Pleural Effusion Radiography Overview

Imaging
Many benign and malignant
Updated: Oct 27, 2015
diseases can cause pleural effusion.
Author: Omar Lababede, The characteristics of the fluid
MD; Chief Editor: Kavita depend on the underlying
Garg, MD more... pathophysiologic mechanism. The
fluid can be transudate, nonpurulent
Kavita Garg, MD is a member of the exudate, pus, blood, or chyle.
following medical societies: Imaging studies are valuable in
American College of Radiology, detecting and managing pleural
American Roentgen Ray Society, effusions but not in accurately
Radiological Society of North characterizing the biochemical nature
America, Society of Thoracic of the fluid. Images of pleural
Radiology effusion are shown below.

Judith K Amorosa, MD,

FACR Clinical Professor of
Radiology and Vice Chair for Faculty
Development and Medical
Education, Rutgers Robert Wood
Johnson Medical School

Judith K Amorosa, MD, FACR is a

member of the following medical
societies: American College
Radiology, American Roentgen Ray
Society, Association of University
Radiologists, Radiological Society of
North America, Society of Thoracic
Radiology
Disclosure: Nothing to disclose.
of
Illustration of the chest, depicted in
an upright position from the lateral
aspect, shows a small effusion
accumulating in the posterior
costophrenic (CP) sulcus. Such small
effusion cannot be detected on the
frontal view but can be visible on the
lateral radiographic view as blunting
of the posterior CP angle (blue arrow
on the next image).
Depiction of upright posteroanterior
and lateral views of the chest (using
overlay on actual normal radiograph)
demonstrates the radiographic
appearance of small left effusion as
the one in the previous image. The
blue arrow points to the effusion.
Illustration of the chest, depicted in
an upright position from the lateral
aspect, shows a larger small effusion
accumulating in the lower chest,
which can be detected on both lateral
and frontal radiographic views. This
effusion produces blunting of the
lateral costophrenic angle on the
frontal view.
Depiction of upright posteroanterior
and lateral views of the chest (using
overlay on actual normal radiograph)
demonstrates the radiographic
appearance of a larger small left
effusion as the one in the previous
image. The blue arrows point to the
effusions.
 llustration of upright posteroanterior
and lateral views of the chest (using
overlay on actual normal radiograph)
demonstrates the radiographic
appearance of a moderate left

Illustration of the chest, depicted in effusion, as in the previous image.

an upright position from the lateral The blue arrows point to the

aspect. This image shows a moderate effusions.

effusion accumulating in the lower

chest, which can be seen on both the
frontal and lateral views as a
dependent density with meniscal-
shaped margin. Note that the actual
fluid upper margin is horizontal.
However, there is more fluid
posteriorly and laterally due to the
shape of the chest and recoil
characteristics of the lung. Illustration of the chest, depicted in
supine position from the lateral
aspect, shows a moderate effusion
accumulating in the posterior aspect
of the chest. This layering effusion
can be visible on the frontal view as
an increased haziness. The vascular
structures can be seen through this used to confirm a pleural effusion,
density. especially in cases of loculated
pleural effusion, complete
opacification of hemithorax, or
associated lung parenchymal
abnormalities. Ultrasonography and
CT scanning are more accurate than
chest radiography in identifying the
[2, 3, 4]
underlying etiology. Both
modalities can depict small effusions
not visualized radiographically, and
they are also used to guide
interventional procedures to manage
pleural effusions. [5, 6, 7, 8, 9, 10, 11, 12]
Right lateral decubitus view in a 42-
year-old woman with breast cancer Magnetic resonance imaging (MRI)
confirms a right pleural effusion by is sometimes used to evaluate
demonstrating dependent layering of questionable CT findings; this
the fluid (arrows). modality has been reported to be
more sensitive than CT scanning in
Preferred examination
differentiating benign from

Different imaging modalities can be malignant causes of effusion. [13]

used to diagnose and manage pleural

Limitations of techniques
disease. Findings on chest
radiographs frequently confirm the Radiographic studies may not help in
presence of pleural effusion. Lateral differentiating parenchymal
decubitus projections enhance the processes from pleural processes. In
sensitivity of conventional addition, chest radiography is limited
radiography. in evaluating the underlying etiology,
as in differentiating benign disease
Depending on the clinical context,
from malignant pleural disease.
ultrasonography or computed
tomography (CT) scanning can be
Other problems to be considered Percutaneous thoracocentesis is
reportedly most successful in
Things to keep in mind when
effusions that are
viewing a chest radiograph are an
ultrasonographically anechoic,
elevated hemidiaphragm and/or
complex, or complex with movable
herniation, pleural thickening and/or
septa, as compared with echogenic or
fibrothorax, and subpleural fat. When
complex effusions with fixed septa.
viewing a CT scan, consider ascites
However, in one study, no correlation
and/or a subphrenic abscess.
was found between the
ultrasonographic appearance of the
Radiologic intervention
effusion and the success of
The advent of percutaneous chest drainage.
ultrasonography and CT scanning
The success rate of radiologically
and the advances in drainage catheter
guided drainage procedures is 72-
design and interventional techniques
88%.
have made imaging-guided
management of intrathoracic
collections a safe and effective
alternative to traditional surgical
therapy. [14]

