899

Pictorial
Essay

Pleural Effusion: Explanation of Some Typical

Appearances
American Journal of Roentgenology 1982.139:899-904.

Bernard N. Raasch,1 Edward W. Carsky,2 Edward J. Lane,3

John P. OCallaghan,14 and E. Robert Heitzman1

Almost 20 years have passed since the publication of due to gravity. Due to its elasticity, the lung tends to preserve
Felix Fleischners classic article on pleural fluid [1]. We its shape while recoiling from the chest wall. Fleischner [1]
review several important observations made in the interim termed this the form elasticity of the lung. This property
and collate them with Fleischners basic tenets. The origins acts to force some fluid to rise against gravity and surround
of some typical radiographic manifestations of pleural fluid the lower part of the lung. Fleischner [1 and Davis et al. [7] ]
are illustrated, including the meniscus configuration, sub- have shown that the upper limit of a free pleural effusion is
pulmonary effusion, apical fluid on supine radiographs, and horizontal and is located about the level of the apex of
interlobar effusion. Several radiographic appearances are the meniscus-shaped radiographic density. The x-ray beam
explained with anatomic specimens. Our recent study of the traverses a greater depth of fluid at the periphery of the
anatomy of the interlobar fissures [2] facilitates the under- thorax where the fluid is tangential to the beam (fig. 1 ). The
standing of interlobar fluid collections. superior margin of the peripheral fluid is therefore visible on
the radiograph, laterally on the erect frontal view and ante-
riorly and posteriorly on the lateral view (fig. 2). The superior
Meniscus Configuration of Pleural Fluid
margin of fluid located more medially does not produce a
The typical concave, upward-sloping contour of free layer of sufficient depth to be visible on the radiograph.
pleural fluid on erect frontal and lateral radiographs (the Davis states that the level of fluid within the interlobar
meniscus appearance) is well known. Earlier authors [3-6] fissures is also indicative of the true level of fluid surrounding
have suggested that this appearance was at least partly due the lung. Interlobar fluid visualized end on is seen to
to the cohesion between pleural surfaces drawing fluid better advantage than fluid between the lung and chest wall
superiorly. Rigler [6] believed that the greater retractile because the x-ray beam traverses a greater depth of fluid.
power of the lung at the periphery was also a contributing
factor. More recently, Fleischner [1 and Davis et al. [7] ] Subpulmonary Effusion

published independent articles showing that the meniscus Subpulmonary effusion was described by Rigler [6] as an
appearance can be explained entirely by the configuration . atypical distribution of pleural fluid. More recently, nu-
of free fluid within the pleural space and its relation to the x- merous authors [8-1 3] have agreed with Hessens [4] find-
ray beam. ing that if the lung is healthy and if there are no pleural
Fluid, of course, collects at the base of the pleural space adhesions, in the erect position pleural fluid normally accu-

Received July 24, 1 981 ; accepted after revision July 26, 1982.
Presented at the annual meeting of the American Roentgen Ray Society, Las vegas, April 1 980 as a scientific exhibit.
Department of Radiology, State University of New York, Upstate Medical Center, 750 E. Adams St., Syracuse, NY 1 3210. Address reprint requests to B. N.
Raasch.
2Department St. Josephs
of Radiology, Hospital Health Center, Syracuse. NY 13203.
3 428 S. Main
St., North Syracuse, NY 13212.
4Present address: Department of Radiology, Jervis Street Hospital, Dublin 1 , Ireland.
AJR 139:899-904, November 1982 0361 -803X/82/1 395-0899 $00.00 American Roentgen Ray Society
 Xrays

Transverse section
of plaster cast of
uniform thickness

Depth of plaster
penetrated by
x rays

I1C

Fig. 1 -A, Plaster cast simulating fluid

within pleural space. B, Frontal radiograph
of cast illustrates meniscus appearance of
pleural fluid. , Transverse section
American Journal of Roentgenology 1982.139:899-904.

through cast. Since x-ray beam must pen-

etrate greater depth of material at periph-
ery of thorax, upper margin at periphery
appears higher. Reprinted from [7].

