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Andrey Yudin
Metaphorical Signs in
Computed Tomography
of Chest and Abdomen
Second Edition
123
Metaphorical Signs in Computed Tomography
of Chest and Abdomen
Andrey Yudin
Metaphorical Signs
in Computed Tomography
of Chest and Abdomen
Second Edition
Andrey Yudin
Moscow, Russia
© The Editor(s) (if applicable) and The Author(s), under exclusive license to Springer Nature Switzerland AG
2014, 2023
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Preface To the Second Edition
The knowledge of radiology and, in particular, computed tomography is largely based on pictorial
features, to which we are looking for associations with images of objects and environmental phe-
nomena, that is, we attach certain signs with metaphorical content to each of them. No other spe-
cialty has as many metaphorical signs as radiology. The popularity of metaphor as a means of
naming a radiological feature has been growing exponentially in recent years, which is evidence
that a metaphor can increase interest in distinctive features, speed up, and simplify their memoriza-
tion in the learning process. But metaphor requires more vivid images than mere analogy or sym-
bolism. Some of the metaphorical signs (such as GROUND GLASS, TREE-IN-BUD) have become
integral parts of the educational process. Others turned out to be not too bright and understandable
or doubtful from a diagnostic point of view and are currently perceived as radiological curiosities.
A good metaphor is able to firmly connect an important radiologic feature with a familiar object,
develops figurative thinking, which is so valued in radiology. Metaphorical signs have expanded
and continue to enrich the vocabulary of the radiologist, make routine work more romantic.
More than 7 years have passed since the publication of the first edition. During this time,
interest in metaphorical signs has grown so much that only the lazy one does not come up with
new images, even your humble servant. The second edition is also supplemented with new
signs, some of which are united into thematic groups.
I will not get tired in the wrong theater of shadows
Perfection to seek until the end of my days.
I affirm: your face is brighter than the sun.
I affirm: your stature is slimmer than the cypress.— (Omar Khayyam)
Study and memorize metaphorical signs in radiology, and you will improve your professional level by
an order of magnitude.
v
Contents
vii
viii Contents
tellate Scar Sign, Spoke-Wheel Sign, and Segmental Enhancement Inversion��������� 165
S
References��������������������������������������������������������������������������������������������������������������������������� 166
Swiss Cheese Sign (Kidneys) ������������������������������������������������������������������������������������������� 167
Putty-Like Calcification��������������������������������������������������������������������������������������������������� 169
Reference ��������������������������������������������������������������������������������������������������������������������������� 169
Crescent Sign��������������������������������������������������������������������������������������������������������������������� 171
Reference ��������������������������������������������������������������������������������������������������������������������������� 171
an (Ragged Fan) Sign, Wedge-Shaped or Striated Nephrogram,
F
and Spotted (Patchy) Nephrogram��������������������������������������������������������������������������������� 173
References��������������������������������������������������������������������������������������������������������������������������� 173
Reverse Rim Sign and Tramline Calcification��������������������������������������������������������������� 175
rterial Cut-Off Sign and Cortical Rim Sign or Rim Nephrogram ��������������������������� 177
A
Reference ��������������������������������������������������������������������������������������������������������������������������� 177
ear Paw Sign������������������������������������������������������������������������������������������������������������������� 179
B
Reference ��������������������������������������������������������������������������������������������������������������������������� 179
taghorn (Coral) Calculi, Toy “Jacks,” Mulberry Stones, Seed Calculi,
S
and Milk of Calcium��������������������������������������������������������������������������������������������������������� 181
all-On-Tee (Golf Ball-On-Tee Appearance) or Egg in Cup Appearance,
B
Lobster Claw, and Signet Ring Appearances or Bottle Opener����������������������������������� 183
Reference ��������������������������������������������������������������������������������������������������������������������������� 184
yramidal Blush, Sunburst or Spray-Like Sign, Paintbrush Appearance,
P
and Bouquet of Flowers Appearance ����������������������������������������������������������������������������� 185
Reference ��������������������������������������������������������������������������������������������������������������������������� 186
oft-Tissue Rim Sign and Comet Tail Sign or Tail Sign
S
(True and Pseudo)������������������������������������������������������������������������������������������������������������� 187
References��������������������������������������������������������������������������������������������������������������������������� 187
