813

Pictorial

American Journal of Roentgenology 1995.165:813-816.

CT Mosaic Pattern
Different Causes
Eric

J. Stern1,

Stephen

of Lung Attenuation:

J. Swensen2,

Thomas

E. Hartman2,

Areas of variable lung attenuation in a lobular or multilobular

distribution are occasionally
seen on CT or high-resolution
CT
scans of the lungs [1], although never as a normal finding. This
mosaic pattern of lung attenuation presents a challenge to the
radiologist when deciding which are the abnormal regions of
lung-those
of low attenuation, those of high attenuation, or both.
We have observed three categories
of disease known to cause a
CT mosaic pattern
of lung attenuation: small-airway disease, vascular lung disease, and infiltrative disease. Diseases from each of
these categories
can cause similar patterns
of mosaic lung attenuation on CT scans. However, it is sometimes possible to distinguish among these categories by using additional CT findings. We
illustrate
the known
causes of a CT mosaic pattern of lung attenuation and highlight distinguishing features.

Primary

Small-Airway

Disease

(Fixed

or Reactive)

CT performed
at suspended
full expiration
shows the physiologic consequence
of small-airway
(bronchiolar)
disease:
air
trapping
[1]. Lung regions
that retain air during exhalation
remain more lucent and show less decrease
in volume than
lung supplied
by normal airways
[2]. The distribution
of air
trapping is often patchy and dependent
on the level and sevenity of the airway obstruction.
When the level of airway obstruction is at or near the lobular level, a mosaic pattern of normal
lung and hyperlucent
lung can result (Figs. 1 and 2). Lung
regions that retain air show a decrease
in the caliber and numben of pulmonary
vessels
compared
with normal lung. The
inciting pathologic
processes
can be permanent,
as seen in
patients with obliterative
bronchiolitis
(Fig. 1), or reversible,
as
seen in patients with asthma (Fig. 2). In some instances,
air

Mark

Essay

Distinguishing

Frank1

S.

trapping
can be completely
unsuspected
on routine
suspended
full inspiration
CT scanning
and becomes
evident
only on CT scans obtained
at suspended
full expiration
(Figs.
1 and 2).

Vascular

Lung

Disease

A CT mosaic
pattern of lung attenuation
can result from
thnomboembolic
disease [3] (Figs. 3 and 4) or pulmonany arterial hypertension.
Regions
of hyperemic
(higher
attenuation)
lung mimic ground-glass
infiltrates
when seen
adjacent
to oligemic
(lower attenuation)
regions of lung. This
type of CT pattern
is often called
mosaic
perfusion
on
mosaic oligemia;
the oligemic
lung shows a decrease
in the
caliber
and number
of pulmonary
vessels
compared
with
normal on hypenemic
lung. In one series, the overall accuracy
of CT for detecting
a CT pattern of mosaic lung attenuation
due to chronic pulmonary
thromboembolism
was 72.7% [4].
pulmonary

Primary
Areas

Parenchymal

Disease

Causing

Ground-Glass

of Attenuation

In these lung diseases,

there is a patchy infiltrative
process within the intenstitium
of the lung on partial filling of the
air spaces by fluid, cells, or fibrosis so that the CT attenuation of the affected lung increases
compared
with that of normal parenchyma.
The caliber and number of vessels are not
appreciably
different
between
the normal
and abnormal
regions
of lung [5]. Diseases
that can produce
such a CT
pattern
of mosaic
lung attenuation
include
Pneumocystis

Received March 30, 1995; accepted after revision

Presented

in part at the meeting

of the Society

May 31 . 1995.
of Thoracic
Radiology,

Amelia

Island,

FL, March

1995.

Department of Radiology, Harborview Medical Center (ZA-65), University of Washington, 325 Ninth Ave., Seattle, WA 98104. Address correspondence
2Department of Radiology,
Mayo Clinic, Rochester,
MN 55905.
1

AJR 1995;165:813-816

0361-803X195/1654-813

American

Roentgen

Ray Society

to E. J. Stern.

STERN

814

ET

AL.

AJR:165,

October

1995

Fig. 1 .-65-year-old
woman
with bronchiolitis obliterans.
A, High-resolution
CT scan at suspended
full inspiration
was interpreted
prospectively
as normal.
B, High-resolution
CT scan at suspended
full expiration
shows multiple focal lobule-size
lucencies,
consistent
with extensive
lobular air
trapping,
a sign
of
severe
small-airway
obstruction.
Note size difference
of centrilobular core
structure
in air trapping
lobule
(straight
arrow)
and normal
lobule
(curved
arrow).
Characteristic
combination
of clinical,

expiratory

CT,

and

physiologic

American Journal of Roentgenology 1995.165:813-816.

