Imaging of Pleural Effusions in Adults

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Imaging of pleural effusions in adults

Author: Paul Stark, MD
Section Editors: Talmadge E King, Jr, MD, Nestor L Muller, MD, PhD, Fabien Maldonado, MD
Deputy Editor: Geraldine Finlay, MD
All topics are updated as new evidence becomes available and our peer review process is complete.
Literature review current through: Jun 2021. | This topic last updated: Apr 24, 2021.
INTRODUCTION
Detection of pleural effusion(s) and the creation of an initial differential diagnosis are highly
dependent upon imaging of the pleural space. Conventional chest radiography and computed
tomography (CT) scanning are the primary imaging modalities that are used for evaluation of all
types of pleural disease, but ultrasound and magnetic resonance imaging (MRI) have a role in
selected clinical circumstances.
The imaging of pleural effusions will be presented here. Imaging of pleural plaques, thickening,
tumors, and pneumothorax are discussed separately. (See "Imaging of pleural plaques, thickening,
and tumors".)
NORMAL PLEURAL ANATOMY
The term pleura is generally meant to encompass the parietal pleura (lining the inner surface of the
chest wall, including the diaphragmatic pleura and the cervical pleura also called dome of pleura or
pleural cupola that covers the lung apex and extends into the cervical region), the visceral pleura
(lining the outer surface of the lung), and the intervening pleural space. The parietal and visceral
pleura merge at the pulmonary hilum and thus separate the thoracic cavity into two separate
hemithoraces [1]. Both visceral and parietal pleural surfaces consist of a mesothelial layer and three
to seven connective tissue layers, but the visceral pleura is thicker than the parietal pleura.
Together, the visceral and parietal pleural layers and the lubricating liquid in the interposed pleural
space (10 to 15 mL per hemithorax) have a combined thickness of 0.2 to 0.4 mm, while the width of
the pleural space is 10 to 20 micrometers. The pleura is drained by a visceral and parietal lymphatic
network. The parietal lymphatic pleural network is the main pathway of pleural liquid resorption
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and communicates with the parietal pleura through gaps in the pleural mesothelium forming
stomata, named Kampmeyer foci [2]. (See "Mechanisms of pleural liquid turnover in the normal
state".)
Normal pleural anatomy can be displayed by computed tomography (CT) scanning [3]. A 1 to 2 mm
thick line of soft-tissue attenuation can be seen at the point of contact between the lung and the
chest wall, corresponding to the visceral and parietal pleura and the minimal amount of lubricating
pleural liquid ( image 1).
Extrapleural fat and the endothoracic fascia, each with a thickness of 0.25 mm, are visible between
the pleural line and the ribs (or the transverse thoracic muscle anteriorly, subcostal muscle
posteriorly, and innermost intercostal muscles laterally), and together form the so-called intercostal
stripe and paravertebral line [4].
The apical part of the endothoracic fascia is thickened and is called Sibson's fascia. Outside this
fascia is a space filled with areolar tissue, called Semb's space. The anterior and posterior junction
lines are well outlined by lung and contain four layers of pleura: two visceral and two parietal
components ( image 2A-B). The interlobar fissures and most accessory fissures in the lungs are
formed by two layers of visceral pleura, with the exception of the azygos vein fissure, which contains
four layers of pleura, ie, two visceral and two parietal layers of pleura.
CONVENTIONAL RADIOGRAPHY
Abnormalities of the 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 the thoracic cavity because the lung, which is physically less dense than liquid,
floats on the effusion. The otherwise normal lung will follow its intrinsic elastic recoil and decrease
in volume while maintaining its shape during collapse.
Because of gravity, pleural liquid initially accumulates in a subpulmonic location, ie, between the
inferior surface of the lower lobes and the diaphragm [5]. Up to 75 mL of pleural effusion can
occupy the subpulmonic space without spillover. As it accumulates, pleural liquid spills over into the
costophrenic sulcus posteriorly, anteriorly, and laterally. It surrounds the lung and forms a cloak, or
cylinder, which looks like a 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 the posterior costophrenic sulcus, and a minimum of 175 mL
is necessary to obscure the lateral costophrenic sulcus on an upright chest radiograph [6]. A pleural
effusion of 500 mL will obscure the diaphragmatic contour on an upright chest radiograph; if the
pleural effusion reaches the level of the fourth anterior rib, close to 1000 mL are present. On
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decubitus radiographs and computed tomography (CT) scans, less than 10 mL, and possibly as little
as 2 mL, can be identified ( image 3) [7].
For quantitation on decubitus views, the 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 [7]. (See "Ultrasound-guided thoracentesis".)
On supine radiographs, as little as 175 mL of effusion can be visible [8], sometimes forming apical
caps which disappear on upright imaging. Mobile effusions also layer along the posterior aspect of
the thorax in the supine position and produce a filter effect or pleural veil that overlies the aerated
lung [9]; a gradient of decreasing opacity towards the apex can be identified. The following features
suggest that this appearance in the supine patient is due to an effusion, as opposed to parenchymal
lung disease (such as pneumonia or pulmonary edema):
● Pulmonary vessels are clearly visible through the added opacity created by the effusion
● Air bronchograms are absent
Subpulmonic effusions — Subpulmonic pleural effusions elevate the lung base, mimicking an

elevated hemidiaphragm ( image 4A-B). The apex of the curvature at the lung base is shifted
laterally, and its slope slants sharply towards the lateral costophrenic sulcus [10]. This configuration
has been dubbed "Rock of Gibraltar sign" and is particularly well seen on the lateral chest
radiograph in patients with a subpulmonic pleural effusion ( image 5) [11]. Large pleural
effusions, especially on the left side, can produce diaphragmatic inversion, making the normally
convex diaphragm appear concave. On the right side, the depressed, inverted diaphragm displaces
the liver caudad. This configuration can lead to paradoxical breathing on the affected side with the
hemidiaphragm rising on inspiration and descending on expiration.
On the left side, a marked separation (>2 cm) of the lung from the stomach bubble suggests a
subpulmonic effusion. This separation of the stomach gas bubble from the lung base, especially
when the bubble appears displaced inferomedially, is of particular importance on the frontal and
lateral views [12].
Atypical localization of a pleural effusion generally results from an abnormality in the underlying
lung. When the lung cannot expand to fill the thoracic cavity, the relative pleural pressure becomes
more negative relative to the atmospheric pressure. The increased negative pleural pressure
enhances pleural liquid formation, leading to the accumulation of pleural effusions which
accumulate in these areas subtended by lung with the greatest elastic recoil [10,13]. (See "Diagnosis
and management of pleural causes of nonexpandable lung".)
Loculated pleural effusions — Pleural effusions can also loculate as a result of adhesions.