obra Head or Spring Onion Sign ��������������������������������������������������������������������������������� 189
C
Reference ��������������������������������������������������������������������������������������������������������������������������� 189
apoleon’s Hat, Ballerina Legs, Sperm, Tadpole, Spirochete,
N
and Sausage-Like Deformity������������������������������������������������������������������������������������������� 191
omb Sign, Spray, Constellation, and Vascular Jejunization of the Ileum����������������� 193
C
Reference ��������������������������������������������������������������������������������������������������������������������������� 194
tratified Attenuation, Water Halo Sign, Double Halo Sign, and Target Sign����������� 195
S
Reference ��������������������������������������������������������������������������������������������������������������������������� 195
at Halo Sign (Submucosal Fat Accumulation)������������������������������������������������������������� 197
F
Reference ��������������������������������������������������������������������������������������������������������������������������� 197
ccordion Sign (Concertina Sign)����������������������������������������������������������������������������������� 199
A
Reference ��������������������������������������������������������������������������������������������������������������������������� 199
mall Bowel Feces Sign����������������������������������������������������������������������������������������������������� 201
S
Reference ��������������������������������������������������������������������������������������������������������������������������� 201
arget Sign, Sausage-Shaped (Layering or Stratification), and Reniform Bowel ����� 203
T
Reference ��������������������������������������������������������������������������������������������������������������������������� 204
hirlpool or Whirl, Swirl, Whirling Sign ��������������������������������������������������������������������� 205
W
Reference ��������������������������������������������������������������������������������������������������������������������������� 205
xii Contents
Index����������������������������������������������������������������������������������������������������������������������������������� 219
Saber-Sheath Trachea or Scabbard Deformation
Saber-Sheath trachea deformity or scabbard deformation is almost always associated with chronic obstructive pulmonary
defined as a significant decrease in the diameter of the trachea disease, primarily with the emphysematous variant. The asso-
in the frontal plane and an increase in the sagittal diameter (↑). ciation of Saber-Sheath configuration of the trachea and evi-
It is believed that this deformity is formed as a result of chronic dence of chronic obstructive pulmonary disease was first
damage, inflammation, and weakness of the tracheal cartilages described by Greene and Lechner in 1975 [1].
with prolonged cough. The sagittal-to- coronal diameter is
over 2:1. The main bronchi and the extrathoracic part of the
trachea are unchanged. Some thickening of the tracheal walls Reference
and ossification of the tracheal rings can also be seen. During 1. Greene A, Lechner GL (1975) “Saber-sheath” trachea: a clinical and
forced expiration, further retraction of the side walls of the functional study of marked coronal narrowing of the intrathoracic
trachea inward may be observed. Saber-Sheath trachea is trachea. Radiology 115:265–268
Eggshell calcification refers to the peripheral rim of calcium 3. In at least one of the lymph nodes, the ring-like shadow
deposited in enlarged mediastinal and/or hilar and peribron- must be complete.
chial lymph nodes (↑). Cervical and intraperitoneal nodes 4. The central part of the lymph node may show additional
may also be affected. This pattern is most commonly seen in calcifications.
silicosis and coal worker’s pneumoconiosis. It may also be 5. One of the affected lymph nodes must be at least 1 cm in
seen with sarcoidosis, after radiation therapy to lymph nodes its greatest diameter.
affected by lymphoma, scleroderma, amyloidosis, blastomy-
cosis, and histoplasmosis. In 1967, Jacobson et al. [1] estab- Necrosis in the lymph nodes causes a decrease in density
lished criteria for diagnosing eggshell calcification: in the central zones (to fatty density). This pattern is usually
due to mycobacterial infection (tuberculous and non-
1. Shell-like calcifications up to 2 mm thick must be present tuberculous). On computed tomograms, enlarged nodes are
in the peripheral zone of at least two lymph nodes. usually manifested by low density in the center due to case-
2. The calcifications may be solid or broken (apparently ous necrosis, and by the peripheral rim enhancement, which
meaning a whole egg and a broken shell). is a vascularized granulomatous inflammatory tissue and
node capsule (▴). With appropriate clinical data, this picture References
may indicate active tuberculosis (or non-tuberculous myco-
bacterial infection) in immunocompromised children or 1. Jacobson G, Felson B, Pendergrass EP, Flinn RH, Lainhart WS
(1967) Eggshell calcifications in coal and metal miners. Semin
adults. The rim enhancement sign is described with the Roentgenol 2:276–282
involvement of both the lymph nodes of the neck and abdo- 2. Im JG, Song KS, Kang HS et al (1987) Mediastinal tuberculous
men, and the lymph nodes of the mediastinum and pulmo- lymphadenitis: CT manifestations. Radiology 164:115–119
nary hilum [2].
