Imaging of pleural effusions in adults
- Paul Stark, MD
Paul Stark, MD
- Professor of Radiology
- University of California San Diego
- Section Editors
- Talmadge E King, Jr, MD
Talmadge E King, Jr, MD
- Editor-in-Chief — Pulmonary and Critical Care Medicine
- Section Editor — Interstitial Lung Disease
- Dean, School of Medicine
- Vice Chancellor, Medical Affairs
- University of California San Francisco
- Nestor L Muller, MD, PhD
Nestor L Muller, MD, PhD
- Section Editor — Pulmonary Imaging
- Professor of Radiology
- University of British Columbia
- V Courtney Broaddus, MD
V Courtney Broaddus, MD
- Section Editor — Pleural Disease
- Professor of Medicine
- University of California San Francisco
- Deputy Editors
- Geraldine Finlay, MD
Geraldine Finlay, MD
- Senior Deputy Editor — UpToDate
- Deputy Editor — Pulmonary, Critical Care, and Sleep Medicine
- Associate Professor
- Tufts University School of Medicine
- Susanna I Lee, MD, PhD
Susanna I Lee, MD, PhD
- Deputy Editor — Radiology
- Associate Professor of Radiology
- Harvard Medical School
- Massachusetts General Hospital
Detection of pleural effusion(s) and the creation of an initial differential diagnosis are highly dependent upon imaging of the pleural space. Conventional chest radiography and computed tomography (CT) scanning are the primary imaging modalities that are used for evaluation of all types of pleural disease, but ultrasound and magnetic resonance imaging (MRI) have a role in selected clinical circumstances.
The imaging of pleural effusions will be presented here. Imaging of pleural plaques, thickening, tumors, and pneumothorax are discussed separately. (See "Imaging of pleural plaques, thickening, and tumors" and "Imaging of pneumothorax".)
NORMAL PLEURAL ANATOMY
The term pleura is generally meant to encompass the parietal pleura (lining the inner surface of the chest wall, including the diaphragmatic pleura and the cervical pleura also called dome of pleura or pleural cupola that covers the lung apex and extends into the cervical region), the visceral pleura (lining the outer surface of the lung), and the intervening pleural space. Both visceral and parietal pleural surfaces consist of a mesothelial layer and three to seven connective tissue layers, but the visceral pleura is thicker than the parietal pleura. Together, the visceral and parietal pleural layers and the lubricating liquid in the interposed pleural space have a combined thickness of 0.2 to 0.4 mm, while the width of the pleural space is 10 to 20 micrometers. (See "Mechanisms of pleural liquid turnover in the normal state".)
Normal pleural anatomy can be displayed by computed tomography (CT) scanning . A 1 to 2 mm thick line of soft-tissue attenuation can be seen at the point of contact between the lung and the chest wall, corresponding to the visceral and parietal pleura and the minimal amount of lubricating pleural liquid (image 1).
Extrapleural fat and the endothoracic fascia, each with a thickness of 0.25 mm, are visible between the pleural line and the ribs (or the subcostal and innermost intercostal muscles). The apical part of the endothoracic fascia is thickened and is called Sibson's fascia. Outside this fascia is a space filled with areolar tissue, called Semb's space. The anterior and posterior junction lines are well outlined by lung and contain four layers of pleura: two visceral and two parietal components (image 2A-B). The interlobar fissures and most accessory fissures in the lungs are formed by two layers of visceral pleura, with the exception of the azygos vein fissure, which contains four layers of pleura, ie, two visceral and two parietal layers of pleura.
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- NORMAL PLEURAL ANATOMY
- CONVENTIONAL RADIOGRAPHY
- Subpulmonic effusions
- Loculated pleural effusions
- COMPUTED TOMOGRAPHY
- MAGNETIC RESONANCE IMAGING
- FDG-PET SCANNING
- TRANSUDATIVE PLEURAL EFFUSIONS
- Hepatic hydrothorax
- EXUDATIVE PLEURAL EFFUSIONS
- Malignant pleural effusion
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS