2. Gamal Rabie Agmy, MD, FCCP
Professor of Chest Diseases, Assiut University

3. Ginkgo leaf sign
• The ginkgo leaf sign is a chest plain
radiography appearance which is
seen at extensive subcutaneous
emphysema of the chest wall. Air
outlines the fibers of the pectoralis
major muscle and creates a
branching pattern that resembles
the branching pattern in the veins of
a ginkgo leaf.

5. Golden S sign
The Golden S sign is seen on both PA chest radiographs and
on CT scans. It is named because this sign resembles a
reverse S shape, and is therefore sometimes referred to as
the reverse S sign of Golden.
Although typically seen with right upper lobe collapse, the S
sign can also be seen with the collapse of other lobes. It is
created by a central mass obstructing the upper lobe
b r o n c h u s a n d s h o u l d r a i s e s u s p i c i o n o f a
primary bronchogenic carcinoma. It can also be caused by
other central masses, such as: metastasis, primary
me di a sti nal t umour, or e nl ar ge d l ymph node s .

6. S Curve of Golden
When there is a mass
adjacent to a fissure, the
fissure takes the shape
of an "S". The proximal
convexity is due to a mass,
and the distal concavity is
due to atelectasis. Note the
shape of the transverse
fissure.
This example represents a
RUL mass with atelectasis

7. Incomplete Border Sign
(Pregnant Lady Sign)
• The incomplete border sign is useful to depict an
extrapulmonary mass on chest radiograph.
• An extrapulmonary mass will often have a inner well
defined border and an ill-defined outer margin . This
can be attributed to the inner margin being
tangential to the x-ray beam and has good inherent
contrast with the adjacent lung. On the other hand,
the outer margin is enface or partially enface with
the x-ray beam and merges with the pleural or chest
wall thus the border is obscured.

9. Holly leaf sign
The holly leaf sign refers to the
appearance of pleural plaques on
chest x-rays. Their irregular
thickened nodular edges are
likened to the appearance of a
holly leaf.

11. Juxtaphrenic peak sign
The juxtaphrenic peak sign refers to the peaked
or tented appearance of a hemidiaphragm which
can occur in the setting of lobar collapse. It is
caused by retraction of the lower end of
diaphragm at an inferior accessory fissure (most
common), major fissure or inferior pulmonary
ligament. It is commonly seen in upper lobe
collapse but may also be seen in middle lobe
collapse.

13. Chang sign refers to a dilatation
and abrupt change in calibre of a
main pulmonary artery due
to pulmonary embolism
Chang sign

14. Coin lesion
Coin lesion refers to a round or oval, well-
circumscribed solitary pulmonary lesion. It is
typically 1-5 cm in diameter and calcification
may or may not be present. Typically but not
always the patient is asymptomatic .

15. Coin lesion
The differential diagnosis for such lesions is :
malignancy
e.g. squamous cell carcinoma-primary lung malignancy
metastases
infection
;tuberculosispulmonary
Streptococcus sp., Staphlycoccus sp., or Klebisialla
sp. infection
cysthydatid
abscess
benign disease processes
granulomatosisWegener's
hamartomapulmonary
malformationarteriovenouspulmonary
rheumatoid nodule
bronchogenic cystadenomabronchial

17. PseudoCoin lesion
pseudo-coin lesion", which are caused
by artifacts (e.g. button on patient's clothing,
unilateral nipple shadow, etc).

18. PseudoCoin lesion

19. Dense hilum sign
The dense hilum sign suggests a
pathological process at the hilum - hilar
malignancy or bronchogenic
carcinoma should be suspected.
On a well-centred chest PA radiograph the
density of the hilum is comparable on both
sides. In absence of calcification
or adenopathy, the hila should appear of
equal density and be symmetric.
.

21. CT angiogram Sign
Identification of vessels within an
airless portion of lung on contrast-
enhanced CT .
The vessels are prominently seen
against a background of low-
attenuation material .
Associatedwith:
bronchoalveolar cell carcinoma
lymphoma
infectious pneumonias.

22. Fallen Lung Sign
This sign refers to the appearance
of the collapsed lung occurring
with a fractured bronchus .
The bronchial fracture results in
the lung to fall away from the
hilum, either inferiorly and laterally
in an upright patient or posteriorly,
as seen on CT in a supine patient.
DD:
Pneumothorax causes a lung to
collapse inward toward the hilum.