Split Pleura Sign
The split pleura sign is evident on a contrast-enhanced CT nying enhancement (↑). Both layers of the pleura can then be
scan of the chest. It is seen in pleural empyema and helps to visualized as linear regions of enhancement that split around
distinguish empyemas from noninfectious pleural effusions a less dense empyema or in other words come together at the
and lung abscesses. This sign is also described in malignant margins of the collection. Do not confuse with subpleural
effusions, mesothelioma, and after talc pleurodesis. The sign lung consolidation.
results from fibrin coating of both the parietal and visceral
surfaces of the pleura with resulting in growth of capillaries
and fibroblasts forming the basis for the most reliable radio- Reference
graphic feature of an empyema, first described by Stark et al. 1. Stark DD, Federle MP, Goodman PC, Podrasky AE, Webb WR
[1]. Following IV contrast injection, CT shows a loculated (1983) Differentiating lung abscess and empyema: radiography and
fluid collection and thickened pleural layers with accompa- computed tomography. AJR 141:163–167
Consolidation, bulging fissure sign or lobar consolidation and air bronchograms sign or open bronchus sign
Air-space (alveolar, parenchymal) consolidation is a radio- sign was described in pneumonia of the upper lobe of the
logic sign of increased lung opacity obscuring vascular and right lung caused by Klebsiella pneumoniae [1]. Other pos-
interstitial structures (↑). Consolidations may be divided sible causative agents of inflammation: Streptococcus pneu-
into diffuse and focal, perihilar and peripheral, round, lin- moniae, Pseudomonas aeruginosa, Staphylococcus aureus,
ear, and patchy. These features are important in differen- Legionella pneumophila, Mycobacterium tuberculosis.
tial diagnosis which is based on the nature of the substance Similar changes can be caused by pulmonary adenocarci-
that is replacing alveolar air: blood (hemorrhage), pus noma, abscess, and hemorrhage.
(exudates, pneumonia), water (transudate, edema), protein
(secretions, lipoprotein), and cells (malignancies, COP). The air bronchograms sign or open bronchus sign is a non-
Air-filled bronchi are often seen under opacified lung paren- specific sign of visualization of the patent airways against the
chyma. The bulging fissure sign is defined as lobar consoli- background of consolidation in the lung of any genesis ( )
dation, in which the affected portion of the lung expands, such as pneumonia, fibroatelectasis, round atelectasis, con-
causing displacement of the adjacent interlobar pleura (▴). glomerate masses in silicosis and sarcoidosis, as well as ade-
Any type of pneumonia or volumetric process can lead to nocarcinoma. The presence or absence of air bronchograms
the appearance of a bulging (sagging) groove. Initially, this cannot be considered as a proof of benign or malignant pro-
cess existence. The air bronchogram sign indicates only the References
patency of the bronchial lumen, but it is not possible to
exclude partial intraluminal obstruction. This sign was first 1. Felson B, Rosenberg LS, Hamburger M (1949) Roentgen findings
in acute Friedlander’s pneumonia. Am J Radiol 53:559–565
noted by Remy in 1969 [2]. 2. Rémy J (1969) Silhouette sign and air bronchogram. Presse Med
77(15):543–545
Ground-Glass Opacity and Dark Bronchus Sign
Ground-Glass opacity (GGO) is a nonspecific finding which The dark bronchus sign refers to visualization of a clearly
represents a hazy area of increased attenuation in the lung with darker (than usually seems) bronchus against the background
preservation of bronchial and vascular margins (↑). GGO usu- of the lung parenchyma (▴), which looks like GGO. Yadav
ally manifests the presence of lung lesions, morphological fea- et al. [1] described this sign in an HIV-infected patient with
tures of which are beyond the resolution of modern computed Pneumocystis jiroveci pneumonia. This sign becomes sig-
tomography. It may be caused by normal expiration, partial nificant in cases where the decrease in lung transparency is
collapse of alveoli, increased capillary blood volume, partial weak and has a diffuse distribution without recognizable
filling of air spaces, or interstitial thickening. In patients with areas of healthy parenchyma.
acute clinical symptoms, the presence of GGO reflects an
active disease (e.g., pneumonia, edema, diffuse alveolar dam-
age). In most patients with chronic symptoms, GGO also indi- Reference
cates active and potentially treatable stages of a long-lasting
pathologic process (e.g., interstitial pneumonia, hypersensitiv- 1. Yadav P, Seith A, Sood R (2006) The 'dark bronchus' sign: HRCT
diagnosis of Pneumocystis carinii pneumonia. Ann Thorac Med
ity pneumonitis, and sarcoidosis). GGO may also be found in 2(1):26–27. https://doi.org/10.4103/1817-1737.30359
patients with pulmonary adenocarcinoma that assumes
dynamic control or morphological verification.
