DOI: 10.1148/radiol.2282020524
(Radiology 2003;228:415-416.)
© RSNA, 2003
The Deep Sulcus Sign1
Andrew Kong, MD
1 From the Department of Radiology, The Queen Elizabeth Hospital, Woodville Rd, Woodville, South Australia 5011, Australia. Received May 7, 2002; revision requested July 10; revision received July 30; accepted August 15. Address correspondence to the author (e-mail: andrew_kong@hotmail.com).
Index terms: Pneumothorax, 66.73 • Signs in Imaging
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APPEARANCE
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The deep sulcus sign (1) is seen on chest radiographs obtained with the patient in the supine position. It represents lucency of the lateral costophrenic angle extending toward the hypochondrium. The abnormally deepened lateral costophrenic angle may have a sharp, angular appearance (Figure).
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Supine chest radiograph of a neonate illustrates the deep sulcus sign with abnormal deepening and lucency of the left lateral costophrenic angle (*). Findings on right lateral decubitus chest radiograph (not shown) confirmed the presence of a pneumothorax on the left side.
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EXPLANATION
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When the patient is in the supine position, air in the pleural space (pneumothorax) collects anteriorly and basally within the nondependent portions of the pleural space; when the patient is upright, the air collects in the apicolateral location. If air collects laterally rather than medially, it abnormally deepens the lateral costophrenic angle and produces the deep sulcus sign.
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DISCUSSION
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Air enters the pleural space by crossing any of its boundaries, such as the chest wall, mediastinum, lung, or diaphragm (2). Recognition of a pneumothorax depends on the volume of air in the pleural space and the position of the body. The deep sulcus sign is a useful clue in the diagnosis of pneumothorax in neonates or in critically ill patients such as those who have undergone major trauma or are in intensive care units (2,3). These patients are least capable of communicating that they are experiencing dyspnea and pleuritic chest pain, which are the typical symptoms of pneumothorax.
The visceral pleural line, which is visible as a thin curvilinear opacity along the lung and is separated from the chest wall by air in the apical pleural space in the upright patient, is commonly not identifiable on radiographs of supine patients unless there is a sizable pneumothorax. Approximately 30% of pneumothoraces are undetected on supine radiographs (3). The deep sulcus sign of pneumothorax may be present following severe chest injury (4). It is important that the lateral costophrenic angles are included on the radiograph, as failure to diagnose pneumothorax may be life-threatening because of the risk of tension. This is also important in the intensive care setting for procedures such as insertion of a subclavian central venous catheter and for the use of positive pressure ventilation.
In addition to the deep sulcus sign, other clues may suggest the presence of a pneumothorax on supine radiographs (2,5,6): (a) relative lucency in the hypochondrial region or the entire hemithorax; (b) depression of an ipsilateral hemidiaphragm; (c) double-diaphragm appearance due to air outlining of the anterior costophrenic angle and aerated lung outlining the diaphragmatic dome; (d) improved sharpness of the cardiomediastinal border due to anteromedial collection of air, which may appear as a lucency; (e) increased sharpness of the pericardial fat pads; (f) visible inferior edge of a collapsed lower lobe or of the undersurface of the heart due to air in the pleural space; (g) band of air in the minor fissure bounded by two visceral pleural lines; or (h) visible lateral edge of the right middle lobe due to medial retraction in the presence of anterior pneumothorax.
Further evaluation with lateral decubitus radiography may be helpful, but computed tomography is more sensitive for confirming the presence of a pneumothorax in supine patients (6). False-positive cases of the deep sulcus sign have been described in patients with chronic obstructive pulmonary disease, in which hyperaeration of the lungs deepens the lateral costophrenic angle (1).
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FOOTNOTES
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A trainee (resident or fellow) wishing to submit a manuscript for Signs in Imaging should first write to the Editor for approval of the sign to be prepared, to avoid duplicate preparation of the same sign.
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REFERENCES
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- Gordon R. The deep sulcus sign. Radiology 1980; 136:25-27.[Abstract/Free Full Text]
- Grainger RG, Allison DJ, Adam A, Dixon AK. Diagnostic radiology New York, NY: Churchill Livingstone, 2001; 254-257.
- Brant WE, Helms CA. Fundamentals of diagnostic radiology Baltimore, Md: Williams & Wilkins, 1994; 503-506.
- Camassa N, Boccuzzi F, Troilo A, D’Ettorre E. Pneumothorax in severe chest injuries. Radiol Med (Torino) 1988; 75:156-159. [Italian].
- Armstrong P, Wilson AG, Dee P, Hansell DM. Imaging of diseases of the chest St Louis, Mo: Mosby, 2000; 770-771.
- Tocino I, Armstrong J. Trauma to the lung. In: Taveras J, eds. Radiology. Philadelphia, Pa: Lippincott-Raven, 1996; 1-8.
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