CT AND MR IN PLEURAL DISEASE

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A number of different imaging modalities are frequently used to image the pleural space. The most important is chest radiography which remains the initial examination in the assessment of pleural disease. Other imaging techniques can be used, however, and they include computed tomography (CT) and ultrasound. High resolution CT (HRCT) is used for evaluation of the lung parenchyma rather than the pleura. When HRCT is used to determine the presence of asbestosis in individuals exposed to asbestos, the pleura can also be imaged with this technique for the detection of pleural abnormalities such as plaques. Magnetic resonance (MR) imaging currently plays a limited, although occasionally important, role in the assessment of pleural abnormalities.

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CT Findings

On CT, free-flowing pleural fluid produces a sickle-shaped opacity in the most dependent part of the thorax posteriorly (Fig. 1).30 CT allows small amounts of pleural fluid to be detected. Loculated pleural fluid collections are seen as lenticular or rounded opacities in a fixed position (Fig. 2).30 CT is of limited value in differentiating transudates from exudates or in the diagnosis of chylous pleural effusions.30, 40, 42 Acute pleural hemorrhage, however, can be identified either by the

CT

CT is particularly helpful in establishing the diagnosis of empyema and in separating empyemas from lung abscesses. The most reliable sign is the so-called “split-pleura” sign which is usually identified during the organizing phase of an empyema (Fig. 7).52 After intravenous administration of a bolus of contrast medium, the parietal and visceral pleura will enhance vigorously, most likely because of the increased vascular supply in the inflamed pleura.52, 57 In an empyema, the parietal and

PNEUMOTHORAX

The majority of pneumothoraces are accurately demonstrated on standard chest radiographs. Subtle pneumothoraces, however, may not be visible, particularly in patients who are radiographed while supine. These include acutely traumatized patients and intensive care unit patients maintained on ventilator therapy. Such occult pneumothoraces are well shown by CT.56

FOCAL PLEURAL DISEASE

The most common focal pleural abnormalities include pleural plaques, localized pleural tumors, and local extension of bronchogenic carcinoma.

DIFFUSE PLEURAL DISEASE

Both benign and malignant diseases may cause diffuse pleural abnormalities. Causes include benign fibrothorax and malignant tumors such as malignant mesothelioma and metastatic carcinoma.

The radiographic definition of diffuse pleural thickening is somewhat arbitrary, and there is no general consensus on such a definition. It has been suggested, however, that diffuse pleural thickening consists of a smooth uninterrupted pleural opacity extending over at least a fourth of the chest wall with or

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    Address reprint requests to Theresa C. McLoud, MD, Department of Radiology - FND 216, Massachusetts General Hospital, 32 Fruit Street, Boston, MA 02114

    *

    Harvard Medical School, the Department of Radiology and Division of Thoracic and Cardiac Radiology, Massachusetts General Hospital, Boston, Massachusetts

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