Air-space edema may be diffuse, multifocal, or patchy but was described in classical radiology as early as the middle
mainly bilateral. Symmetrical perihilar ground-glass of the last century [1].
opacities, known as the bat wing, butterfly or angel wing
sign (↑), may be seen sometimes and attributed to rapid
accumulation of edema fluid, that is, the rapid develop-
ment of pulmonary edema. Similar pulmonary opacities Reference
can be found in patients with septic shock, inhalation
1. Hodson CJ (1950) Pulmonary oedema and the “batswing” shadow.
injuries, alveolar proteinosis, pulmonary hemorrhage, sar- J Fac Radiol 1:176–186
coidosis, and pulmonary adenocarcinoma. This symptom
Intralobular gradient resembling traditional Chinese landscape paintings of karst mountain tops
With re-expansion pulmonary edema, which occurs after the resembling traditional Chinese landscape paintings of karst
removal of a large amount of fluid from the pleural cavity, mountain tops interspersed with misty clouds. The sign is
the alveolar spaces in the secondary lobules are quickly filled described by Lai et al. in 2019 [1]. This sign can be seen in
with transudate due to dysfunction of the alveolar–capillary edema cases of other causes.
barrier. Through the intralobular communications formed by
pores of Cohn and canals of Lambert, this fluid easily moves
inside the secondary lobule, obeying the force of gravity and Reference
forming a gravitational effect in each separately taken sec-
ondary lobule (↑). Interlobular septa form relatively imper- 1. Lai YK, Lindholm P, Guo HH (2019) The intralobular gradient
meable walls of secondary lobules. On computed tomograms, as seen in re-expansion pulmonary edema. Radiol Cardiothorac
Imaging 1(5):e190084. https://doi.org/10.1148/ryct.2019190084
alveolar edema forms an intralobular gradient visually
Crazy-Paving Sign or Paving Stone Sign
The combination of ground-glass opacity and fine reticular pneumonia, sarcoidosis, lymphangitic spread of malignancy,
pattern in the same lung regions (↑) is known as the crazy- exogenous lipoid pneumonia, and pulmonary pneumocystis
paving sign or paving stone sign. This name refers to the jiroveci infection. For proper diagnosis, biopsy or bronchoal-
appearance of irregularly shaped paving tiles in medieval veolar lavage may be warranted.
Italian patios. It is a nonspecific finding that can be seen in a
number of conditions both acute and chronic, but classically
described in pulmonary alveolar proteinosis [1]. Common
causes of this sign are almost identical to that of isolated Reference
GGO and include acute lung injury, pneumonia, pulmonary
1. Godwin JD, Muller NL, Takasugi JE (1988) Pulmonary alveolar
edema, hemorrhage, mucinous adenocarcinoma, interstitial proteinosis: CT findings. Radiology 169(3):609–613
Honeycomb lung
The term honeycomb lung is used to describe pathologic nia. Other causes include collagen diseases, pneumoconiosis,
processes that cause appearance of multiple variably sized sarcoidosis, allergic alveolitis, eosinophilic granuloma.
thick-walled cystic spaces in a background of densely scarred Recognition of honeycombing is critical as its presence is
lung tissue. Clustered cystic air spaces (0.3–1.0 cm in diam- associated with a poor prognosis. The term honeycomb lung
eter) or scattered cysts are usually (but not always) visible might have been offered by Oswald and Parkinson [1].
near the pleural surfaces in several contiguous layers (↑). In
most cases, visualization of the “honeycombing” indicates
extensive pulmonary fibrosis with complete destruction of Reference
the alveoli (end-stage fibrosis). In up to 70% of cases, honey-
combing reflects the presence of usual interstitial pneumo- 1. Oswald N, Parkinson T (1949) Honeycomb lungs. QJM 18:1–20
Pulmonary emphysema is an abnormal permanent enlarge- against a background of the secondary lobules parenchyma
ment of the airspaces distal to the terminal bronchioles, (↑). These areas are usually round or oval in shape and have
accompanied by destruction of the alveolar walls, and with- no visible wall, unless they are partially bordered by the wall
out obvious fibrosis. Computed tomography can show small of the secondary lobule or the bronchovascular bundle. The
areas of lung destruction and can reveal mild emphysema, typical pattern resembles a moth-eaten cloth.
which manifests itself as small focal areas of air density
A condition called vanishing lung, also known as progressive difficult. Computed tomography can reveal a valuable fea-
(idiopathic) lung atrophy and idiopathic giant bullous ture that distinguishes pneumothorax from adjacent giant
emphysema, is a rare disorder of unknown etiology used to bullae—a double wall sign where air outlines both sides of
describe lungs that seem to disappear on X-rays (↑). It is a the bulla wall (▴). The peripheral part of the wall of the bulla
progressive condition characterized by the presence of giant is usually not visible, but with pneumothorax, its course is
emphysematous bullae in one or both lungs which com- determined parallel to the inner surface of the chest wall. The
monly arise in the upper lobes and in the subpleural location. sign is described by Waitches et al. in 2000 [2].