Ultrasonography or CT scanning can

be used to guide thoracocentesis or
[15]
catheter drainage of effusions.
Thoracocentesis is primarily
performed under ultrasonographic
rather than CT scan guidance. The
use of image guidance improves the
safety of the procedure and reduces
the rate of complications. The small
catheters are also associated with a
complication rate lower than that
associated with thoracotomy tubes.
Radiography remain horizontal. The relation
between orientation of the x-ray
Typical pleural effusion: overview
beam and the fluid surface affects the
radiographic appearance of the
Many factors influence the
effusion.
radiographic findings of pleural
effusion, including the nature of the
Typical pleural effusion: upright
fluid (free vs loculated), the amount
frontal view
of fluid, the patient's position, the
radiographic projection, and the A small amount of effusion
presence of underlying lung accumulates in a subpulmonic
abnormalities. In the absence of location, causing slight elevation of
clinically significant lung the hemidiaphragm. As the fluid
parenchymal changes, free pleural increases, the fluid starts to spill over
fluid tends to accumulate in the most into the most dependent costophrenic
dependent portion of the chest sulci. Small effusions may not be
because of a difference in density visualized on frontal views due to the
compared with the air-filled lung. orientation of the diaphragm,
The pressure of the fluid causes because the posterior costophrenic
atelectasis of the adjacent sulcus is inferior to the lateral
(dependent) lung tissue. Lung costophrenic sulcus. Fluid
elasticity tends to preserve the shape accumulating posteriorly can be seen
of the collapsed lung. As a on the lateral view before it becomes
consequence, the lung collapses from visible on the frontal view (see the
the periphery toward the hilum, with images below).
a higher degree of collapse in the
When the fluid is slightly above the
dependent portion of the lung.
level of the upper portion of the
These factors force some of the fluid diaphragm, blunting of the lateral
to rise against gravity and surround costophrenic angle is seen. This is
the dependent portion of the lung. the earliest sign of pleural effusion
The fluid-lung interface is curved, on the frontal view. A minimal
but the upper limits of the fluid amount of fluid (approximately 175
mL) is required to produce detectable A very large pleural effusion appears
blunting. As much as 500 mL of as an opaque hemithorax with a
pleural fluid can be present without mediastinal shift to the contralateral
apparent changes on the frontal view. side. The mediastinal shift can be
less prominent or even absent in the
A large free pleural effusion appears
presence of underlying lung
as a dependent opacity with lateral
pathology (eg, atelectasis) or
upward sloping of a meniscus-shaped
contralateral hemithorax
contour. The diaphragmatic contour
abnormality.
is partially or completely obliterated,
depending on the amount of the fluid
(silhouette sign). Differences in the
depth to which the x-ray beam
traverses the fluid produce the
contour of the meniscus. Although
the true upper limit of the fluid is
horizontal, only the lateral aspect of
the fluid is visible as the meniscal
apex. (The apex of the meniscus can
be slightly lower than the actual Posteroanterior chest radiograph in a
upper limit.) Because the fluid is 42-year-old woman with breast
laterally tangential to the x-ray beam, cancer shows blunting of the right
the depth of fluid penetration cardiophrenic angle (arrow) with
increases and consequently increases slight elevation of the right
attenuation of the radiation. The hemidiaphragm.
depth of the fluid penetrated
anteriorly and posteriorly is small,
especially in the upper portion of the
effusion. The attenuation is not
sufficient to produce a shadow on the
radiograph.
 Loculated effusion in the minor
fissure (arrow). The opacity is
smoothly marginated and biconvex.

Posteroanterior chest radiograph in a

50-year-old man with non-Hodgkin
lymphoma shows an opacity (E) in
the lower left hemithorax with
obliteration of the left Posteroanterior chest radiograph in a

hemidiaphragm and a curvilinear 69-year-old man demonstrates right

upper margin (arrow) and a pleural effusion. No other definite

mediastinal shift to the right. These abnormalities are seen.

findings are typical of a pleural

effusion. In addition, minimal
blunting of the right costophrenic
angle is present. Cardiomegaly and a
possible mediastinal mass are noted.