Loculation (or encapsulation) is most common when the underlying effusion is due to hemothorax,
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pyothorax, chylothorax, or tuberculous pleuritis. A typical configuration of a loculation along the

chest wall, often described as a pleural or extrapleural sign, has the following features ( image 6
and image 7) [6]:
● The angles of interface between the pleural "mass" and the chest wall are obtuse, and the mass
displays tapered borders
● The surface of the "mass" is usually smooth when seen in tangent, poorly marginated when
seen "en face," and only partially visualized when displayed in an oblique projection
("incomplete margin sign") also called "one-edged lesions" [14-16]
● The content is homogeneous
● The "mass" droops on upright images owing to its liquid content and the effect of gravity
COMPUTED TOMOGRAPHY
Computed tomography (CT) detects small pleural effusions, ie, less than 10 mL and possibly as little
as 2 mL of liquid in the pleural space. Thickening of the visceral and parietal pleura as well as
enhancement of the visceral and parietal pleura after injection of intravenous contrast material (the
"split pleura sign") suggest the presence of inflammation and thus an exudative, rather than
transudative, effusion [17]. The administration of intravenous contrast material in patients with
pleural abnormalities is important, because it facilitates the differential diagnosis of pleural
effusions.
Other uses of CT scanning in the evaluation of pleural disease include [18-23]:
● Facilitating measurement of pleural thickness
● Distinguishing an empyema from a lung abscess
● Visualizing small pneumothoraces in supine patients
● Visualizing underlying lung parenchymal processes that are obscured on the chest radiograph
by a large pleural effusion
● Determining the exact location of pleural masses and characterization of their composition (see
"Imaging of pleural plaques, thickening, and tumors")
● Occasionally identifying peripheral bronchopleural fistulae
● Occasionally identifying a diaphragmatic defect in a cirrhotic patient with hepatic hydrothorax
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● Identifying lung parenchymal or upper abdominal abnormalities that may provide a clue to the
etiology of the pleural effusion (eg, lung mass, apical cavities, aortic dissection,
infradiaphragmatic abscess, liver cirrhosis with ascites leading to hepatic hydrothorax)
● Guiding thoracentesis and tube thoracostomy of loculated empyemas (see "Epidemiology,

clinical presentation, and diagnostic evaluation of parapneumonic effusion and empyema in
adults", section on 'Diagnostic imaging' and "Epidemiology, clinical presentation, and diagnostic
evaluation of parapneumonic effusion and empyema in adults")
ULTRASONOGRAPHY
Ultrasonography permits easy identification of free or loculated pleural effusions, and it facilitates
differentiation of loculated effusions from solid masses [24]. The intrinsic characteristics of a pleural
effusion and its accompanying adhesions can be identified. (See "Bedside pleural ultrasonography:
Equipment, technique, and the identification of pleural effusion and pneumothorax".)
Thoracentesis of loculated pleural effusions is facilitated by ultrasound guidance. However,

computed tomography (CT) is the method of choice for more complicated interventional
procedures, such as empyema drainage or biopsy of pleural masses. (See "Ultrasound-guided
thoracentesis" and "Medical thoracoscopy (pleuroscopy): Equipment, procedure, and
complications".)
MAGNETIC RESONANCE IMAGING
Magnetic resonance imaging (MRI) can display pleural effusions, pleural tumors, and chest wall
invasion [25]. In selected cases, it can characterize the content of pleural effusions [26,27]. The role
of MRI in the imaging of hemothorax is discussed below; other aspects of thoracic MRI are
presented separately. (See "Magnetic resonance imaging of the thorax" and "Principles of magnetic
resonance imaging".)
FDG-PET SCANNING
This modality has shown only modest accuracy in discriminating malignant from benign pleural
effusions. While it can differentiate between exudative and transudative pleural effusions, it is not
routinely recommended to facilitate the distinction between benign and malignant pleural effusions
[28]. Rarely, if the pleural effusion is accompanied by a solid pleural component, some value may be
found in performing positron emission tomography (PET) in individual patients. Technical details
and indications for thoracic PET are discussed in detail separately.
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TRANSUDATIVE PLEURAL EFFUSIONS
The most common cause of a transudative pleural effusion is left ventricular failure. Pulmonary
edema liquid permeates the lung interstitium and the visceral pleura, eventually accumulating in
the pleural space, in order to be resorbed by the lymphatics of the parietal pleural [29]. Pleural
effusions related to left ventricular failure are bilateral in nearly 90 percent of cases [6]. Other
causes of transudative pleural effusion include constrictive pericarditis, hepatic cirrhosis ( image 8
), and renal failure ( table 1). In general, transudative pleural effusions are the product of
imbalanced hydrostatic forces. (See "Diagnostic evaluation of a pleural effusion in adults: Initial
testing".)
Occasionally these pleural effusions loculate and mimic masses, particularly in the interlobar
fissures; these have also been called pseudotumors or vanishing tumors ( image 6) [10].
Computed tomography (CT) scanning can sometimes determine the true nature of such a mass by
showing its liquid content and its relationship to the fissures, thereby excluding an intrapulmonary
origin.
In rare instances, patients have bilateral pleural effusions with markedly different characteristics (
image 9 and image 10). This situation is called "Contarini's condition," named after the 95th
Doge of Venice, who died of cardiac decompensation with a unilateral transudative pleural effusion
and a contralateral empyema caused by necrotizing pneumonia [30]. CT scanning in such situations
can identify small collections of gas, loculations, or pleural thickening and pleural enhancement or
the so-called split pleura sign in an empyema, characteristics not found in a transudative pleural
effusion.
Hepatic hydrothorax — Hepatic hydrothorax is defined as a pleural effusion, usually greater than