Bullae occupy at least one-third of the hemithorax and may
compress surrounding normal lung parenchyma. They are
usually seen in association with paraseptal and centrilobular References
emphysema, common in young men, mostly in smokers.
Vanishing lungs syndrome is first described by Burke in 1. Burke R (1937) Vanishing lungs: a case report of bullous emphy-
1937 [1]. sema. Radiology 28:367–371
Giant bullous emphysema (vanishing lung) can be com- 2. Waitches GM, Stern EJ, Dubinsky TJ (2000) Usefulness of the
double-wall sign in detecting pneumothorax in patients with giant
plicated by spontaneous pneumothorax. Clinical and radio- bullous emphysema. AJR 174:1765–1768. https://doi.org/10.2214/
logical diagnosis of pneumothorax in these patients is usually ajr.174.6.1741765
Mosaic perfusion (mosaic attenuation, mosaic lung sign) a suggestive pattern of bronchiolitis [1] and by King et al. in
refers to areas of decreased attenuation of lung parenchyma 1994 as an abnormality of pulmonary parenchyma in cases
in the regions of reduced blood perfusion. The term mosaic of chronic pulmonary embolism [2].
reflects patchy and uneven distribution of abnormalities ( ).
This sign is usually seen in patients with small airways dis-
eases (cystic fibrosis, bronchiolitis obliterans, and chronic References
obstructive lung disease) and pulmonary vascular disease
(mosaic oligemia in chronic pulmonary embolism). In cases 1. Eber C, Stark P, Bertozzi P (1993) Bronchiolitis obliterans on high-
with mosaic perfusion, regional pulmonary artery branches resolution CT: a pattern of mosaic oligoemia. J Comput Assist
are always reduced in size (↑). This pattern gives opportunity Tomogr 17(6):853–856
2. King MB, Harmon KR (1994) Unusual forms of pulmonary embo-
to distinguish mosaic perfusion from ground-glass opacities. lism. Clin Chest Med 15(3):561–580
Mosaic lung sign was first described by Eber et al. in 1993 as
Air trapping
When computed tomography is performed during exhala- coexists with other signs of pathological changes in the bron-
tion, the density of the lungs normally increases because the chi and bronchioles (mosaic perfusion, tree-in-buds, tram-
amount of air in the scanned lung volume decreases. With air track, and signet ring signs). Expiratory CT provides
retention in the secondary lobules, caused by increased resis- important information about the anatomical and physiologi-
tance at the level of the distal bronchioles, the affected lung cal features of the lungs that complements inspiratory CT
parenchyma remains more lucent than the surrounding nor- and spirometry results. The term air trapping was first used
mal tissue (↑). The term air trapping (or expiratory trapping) by the physiologist Comroe in 1955 [1].
is defined as the retention of excess air in the secondary lob-
ules of the lungs during expiratory scans (less than usual
increase in lung parenchyma density during an expiratory Reference
scans). In contrast to emphysema, normal pulmonary archi-
tectonics is preserved. The presence of this sign usually indi- 1. Comroe JH (1955) The lung: clinical physiology and pulmonary
cates a disease of the small airways (bronchiolitis obliterans, function tests (based on the 1954 Beaumont lecture). Year Book
Medical Publishers, Chicago, Illinois
chronic obstructive pulmonary disease). Air trapping often
Swiss Cheese Appearance and Head Cheese Sign
With the development of pneumonia against the background over the world, with different recipes. On computed tomo-
of pulmonary emphysema, the infiltration of the parenchyma grams, the head cheese sign is characterized by alternation of
does not extend to the cavities of emphysematous destruc- secondary lobules of the lung with high, normal, and low
tion, which retain the air density. On computed tomography, densities (▴). Areas of high density (consolidations and
in such cases, the areas of consolidation and ground glass GGO) represent an infiltrative parenchymal process. Lobules
appear nonuniformly “perforated” (↑), containing many cav- with low density reflect obstructive pulmonary disease and,
ities and forming images similar to Swiss cheese (e.g., accordingly, become more pronounced during expiratory
Emmenthal or Gruyère). The predominance of emphysema scanning. Thus, this pattern characterizes the coexistence of
can lead to imitation of the “honeycombing” and false diag- inflammatory alveolar infiltration and obstructive small air-
nosis of interstitial lung disease. Such pseudo-cavitation and way disease. The head cheese sign was proposed by Patel
pseudo- honeycombing must be distinguished from true cav- et al. in 2000 as a typical sign of subacute and chronic hyper-
ities and honeycombs. Images that look like SWISS CHEESE sensitivity pneumonitis [2]. Other causes of this symptom
were the first to be noted by Fraser et al. [1]. are atypical cases of sarcoidosis, respiratory bronchiolitis,
Head cheese or brawn (meat cheese, Sülze, terrine, 편육) and atypical infections associated with bronchiolitis (e.g.,
is a cooked pressed meat product that is often prepared from Mycoplasma pneumoniae), respiratory bronchiolitis, des-
the head of a calf or a pig (less often a sheep or a cow) with quamative interstitial pneumonia. The coexistence of inde-
the addition of bacon, as well as tongues, liver and other pendent infiltrative and obstructive processes can also lead to
offal, sometimes poured jelly. Head cheese varieties exist all the appearance of this sign.
