visceral and
parietal pleura after injection of contrast material (“split pleura sign”) suggest presence of
inflammation and thus exudative, rather than transudative, effusion. The administration of
contrast material in patients with pleural abnormalities is important, since it facilitates
differential diagnosis of pleural effusions.
2. Other uses of CT in evaluation of pleural disease.
Facilitating measurement of pleural thickness
Distinguishing empyema from lung abscess
Visualization of small pneumothoraces in supine patients
Visualization of underlying lung parenchymal processes that are obscured on CXR by
large pleural effusion
Determination of exact location of pleural masses and characterization
Occasionally identifying peripheral bronchopleural fistulae
Occasionally identifying a diaphragmatic defect in cirrhotic patient with hepatic
Identification of lung parenchymal or upper abdominal abnormalities that may provide
clue to etiology of pleural effusion (lung mass, apical cavities, aortic dissection,
infradiaphragmatic abscess, liver cirrhosis with ascites leading to hepatic hydrothorax)
I. Guidance for thoracentesis and tube thoracostomy of loculated empyema
1. Ultrasonography permits easy identification of free or loculated pleural effusions, and it
facilitates differentiation of loculated effusions from solid masses. The intrinsic characteristics
of pleural effusion and its accompanying adhesions can be identified.
2. Thoracentesis of loculated pleural effusions is facilitated by ultrasound guidance. However,
CT is method of choice for more complicated interventional procedures, such as empyema
drainage or biopsy of pleural masses.
1. MRI can display pleural effusions, pleural tumors, and chest wall invasion. In selected cases, it
can characterize content of pleural effusion. The role of MRI in imaging of hemothorax is
discussed below; other aspects of thoracic MRI are presented separately.
1. The most common cause of transudative pleural effusion is HF. Pulmonary edema liquid
permeates lung interstitium and visceral pleura, eventually accumulating in pleural space, in
order to be resorbed by lymphatics of parietal pleural. Pleural effusions related to left
ventricular failure are bilateral in nearly 90% of cases. Other causes of transudative pleural
effusion include constrictive pericarditis, hepatic cirrhosis, and renal failure. In general,
transudative pleural effusions are product of imbalanced hydrostatic forces.
Occasionally these pleural effusions loculate and mimic masses, particularly in interlobar
fissures; these have also been called pseudotumor or vanishing tumor. CT can sometimes
determine true nature of such mass by showing its liquid content and its relationship to
fissures, thereby excluding intrapulmonary origin.
In rare instances, patients have bilateral pleural effusions with markedly different
characteristics. This situation is called "Contarini's condition," named after 95th Doge of
Venice, who died of cardiac decompensation with unilateral transudative pleural effusion and
contralateral empyema caused by necrotizing pneumonia. CT in such situations can identify
small collections of gas, loculations, or pleural thickening and pleural enhancement in an
empyema, characteristics not found in a transudative pleural effusion.
Hepatic hydrothorax
Hepatic hydrothorax is defined as pleural effusion, usually > 500 mL, in patients with
cirrhosis, but without primary cardiac, pulmonary, or pleural disease. The majority occur
in right hemithorax (85%). The evaluation of suspected hepatic hydrothorax is discussed
1. The most common conditions leading to exudative pleural effusion are pneumonia (resulting
in sterile parapneumonic effusion or empyema) and malignant tumors. Large unilateral
exudative pleural effusions in young patients are suspicious for TB, whereas in older
individuals they frequently indicate malignant process.
2. Empyema
The vast majority of empyemas is due to pulmonary infections and occurs in
post-pneumonic period; surgical procedures and trauma are other common causes.
Empyemas are most often due to anaerobic bacteria or mixed aerobic-anaerobic flora.
Aerobic bacteria, tuberculous mycobacteria, and fungi are less frequent causative agent.
The radiologic diagnosis of empyema can be facilitated by CT. Three stages are
recognized in evolution of empyema.