500 mL, in patients with cirrhosis, but without primary cardiac, pulmonary, or pleural disease. The
majority occur in the right hemithorax (85 percent). The evaluation of suspected hepatic
hydrothorax is discussed separately. (See "Hepatic hydrothorax", section on 'Diagnosis'.)
Demons-Meigs syndrome indicates the association of a right-sided pleural effusion with ascites and
a large ovarian fibroma. It is a rare occurrence but can mimic some of the features of hepatic
hydrothorax due to its association with ascites and preferential accumulation of pleural effusion in
the right hemithorax [31].
EXUDATIVE PLEURAL EFFUSIONS
The most common conditions leading to an exudative pleural effusion are pneumonia (resulting in a
sterile parapneumonic effusion or an empyema) and malignant tumors ( table 2). Large unilateral
exudative pleural effusions in young patients are suspicious for tuberculosis ( image 11A-B),
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whereas in older individuals they frequently indicate a malignant process ( image 12) [32]. (See
"Diagnostic evaluation of a pleural effusion in adults: Initial testing".)
Empyema — The vast majority of empyemas are due to pulmonary infections; surgical procedures
and trauma are other common causes. Empyemas are most often due to streptococcus species,
anaerobic bacteria (bacteroides and peptostreptococcus), or mixed aerobic-anaerobic flora [33].
Aerobic bacteria like methicillin-resistant staphylococcus and gram-negative bacteria (eg,
Enterobacter) are found in hospital-acquired empyemas; tuberculous mycobacteria and fungi are
less frequent causative agents ( image 13A-B and image 14 and image 15) [34]. (See
"Epidemiology, clinical presentation, and diagnostic evaluation of parapneumonic effusion and
empyema in adults".)
The radiologic diagnosis of empyema can be facilitated by computed tomography (CT) scanning.
Three stages are recognized in the evolution of empyemas:
● Stage 1 consists of an exudative pleural effusion that contains more than 15,000 leukocytes per
microliter
● Stage 2 is a fibrinopurulent stage in which adhesions have already formed
● Stage 3 is the organizing stage, with development of a 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 the fibrinopurulent stage of an empyema
( image 16 and image 17). Linear, irregular, honeycomb-like adhesions predict difficulties in
drainage.
In the early, exudative stage of an empyema, the pleural effusion appears on radiography to be
freely layering. When the effusion becomes loculated, it forms tapered borders with obtuse angles
at its interface with the chest wall, often showing gravity dependent changes in shape, such as
"drooping" ( image 18A-D) and on occasion the "incomplete margin" sign. (See 'Loculated pleural
effusions' above.)
In the fibrinopurulent and organizing stages, an intravenous contrast material enhanced CT scan
shows strong enhancement of the visceral and parietal pleurae, producing the "split pleura sign" (
image 19A-B) [17,19]. The pleura is also frequently thickened, exceeding 3 to 5 mm [35].
Empyemas tend to compress the adjacent lung rather than destroy it, thereby allowing
differentiation from large lung abscesses [19]. 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 an obtuse angle of interface with the chest wall,
compared with lung abscesses, which commonly have an acute angle. However, the angle of
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interface is probably less useful for differentiation of empyema from lung abscess than the
thickness and uniformity of the wall and the effect on adjacent vascular structures, particularly with
very large juxtapleural abscesses that abut the chest wall and can, on rare occasions, also form
obtuse angles of interface with the chest wall.
The finding of a gas-liquid level in an empyema indicates the presence of a bronchopleural fistula
(BPF) ( image 20). In this setting, the gas-liquid levels in the frontal and lateral projections on an
upright chest radiograph characteristically have unequal linear dimensions and typically extend to
the chest wall [36]. CT scanning is also capable of identifying a BPF [20-22]. Central BPFs occur most
often after surgical procedures or trauma and can be confirmed by bronchoscopy. In contrast,
peripheral BPFs are often a complication of necrotizing pneumonia ( image 21) [20]. (See
"Management of persistent air leaks in patients on mechanical ventilation".)
Tuberculous empyemas tend to persist for decades and exhibit extensive calcification of the pleura (
image 18A). They were seen more frequently in the past after pneumothorax therapy for
tuberculosis.
Malignant pleural effusion — The second most common cause of an exudative pleural effusion is
related to a malignant tumor [37,38]. Carcinoma of the lung, breast, or ovary, and lymphoma [39],
including primary effusion lymphoma in patients infected with HIV [40], account for approximately
80 percent of all malignant effusions ( image 12). The mechanisms of formation include:
● Increased pleural membrane and capillary permeability
● Decreased clearance due to lymphatic obstruction
● Bronchial obstruction leading to atelectasis and a marked regional decrease in intrapleural

pressure, which favors pleural liquid accumulation
Findings on CT imaging that suggest a malignant pleural effusion include an irregular, nodular, or
thickened pleura. Enhancement of the visceral pleura after administration of intravenous contrast
material suggests pleural inflammation or malignancy. The size of malignant effusions varies, but
metastatic malignancies are the most common cause of a massive pleural effusion obliterating an
entire hemithorax. Malignant effusions can become loculated ( image 22).
The diagnosis and management of malignant pleural effusions are discussed separately. (See
"Management of malignant pleural effusions".)
Hemothorax — A hemothorax is defined as a bloody pleural effusion with a hematocrit exceeding

half the value in peripheral blood [6]. It can be seen after trauma, following an iatrogenic puncture
or transection of a vessel, after pulmonary embolism ( image 23), as a result of metastatic
disease, after anticoagulant therapy, or as a sequela of a leaking aortic aneurysm. Large
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posttraumatic hemothoraces exceeding 500 mL are readily seen on chest radiographs and can
contain more than one-half the blood volume of an injured patient per involved hemithorax [41].
Smaller volumes of intrapleural blood may be only visible on CT scans, and have been referred to as
occult hemothorax [42].
CT scanning of a hemothorax shows an effusion with relatively high attenuation, exceeding 35