(including
no clinical
or spirometric
to bronchodilator
therapy)
suggests
of idiopathic
bronchiolitis
obliterans.
(Case
courtesy
of Chris
Meyer,
Army Medical Center, WA; reproduced
mission from Stern and Frank (1])

features
response
diagnosis
Madlgan
with per-

Fig. 2.-40-year-old
woman with asthma.
A, High-resolution
CT scan obtained
at suspended
full inspiration
shows
B, Repeat
high-resolution
CT scan obtained
at suspended
full expiration

normal
shows

findings,
Including
normal
patchy diffuse air trapping

gradient
of attenuation.
with typical CT mosaic

pattern

of lung

attenuation.

Fig. 3-71-year-old
man with recurrent
and chronic
pulmonary
emboll and resulting
pulmonary
arterial hypertension.
A, Posterior-anterior
chest radiograph
shows apparent
bilateral
perihilar
pulmonary
infiltrates.
B, High-resolution
CT scan shows mosaic pattern of lung attenuation
with perihilar
ground-glass
attenuation
and oligemic
peripheral
lung. Note that
caliber of vessels
in regions of higher attenuation
(straight
arrow) is greater than in lower-attenuation
oligemic lung (curved
arrow).
Apparent
lung infiltrates
on chest radiograph
and high-resolution
CT scan are due to hyperperfused
normal lung. Peripheral
oligemic
hyperlucent
lung
showed no evidence
of air trapping
on expiratory
views. It is oligemic and hyperlucent
because of chronic pulmonary
thromboembolic
disease.

AJR:165,

October

Fig.

4.-65-year-old

arterial

CT MOSAIC

1995

hypertension

woman

PATTERN

OF LUNG

ATTENUATION

815

with pulmonary

due to chronic

pulmonary

thromboembolism.
A and B, Inspiratory
(A) and expiratory
(B)
high-resolution
CT scans show mosaic pattern
of lung attenuation,
so-called
mosaic
perfusion. lnspiratory
image shows caliber
of yessels
is
greater
within
relatively
higherattenuation
lung (straight
arrow)
than lowerattenuation
lung (curved
arrow).
Expiratory
image shows no evidence
of air trapping;
both
hyperperfused
and ollgemic
lung increase
in
attenuation.
CT pattern of mosaic lung attenuation, with larger vessels
in regions of lung haying
relatively
higher
attenuation
and
the

absence of air trapping on expiratory images,

is strong Indication that CT mosaic pattern is

American Journal of Roentgenology 1995.165:813-816.

caused

by pulmonary

vascular

lung

disease.

carinii pneumonia
(Fig. 5), chronic
eosinophilic
pneumonia,
hypersensitivity
pneumonia,
bnonchiolitis
oblitenans
organizing pneumonia,
and pyogenic
pneumonia.

Discussion
The term mosaic pattern of lung attenuation
is nonspecific
and refers to a pattern that occurs in a variety of lung diseases. The terms mosaic perfusion and mosaic oligemia
should be reserved for known cases of primary vascular
lung
disease. Table 1 reviews both the nadiologic and clinical distinguishing
features
of the three different categories
of disease
that can cause a CT mosaic pattern of lung attenuation.
In small-airway
disease and primary vascular
lung disease,
the pulmonary
vessels within the lucent regions of the lung
are small compared
with the vessels in the more opaque
regions of the lung. This discrepancy
in vessel size is likely
due, at least in part, to local hypoxic reflex vasoconstniction
in
small-airway
disease
[2], whereas
the difference
in vessel
size in primary vascular lung disease is due to the underlying
hypoperfusion.
In infiltrative
diseases,
the vessels are more
uniform in size throughout
the different regions of lung attenuation. Thus, analysis
of the size of the pulmonary
vessels
should be an early step in distinguishing
among the causes of
a CT mosaic pattern of lung attenuation.
Using paired inspiratory
and expiratory
CT scans is useful for
distinguishing
small-airway
disease
from a pnmary vascular
lung disease.
In small-airway
disease,
the lucent regions of
lung seen at inspiration
will remain lucent at expiration
because
of air trapping, showing no on minimal increase in lung attenuation and no on minimal
decrease
in volume.
The relatively
opaque normal lung willincrease in attenuation and decrease
in volume, as expected
[6]. In primary vascular
lung disease,
because there is no air trapping or airway disease, the attenuation of both the hyperemic
and oligemic lung at inspiration
will
increase in a similar fashion, and the volume of both will
decrease
uniformly
at expiration.
One can qualitatively
com-

