69 year-old male presents with right posterolateral …...ischemic pleuritis pulmonary embolus...
TRANSCRIPT
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69 year-old male presents with
right posterolateral pleuritic chest
pain.
Sophia Walker, MS4
Ryan Joyce, MD
Douglas Gibson, MD
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?
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Pulmonary embolus
(Westermark and Palla
Signs)
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prominent
central right
pulmonary artery
relative oligemia
[decreased caliber of
pulmonary arterial
markings on the right
(green circle) compared
to the left (yellow circle)].
Palla Sign
Westermark Sign
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embolus at branch
point of distal of right
main pulmonary artery
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embolus in
interlobar
branch
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embolus in
segmental branch to
RML
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embolus in sub-
segmental branch of
right pulmonary artery
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embolus in sub-
segmental branch of
right pulmonary artery
pleural thickening,
likely representing
reactive or
ischemic pleuritis
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Pulmonary Embolus (Westermark
and Palla signs)• Westermark Sign – areas of relative oligemia secondary to decreased
caliber of regional pulmonary arteries.
– The relative oligemia occurs as a result of proximal occlusion of the
involved pulmonary arteries.
• As seen in this case, the more central pulmonary artery may be dilated
(Palla sign).
• Westermark sign has the highest positive predictive value (~38%) and
specificity (~92%) for pulmonary embolism relative to other plain
radiographic findings.
• Note that generally, plain radiographs are used to exclude alternative
diagnoses on the differential, i.e. pneumonia, CHF, or pneumothorax.
• Most plain chest radiographs in the setting of PE are NORMAL.
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Pulmonary Embolus (other signs)
• Fleischner sign – enlarged main pulmonary artery.
• Hampton hump – peripheral wedge-shaped region of
opacity suggesting lung infarction distal to embolus.
• Palla sign – enlarged right pulmonary artery.
– When seen with Westermark sign suggests emboli in
segmental or smaller sub-segmental pulmonary
arteries
• Chang & Knuckle signs – dilated and abruptly cut off
right pulmonary artery
• Note that the absence of any of these signs does not
exclude a pulmonary embolism
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References• D'Souza, D. “Pulmonary embolism. Radiology Reference
Article.” Radiopaedia.org. https://radiopaedia.org/articles/pulmonary-embolism.
• Herring William. Learning Radiology: Recognizing the Basics. Philadelphia, PA: Elsevier, 2015.
• Brenes-Salazar, J. A. (2014). Westermark’s and Palla’s signs in acute and chronic pulmonary embolism: Still valid in the current computed tomography era. Journal of Emergencies, Trauma, and Shock, 7(1), 57–8. https://doi.org/10.4103/0974-2700.125645
• Omar, M., Elaini, T., & Natt, B. (2015). Medical image of the week: Westermark sign. Southwest Journal of Pulmonary and Critical Care, 10(3), 125–126. https://doi.org/10.13175/swjpcc015-15.
• Worsley, D. F., Alavi, A., Aronchick, J. M., Chen, J. T., Greenspan, R. H., & Ravin, C. E. (1993). Chest radiographic findings in patients with acute pulmonary embolism: observations from the PIOPED Study. Radiology, 189(1), 133–6. https://doi.org/10.1148/radiology.189.1.8372182.