1. CT halo sign (part 2) 2. Hampton hump sign 3. Westermark sign

1. Dr Mazen Qusaibaty
MD, DIS
Head Pulmonary and Internist
Department
Ibnalnafisse Hospital
Ministry of Syrian health
Email: Qusaibaty@gmail.com
1. CT halo sign (part 2)
2. Hampton hump
sign
3. Westermark sign

2. Topic Outline
1. CT halo sign (part 2)
2. Hampton hump sign
3. Westermark sign
2

3. Useful links
3
http://bjr.birjournals.org
http://radiographics.rsna.org
http://radiology.rsna.org

4. CT halo sign (part 2)

5. Bronchiolitis Obliterans with Organizing
Pneumonia
• An idiopathic disease
that produces
polypoid granulation
tissue in:
 Bronchioles
 alveolar ducts
5
ColbyTV. Pathologic aspects of bronchiolitis obliterans organizing
pneumonia. Chest 1992; 102(1 suppl): 38S–43S.

6. Bronchiolitis Obliterans with Organizing
Pneumonia
• Variable degrees of
interstitial and
airspace infiltration
by mononuclear cells
and foamy
macrophages
6
ColbyTV. Pathologic aspects of bronchiolitis obliterans organizing
pneumonia. Chest 1992; 102(1 suppl): 38S–43S.

7. The most common CT finding in patients with
BOOP
• Asymmetric bilateral
ground-glass opacity
• with a
predominantly
peripheral
distribution (arrows)
7 Courtesy of Paul Stark, MD.

8. The most common CT finding in patients with
BOOP
Consolidation
8

9. The most common CT finding in patients with
BOOP
Consolidation
Peribronchovascular
distribution
(peripheral)
9

10. The most common CT finding in patients with
BOOP
Consolidation
Peribronchovascular
distribution
(peripheral)
Lower zones
localization
10

11. The most common CT finding in patients with
BOOP
Consolidation
Peribronchovascular
distribution
(peripheral)
Lower zones
localization
Air bronchogram
11

12. The most common CT finding in patients with
BOOP
Consolidation
Peribronchovascular
distribution
(peripheral)
Lower zones
localization
Air bronchogram
One or more
nodules
12

13. The most common CT finding in patients with
BOOP
Consolidation
Peribronchovascular
distribution
(peripheral)
Lower zones
localization
Air bronchogram
One or more
nodules
One or more masses
13

14. BOOP
• Kim et al reported that
CT images of 06 of 31
patients with BOOP
showed nodular
ground-glass opacity
14
KimSJ, Lee KS, Ryu YH, et al. Reversed halo sign on high-resolution CT of cryptogenic organizing
pneumonia: diagnostic implications. AJR Am J Roentgenol 2003; 180: 1251–1254.

15. BOOP
A 46-year-old woman
• Axial CT image at the
level of the aortic arch
15
KimSJ, Lee KS, Ryu YH, et al. Reversed halo sign on high-resolution CT of cryptogenic organizing
pneumonia: diagnostic implications. AJR Am J Roentgenol 2003; 180: 1251–1254.

16. BOOP
A 46-year-old woman
• Shows multiple bilateral
areas of ill-defined
nodular ground-glass
opacity, some of which
contain solid
components (arrows).
16
KimSJ, Lee KS, Ryu YH, et al. Reversed halo sign on high-resolution CT of cryptogenic organizing
pneumonia: diagnostic implications. AJR Am J Roentgenol 2003; 180: 1251–1254.

17. Case
• 48-year-old woman with an eight-week
history of cough, dyspnea with exertion,
fatigue, and slight weight loss.
17

18. Case/ High-resolution CT scan of this patient
• RLL reticular and
hazy opacities that
are subpleural
18 Courtesy of Talmadge E King Jr, MD

19. Quiz conti…………..
• This picture is look like:
A. Idiopathic pulmonary
fibrosis.
B. Sarcoidosis stage IV
C. TB
D. BOOP
E. All above
19

20. Quiz conti…………..
• This picture is look like:
A. Idiopathic pulmonary
fibrosis.
B. Sarcoidosis stage IV
C. TB
D. BOOP
E. All above
20

21. Reverse halo sign: BOOP
CT of localized organizing pneumonia
manifesting as a solitary nodule of the
left lower lobe
21