Fig. 2.-Typical meniscus appearance

of free pleural fluid on erect frontal (A) and
lateral (B) radiographs.

ib
Fig. 3.-Subpulmonary effusion. Lateral position of apex of pseudodia- Fig. 4.-Subpulmonary effusion. Pulmonary vessel shadows are not visible
phragmatic contour is less evident on inspiration film (A), but is accentuated through pseudodiaphragmatic contour and there is increased distance to
on expiration film (B). gastric air bubble.
 ... . -

dodiaphragmatic
.iubpulmonary
surface
effusion.
has relatively
Pseu-
fiat
contour which appears to terminate at ma-
jon fissure.
Fig. 6.-A, Right lung viewed from me-
dial side. Undersurface of lower lobe is
sharply curved, resulting in interface me-
dially (arrowheads) that is in profile to lat-
American Journal of Roentgenology 1982.139:899-904.

eral x-ray beam. Undersurface of middle

lobe is continuous with major fissure and
extends medially to lesser degree than
posterior undersurface; therefore medial
edge (arrow) may or may not be in profile
to lateral beam. B, Lung radiographed in
plastic bag filled with water. Lung-fluid
interfaces both anterior and posterior to
major fissure are in profile to lateral x-ray
beam. Fluid is also extending superiorly
into major fissure.
Fig. 7.-Apical pleural fluid (arrows) on
supine radiograph.
Fig. 8.-CT images of right pleural ef-
fusion. Lower image located St carina, up-
per image at apex. Due to relatively small
capacity of apical thorax, fluid extends
laterally between lung and chest wall to
greater degree at apex than at base. Lat-
eral extension of fluid is tangential to fron-
tal x-ray beam (arrow).

Fig. 9.-A, Frontal radiograph of left thorax. Thumbtacks were carefully tangential to frontal x-ray beam.
placed along edge of thorax tangent to frontal x-ray beam (tacks placed by Fig. 10.-Erect radiograph taken same day on same patient as fig. 7. No
B. N. R. and E. R. H.). B, Lateral radiograph of same specimen. Thumbtacks apparent pleural fluid at lateral costophrenic angle.
demonstrate that in supine position, apex is most dependent part of thorax
 Fig. 1 1 -Typical appearance of fluid
in major fissure on erect frontal radio-
graph. Sharp lung-fluid interface medially
(arrows); density fades off laterally and
superiorly.
Fig. 1 2.-Parenchymal process in
lower lobe produces interface dense me-
American Journal of Roentgenology 1982.139:899-904.

dially and lucent laterally (black arrow).

Fluid in major fissure (white arrow) and
fluid capping apex (arrowheads).
Fig. 1 3.-Incomplete left major fissure
with wire placed along medial border. Due
to incompleteness, fluid within this fissure
could not be located medial to wire. Note
similarity of position of wire in this speci-
men to position of lung-fluid interface in
fig. 11.
Fig. 1 4.-A, Middle lobe step de-
scnibed by Fleischner [1]. Horizontal pla-
teau of fluid at minor fissure (arrowhead)
and curvilinear lung-fluid interface (arrow)
below minor fissure. B, Right lung with
wires placed along medial margins of mi-
nor and major fissures (cf. with A). Fluid
within incomplete minor fissure would pro-
duce horizontal plateau (arrowhead). Fluid
within incomplete major fissure would pro-
duce curvilinear lung-fluid interface below
minor fissure (arrow). Continuation of this
curvilinear interface can sometimes be
faintly seen above minor fissure.

I 1 5C
Fig. 15.-A, Left lung specimen in plastic bag of water, lateral view. Fluid [18]. f, CT scan through upper part of specimen in A. Fluid laterally within
in upper part of major fissure typically produces sharp interface posteriorly major fissure is tangential to lateral x-ray beam (arrow); fluid medially is
(arrows) which fades oft anteriorly. B, Cross-section of left lung at level of oriented obliquely to lateralbeam.
aortic arch. Note configuration of major fissure (arrows). Reprinted from
 Fig. 1 6.-A, Right lung specimen in plastic bag of water, frontal projection. Posteromedial margin of minor fissure (arrowhead) is oriented in same
Small amount of fluid is seen at both anterior and posterior parts (arrowheads) direction as superomedial margin of major fissure (arrow).
of incomplete minor fissure. Medial and superior extension of posterior part Fig. 1 7.-Fluid within minor and right major fissures, both of which are
is medial margin of major fissure (arrow). B, Right lung specimen with wires incomplete. Note anterior and posterior margins of minor fissure (white
placed along medial margins of minor and major fissures, frontal projection. arrows) and medial margin of major fissure (black arrows).
American Journal of Roentgenology 1982.139:899-904.