References lung injury [Mirvis SE (2005) Imaging of acute thoracic injury: the
advent of MDCT screening. Semin. Ultrasound CT MR 26:305–331
2. Patel RA, Sellami D, Gotway MB, Golden JA, Webb WR (2000) Hyper-
1. Fraser RS, Pare JAP, Fraser RG, Pare PD (1994) Infectious disease of
sensitivity pneumonitis: patterns on high-resolution CT. J Comput
the lungs. Synopsis of diseases of the chest, 2nd edn. W.B. Saunders
Assist Tomogr 24(6):965–970. https://doi.org/10.1097/00004728-
Company, USA, pp 287–391. The term SWISS CHEESE has also
200011000-00025
been used for the description of pneumatoceles formed with blunt
Feeding Vessel Sign or Fruits
on the Branch Sign
The feeding vessel sign, also known as the fruits on the and therefore rarely accompanied by this sign. One must
branch sign, is defined as the visualization of a small branch know that (1) in some cases the so-called feeding vessel is a
of the pulmonary artery leading directly to a nodule or a pulmonary vein and (2) fine collimated tomograms and mul-
mass (↑). Computed tomography permits visualization of tiplanar reconstructions may show the apparent feeding ves-
the relationship of small pulmonary vessels with focal path- sel passing around or past the nodules instead of entering
ological changes. Meziane et al. noted that this feature sug- them.
gests a hematogenous origin of the process [1] and includes
primarily metastases, infarcts, and septic embolism. A num-
ber of vascular-related lung diseases also cause focal abnor- Reference
malities with the likely potential for this feature (e.g.,
pulmonary vasculitis, arteriovenous malformation, angioin- 1. Meziane MA, Hruban RH, Zerhouni EA, Wheeler PS, Khouri NF,
Fishman EK, Hutchins GM, Siegelman SS (1988) High resolution CT
vasive pulmonary aspergillosis). Primary tumors or granu- of the lung parenchyma with pathologic correlation. Radiographics
lomas receive their blood supply from the bronchial artery 8(1):27–54. https://doi.org/10.1148/radiographics.8.1.3353534
Miliary Dissemination, Snowstorm Sign,
and Cannonball Metastases
The term miliary dissemination goes back to the word millet of the lungs. In this regard, first of all, one should look for
and in classical radiology means the presence of multiple vascularized primary tumors (thyroid carcinoma, renal cell
small foci chaotically located in the lung parenchyma. carcinoma). If the nodes are large and are accurately out-
Random dissemination is usually caused by hematogenous lined (▲), then they are called cannonball metastases (the
spread of pathological processes, among which tuberculo- cannonball is a solid projectile fired from a smoothbore can-
sis, fungal infection, and metastases should be confirmed or non). Such metastases are characteristic of tumors of the
excluded first. The causes of dissemination in the lungs can- gastrointestinal tract and urogenital area. The snowstorm
not be enumerated (more than 200). The snowstorm sign, in sign is mentioned in the context of other disseminations, in
fact, means the same thing—miliary dissemination of innu- particular as a characteristic of pulmonary alveolar microli-
merable foci (measuring 1–2 mm) across the entire paren- thiasis. For this disease, the term sandstorm is more
chyma of the lungs (↑), but rather refers to metastatic lesions familiar.
