Circulation. 2007;115:e211
doi: 10.1161/CIRCULATIONAHA.106.665422
(Circulation. 2007;115:e211.)
© 2007 American Heart Association, Inc.
Images in Cardiovascular Medicine |
Westermark’s and Palla’s Signs in Acute Pulmonary Embolism
Shiva Sreenivasan, MBBS, MRCP(UK);
Sarah Bennett, MBBS;
Vernon J. Parfitt, MBChB, MRCP(UK), MD, FRCP
From the North Bristol NHS Trust, Bristol, United Kingdom.
Correspondence to Shiva Sreenivasan, Emergency Assessment Unit, Weston General Hospital, Grange Rd, Weston-super-Mare BS23 4TQ, United Kingdom. E-mail shivasreenivasan{at}nhs.net
A 58-year-old asthmatic man was referred to the Medical Assessment Unit with exertional breathlessness, left shoulder pain, and recurrent syncope. Six weeks before admission, he had sustained a fracture of his right third metatarsal and had been in a right below-knee plaster cast, which had been removed a few days earlier. He had been seen on 2 occasions in the preceding 10 days by his general practitioner and the local emergency department, and he had been started on treatment for angina and antibiotics for a lower–respiratory tract infection. On arrival, his oxygen saturations were 88% on air. A chest x-ray showed an elevated left hemidiaphragm and an area of focal oligemia (Westermark’s sign1) in the right lung (Figure 1, area between white arrowheads), with a prominent right descending pulmonary artery (Palla’s sign2; Figure 1, black arrow). The patient was started on low-molecular-weight heparin. Ventilation–perfusion lung scintigraphy revealed bilateral large mismatched ventilation–perfusion defects, one of which corresponded to the radiographic area of focal oligemia (Figure 2, white arrowhead).
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Figure 1. Chest radiograph demonstrating focal oligemia in the right lung (area between white arrowheads) and a prominent right descending pulmonary artery (black arrow).
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Figure 2. Perfusion lung scintigraphy demonstrating large bilateral perfusion defects, one of which corresponds to the area of focal oligemia seen on the chest radiograph (white arrowhead).
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Westermark’s and Palla’s signs in combination are rare3 but, when seen, can help confirm diagnosis of pulmonary embolism.
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Disclosures
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None.
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References
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1. Westermark N. On the roentgen diagnosis of lung embolism.
Acta Radiol. 1938; 19: 357–372.
[CrossRef]2. Palla A, Donnamaria V, Petruzzelli S, Rossi G, Riccetti G, Giuntini C. Enlargement of the right descending pulmonary artery in pulmonary embolism. AJR Am J Roentgenol. 1983; 141: 513–517.[Abstract/Free Full Text]
3. Piazza D, Goldhaber SZ. Acute pulmonary embolism: epidemiology and diagnosis. Circulation. 2006; 114: e28–e32.[Free Full Text]
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Circulation 2007 115: 945.
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