Hounsfield units (HU) when the blood is fresh, and reaching 70 HU with clotted blood (
image 24A-D) [43]. Of note an increased attenuation of a pleural effusion with elevated HU may,
on rare occasions, be due to the retention of contrast material in the pleural space [44]. A
hematocrit effect with a liquid-liquid level can become visible in subacute hematomas, due to the
higher attenuation of the sedimented red blood cells compared with that of the supernatant, which
contains serum of lower attenuation ( image 25 and image 26).
MRI is able to identify blood and to estimate the age of the hemorrhage [26,27,33,45]:
● Oxyhemoglobin exists in fresh blood, which has a low signal on T1-weighted spin-echo
sequences and a high signal on T2-weighted sequences.
● Deoxyhemoglobin exists in subacute bleeding (ie, several hours to days old), which has a low
signal on T1- and T2-weighted sequences.
● Methemoglobin can be seen when blood is several days to several weeks old ( image 27). If it
is intracellular, it displays a high signal on T1-weighted imaging but a low signal on T2-weighted
imaging. When it is extracellular, methemoglobin exhibits a high signal on both T1- and T2-
weighted images.
● Hemosiderin shows a low signal on both T1- and T2-weighted imaging and usually indicates
blood that is several weeks to several months old.
Chylothorax — Chylothorax is most likely the result of mediastinal tumor involvement by

lymphoma or bronchogenic carcinoma [46]. These two neoplasms account for 54 percent of all
chylothoraces, while trauma, including surgery, accounts for another 25 percent. Rare causes of
chylothorax include filariasis, lymphangioleiomyomatosis, congenital anomalies of the thoracic
duct, and so-called idiopathic chylothorax. (See "Etiology, clinical presentation, and diagnosis of
chylothorax".)
Disruption of the thoracic duct leads to formation of a chylous duct cyst, which can appear as a
posterior mediastinal mass. It can perforate, usually after an interval of 10 days, leading to the
delayed development of a pleural effusion. Radiologically, a large pleural effusion is characteristic,
and loculation can occasionally be seen ( image 28A and image 28B and image 29) .
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On CT scanning, the pleural accumulation of chyle can display lower attenuation values than other
effusions. MRI can show high signal on T1-weighted sequences, due to the high fat content. An
additional report suggests that morphological changes of the thoracic duct and accessory lymphatic
channels can also be identified on T2 weighted sequences [47]. Non-enhanced magnetic resonance
(MR) lymphography uses strongly T2-weighted imaging to identify slow-flowing lymph [2]. Based on
the location of the thoracic duct, traumatic right-sided chylothoraces suggest injury to the lower
third of the thoracic duct, whereas left-sided chylothoraces suggest a lesion in the upper two-thirds
of the thoracic duct ( image 28A-B and image 29).
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Here are the patient education articles that are relevant to this topic. We encourage you to print or
e-mail these topics to your patients. (You can also locate patient education articles on a variety of
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● Basics topics (see "Patient education: Pleural effusion (The Basics)")
SUMMARY AND RECOMMENDATIONS
● Conventional chest radiography and computed tomography (CT) scanning are key to the
detection and characterization of pleural effusions; pleural ultrasound and magnetic resonance
imaging (MRI) play a role in selected clinical circumstances. (See 'Introduction' above.)
● 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 ( image 3). (See
'Conventional radiography' above.)
● 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
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sampling by thoracentesis, because at least 200 mL of liquid are already present. (See
'Conventional radiography' above.)
● Subpulmonic pleural effusions elevate the lung base, mimicking an elevated hemidiaphragm (
image 4A-B). 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. (See
'Subpulmonic effusions' above.)
● 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. (See 'Loculated pleural effusions' above.)
● On CT scans, 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 ( image 1). Extrapleural fat and the endothoracic
fascia, each with a thickness of 0.25 mm, may be visible between the pleural line and the ribs.
(See 'Normal pleural anatomy' above.)
● 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 positioning thoracostomy tubes for
drainage of loculated pleural effusions. (See 'Computed tomography' above.)
● The presence of an exudative, rather than transudative, pleural effusion is suggested by

thickening of the pleurae on CT scanning (eg, >3 to 5 mm) and by intravenous contrast material
enhancement of the visceral and parietal pleurae. (See 'Computed tomography' above and
'Transudative pleural effusions' above and 'Exudative pleural effusions' above.)
● 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. (See 'Ultrasonography' above
and "Bedside pleural ultrasonography: Equipment, technique, and the identification of pleural
effusion and pneumothorax".)
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● Pleural effusions and tumors can also be delineated by MRI. The main roles for MRI in the
evaluation of a 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. (See 'Magnetic resonance imaging' above and
'Hemothorax' above and "Magnetic resonance imaging of the thorax", section on 'Pleura'.)
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22. Seo H, Kim TJ, Jin KN, Lee KW. Multi-detector row computed tomographic evaluation of
bronchopleural fistula: correlation with clinical, bronchoscopic, and surgical findings. J Comput
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Imaging 2002; 17:230.
24. Moore CL, Copel JA. Point-of-care ultrasonography. N Engl J Med 2011; 364:749.
25. Raptis CA, McWilliams SR, Ratkowski KL, et al. Mediastinal and Pleural MR Imaging: Practical
Approach for Daily Practice. Radiographics 2018; 38:37.
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139:254.
27. Zerhouni EA. MR imaging in chest disease: Present and future applications Syllabus: A
categorical course in chest radiology. RSNA 1992; :25.
28. Porcel JM, Hernández P, Martínez-Alonso M, et al. Accuracy of fluorodeoxyglucose-PET imaging