Posteroanterior chest radiograph in a

54-year-old man with hemoptysis
demonstrates opacification of the
right hemithorax with mediastinal
shift to the right. In addition, an
abrupt cutoff of the right mainstem
bronchus is present.

Typical pleural effusion: upright

lateral view

A small amount of effusion

accumulates in a subpulmonary
location, causing slight elevation of
the ipsilateral hemidiaphragm. As the
fluid increases, the amount of fluid
spills over into the most dependent
(posterior) costophrenic sulci. Small
effusions appear as a dependent
opacity with posterior upward
sloping of a meniscus-shaped Illustration of the chest, depicted in

contour. The opacity obliterates the an upright position from the lateral

underlying portion of the aspect, shows a small effusion

diaphragmatic contour (silhouette accumulating in the posterior

sign). The images below demonstrate costophrenic (CP) sulcus. Such small

the position and appearance of effusion cannot be detected on the

pleural effusions as seen in upright frontal view but can be visible on the

lateral views. lateral radiographic view as blunting

of the posterior CP angle (blue arrow
on the next image).
 lateral costophrenic angle on the
frontal view.

Depiction of upright posteroanterior

and lateral views of the chest (using
overlay on actual normal radiograph)
demonstrates the radiographic
Depiction of upright posteroanterior
appearance of small left effusion as
and lateral views of the chest (using
the one in the previous image. The
overlay on actual normal radiograph)
blue arrow points to the effusion.
demonstrates the radiographic
appearance of a larger small left
effusion as the one in the previous
image. The blue arrows point to the
effusions.

Illu
stration of the chest, depicted in an
upright position from the lateral
aspect, shows a larger small effusion
accumulating in the lower chest,
which can be detected on both lateral
and frontal radiographic views. This Illustration of the chest, depicted in
effusion produces blunting of the an upright position from the lateral
aspect. This image shows a moderate
effusion accumulating in the lower
chest, which can be seen on both the
frontal and lateral views as a
dependent density with meniscal-
shaped margin. Note that the actual
fluid upper margin is horizontal.
However, there is more fluid
posteriorly and laterally due to the
shape of the chest and recoil
characteristics of the lung.
Illustration of upright posteroanterior
and lateral views of the chest (using
overlay on actual normal radiograph)
demonstrates the radiographic
appearance of a moderate left
effusion, as in the previous image.
The blue arrows point to the
effusions.
Large free pleural effusion appears as
a dependent opacity with a meniscus-
shaped contour. The highest points of
the meniscus are anteriorly and
posteriorly located at approximately
the same level. The ipsilateral
diaphragmatic contour is obliterated
(silhouette sign). Variation in the
depth of fluid traversed by the x-ray
beam produces the contour of the
meniscus. As noted, the actual upper
limit of the fluid is horizontal. The
anterior and posterior aspects are
visible as the meniscal apices
because the fluid is tangential to the
x-ray beam, with increased depth of
fluid penetration and attenuation. The
depth of the penetrated fluid laterally
is too small to produce a shadow on
the radiograph, especially in the
upper portion of the effusion.
A very large pleural effusion
produces generalized increased
opacity with obliteration of the
underlying hemidiaphragm. Only 1
diaphragm on the lateral view may
be a clue to a large pleural effusion.
The images below demonstrate the
position and appearance of pleural
effusions as seen in upright lateral
views.
Typical pleural effusion: supine
frontal view

The normal supine view does not

exclude the presence of effusion.
This view is the least sensitive for
detecting pleural effusions. A
somewhat large amount of fluid is
required to produce detectable
Posteroanterior supine view of the
radiographic findings, especially in
chest in a 60-year-old man with
bilateral effusions (see the following
right-sided effusion. The pleural fluid
images).
is layering, given the position of the
patient. There is asymmetric density
with increased haziness in the lower
right hemithorax (blue arrow). Note
that the pulmonary vascular
structures are not obscured or
silhouetted by the vague density but,
rather, are still visible through it
(open arrow).
Illustration of the chest, depicted in
supine position from the lateral In one study, a minimal volume of
aspect, shows a moderate effusion 175 mL was required to produce
accumulating in the posterior aspect notable change on the supine
of the chest. This layering effusion radiograph. [16] The fluid accumulates
can be visible on the frontal view as in the posterior aspect of the
an increased haziness. The vascular hemithorax. The lung fluid interface
structures can be seen through this is mostly in a plane perpendicular or
density. oblique (not tangential) to the
orientation of the x-ray beam.
Subsequently, the effusion initially
causes generalized hazy
homogeneous opacity with
defined margins.
The opacity first projects over the
lower lung zones. With further fluid
accumulation, the opacity of the
entire hemithorax increases, and
obliteration of the diaphragm
becomes obvious. Depending on the
amount of the fluid and the degree of
the lung collapse, lung markings (eg,
vessels) can be seen through this
opacity (see the image below). This
finding helps in differentiating
opacity secondary to effusion from
one caused by lung parenchymal
abnormalities, such as atelectasis or
airspace disease.
ill- with increased haziness in the lower
right hemithorax (blue arrow). Note
that the pulmonary vascular
structures are not obscured or
silhouetted by the vague density but,
rather, are still visible through it
(open arrow).
The absence of an air bronchogram
also helps in differentiation. Well-
defined ipsilateral apical opacity
(apical capping) is often produced,
especially with large effusions. This
opacity is believed to be secondary to
small capacity of the lung at the apex
with the extension of the fluid lateral
and superior to the lung tissue.
Blunting of the costophrenic angles
(meniscus sign), which can be seen
in more than 50% of large effusions,
is attributed to accumulation of fluid
about the level of the lateral
costophrenic sulcus.