The sandstorm sign is characterized by dissemination of pleura. It seems that each lobe is surrounded by a thin,
small calcifications (1–5 mm) observed in pulmonary alve- dense surface, which creates the overall appearance of a
olar microlithiasis (↑). Visible calcifications are the deposi- stony lung ( ). A thin black line can often be seen between
tion of calcium phosphate microliths (called calciferites) the inner surface of the chest wall and the pulmonary sur-
on the inner surface of the alveoli. Both lungs are involved face (▲), known as the black pleural line sign. This line is
in the pathological process, the changes are most pro- formed by small subpleural emphysematous cysts. The
nounced in the middle and lower parts of the lungs. On CT manifestation of a crazy-paving sign is possible, since cal-
scans, small lesions may have a soft tissue density, or ciferites are deposited along the alveolar walls. The first
ground-glass opacity due to a partial volume effect. radiologic description of the disease was given, apparently,
Calcifications are most pronounced lengthwise the bronchi by Harbitz in 1918 [1]. A similar picture can be obtained
and at the periphery along the visceral and interlobar with other lung diseases: tuberculosis, desert lung syn-
Cavitation (from Latin cavitas—emptiness) is the physical pro- Cheerios is a brand of oatmeal that has the geometric
cess of the formation of bubbles (voids) in liquid media, fol- shape of a toroid (it is easier to imagine the shape of a
lowed by their collapse and the release of a large amount of donut). The cheerios sign is defined as pulmonary nodules
energy, which is accompanied by noise and hydraulic shocks. containing a small central air cavity with a visible bronchus
Kuhlman et al. described pseudocavitations against the back- (▴). Very often the nodules and especially the cavities in
ground of consolidation (↑) caused by adenocarcinoma as sev- them have the same “screen-printed” shape and size. The
eral small oval areas of low density, mimicking tiny cavities cavities are, as it were, pierced with the same punch ( ). A
[1]. Pseudocavitations on computed tomograms reflect the punch or a piercer is a hand-held tool for punching small
same condition as the air bronchogram sign: the tendency of holes in metal, stone, skin, etc. The cheerios sign is formed
the tumor to grow along the walls of the alveoli without dis- as a result of the proliferation of cells, both malignant and
rupting the general architectonics of the lungs and maintaining benign, around an unobstructed branch of the bronchus,
the patency of the bronchi. Pseudocavitations correspond to bronchiole, or alveolar ducts. The sign was proposed by
either a free small bronchus inside the nodule or extended alve- Reed and O’Neil in 1993 [2] as a sign of bronchioloalveo-
olar spaces in the areas of tumor growth. A zone of reduced lar carcinoma. Most often these are adenocarcinomas with
lucency with the density of ground glass in combination with predominantly lepidic growth. This sign has also been
pseudocavitations and the air bronchogram sign are early signs described in Langerhans cell histiocytosis and the minute
of invasive mucinous (pneumonia-like) adenocarcinoma. pulmonary meningothelial-like nodules (formerly known
Halo sign
Halo sign is defined as a rim of ground glass that forms an associated lymphoma, Kaposi’s sarcoma, hemorrhagic
aureole around a denser nodule (group of nodules) or an area pulmonary metastases, organizing pneumonia, radiation
of consolidation (↑). It was first described by Kuhlman et al. pneumonitis, pulmonary infarction, etc. This sign is often
in 1985 [1] as a sign of hemorrhage around foci of invasive seen in patients with COVID-19 and other viral lesions.
pulmonary aspergillosis. The halo sign is nonspecific and
can be caused by various pathologic processes: hemorrhagic
pulmonary nodules, both infectious and non-infectious, pro- Reference
liferation of tumor cells into the surrounding parenchyma
and non-hemorrhagic inflammatory processes: aspergillosis, 1. Kuhlman JE, Fishman EK, Siegelman SS (1985) Invasive pulmo-
nary aspergillosis in acute leukemia: characteristic findings on CT,
mucormycosis, candidiasis, mycobacterial infection, ANCA- the CT halo sign, and the role of CT in early diagnosis. Radiology
associated pulmonary vasculitis, adenocarcinoma, bronchus- 157:611–614. https://doi.org/10.1148/radiology.157.3.3864189
Sunburst sign, also known as corona radiata or corona was described by O’donovan in 1997 [1]. It is believed that
maligna, represents the spiky protrusion and jagged edges of the sunburst sign indicates a malignant lesion, especially an
a pulmonary nodule or mass that distorts the course of the adenocarcinoma of the lung, with a probability of 2.5–1 in
surrounding blood vessels (↑). The appearance of spicular relation to other nodules obtained as a result of screening
contours leads to an association with the sun’s rays. The sign studies. According to other data, 90% of nodes with spicules
and only 20% of nodes with clearly defined smooth contours Reference
are malignant. Nevertheless, both desmoplastic reactions
and tumor invasion can be determined in the structure of the 1. O'donovan PB (1997) The radiologic appearance of lung cancer.