23. Ring Around Artery Sign
•Visualized on lateral chest radiographs
•Lucency along or surrounding RPA
•Characteristic of pneumomediastinum
•Usually is accompanied by other ancillary signs:
•continuous diaphragm sign
•Naclerio’s V sign
•thymic sail sign

25. Thymic Sail Sign Naclerio’s V Sign

26. Flat waist Sign
This sign refers to flattening of the contours of the aortic knob and adjacent
main pulmonary artery .
It is seen in severe collapse of the left lower lobe and is caused by leftward
displacement and rotation of the heart

28. Finger in Glove Sign
Visible on chest radiographs or CT
•Indicates mucoid impaction within an obstructed bronchus
•Characterized by branching tubular or fingerlike opacities

29. Finger in Glove Sign
Originate from the hilum and are directed
peripherally
•Also seen in cases of dilated bronchi with
secretions
•Distal lung remains aerated by collateral
drift through interalveolar pores (pores of
Kohn) and Lambert canal

31. Hampton Hump Sign
Pulmonary infarction secondary to pulmonary embolism produces
an abnormal area of opacification on the chest radiograph, which
is always in contact with the pleural surface.

32. Luftsichel Sign
•German for sickle of air (luft: air sichel:
crescent)
•Paramediastinal lucency due to
interposition of lower lobe apex between
mediastinum and shrunken upper lobe
•Occurs more commonly on the left than in
the right

35. Halo Sign
CT shows nodular consolidation associated with a halo of ground-glass opacity
(GGO) in both apices resulting from invasive pulmonary aspergillosis.
This halo represents hemorrhage.
When seen in leukemic patients, is highly suggestive of the diagnosis of
invasive pulmonary aspergillosis.

36. Double Density Sign
•Indicates left atrial enlargement
•Occurs when right side of the left atrium
pushes into adjacent lung
•Splaying of the carina
•Superior displacement of left main stem
bronchus on frontal view

37. Double Density Sign
•Posterior displacement of left main stem
bronchus on lateral view
•Posterior displacement of esophagus on
barium study

38. Walking Man Sign

39. Juxtaphrenic Peak Sign
This sign refers to a small triangular shadow that obscures the dome of
the diaphragm secondaryto upper lobe atelectasis . The shadow is
caused by traction on the lower end of the major fissure, the inferior
accessory fissure, or the inferior pulmonaryligament.

40. Luftsischel Sign
In left upper lobe collapse, the superior segment of the left lower lobe, which is
positioned between the aortic arch and the collapsed left upper lobe, is
hyperinflated. This aerated segment of left lower lobe is hyperlucent and
shaped like a sickle, where it outlines the aortic arch on the frontal chest
radiograph.
This peri-aortic lucency has been termed the luftsichel sign, derived from the
German words luft (air) and sichel (sickle).

41. Doughnut Sign
•Detect mediastinal adenomegaly
•Lateral chest radiograph
•Subcarinal lymphadenopathy
•Mass posterior to bronchus intermedius
and inferior hilar window
•CT primary modality for detecting
mediastinal lymphadenopathy

42. Pulmonary
hypertension
Normal
Lymphadenopathy

43. Cervicothoracic Sign
•Used to determine location of mediastinal
lesion in the upper chest
•Based on principle that an intrathoracic
lesion in direct contact with soft tissues of
the neck will not outlined by air
•Uppermost border of the anterior
mediastinum ends at level of clavicles

44. Cervicothoracic Sign
• Middle and posterior mediastinum extends
above the clavicles
•Mediastinal mass projected superior the
level of clavicles must be located either
within middle or posterior mediastinum
•More cephalad the mass extends the most
posterior the location

47. Thoracoabdominal Sign
•Posterior costophrenic sulcus extends
more caudally than anterior basilar lung
•Lesion extends below the dome of
diaphragm must be in posterior chest
whereas lesion terminates at dome must be
anterior
•Cervicothoracic and thoracoabdominal
signs were described by Felson

49. Tapered Margins Sign
•A lesion in the chest wall, pleura or
mediastinum have smooth tapered
borders and obtuse angles
•While parenchymal lesions usually form
acute angles

52. Water Bottle Sign

53. Westermark Sign
•Described by Neils Westermark in 1938
•Chest radiograph and CT show
increased lucency or hypoattenuation
•Typically signifies either occlusion of a
larger lobar/segmental artery or
widespread small vessel occlusion