for differentiating benign from malignant pleural effusions: a meta-analysis. Chest 2015;
147:502.
29. Müller NL. Imaging of the pleura. Radiology 1993; 186:297.
30. Kutty CP, Varkey B. "Contarini's condition:" bilateral pleural effusions with markedly different
characteristics. Chest 1978; 74:679.
31. Meigs JV. Fibroma of the ovary with ascites and hydrothorax. Obstet Gynecol 1939; 110:731.
32. Maher GG, Berger HW. Massive pleural effusion: malignant and nonmalignant causes in 46
patients. Am Rev Respir Dis 1972; 105:458.
33. Light RW. Pleural Diseases, 5th ed, Lippincott, Williams, and Wilkins, Philadelphia 2013.
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34. Hulnick DH, Naidich DP, McCauley DI. Pleural tuberculosis evaluated by computed tomography.
Radiology 1983; 149:759.
35. Kearney SE, Davies CW, Davies RJ, Gleeson FV. Computed tomography and ultrasound in
parapneumonic effusions and empyema. Clin Radiol 2000; 55:542.
36. Friedman PJ, Hellekant CA. Radiologic recognition of bronchopleural fistula. Radiology 1977;
124:289.
37. Chernow B, Sahn SA. Carcinomatous involvement of the pleura: an analysis of 96 patients. Am J
Med 1977; 63:695.
38. Fentiman IS, Millis R, Sexton S, Hayward JL. Pleural effusion in breast cancer: a review of 105
cases. Cancer 1981; 47:2087.
39. Bligh MP, Borgaonkar JN, Burrell SC, et al. Spectrum of CT Findings in Thoracic Extranodal Non-
Hodgkin Lymphoma. Radiographics 2017; 37:439.
40. Yarchoan R, Uldrick TS. HIV-Associated Cancers and Related Diseases. N Engl J Med 2018;
378:1029.
41. Dreizin D, Munera F. Multidetector CT for Penetrating Torso Trauma: State of the Art. Radiology
2015; 277:338.
42. Talbot BS, Gange CP Jr, Chaturvedi A, et al. Traumatic Rib Injury: Patterns, Imaging Pitfalls,
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43. Wolverson MK, Crepps LF, Sundaram M, et al. Hyperdensity of recent hemorrhage at body
computed tomography: incidence and morphologic variation. Radiology 1983; 148:779.
44. Romero M, Bächler P. Pseudo-hemothorax at computed tomography due to residual contrast
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45. Davis SD, Henschke CI, Yankelevitz DF, et al. MR imaging of pleural effusions. J Comput Assist
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46. Roy PH, Carr DT, Payne WS. The problem of chylothorax. Mayo Clin Proc 1967; 42:457.
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Topic 6688 Version 17.0
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GRAPHICS
Normal pleura in right posterolateral hemithorax
On CT scan, the thin pleural complex is outlined by lung internally and extrapleural fat
externally. Outside the fat are the endothoracic fascia and the intercostal muscles.
CT: computed tomography.
Courtesy of Paul Stark, MD.
Graphic 66548 Version 3.0
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Anterior pleural junction line on chest CT scan
CT scan shows anterior junction line formed by four layers of pleura. This represents
the potential space of the anterior mediastinum.
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Posterior pleural junction line on chest CT scan
CT scan shows the posterior junction line formed by four layers of pleura that join
posterior to the esophagus.
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Free layering pleural effusion
Panel A shows blunting of the right costophrenic sulcus (arrow) on an upright chest radiograph due to the
presence of a pleural effusion. Panel B shows a right lateral decubitus radiograph from the same patient,
and reveals layering of pleural effusion (arrowhead). Effusions thicker than 1 cm on decubitus views are
usually large enough for sampling with thoracentesis.
Courtesy of Steven E Weinberger, MD.
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Right subpulmonic pleural effusion
Chest radiograph of a right subpulmonic pleural effusion. The right lung base is
slightly elevated. A small pneumoperitoneum outlines the actual level of the right
hemidiaphragm. Left pleural effusion has spilled over into the left lateral costophrenic
sulcus.
Normal chest radiograph
Posteroanterior view of a normal chest radiograph.
Courtesy of Carol M Black, MD.
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Subpulmonic pleural effusion
Left panel: Right subpulmonic pleural effusion in patient after mediastinal irradiation. The right lung
base is elevated as well as the right hilum. Right panel: After thoracentesis, a residual
hydropneumothorax with a large right sided gas-liquid level ensues, thus proving that the elevation
of the right lung base was not due to an elevated right hemidiaphragm but to a subpulmonic pleural
effusion.
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Subpulmonic effusions with Rock of Gibraltar sign
Bilateral subpulmonic pleural effusions, larger on the right side: Chest frontal (panel A) and lateral
(panel B) views and image of the Rock of Gibraltar (panel C). The elevation of the lung bases with
an abrupt drop-off laterally on the frontal view and posteriorly on the lateral view has been
dubbed the "Rock of Gibraltar sign." This finding is best seen on the right side on the frontal view
and bilaterally on the lateral view.
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Loculated pleural effusion
Chest radiographs show a loculated pleural effusion in the left major fissure. The mass-like
appearance on the frontal view (left) forms a pseudotumor. The lateral view (right) clearly localizes
the mass to the major fissure.
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Loculated pleural effusion
Axial chest computed tomography (CT) scan (A) and coronal reformat (B) in a patient with left ventricular failure. CT scans show bilateral
loculated pleural effusions in the right minor fissure (arrows) and right major fissure (arrowheads).
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Hepatic hydrothorax
Large right sided pleural effusion forming typical meniscoid arc (arrow) in patient with
advanced liver cirrhosis.
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Causes of transudative pleural effusions
Causes of
transudative Comment
effusions
Processes that always cause a transudative effusion
Atelectasis Caused by increased intrapleural negative pressure
Cerebrospinal fluid leak Thoracic spinal surgery or trauma and ventriculopleural shunts
into pleural space
Heart failure Acute diuresis can result in borderline exudative features
Hepatic hydrothorax Rare without clinical ascites
Hypoalbuminemia Edema liquid rarely isolated to pleural space
Iatrogenic Misplaced intravenous catheter into the pleural space; post Fontan procedure
Nephrotic syndrome Usually subpulmonic and bilateral
Peritoneal dialysis Acute massive effusion develops within 48 hours of initiating dialysis
Urinothorax Caused by ipsilateral obstructive uropathy or by iatrogenic or traumatic GU injury
Processes that may cause a transudative effusion, but usually cause an exudative effusion
Amyloidosis Often exudative due to disruption of pleural surfaces
Chylothorax Most are exudative effusions
Constrictive pericarditis Bilateral effusions
Hypothyroid pleural From hypothyroid heart disease or hypothyroidism per se

