Westermark sign

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Westermark sign
Differential diagnosis hypovolemia

In chest radiography, the Westermark sign is a sign that represents a focus of oligemia (hypovolemia) (leading to collapse of vessel) seen distal to a pulmonary embolism (PE). [1] While the chest x-ray is normal in the majority of PE cases, [2] the Westermark sign is seen in 2% of patients. [3]

Contents

Essentially, this is a plain X-ray version of a filling defect as seen on computed tomography pulmonary arteriogram.

The sign results from a combination of:

  1. the dilation of the pulmonary arteries proximal to the embolus and
  2. the collapse of the distal vasculature creating the appearance of a sharp cut off on chest radiography.

Sensitivity and specificity

The Westermark sign, like Hampton's hump (a wedge shaped, pleural based consolidation associated with pulmonary infarction), has a low sensitivity (11%) and high specificity (92%) for the diagnosis of pulmonary embolism. [4] Put more simply, the Westermark sign is seldom seen in pulmonary embolism. When visible on a chest X-ray, the Positive Predictive Value is only 33%. That is, 33% of the time that Westermark sign is seen on Chest XRay does a pulmonary embolism actually exist .

Etymology

It is named after Nils Westermark, a Swedish radiologist. [5]

Related Research Articles

<span class="mw-page-title-main">Pulmonary embolism</span> Blockage of an artery in the lungs

Pulmonary embolism (PE) is a blockage of an artery in the lungs by a substance that has moved from elsewhere in the body through the bloodstream (embolism). Symptoms of a PE may include shortness of breath, chest pain particularly upon breathing in, and coughing up blood. Symptoms of a blood clot in the leg may also be present, such as a red, warm, swollen, and painful leg. Signs of a PE include low blood oxygen levels, rapid breathing, rapid heart rate, and sometimes a mild fever. Severe cases can lead to passing out, abnormally low blood pressure, obstructive shock, and sudden death.

<span class="mw-page-title-main">Pleural effusion</span> Accumulation of excess fluid in the pleural cavity

A pleural effusion is accumulation of excessive fluid in the pleural space, the potential space that surrounds each lung. Under normal conditions, pleural fluid is secreted by the parietal pleural capillaries at a rate of 0.6 millilitre per kilogram weight per hour, and is cleared by lymphatic absorption leaving behind only 5–15 millilitres of fluid, which helps to maintain a functional vacuum between the parietal and visceral pleurae. Excess fluid within the pleural space can impair inspiration by upsetting the functional vacuum and hydrostatically increasing the resistance against lung expansion, resulting in a fully or partially collapsed lung.

<span class="mw-page-title-main">Air embolism</span> Vascular blockage by air bubbles

An air embolism, also known as a gas embolism, is a blood vessel blockage caused by one or more bubbles of air or other gas in the circulatory system. Air can be introduced into the circulation during surgical procedures, lung over-expansion injury, decompression, and a few other causes. In flora, air embolisms may also occur in the xylem of vascular plants, especially when suffering from water stress.

<span class="mw-page-title-main">Pulmonary artery</span> Artery in pulmonary circulation carrying deoxygenated blood from heart to lungs

A pulmonary artery is an artery in the pulmonary circulation that carries deoxygenated blood from the right side of the heart to the lungs. The largest pulmonary artery is the main pulmonary artery or pulmonary trunk from the heart, and the smallest ones are the arterioles, which lead to the capillaries that surround the pulmonary alveoli.

<span class="mw-page-title-main">Deep vein thrombosis</span> Formation of a blood clot (thrombus) in a deep vein

Deep vein thrombosis (DVT) is a type of venous thrombosis involving the formation of a blood clot in a deep vein, most commonly in the legs or pelvis. A minority of DVTs occur in the arms. Symptoms can include pain, swelling, redness, and enlarged veins in the affected area, but some DVTs have no symptoms.

<span class="mw-page-title-main">Atelectasis</span> Partial collapse of a lung causing reduced gas exchange

Atelectasis is the partial collapse or closure of a lung resulting in reduced or absence in gas exchange. It is usually unilateral, affecting part or all of one lung. It is a condition where the alveoli are deflated down to little or no volume, as distinct from pulmonary consolidation, in which they are filled with liquid. It is often referred to informally as a collapsed lung, although more accurately it usually involves only a partial collapse, and that ambiguous term is also informally used for a fully collapsed lung caused by a pneumothorax.