22. Reverse halo sign: BOOP
This pattern may be diagnosed as
primary or metastatic lung tumor
22

23. Thoracic Endometriosis
Catamenial syndrome
23

24. Monthly recurrence
Hemoptysis, during
the menstrual
period
24
AlifanoM, Trisolini R, Cancellieri A, Regnard JF. Thoracic endometriosis: current knowledge. Ann Thorac
Surg 2006; 81: 761

25. Monthly recurrence
Hemoptysis, during
the menstrual
period
History
25
AlifanoM, Trisolini R, Cancellieri A, Regnard JF. Thoracic endometriosis: current knowledge. Ann Thorac
Surg 2006; 81: 761

26. Monthly recurrence
Hemoptysis, during
the menstrual
period
History
Pregnancy
26
AlifanoM, Trisolini R, Cancellieri A, Regnard JF. Thoracic endometriosis: current knowledge. Ann Thorac
Surg 2006; 81: 761

27. Monthly recurrence
Hemoptysis, during
the menstrual
period
History
Pregnancy
Obstetric-
gynecologic surgery
27
AlifanoM, Trisolini R, Cancellieri A, Regnard JF. Thoracic endometriosis: current knowledge. Ann Thorac
Surg 2006; 81: 761

28. Catamenial syndrome
• This disease group includes four well-
recognized clinical entities
1. Catamenial pneumothorax
2. Catamenial hemothorax
3. Catamenial hemoptysis
4. Lung nodules
28
AlifanoM, Trisolini R, Cancellieri A, Regnard JF. Thoracic endometriosis: current knowledge. Ann
Thorac Surg 2006; 81: 761

29. CPT
• Catamenial
pneumothorax is a
rare condition
characterized by a
reoccurrence of air
in the pleural space
coinciding with the
onset of menses.
29
http://www.catamenial-pneumothorax.com/id15.htm

30. CPT
• CPT was first
described in
literature in 1958
30
http://www.catamenial-pneumothorax.com/id2.htm

31. CPT
• It is almost always
right-sided
31
http://www.catamenial-pneumothorax.com/id2.htm

32. CPT
• Generally affects
women in their
thirties and forties
32
http://www.catamenial-pneumothorax.com/id2.htm

33. CPT
• Although the exact etiology of the condition is
unknown
• Most physicians agree that endometriosis is
involved.
33
http://www.catamenial-pneumothorax.com/id2.htm

34. CPT
• Documented case
studies have described
endometrial implants
on the:
 Lung
 Pleura
 Diaphragmatic
fenestrations (holes in the
diaphragm)
34
http://www.catamenial-pneumothorax.com/id2.htm

35. CPT
• Case studies report
women with CPT
experiencing monthly
 Chest pain
 Shortness of breath
 Dizziness and fatigue
35
http://www.catamenial-pneumothorax.com/id2.htm

36. CPT
• Case studies report women with CPT
experiencing monthly
Some women have experienced multiple lung
collapses over a period of several years.
Many of these women have also been diagnosed
with pelvic endometriosis.
36
http://www.catamenial-pneumothorax.com/id2.htm

37. Case 1
• In a 42-year-old woman who presented with:
 Three episodes of spontaneous pneumothorax,
each associated with the onset of menses.
37
http://radiographics.rsna.org/content/21/1/193/F43.expansion.html

38. Case 1
 She had
undergone a prior
hysterectomy for
endometriosis
38
http://radiographics.rsna.org/content/21/1/193/F43.expansion.html

39. Case 1
Had a 2-3-year history of:
• Episodic cough
• Hemoptysis
• Pleuritic chest pain
39
http://radiographics.rsna.org/content/21/1/193/F43.expansion.html

40. Posteroanterior chest radiograph
• Shows a right-sided
pneumothorax
• A nodular opacity in
the right lung base
(arrow)
40
http://radiographics.rsna.org/content/21/1/193/F43.expansion.html

41. Case 2
Chest CT scan (lung windows)
• Shows a 2.5-cm solitary
pulmonary nodule in
the right lower lobe
(arrow).
41
http://radiographics.rsna.org/content/21/1/193/F43.expansion.html

42. Parenchymal endometrioma in a 74-year-old
woman
• The lesion was found
on a routine
preoperative chest
radiograph obtained
for cataract surgery.
42
http://radiographics.rsna.org/content/21/1/193/F43.expansion.html