effusion
Malignancy Usually exudative, but 3 to 10 percent transudative possibly due to early lymphatic obstruction,
obstructive atelectasis, or concomitant disease (eg, heart failure)
Pulmonary embolism Most are exudative effusions
Sarcoidosis Stage II and III disease
Superior vena caval May be due to acute systemic venous hypertension or acute blockage of thoracic lymph flow
obstruction
Nonexpandable lung* A result of remote or chronic inflammation
GU: genitourinary.
* Trapped and entrapped lung are examples of nonexpandable lung. While trapped lung typically causes a transudative pleural effusion,
entrapped lung is typically associated with an exudative effusion.
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Contarini's condition
Patient with a right sided transudate from left ventricular failure and with a left sided
empyema that is loculated, adjacent to a focus of pneumonia with air bronchograms in
the subjacent lung. This is also called Contarini's condition and refers to bilateral
pleural effusions of differing etiologies.
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Left pleural empyema
Axial computed tomography (CT) scan of the chest (A) and coronal reformat (B) in a patient with left pleural empyema caused by Group A
Streptococcus. CT scans show several left apico-lateral and left medial, paracardiac loculations of pleural effusion with internal septations
with contrast-enhancing pleural and adjacent compressed lung (dashed arrow). An accompanying unrelated right transudative pleural
effusion is also present: an example of Contarini's condition. Arrows in the coronal reformat shows a liver abscess.
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Causes of exudative pleural effusions
Infectious Increased negative intrapleural pressure with

Bacterial pneumonia accompanying pleural malignancy or
inflammation
Tuberculous pleurisy
Lung entrapment
Parasites
Cholesterol effusion (eg, due to tuberculosis, rheumatoid
Fungal disease
arthritis)
Atypical pneumonias (viral, mycoplasma)
Connective tissue disease
Nocardia, Actinomyces
Lupus pleuritis
Subphrenic abscess
Rheumatoid pleurisy
Hepatic abscess
Mixed connective tissue disease
Splenic abscess
Eosinophilic granulomatosis with polyangiitis (Churg-Strauss)
Hepatitis
Granulomatosis with polyangiitis (Wegener's)
Spontaneous esophageal rupture
Familial Mediterranean fever
Cholecystitis
Endocrine dysfunction
Iatrogenic or trauma
Hypothyroidism
Central venous catheter misplacement/migration
Ovarian hyperstimulation syndrome
Drug-induced (eg, nitrofurantoin, dantrolene, methysergide,
dasatinib, amiodarone, interleukin-2, procarbazine, Lymphatic abnormalities
methotrexate, clozapine, phenytoin, beta blocker, ergot drugs)
Malignancy
Esophageal perforation
Chylothorax (eg, yellow nail syndrome,
Esophageal sclerotherapy lymphangioleiomyomatosis, lymphangiectasia)
Enteral feeding tube in pleural space
Movement of liquid from abdomen to pleural
Radiofrequency ablation of pulmonary neoplasms space
Hemothorax Pancreatitis
Chylothorax Pancreatic pseudocyst
Malignancy-related Meigs' syndrome
Carcinoma Chylous ascites
Lymphoma Malignant ascites
Mesothelioma Subphrenic abscess
Leukemia Hepatic abscess (bacterial, amebic)
Chylothorax Splenic abscess, infarction
Paraproteinemia (multiple myeloma, Waldenstrom's Miscellaneous

macroglobulinemia)
Pulmonary vein stenosis
Paramalignant effusions
Endometriosis
Other inflammatory disorders Drowning
Pancreatitis (acute, chronic) Electrical burns
Benign asbestos pleural effusion Capillary leak syndrome
Pulmonary embolism Extramedullary hematopoiesis
Radiation therapy
Uremic pleurisy
Sarcoidosis
Postcardiac injury syndrome
Acute respiratory distress syndrome (ARDS)
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Primary tuberculosis in infant
Large left sided pleural effusion produces complete opacification of the left
hemithorax with cardiomediastinal shift to the right.
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Primary tuberculosis in pregnant woman
Large right sided pleural effusion with typical meniscoid arc and with extension into
the major fissure.
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Malignant pleural effusions
Bilateral malignant pleural effusions in patient with metastatic carcinoma of the

breast. The right breast is surgically absent. CT scan shows bilateral posterior pleural
effusions and passive atelectasis of the right lower lobe with marked enhancement
after intravenous contrast material injection.
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Bilateral empyema due to staphylococcus aureus
CT scan shows bilateral loculations of effusion with adjacent consolidated or