54. Fleischner Sign
•Described by Felix Fleischner
•Enlargement proximal pulmonary
arteries on plain film or angiography
•PA enlargement due to embolus
•Commonly in the setting of massive PE
•It has relatively low sensitivity
•Abrupt tapering of an occluded vessel
distally (knuckle sign)

56. Hilum Overlay Sign
•Described by B. Felson
•If hilar vessels are sharply delineated it
can be assumed that the overlying mass
is anterior or posterior
•If mass inseparable pulmonary arteries
structures are adjacent to one another

59. Hilum Convergence Sign
•Described by B. Felson
•Used to distinguish between a prominent
hilum and an enlarged pulmonary artery
•If branches of PA converge toward central
mass is an enlarged PA
•If branches of PA converge toward heart
rather than mass is a mediastinal tumor

61. CT Halo Sign

62. CT Halo Sign
•Ground glass attenuation surrounding a
pulmonary nodule/mass on CT images
•Described by Kuhlman in 1985 in patients
with invasive aspergillosis
•Associated w hemorrhagic nodules and
may be caused neo or inflammatory
•Disease pathologically active with tumor
spread, hemorrhage or inflammation

64. Reverse Halo Sign
•Central ground-glass opacity surrounded
by denser consolidation of crescentic or
ring shape, at least 2 mm thick
•First described by Voloudaki in 1996
•Kim in 2003 used the term reverse halo
•Found to be relatively specific for crypto-
genic organizing pneumonia (COP)

65. Reverse Halo Sign
•Seen in other conditions:
•Wegener’s granulomatosis
•lymphomatoid granulomatosis
•paracoccidiodomycosis
•neoplastic (metastasis)
•invasive aspergillosis
•lipoid pneumonia

67. Split Pleura Sign
•Seen on contrast enhanced CT of
chest
•Thickened visceral and parietal pleura
with separation by a collection
•Empyema or exudative effusion
•Exudative: bacterial pneumonia,
cancer, viral infection, PE

69. Tree-in-Bud Sign
•Commonly seen at thin-section CT
•Initially described in endobronchial spread
of Tuberculosis
•Recognized in diverse entities
•Small centrilobular nodules soft-tissue
attenuation connected to multiple branching
structures

70. Tree-in-Bud Sign
•

72. Crazy Paving Sign
•Scattered or diffuse GG attenuation w
superimposed intralobular and interlobular
septa thickening
•Commonly seen at thin-section CT
•Initially described in PAP
•Recognized in diverse entities

73. Crazy Paving Sign

75. Comet Tail Sign
•Seen on CT of the chest
•Consists of curvilinear opacity extending
from subpleural mass toward hilum
•Produced by the distortion vessels and
bronchi that lead to adjacent rounded
atelectasis

77. Signet Ring Sign
•Seen on CT/HRCT scans of chest
•CT finding in patient with bronchiectasis
•Ring shadow representing dilated thick-
walled bronchus associated a nodular opacity
representing pulmonary artery
•Distinguish from cystic lung lesions

78. Pearl ring sign

79. More black sign
The more black sign is a normal finding in lateral chest x-
ray, and refers to the gradual increased apparent
radiolucency (blackness) of the vertebral bodies, when
proceeding from upper to lower chest. This is due to the
increased proportion of the chest comprised of air
containing lungs over distal dorsal spine compared to the
upper parts.
When the air is displaced by higher attenuation material,
such as consolidation, fluidor a mass (e.g. bronchogenic
carcinoma, paraspinal neurogenic tumour) then the lower
dorsal vertebral bodies become more radiodense; this is
referred to as the loss of the more back sign and is also
known as the spine sign.

81. Steeple sign
The steeple sign (also called wine bottle
sign) refers to tapering of the
upper trachea on a frontal chest
radiograph reminiscent of a church
steeple. The appearance is suggestive
of croup, which should be obvious
clinically. A corresponding lateral x-ray
would show narrowing of the subglottic
trachea and ballooning of the
hypopharyn

83. Shmoo sign
Shmoo sign refers to appearance of
prominent, rounded left ventricle and dilated
aorta on a plain AP radiograph of chest giving
the appearance of Shmoo, a fictional cartoon
character in the comic strip Abner in the
1940s. This signs indicates left ventricular
hypertrophy.