Fig. 5-46-year-old
man with AIDS and Pneumocystis
carlnll pneumonia. High-resolution
CT scan shows pattern of mosaic lung attenuation due to ground-glass
infiltrate
that spares
single
lobular
and
multilobular
regions.
No appreciable
difference
exists
in number
and
size of vessels
in either
region
of lung. No air trapping
would
be
expected
on expiratory
CT.

pare the different

regions
of lung attenuation
for changes
between
inspiration
and expiration,
but occasionally
it will be
helpful to quantitatively
compare the Hounsfield
measurements
of lower-attenuation
and higher-attenuation
areas of lung in
scans obtained at inspiration
and at expiration
(Fig. 6).
A CT mosaic pattern of lung attenuation
may have many
causes.
Just as lung parenchymal
ground-glass
attenuation
is nonspecific,
a CT mosaic
pattern
of lung attenuation
is

STERN

816

TABLE

1 : Distinguishing

Features

of the Three Categories

ET

of Disease

AL.

Causing

AJR:165,

October

1995

a CT Mosaic Pattern of Lung Attenuation

Radiolo gic Features

Disease

Clinical Features
Vessels

Small-airway

disease

Decreased

size

and

CT Scansa
number

in

lucent lung compared with

higher-attenuation
lung

Air trapping

expiratory

Vascular

Infiltrative

lung disease

diseases

Same as small-airway

disease

Similar size and number of

vessels in both regions of lung

present

as evidenced

Dyspnea

by no increase in attenuation or
decrease in volume of lucent lung on
CT scans

Cough
Variable response to bronchodilators
Wheezing

No air trapping
CTscans

seen on expiratory

No air trapping
CT scans

seen on expiratory

No fever
Exertional dyspnea
No cough
No response to bronchodilators
No wheezing
No fever
Dyspnea
Cough
No response
No wheezing

to bronchodilators

Fever
Constitutional
CT scans.

American Journal of Roentgenology 1995.165:813-816.

a Paired inspiration/expiration

symptoms

6-34-year-old
woman with chronic thromboembolic
disease.
A and B, lnsplratory
(A ) and expiratory
(B) high-resolution
CT scans show CT mosaic
pattern of lung attenuation.
Lung attenuation
measured
in
hypoperfused
right upper lobe (region
of interest
(ROl] 1) increased
85 H (from -818 H to -733 H) between
inspiration
and expiration
CT scanning.
Lung attenuation
measured
in hyperperfused
left upper lobe (ROI 2) increased
a similar amount,
79 H (from -721 H to -642 H), between
inspiration
and expiration
CT scanning.
If air trapping
were causing
mosaic
lung attenuation,
differences
between
two regions
would
be much more pronounced
(6]. Note that placements
of ROI are anatomically
within same mosaic regions of lung; slight differences
in positions
of ROI between inspiration and expiration
avoid placing
large vessels
within ROl. Lung attenuation
in oligemic
regions
in left upper lobe (ROl 3) showed
an increase
of
60 H (from -794 H to -734 H), similar to that seen in oligemic
regions
of right lung.
Fig.

also nonspecific.
However,
by using additional
CT and clinical findings
and by obtaining
supplementary
expiratory
CT
scans, it is often possible
to determine
the underlying
disease category
responsible
for the pattern
and, in some
instances,
to suggest
a specific diagnosis.

2. Stern EJ, Webb WR. Dynamic

imaging of lung morphology with ultrafast

J Thorac Imaging 1993:8:273-282
3. Martin KW, Sagel 55, Siegel BA. Mosaic oligemia simulating pulmonary
high-resolution
infiltrates

computed

tomography.

on CT. AJR 1986:147:670-673

4. King MA, Bergin CJ, Yeung DW, et al. Chronic pulmonary thromboembolism:
detection

of regional

hypoperfusion

with CT. Radiologyl994:191

5. Primack SL, MUller NL, Mayo JR, Remy-Jardin

parenchymal
abnormalities
of vascular
RadioGraphics 1994:14:739-746

REFERENCES
1 . Stern EJ, Frank MS. Small-airway
ratory

CT. AJR

1994:163:37-41

diseases

of the lungs: findings at expi-

origin:

:359-363

M, Remy J. Pulmonary

high-resolution

CT findings.

6. Webb WR, Stern EJ, Kanth N, Gamsu G. Dynamic pulmonary

ings in healthy

adult

men.

Radiology

1993:186:117-124

CT: find-

American Journal of Roentgenology 1995.165:813-816.

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