corona radiata. Oncology (Williston Park) 11(9):1387–1402
Tail Sign, Pleural Tags, Rabbit’s Ears,
Pleural Tail Sign
Tail sign, also known as pleural tags, rabbit ears, and pleural through the substance of the peripheral pulmonary nodule
tail sign, represents thin, linear opacities arising from the lat- was first described by Rigler in 1965 [1]. It is believed that
eral edge of a peripheral pulmonary nodule, continuing to the this sign most often occurs in adenocarcinoma, but this pat-
pleural surface without interruption, and forming a wedge- tern is nonspecific and can be determined in granulomatous
shaped protrusion on the visceral pleura (↑). The line passing diseases and fibrosis. Pleural tails result from thickening of
Positive bronchus sign and navel-like retraction, rigler notch sign, rigler sign
The positive bronchus sign is considered valid if, on com- that this retraction is due to the bronchus passing along the
puted tomograms, the bronchus with a visible air lumen edge of the tumor (▲). The bronchus may be deformed, but
enters the peripheral node (or mass) and breaks off in it (↑). still passes by the mass, and does not break off in it. Today,
This sign is most often observed in malignant neoplasms the presence of а navel-like retraction means that verification
and, in particular, in adenocarcinomas of the lungs. Naidich by means of bronchoscopy is unlikely. This sign can also be
et al. [1] noted the importance of this sign for planning a seen in other conditions, including granulomatous diseases,
transbronchial biopsy. Taking this feature into account leads making it less specific for malignancy. This and several other
to positive biopsy resulting in 9 cases out of 10 at the bron- signs are named after the radiologist Rigler [2].
chial level of the 4th order. In the absence of a positive bron-
chus sign, the results of transbronchial biopsy are positive
only in 30% of cases with nodes less than 3 cm in diameter. References
Navel-Like retraction, also known as Rigler's Notch or
Rigler's sign, is defined on radiographs as a groove along the 1. Naidich DP, Sussman R, Kutcher WL, Aranda CP, Garay SM,
Ettenger NA (1988) Solitary pulmonary nodules. CT-bronchoscopic
medial (upper-medial, lower-medial) contour of the correlation. Chest 93(3):595–598
shadow—the site of tumor overgrowth of an adjacent large 2. Jacobson HG (1980) In memoriam. Leo G. Rigler, M.D. 1896–
vessel. On computed tomograms, it is clearly determined 1979. Radiology 135:247–248
Popcorn calcifications are a conglomerate of calcifications Concentric laminar calcifications of the peripheral lung node
that occupy most of the peripheral lung node (↑). On com- are called a target sign (▴), which occurs (in these latter days
puted tomograms, calcifications are amorphous, sharply rarely) with tuberculomas and histoplasmomas. The target is
outlined, irregularly lobed, with irregular rings and arcs, usually represented by concentric rings, in the center of the target
resembling popcorn in shape. It is believed that this sign is there is a bull’s eye ( ). The target center got its name from the
characteristic of pulmonary hamartomas, detection of practice of English archers, who tried to shoot an arrow through
macrostructural fat further confirms the diagnosis. Rare the eye socket of a bull’s skull. This sign occurs with hamarto-
cartilaginous tumors also show a similar pattern. mas, histoplasmomas, it is possible with any granulomas.
Birds on a wire
The perilymphatic distribution of nodules in the lungs is Along with other signs characteristic of sarcoidosis, the
characterized by their location along the blood vessels and location of the foci along the interlobar pleura is often noted,
airways and along the interlobular septa. The posterior walls which resembles a picture of the favorite pastime of Birds—
of peripherally located secondary lobules are adjacent to the in a Chainlet resting On a Wire (↑).
visceral pleura, including the area of interlobar fissures.
— Ja sitten yksi asia, puhuu hän vihdoin, -en ole tullut sitä ennen
sanoneeksi, en tiedä, miksi. Älä vahingossakaan sano Kallelle sitä…
tiedäthän?
— Sinä olet ollut hyvä vaimo, sanoo Hilu, -ja armo on meitä
kohtaan ollut suuri. Mutta se tulee vielä suuremmaksi… Hyvä on
lähteä, sinua jää vain ikävä, vaikkei saisi….
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