Chest > Diagnosis > Overview of Chest Imaging > Chest Radiographic and CT Signs

Fat Pad Sign

Santiago Martínez-Jiménez, MD

Selected Images Hide Images

PA chest radiograph of a patient
with a moderate pericardial effusion
shows diffuse enlargement of the
cardiomediastinal silhouette with a
globular morphology concerning for
the water bottle sign of pericardial
effusion.
Lateral chest radiograph of the
same patient shows a water density
band outlined by anterior and
posterior fat density stripes,
the so-called fat pad or Oreo cookie
sign. While not always visible, when
present, this sign is very specific for
the diagnosis of pericardial effusion.
Axial CECT of the same patient
confirms a moderate circumferential
pericardial effusion outlined
anteriorly by mediastinal fat
and posteriorly by subepicardial fat
. Note small bilateral pleural
effusions.
PA chest radiograph of a patient
with a moderate pericardial effusion
shows an enlarged cardiac
silhouette and a subtle arcuate
lateral lucency that represents
subepicardial fat adjacent to
pericardial fluid. While not as
frequently visualized, the fat pad
sign may be seen on frontal chest
radiography.

Additional Images

Composite image with lateral chest
radiographs with routine (left) and
narrow (right) window settings
shows a large pericardial effusion
manifesting as a water density band
outlined by anterior and posterior
fat density stripes . The
abnormality may be difficult to
identify if the window is not
purposely manipulated.
Axial NECT of the same patient Lateral chest radiograph of a patient
confirms a large circumferential with a large pericardial effusion
pericardial effusion outlined shows the fat pad sign. In this case,
anteriorly by mediastinal fat the window has been manipulated
and posteriorly by subepicardial fat to highlight the mediastinal and
. subepicardial fat .

KEY FACTS

Terminology
Definition: Water density band (> 2 mm) that represents pericardial effusion and separates mediastinal and subepicardial fat
stripes on radiography
Synonyms: Sandwich sign, Oreo cookie sign, bun sign
Imaging
Radiography
Retrosternal water attenuation band between 2 fat density stripes on lateral chest radiography
Often more conspicuous if narrow window (more contrast) used to view images
May be visible on PA chest radiography, as lucent band subjacent to cardiac border
Interim enlargement of heart and cardiomediastinal silhouette may be identified using comparison prior studies
CT
Fluid between mediastinal and subepicardial fat
 Top Differential Diagnoses
Pneumomediastinum
Linear air collections in retrosternal region without conspicuous water density component
Morgagni hernia
Retrosternal opacity; may exhibit intrinsic lucency and occasionally air-filled bowel loops
Mediastinal fat
Retrosternal opacity, may exhibit intrinsic fat density
Diagnostic Checklist
High index of suspicion and window manipulation (i.e., narrow window) important for identification of this finding
Prior radiographs helpful for identification of interim increase in size of cardiac silhouette
Rapid changes almost always associated with pericardial effusion
Consider further evaluation with echocardiography for confirmation or if radiography inconclusive

SELECTED REFERENCES

1. Chiarenza A et al: Chest imaging using signs, symbols, and naturalistic images: a practical guide for radiologists and non-
radiologists. Insights Imaging. 10(1):114, 2019
2. Li I et al: Pericardial effusion with Oreo Cookie sign. J Emerg Med. 52(5):756-7, 2017
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