<span class="mw-page-title-main">Chest radiograph</span> Projection X-ray of the chest

A chest radiograph, chest X-ray (CXR), or chest film is a projection radiograph of the chest used to diagnose conditions affecting the chest, its contents, and nearby structures. Chest radiographs are the most common film taken in medicine.

<span class="mw-page-title-main">Pulmonary consolidation</span> Medical condition of the lung

A pulmonary consolidation is a region of normally compressible lung tissue that has filled with liquid instead of air. The condition is marked by induration of a normally aerated lung. It is considered a radiologic sign. Consolidation occurs through accumulation of inflammatory cellular exudate in the alveoli and adjoining ducts. The liquid can be pulmonary edema, inflammatory exudate, pus, inhaled water, or blood. Consolidation must be present to diagnose pneumonia: the signs of lobar pneumonia are characteristic and clinically referred to as consolidation.

<span class="mw-page-title-main">Hampton hump</span> Pattern seen in radiologic examinations

Hampton's hump, also called Hampton hump, is a radiologic sign which consists of a shallow wedge-shaped opacity in the periphery of the lung with its base against the pleural surface. It is named after Aubrey Otis Hampton, who first described it in 1940. Hampton's hump along with Westermark sign may aid in the diagnosis of pulmonary embolism, although they are rare and their sensitivities and interoperator reliabilities are low. If the sign is present in an image, there is a high chance that the person has a pulmonary embolism, but when the sign is absent a pulmonary embolism is not ruled out.

<span class="mw-page-title-main">Computed tomography angiography</span> Medical investigation technique

Computed tomography angiography is a computed tomography technique used for angiography—the visualization of arteries and veins—throughout the human body. Using contrast injected into the blood vessels, images are created to look for blockages, aneurysms, dissections, and stenosis. CTA can be used to visualize the vessels of the heart, the aorta and other large blood vessels, the lungs, the kidneys, the head and neck, and the arms and legs. CTA can also be used to localise arterial or venous bleed of the gastrointestinal system.

<span class="mw-page-title-main">CT pulmonary angiogram</span> Medical imaging of blood flow between heart and lungs

A CT pulmonary angiogram (CTPA) is a medical diagnostic test that employs computed tomography (CT) angiography to obtain an image of the pulmonary arteries. Its main use is to diagnose pulmonary embolism (PE). It is a preferred choice of imaging in the diagnosis of PE due to its minimally invasive nature for the patient, whose only requirement for the scan is an intravenous line.

<span class="mw-page-title-main">Keutel syndrome</span> Medical condition

Keutel syndrome (KS) is a rare autosomal recessive genetic disorder characterized by abnormal diffuse cartilage calcification, hypoplasia of the mid-face, peripheral pulmonary stenosis, hearing loss, short distal phalanges (tips) of the fingers and mild mental retardation. Individuals with KS often present with peripheral pulmonary stenosis, brachytelephalangism, sloping forehead, midface hypoplasia, and receding chin. It is associated with abnormalities in the gene coding for matrix gla protein, MGP. Being an autosomal recessive disorder, it may be inherited from two unaffected, abnormal MGP-carrying parents. Thus, people who inherit two affected MGP alleles will likely inherit KS.

<span class="mw-page-title-main">Pulmonary contusion</span> Internal bruise of the lungs

A pulmonary contusion, also known as lung contusion, is a bruise of the lung, caused by chest trauma. As a result of damage to capillaries, blood and other fluids accumulate in the lung tissue. The excess fluid interferes with gas exchange, potentially leading to inadequate oxygen levels (hypoxia). Unlike pulmonary laceration, another type of lung injury, pulmonary contusion does not involve a cut or tear of the lung tissue.

<span class="mw-page-title-main">Lung nodule</span> Medical condition

A lung nodule or pulmonary nodule is a relatively small focal density in the lung. A solitary pulmonary nodule (SPN) or coin lesion, is a mass in the lung smaller than three centimeters in diameter. A pulmonary micronodule has a diameter of less than three millimetres. There may also be multiple nodules.