43. Parenchymal endometrioma in a 74-year-old
woman
• She had been receiving
estrogen replacement
therapy since
undergoing
hysterectomy
• She had no known
history of
endometriosis
43
http://radiographics.rsna.org/content/21/1/193/F43.expansion.html

44. Case 3
Catamenial hemoptysis syndrome in a 24-
year-old woman with recurrent monthly
hemoptysis during menstruation
44
http://radiographics.rsna.org/content/27/2/391/F29.expansion.html

45. Axial CT image at the level of the
diaphragmatic dome
Multiple areas of ill-defined nodular
ground-glass opacity (arrows)
45 http://radiographics.rsna.org/content/27/2/391/F29.expansion.html

46. The patient underwent a
bronchoscopic examination, and
endometrial tissue was found at
bronchial lavage
46 http://radiographics.rsna.org/content/27/2/391/F29.expansion.html

47. Focal Traumatic Lung Injury
47

48. Focal Traumatic Lung Injury
• Traumatic lung injury may be manifested as
nodular ground-glass opacity at CT during
subsequent disease progression
48

49. Focal Traumatic Lung Injury
• A transthoracic lung
biopsy
• A transbronchial
biopsy
49
KazerooniEA, Cascade PN, Gross BH. Transplanted lungs: nodules following transbronchial
biopsy. Radiology 1995; 194: 209–212.

50. Pseudonodule in a 56-year-old woman who
underwent a previous percutaneous lung biopsy
• Thin-section CT
image obtained at
the level of the
aortic arch
50

51. Pseudonodule in a 56-year-old woman who
underwent a previous percutaneous lung biopsy
• Shows a 9-mm well-
defined nodular
ground-glass opacity
(arrow) in the right
upper lobe
51

52. Pseudonodule in a 56-year-old woman who
underwent a previous percutaneous lung biopsy
• Axial image obtained
during CT-guided
percutaneous
transthoracic biopsy
with the patient in the
supine position shows
the biopsy needle
(arrow), which has
been inserted near the
nodule
52

53. Pseudonodule in a 56-year-old woman who
underwent a previous percutaneous lung biopsy
• Axial CT image,
obtained after the
biopsy, shows a poorly
defined pseudonodule
represented by ground-
glass opacity (arrow)
along the biopsy tract
53

54. Pseudonodule in a 56-year-old woman who
underwent a previous percutaneous lung biopsy
• The pathologic
diagnosis, obtained
after a wedge
resection, was focal
interstitial fibrosis
54

55. Pulmonary Embolism Signs
55

56. Radiographic signs with a relatively high
specificity but low sensitivity for PTE
1. Pleura-based areas of increased opacity
(Hampton sign)
2. Decreased vascularity in the peripheral lung
(Westermarck sign)
3. Enlargement of the central pulmonary artery
(Fleischner sign)
4. Hemidiaphragm elevation
56
Worsley DF, Alavi A, Aronchick JM, Chen JT, Greenspan RH, Ravin CE.Chest radiographic findings in patients
with acute pulmonary embolism: observations from the PIOPED Study. Radiology 1993; 189:

57. Helical CT Findings in Acute PTE
57

58. Helical CT Findings in Acute PTE
58

59. Helical CT Findings in Acute PTE
59

60. Helical CT Findings in Acute PTE
60

61. Helical CT Findings in Acute PTE
61

62. Helical CT Findings in Acute PTE
62

63. Helical CT Findings in Acute PTE
63

64. Acute PE

65. Helical CT Findings in Chronic PTE
65

66. Pulmonary Embolism
Acute PE
Central intraluminal filling defects
Parenchyma: rounded pleural-based densities, pleural
effusion
Subacute PE
Convex mural filling defects
Parenchyma: oval pleural-based densities, pleural effusion
Chronic PE
Concave mural filling defects, intraluminal “rope ladder”
Irregular wall thickening, abnormal vascular tapering,
variation in size of segmental vessels
Parenchyma: translobular lines, mosaic perfusion, pleural
effusion
BC: Wacker_Gustav_19330609_BC_zentral/Akute LE: Sauer_Erna_DOB19211226_LE
CTEPH: Prell/Sarkom: Jpn. J. Clin. Oncol. Uchida et al. 35 (7): 417