Stage 1 consists of exudative pleural effusion that contains > 15,000 WBC/μL
Stage 2 is fibrinopurulent stage in which adhesions have already formed
Stage 3 is organizing stage, with development of thick pleural peel
The effusion can be easily drained in stage 1; in contrast, decortication may be required
in stages 2 and 3. Ultrasound is able to image early adhesions during fibrinopurulent
stage of empyema. Linear, irregular, honeycomb-like adhesions predict difficulties in
In early, exudative stage of empyema, pleural effusion appears on radiography to be
freely layering. When effusion becomes loculated, it forms tapered borders with obtuse
angles at its interface with chest wall, often showing gravity dependent changes in shape,
such as "drooping" (image 13A-D) and on occasion the “incomplete margin” sign.
In fibrinopurulent and organizing stages, contrast CT shows strong enhancement of
visceral and parietal pleurae, producing "split pleura sign". The pleura is also frequently
thickened, exceeding 3 to 5 mm.
Empyemas tend to compress adjacent lung rather than destroy it, thereby allowing
differentiation from large lung abscesses. In addition, empyemas typically have thinner,
smoother walls than lung abscesses, which tend to have thicker walls and irregular
luminal and exterior surfaces. Empyemas tend to form obtuse angle of interface with
chest wall, compared with lung abscesses, which commonly have acute angle. However,
wall thickness, uniformity, and crowding of adjacent vascular structures rather than
their destruction or incorporation are more accurate for differentiation of these
processes than chest wall angle of interface.
The finding of gas-liquid level in empyema indicates presence of bronchopleural fistula
(BPF). In this setting, gas-liquid levels in frontal and lateral projections on upright CXR
characteristically have unequal, disparate linear dimensions and typically extend to chest
wall. CT is also capable of identifying BPF. Central BPF occurs most often after surgical
procedures or trauma and can be confirmed by bronchoscopy. In contrast, peripheral
BPFs are often complication of necrotizing pneumonia.
Tuberculous empyemas tend to persist for decades and exhibit extensive calcification of
pleura. They were seen more frequently in the past after pneumothorax for TB.
Malignant pleural effusion
A. The second most common cause of exudative pleural effusion is malignant tumor.
Carcinoma of lung, breast, or ovary, and lymphoma account for about 80% of all
malignant effusions.
Increased pleural membrane and capillary permeability
Decreased clearance due to lymphatic obstruction
Bronchial obstruction leading to atelectasis and marked regional decrease in
intrapleural pressure, which favors pleural liquid accumulation
B. Findings on CT imaging that suggest malignant pleural effusion include irregular, nodular,
or thickened pleura submerged in effusion. Enhancement of visceral pleura after
administration of contrast suggests pleural inflammation or malignancy.
The size of malignant effusions varies, but metastatic malignancies are the most
common cause of massive pleural effusion obliterating entire hemithorax. Malignant
effusions can become loculated.
D. The diagnosis and management of malignant pleural effusions are discussed separately.
A. A hemothorax is defined as bloody pleural effusion with hematocrit exceeding half value
in peripheral blood. It can be seen after trauma, pulmonary embolism, as result of
metastatic disease, after anticoagulant therapy, or as sequela of leaking aortic
B. CT of hemothorax shows effusion with relatively high attenuation, exceeding 35 HU
when blood is fresh, and reaching 70 HU with clotted blood. A hematocrit effect with
liquid-liquid level can become visible in subacute hematomas, due to the higher
attenuation of sedimented RBC compared to that of supernatant, which contains serum
of lower attenuation.
MRI is able to image blood and to determine age of hemorrhage.
Oxyhemoglobin exists in fresh blood, which has low signal on T1W and high signal
on T2W.
Deoxyhemoglobin exists in subacute bleeding (several hours to days old), which has
low signal on T1W and T2W.
Methemoglobin can be seen when blood is several days to several weeks old. If it is
intracellular, it displays high signal on T1W but low signal on T2W. When it is
extracellular, methemoglobin exhibits high signal on both T1W and T2W.
Hemosiderin shows low signal on both T1W and T2W and usually indicates blood
that is several weeks to several months old.