mulates in a subpulmonic location. As the amount of fluid on the lateral view. Typically, the pseudodiaphragmatic con-
increases there is flattening and some inversion of the tour presents a flat superior surface that slants sharply
diaphragm [1 4], but there is no significant blunting of the downward at the major fissure [1 1 ](fig. 5). The undersurface
lateral costophrenic angle (there may or may not be blunting of the lung posterior to the major fissure is sharply curved;
of the more dependent posterior costophrenic angle on the the interface between subpulmonary fluid and the medial
lateral view). Rigby et al. [1 3] recently studied the distribu- undersurface is therefore in profile to a lateral x-ray beam
tion of pleural fluid in dogs in an erect position. When the (fig. 6A). The undersurface of the anterior lung is continuous
dogs lungs were normally aerated, the fluid remained in a with the major fissure (fig. 6A) and is less sharply curved;
subpulmonic location, even when up to 2,000 ml was pres- therefore the interface between subpulmonary fluid and the
ent. Only when lower lobe collapse was induced did blunting medial undersurface may (fig. 6B) or may not be in profile
of the costophrenic angles occur. These findings are in to a lateral x-ray beam. Fluid is often seen extending supe-
disagreement with Fleischners ]
[1 hypothesis; he believed riorly into the fissure.
that subpulmonary effusion without blunting of the lateral
costophrenic angle was due to atelectasis in the lower lobe
attracting fluid to this location. Despite these disagreements, Apical Fluid
there is little doubt that subpulmonary effusion is not really
atypical, and is, in fact, rather common. Free pleural fluid characteristically layers posteriorly on
Several radiographic signs on erect frontal views suggest supine radiographs, producing a hazy density over the
the existence of subpulmonary fluid. The apex of the pseu- hemithorax [1 , 4, 1 6]. The fluid also often caps the apex of
dodiaphragmatic contour is often more lateral than the apex the lung on supine radiographs (fig. 7). We believe apical
of the normal diaphragm [1 , 5, 1 1 , 1 5]. This appearance is fluid on supine films is due to two factors. One is the
present in about 50% of cases but is accentuated and more relatively small capacity of the apex of the thorax compared
often present on expiration films [1 5] (fig. 3). When a sub- to the base. Fluid at the apex therefore tends to extend
pulmonary effusion is present, pulmonary vessel shadows between the lung and the superolateral chest wall, a locali-
cannot be seen through the pseudodiaphragmatic contour zation that is tangential to a frontal x-ray beam (fig. 8). A
[1 2] (fig. 4). This finding can also be produced by lower- second factor responsible for apical capping in the supine
lobe disease or by various abdominal conditions such as position is that the superior and lateral aspect of the apex is
ascites. On the left, the pseudodiaphragmatic contour is the most dependent part of the thorax tangential to a frontal
abnormally separated from the gastric air bubble [1 , 5, 1 1] x-ray beam (fig. 9).
(fig. 4). Since the normal distance between the gastric air In some cases, a small amount of pleural fluid may be
bubble and the left hemidiaphragm varies from a few milli- visible at the apex on a supine film even though it cannot be
meters to 1 cm (Hessen has stated up to 2 cm [4]), this detected at the lateral costophrenic angle on an erect film
finding is best evaluated when previous films are available (fig. 1 0). Conversely, free fluid does not always cap the
for comparison. apex on supine radiographs, and failure to visualize an
Equivocal findings on frontal radiographs are supported apical cap does not exclude the presence of a pleural
by the characteristic appearance of subpulmonary effusion effusion.
 904 RAASCH ET AL. AJR:139, November 1982

Interlobar Fluid Discussion

The radiographic appearance of interlobar fluid depends The typical radiographic appearances of pleural fluid are
on a number of factors: the shape of the fissure (its frontal well known; the anatomic basis for these appearances is not
outline and its concave or convex surface contour) [2], the as well known. A better understanding of the anatomy
orientation of the fissure (medial or lateral facing) [2], the producing the radiographic manifestations of pleural fluid
location of fluid within the fissure, and the direction of the x- cannot help but heighten diagnostic accuracy.
ray beam. The contact of interlobar fluid with lung produces
a sharp outline if the interface is tangential to the x-ray
beam. A hazy density results if the interface is oriented en
ACKNOWLEDGMENTS
face or obliquely to the beam.
The usual appearance of fluid within the major fissure on We thank Dr. Bedros Markanian for assistance in our studies of
the frontal view is characterized by a sharp curvilinear fixed and inflated lung specimens, Allen Ayres for art work, John
interface (often faint) which is lucent medially and more Hodgson for photography, and Linda King for manuscript prepara-
dense laterally and superiorly [1 7] (fig. 1 1 ). In contrast, an tion.
interface lucent laterally and more dense medially is due to
parenchymal disease in the lower lobe (fig. 1 2). The medial
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