67. Chronic PE
Concave mural filling defects
67

68. Chronic PE
Intraluminal “rope ladder”
68

69. Hampton hump sign
69

70. Hampton hump sign
A homogeneous
wedge-shaped
consolidation in the
lung periphery

71. Hampton hump sign
A base contiguous to a
visceral pleural

72. Hampton hump sign
A rounded convex apex
directed toward the
hilum

73. Hampton hump sign
Associated with
pulmonary infarct

74. Hampton hump sign
• Left intraluminal filling defects in left pulmonary artery
• Pulmonary infarction secondary to pulmonary embolism
• Bilateral pleural effusion
74

75. Computed tomography angiogram in a 53-year-
old man with acute pulmonary embolism
• This image shows an
intraluminal filling
defect that occludes :
The anterior basal
segmental artery of
the right lower lobe
Acute Pulmonary Embolism (Helical CT): Imaging Contributor Information and Disclosures
Updated: May Author: Kavita Garg, MD, Professor, Department of Radiology, University of Colorado Health
Sciences Center- 14, 2008

76. Computed tomography angiogram in a 53-year-
old man with acute pulmonary embolism
• An infraction of the
corresponding lung,
which is indicated by:
o A triangular, pleura-
based consolidation
(Hampton hump)
Acute Pulmonary Embolism (Helical CT): Imaging Contributor Information and Disclosures
Updated: May Author: Kavita Garg, MD, Professor, Department of Radiology, University of Colorado Health
Sciences Center- 14, 2008

77. Case 3
• A young man who
experienced:
o Acute chest pain
o Shortness of breath
after a
transcontinental
flight
77
Acute Pulmonary Embolism (Helical CT): Imaging Contributor Information and Disclosures
Updated: May Author: Kavita Garg, MD, Professor, Department of Radiology, University of Colorado Health
Sciences Center- 14, 2008

78. Case 3
Computed tomography angiography
• This image
demonstrates a clot in :
o The anterior
segmental artery in
the left upper lung
o A clot in the anterior
segmental artery in
the right upper lung
78
Acute Pulmonary Embolism (Helical CT): Imaging Contributor Information and Disclosures
Updated: May Author: Kavita Garg, MD, Professor, Department of Radiology, University of Colorado Health
Sciences Center- 14, 2008

79. Westermark sign
79

80. Westermark sign
Refers to an area of
oligemia with minimal
change in lung volume
distal to a large PE

81. Westermark sign
This regional oligemia
is caused either by:
•Mechanical
obstruction to blood
flow by the clot
•Reflex vasoconstriction

82. Case 4
• A 41-year-old woman presented to the
emergency department complaining of a
three-day history of left-sided chest pain.
82

83. Case 4
• The pain was described as pressure-like,
pleuritic, made worse with ambulation and
when supine.
83

84. Case 4
• The pain was constant, increasing in intensity
and not associated with any alleviating
factors, hence her request for evaluation
84

85. Case 4
• Six weeks prior to the onset of her chest pain
she had complained of:
Right hip pain, radiating down the leg.
This was diagnosed as radicular pain secondary to
sciatica for which she had been under bed rest
and analgesics
85

86. Case 4
• Her past medical history was remarkable for:
Depression
Occasional migraine headaches
Two cesarean sections
Oral contraceptive
86

87. Case
• Physical examination was normal
87

88. Axial CT image of the chest
A mass extending outside the vessel
wall + a large filling defect involving
the left main pulmonary artery and
extending into all sub-branches.
88

89. Coronal reformatted CT image of the chest
Demonstrating a mass extending
outside the vessel wall
89

90. Sagittal reformatted CT image of the chest
Demonstrating a mass extending
outside the vessel wall
90

91. What diagnosis that do you expect?
A. Left large cell
carcinoma
B. Bronchioloalveolar
carcinoma
C. Left small cell
carcinoma
D. Chronic left chronic
pulmonary embolism
E. Pulmonary
angiosarcoma
91

92. What diagnosis that do you expect?
A. Left large cell
carcinoma
B. Bronchioloalveolar
carcinoma
C. Left small cell
carcinoma
D. Chronic left chronic
pulmonary embolism
E. Pulmonary
angiosarcoma
92

93. ‫خلقنا‬ ‫داق‬ ‫بقا‬ ‫حاجه‬