Typical pleural effusion: lateral

decubitus view

A lateral decubitus view obtained

with a horizontal x-ray beam is the
Posteroanterior supine view of the
most sensitive radiographic
chest in a 60-year-old man with
projection for detecting an effusion.
right-sided effusion. The pleural fluid [17]
A small amount of fluid (10-25
is layering, given the position of the
mL) can be depicted on this
patient. There is asymmetric density
projection. The layering fluid can
easily be detected as a dependent,
sharply defined, linear opacity
separating the lung from the parietal
pleural and chest wall (see the image
below), and the parietal pleurachest
wall margin can be identified as a
line connecting the inner apices of
the curvature of the ribs.
Right lateral decubitus view in a 42-
year-old woman with breast cancer
confirms a right pleural effusion by
demonstrating dependent layering of
the fluid (arrows).
In some patients, especially obese
patients, the parietal pleura is slightly
medial to this line because of
subpleural fat. This appearance is
easily appreciated, because it is
bilateral on frontal examination and
because it persists on the
nondependent hemithorax of the
contralateral decubitus image.
Atypical pleural effusion: overview
Although a small effusion may
accumulate first in a subpulmonary
location, accumulated fluids usually
spill into the posterior costophrenic
sulcus.
Atypical pleural effusion: large
subpulmonary effusion
A large subpulmonary effusion can
be considered an atypical effusion.
Unilateral subpulmonary effusion is
more common on the right side. On
upright frontal and lateral views,
subpulmonary effusion presents as an
elevated diaphragm
(pseudodiaphragmatic contour).
Additional findings, which can help
in suggesting the presence of
effusion, include the following:
 On the posteroanterior (PA)
view: The peak of the
pseudodiaphragmatic contour
is more lateral than the peak
of the normal diaphragm.
Sometimes, thin triangular
upward extension of the fluid
can be seen medially on the
left side.
On the lateral view:
Frequently, the
pseudodiaphragmatic contour
is interrupted anteriorly by
the major fissure, with a
sharp descent into the anterior
costophrenic sulcus.
Extension of a small amount
of fluid through the inferior
aspect of the major fissure
can be seen as well.
On both PA and lateral views:
In contrast to the normal
diaphragmatic opacity, the
pulmonary vessels are poorly
visualized through the
pseudodiaphragmatic contour.
The gastric gas lucency is
widely separated (>2 cm)
from the
pseudodiaphragmatic contour
in cases of left subpulmonic
effusion.
Atypical pleural effusion: loculated
pleural effusion
An atypical distribution of pleural
fluid can be also caused by loculation
secondary to adhesions or by lung
parenchymal changes that alter the
recoil characteristics of the lung. The
second mechanism can occur in
atelectasis. Loculation secondary to
adhesions is usually secondary to an
infected or hemorrhagic effusion.
Loculated effusions produce
peripheral soft-tissue opacity with
smooth obtuse tapering margins
when seen tangentially. Loculated
effusion in the pulmonary fissures
(demonstrated below) appears as a
well-defined elliptical opacity with
pointed margins.
 projections are the most sensitive
radiographic images for detecting
free pleural effusion. Even large,
loculated or atypical effusions may
demonstrate substantial gravitational
movement to suggest their nature.

False Positives/Negatives

Pleural thickening and/or fibrothorax

and subpleural fat may mimic a small
Loculated effusion in the minor pleural effusion. Subpulmonic
fissure (arrow). The opacity is effusion is sometimes hard to
smoothly marginated and biconvex. differentiate from an elevated
hemidiaphragm.

Small pleural effusions can be

difficult to detect radiographically. In
addition, lung parenchymal
abnormalities may obscure large
Degree of Confidence effusions.

Upright chest radiography is highly

sensitive in detecting pleural
effusion. Lateral decubitus