compressed lung.
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Pseudomonas empyema
Large left sided empyema due to Pseudomonas aeruginosa. Posterior collection of

pleural effusion compresses the left lung and displaces the cardiomediastinal
silhouette to the right.
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Tuberculous empyema
(A) Axial view of computed tomography of the thorax shows a right peripheral
crescentic collection of liquid surrounded by a circumferential calcific shell (arrow),
with thickening of the adjacent extrapleural layer of fat, thickening of the cortex and
sclerosis of the adjacent right ribs. Due to restriction of the right lung expansion, the
right hemithorax is smaller than the left and the cardiomediastinal structures are
shifted to the right.
(B) Coronal multiplanar reformation of the chest CT images demonstrates the

craniocaudal extent of the pleural process.
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Right pleural empyema
Chest radiograph (A) shows a large right pleural mass with incomplete margin sign, obtuse angle of interface with the chest wall, and
caudad drooping. Axial computed tomography (CT) scan of the chest (B) shows a right lateral pleural loculated collection of
pleural effusion with a small anterior gas-liquid level and contrast-enhancing visceral and parietal pleura yielding the "split pleura" sign.
Coronal reformat (C) confirms the right loculated pleural empyema with slight enhancement of the adjacent pleura.
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Thoracic ultrasound of pleural empyema
Empyema with multiple septations demonstrated on an ultrasonogram of the lower

left hemithorax.
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Ultrasound empyema in the pleural space
Transthoracic ultrasound demonstrates multiple internal septations forming so called "cobwebs."
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Empyema with calcifications
Empyema due to previous pneumothorax therapy for cavitary tuberculosis. Left: Chest radiograph
shows large right sided pleural mass with a sharp border towards the lung and obtuse angles of
interface towards the chest wall. Slight caudad "drooping" is visible. Pleural calcifications are present.
The right costophrenic sulcus is obscured. Right: CT scan shows a large loculated collection of liquid in
the right hemithorax with obvious calcifications of the visceral and parietal pleura. Restrictive changes
are evident and account for the small size of the right hemithorax. The thickness of the extrapleural fat
in the posterolateral aspect of the right hemithorax is increased when compared to the left side. This
compensates for the low lung volume on the right side.
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Empyema after liver biopsy
Homogeneous opacification of the right hemithorax with visible pulmonary vessels,

the so-called filter effect, typical of a pleural process.
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Typical characteristics of a pleural mass are shown: a "one-edged" mass, sharply

marginated against the lung and with obtuse angles of interface towards the chest
wall. Slight "drooping" of the mass caudad is present.
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Posterior accumulation of low attenuation pleural effusion and the compressed

atelectatic right lower lobe, forming a higher attenuation wedge-shaped structure.
Note the right middle lobe bronchus pointing ventrally and the superior segmental
bronchus of the right lower lobe pointing dorsally towards the collapsed lung.
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Split pleura sign in empyema after coronary artery bypass

grafting
CT scan shows a crescentic collection of pleural liquid with enhancing visceral and
parietal pleura ("split pleura" sign), which is characteristic of an inflammatory process.
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Empyema with split pleura sign
CT scan demonstrates a loculated collection of pleural effusion in the left hemithorax

with enhancing visceral and parietal pleura ("split pleura" sign) and a few bubbles of
gas within the empyema, likely due to a gas forming organism. The left lower
atelectatic lung is compressed against the mediastinum. Larger collections of gas are
usually indicative of a bronchopleural fistula. The contralateral right transudative
effusion does not show enhancement of the pleura after intravenous contrast material
administration (Contarini's condition).
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Empyema with gas-liquid level
Empyema with large gas-liquid level in the left posterior hemithorax due to a
bronchopleural fistula. The adjacent lung is compressed and partially atelectatic.
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Lung abscess
Lung abscess in the right lower lobe with cavitation and narrow neck fistula leading to
an empyema in the adjacent pleural space.
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Malignant pleural effusions
Bilateral malignant pleural effusions in patient with carcinoma of the breast and
bilateral mastectomies. CT scan shows a free right pleural effusion and two left-sided
collections of pleural liquid, loculated medially and anterolaterally.
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Patient with chronic pulmonary thromboembolism
Coronal computed tomography (CT) reformation with intravenous contrast material enhancement shows a dilated
left descending pulmonary artery, a large incorporated, eccentric, parietal chronic pulmonary embolus (arrow), a
large chronic pleural effusion, and lower lobe passive atelectasis.
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Large pleural hematoma after trauma
CT scan performed without intravenous injection of contrast material shows

heterogeneous opacification of the right hemithorax with mostly higher attenuation
material. A right-sided chest tube is in place. Cardiomediastinal shift to the left is seen.
The interventricular cardiac septum is seen as a higher attenuation structure when
compared to the interventricular blood. This suggests a severe dilutional anemia due
to severe hemorrhage with a hemoglobin level of less than 7 g/dL.
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Pleural hematoma in right hemithorax
Spontaneous hemorrhage in an anticoagulated patient. The right effusion has high

attenuation due to the fresh blood. The left pleural effusion is transudative and has
lower attenuation (Contarini's condition).
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Loculated pleural hematoma
Loculated pleural hematoma in left hemithorax after CABG. The loculated collection of
blood has higher attenuation than the chest wall musculature.
CABG: coronary artery bypass graft.
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Infected pleural hematoma
Loculated collection of blood with fresh thrombus exhibiting higher attenuation.