Obstructive shock is one of the four types of shock, caused by a physical obstruction in the flow of blood. Obstruction can occur at the level of the great vessels or the heart itself. Causes include pulmonary embolism, cardiac tamponade, and tension pneumothorax. These are all life-threatening. Symptoms may include shortness of breath, weakness, or altered mental status. Low blood pressure and tachycardia are often seen in shock. Other symptoms depend on the underlying cause.

<span class="mw-page-title-main">Palla's sign</span> Pattern seen in radiologic examinations

Palla's sign is a clinical sign in which an enlarged right descending pulmonary artery is seen on the chest x-ray in patients with pulmonary embolism. It is of low sensitivity, and its specificity is not known. It exhibits as a "sausage" appearance on X-ray. It is named after italian radiologist Antonio Palla. In 1983, he published his observations that close to 25% of patients with pulmonary embolism had a chest x-ray sign of enlarged right descending pulmonary artery.

<span class="mw-page-title-main">Ground-glass opacity</span> Radiologic sign on radiographs and computed tomography scans

Ground-glass opacity (GGO) is a finding seen on chest x-ray (radiograph) or computed tomography (CT) imaging of the lungs. It is typically defined as an area of hazy opacification (x-ray) or increased attenuation (CT) due to air displacement by fluid, airway collapse, fibrosis, or a neoplastic process. When a substance other than air fills an area of the lung it increases that area's density. On both x-ray and CT, this appears more grey or hazy as opposed to the normally dark-appearing lungs. Although it can sometimes be seen in normal lungs, common pathologic causes include infections, interstitial lung disease, and pulmonary edema.

<span class="mw-page-title-main">Mediastinal shift</span> Medical condition of the chest cavity

Mediastinal shift is an abnormal movement of the mediastinal structures toward one side of the chest cavity. A shift indicates a severe imbalance of pressures inside the chest. Mediastinal shifts are generally caused by increased lung volume, decreased lung volume, or abnormalities in the pleural space. Additionally, masses inside the mediastinum or musculoskeletal abnormalities can also lead to abnormal mediastinal arrangement. Typically, these shifts are observed on x-ray but also on computed tomography (CT) or magnetic resonance imaging (MRI). On chest x-ray, tracheal deviation, or movement of the trachea away from its midline position can be used as a sign of a shift. Other structures, like the heart, can also be used as reference points. Below are examples of pathologies that can cause a mediastinal shift and their appearance.

Fleischner sign is a radiological sign that aids the diagnosis of pulmonary embolism. The sign indicates the dilatation of the proximal pulmonary arteries due to pulmonary embolism. It was named after Felix Fleischner, who first described it. The Fleishner sign is seen both on X-ray and CT scan of chest/thorax.

Knuckle sign is a radiologic sign used for diagnosing pulmonary embolism. The presence of a blood clot in the branch of a pulmonary artery can resemble a knuckle in CT and X-ray images, which is why it is called knuckle sign. It is frequently seen along with other signs of pulmonary embolism, such as the Fleischner sign and Westermark sign.

References

  1. Ray J (2003). "Westermark sign and suspected pulmonary embolism". Can J Cardiol. 19 (3): 317, author reply 317. PMID   12680403.
  2. Introduction to Chest Radiography. http://www.med-ed.virginia.edu/courses/rad/cxr/index.html
  3. Worsley D, Alavi A, Aronchick J, Chen J, Greenspan R, Ravin C (1993). "Chest radiographic findings in patients with acute pulmonary embolism: observations from the PIOPED Study". Radiology. 189 (1): 133–6. doi:10.1148/radiology.189.1.8372182. PMID   8372182.
  4. Gurney J. CT: Diagnosis of Pulmonary Embolism. chestx-ray.com. Available at: http://www.chestx-ray.com/Lectures/PulmEmbLecture/PulmEmbolus.pdf. Accessed on: November 13, 2006.
  5. Dorland's Illustrated Medical Dictionary (32 ed.). Elsevier Health Sciences. 2011-06-09. p. 2080. ISBN   978-1455709854.