A. Chylothorax is most likely result of mediastinal tumor involvement by lymphoma or
bronchogenic carcinoma. These two neoplasms account for 54% of all chylothoraces,
while trauma, including surgery, accounts for another 25%. Rare causes of chylothorax
include filariasis, lymphangioleiomyomatosis, congenital anomalies of thoracic duct, and
so-called idiopathic chylothorax.
Disruption of thoracic duct leads to formation of chylous duct cyst, which can appear as
posterior mediastinal mass. It can perforate, usually after interval of 10 days, leading to
delayed development of pleural effusion. Radiologically, large pleural effusion is
characteristic, and loculation can occasionally be seen.
C. On CT, pleural accumulation of chyle can display lower attenuation values than other
effusions. MRI can show high signal on T1W, due to high fat content. Traumatic
right-sided chylothoraces indicate injury to lower third of thoracic duct, whereas
left-sided chylothoraces indicate lesion in upper two-thirds of thoracic duct.
1. Conventional CXR and CT are key to the detection and characterization of pleural effusions;
pleural ultrasound and MRI play role in selected clinical circumstance.
On conventional chest radiographs, frontal, lateral, and decubitus views are used to detect
the presence of a pleural effusion and to differentiate pleural liquid from pleural thickening.
Pleural effusions and thickening can both cause blunting of the costophrenic sulcus, but only
freely mobile effusions will result in layering of liquid on the decubitus view.
The amount of pleural effusion can be estimated based on decubitus chest radiographs; small
effusions are thinner than 1.5 cm, moderate effusions are 1.5 to 4.5 cm thick, and large
effusions exceed 4.5 cm. Effusions forming a rind thicker than 1 cm are usually large enough
for sampling by thoracentesis, since at least 200 mL of liquid are already present.
Subpulmonic pleural effusions elevate the lung base, mimicking an elevated diaphragmatic
leaflet. The apex of the curvature at the lung base is shifted laterally, and its slope slants
sharply towards the lateral costophrenic sulcus. On the left side, a marked separation (> 2 cm)
of the lung from the stomach bubble suggests a subpulmonic pleural effusion.
Loculated pleural effusions are differentiated from lung masses by certain characteristics: the
angles of interface between a pleural loculation and the chest wall are obtuse with tapered
borders; the surface of a loculated pleural effusion is usually smooth or displays the
“incomplete border sign”, when not imaged in tangent; the content is homogeneous; and
pleural loculations appear to droop on upright images owing to the liquid content and the
effect of gravity.
On CT, the visceral and parietal pleura and the minimal amount of lubricating pleural liquid
between them appear as a line of soft-tissue attenuation 1 to 2 mm thick at the point of
contact between the lung and the chest wall. Extrapleural fat and the endothoracic fascia,
each with thickness of 0.25 mm, are visible between the pleural line and the ribs.
CT scans can detect very small pleural effusions, ie, less than 10 mL and possibly as little as 2
mL of liquid in the pleural space. CT is helpful in evaluating complex pleural disease, such as
empyemas, pleural liquid loculations, pleural masses associated with pleural effusions, and
lung parenchymal processes obscured by pleural effusions. Intravenous administration of
iodinated contrast material is important for optimal evaluation of pleural disease by CT
scanning. In addition, CT guidance improves the accuracy of tube thoracostomy for drainage
of loculated pleural effusion.
The presence of an exudative, rather than transudative, pleural effusion is suggested by
thickening of the pleurae on CT scanning (> 3 to 5 mm) and by contrast enhancement of the
visceral and parietal pleurae.
9. Thoracic ultrasonography is useful to identify free or loculated pleural effusions and to
differentiate loculated effusions from solid masses. Thoracic ultrasound guidance for
thoracentesis improves the accuracy and safety of the procedure.
10. Pleural effusions and tumors can also be delineated by MRI. The main roles for MRI in the
evaluation of pleural effusion are to characterize a hemothorax and determine whether a
pleural tumor extends into the surrounding soft tissues of the chest wall, mediastinum,
supraclavicular region, or abdomen.