Bubbles of gas are likely due to gas-forming organisms.
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Loculated pleural hematoma
Loculated hematoma in left paraspinal location after cardiac transplantation. Low

attenuation with several specks of slightly higher attentuation material indicate an
aging hematoma.
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Loculated extrapleural empyema
Axial computed tomography (CT) scan of the chest (A) and coronal reformation (B) demonstrate a left, apicolateral, higher attenuation
extrapleural mass consisting of coagulated blood with incomplete margin, obtuse angles of interface with the chest wall, and adjacent
internal rim of extrapleural fat and atelectatic lung.
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Hemorrhagic pleural effusion
Hemorrhagic effusion in patient with malignant mesothelioma. MRI of the chest,

sagittal sequence in supine patient. A liquid level is evident, forming a "hematocrit
effect." The red blood cells have a high signal due to intracellular methemoglobin.
MRI: magnetic resonance imaging.
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Chylothorax post right pneumonectomy
Chest radiograph shows multiple gas-liquid levels in the postpneumonectomy space,

with cardiomediastinal shift to the left.
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Chylothorax after esophagectomy
CT shows large low attenuation right pleural effusion with inversion of the right
hemidiaphragm and cardiomediastinal shift to the left.
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Esophageal perforation
Chest radiograph (A) shows a large left hydropneumothorax with slight cardiomediastinal deviation to the right. Chest computed
tomography (CT) scan (B) shows residual anterior loculated hydropneumothorax (black arrow) and a left chest tube and a stent covering
the lower esophageal perforation (black dashed arrow). A left hemorrhagic loculated basal pleural effusion with higher attenuation (black
arrowhead) is also seen in the left paravertebral location, displacing and compressing the left lower lobe. Contrast esophagram (C) shows
extravasation of contrast material into the left hemithorax (white arrow). A white dashed arrow points to the stenotic esophageal
segment, likely a sequela of Barret's esophagus. The white arrowhead points to a small axial hiatal hernia.
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Contributor Disclosures
Paul Stark, MD Nothing to disclose Talmadge E King, Jr, MD Nothing to disclose Nestor L Muller, MD,
PhD Nothing to disclose Fabien Maldonado, MD Grant/Research/Clinical Trial Support: Lung Therapeutics
[Pleural infection]; Medtronic [bronchoscopy]. Consultant/Advisory Boards: Medtronic
[Bronchoscopy]. Geraldine Finlay, MD Nothing to disclose
Contributor disclosures are reviewed for conflicts of interest by the editorial group. When found, these are
addressed by vetting through a multi-level review process, and through requirements for references to be
provided to support the content. Appropriately referenced content is required of all authors and must conform
to UpToDate standards of evidence.
Conflict of interest policy

Imaging of Pleural Effusions in Adults

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Imaging of pleural effusions in adults

NORMAL PLEURAL ANATOMY

Subpulmonic effusions — Subpulmonic pleural effusions elevate the lung base, mimicking an

Loculated pleural effusions — Pleural effusions can also loculate as a result of adhesions.

pyothorax, chylothorax, or tuberculous pleuritis. A typical configuration of a loculation along the

● The content is homogeneous

Other uses of CT scanning in the evaluation of pleural disease include [18-23]:

● Facilitating measurement of pleural thickness

● Distinguishing an empyema from a lung abscess

● Visualizing small pneumothoraces in supine patients

● Occasionally identifying peripheral bronchopleural fistulae

● Occasionally identifying a diaphragmatic defect in a cirrhotic patient with hepatic hydrothorax

● Guiding thoracentesis and tube thoracostomy of loculated empyemas (see "Epidemiology,

Thoracentesis of loculated pleural effusions is facilitated by ultrasound guidance. However,

MAGNETIC RESONANCE IMAGING

TRANSUDATIVE PLEURAL EFFUSIONS

Hepatic hydrothorax — Hepatic hydrothorax is defined as a pleural effusion, usually greater than

EXUDATIVE PLEURAL EFFUSIONS

● Stage 2 is a fibrinopurulent stage in which adhesions have already formed

● Stage 3 is the organizing stage, with development of a thick pleural peel

● Increased pleural membrane and capillary permeability

● Decreased clearance due to lymphatic obstruction

● Bronchial obstruction leading to atelectasis and a marked regional decrease in intrapleural

Hemothorax — A hemothorax is defined as a bloody pleural effusion with a hematocrit exceeding

CT scanning of a hemothorax shows an effusion with relatively high attenuation, exceeding 35

Chylothorax — Chylothorax is most likely the result of mediastinal tumor involvement by

INFORMATION FOR PATIENTS

● Basics topics (see "Patient education: Pleural effusion (The Basics)")

SUMMARY AND RECOMMENDATIONS

● The presence of an exudative, rather than transudative, pleural effusion is suggested by

● Thoracic ultrasonography is useful to identify free or loculated pleural effusions and to

Use of UpToDate is subject to the Subscription and License Agreement.

1. Feller-Kopman D, Light R. Pleural Disease. N Engl J Med 2018; 378:740.

15. Völk M, Strotzer M, Feuerbach S. Case of the month. Intrapulmonary or extrapulmonary? Br J

28. Porcel JM, Hernández P, Martínez-Alonso M, et al. Accuracy of fluorodeoxyglucose-PET imaging

Normal pleura in right posterolateral hemithorax

CT: computed tomography.

Courtesy of Paul Stark, MD.

Graphic 66548 Version 3.0

Anterior pleural junction line on chest CT scan

CT: computed tomography.

Courtesy of Paul Stark, MD.

Graphic 58367 Version 4.0

Posterior pleural junction line on chest CT scan

CT: computed tomography.

Courtesy of Paul Stark, MD.

Graphic 64421 Version 4.0

Free layering pleural effusion

Courtesy of Steven E Weinberger, MD.

Graphic 51660 Version 3.0

Right subpulmonic pleural effusion

Courtesy of Paul Stark, MD.

Graphic 57250 Version 2.0

Normal chest radiograph

Posteroanterior view of a normal chest radiograph.

Courtesy of Carol M Black, MD.

Graphic 65576 Version 5.0

Subpulmonic pleural effusion

Courtesy of Paul Stark, MD.

Graphic 75184 Version 3.0

Subpulmonic effusions with Rock of Gibraltar sign