Journal of Emergencies, Trauma, and Shock
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LETTER TO EDITOR  
Year : 2014  |  Volume : 7  |  Issue : 1  |  Page : 57-58
Westermark's and Palla's signs in acute and chronic pulmonary embolism: Still valid in the current computed tomography era


Department of Medicine, Division of Cardiovascular Diseases, 200 First St SW Rochester MN, 55905, United States

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Date of Web Publication23-Jan-2014
 

How to cite this article:
Brenes-Salazar JA. Westermark's and Palla's signs in acute and chronic pulmonary embolism: Still valid in the current computed tomography era. J Emerg Trauma Shock 2014;7:57-8

How to cite this URL:
Brenes-Salazar JA. Westermark's and Palla's signs in acute and chronic pulmonary embolism: Still valid in the current computed tomography era. J Emerg Trauma Shock [serial online] 2014 [cited 2020 May 30];7:57-8. Available from: http://www.onlinejets.org/text.asp?2014/7/1/57/125645


Sir,

Pulmonary embolism is a dreaded complication of venous thrombosis that accounts for at least 300,000 deaths in the United States yearly. [1] Not many decades ago, [2] plain chest X-rays were a preferred non-invasive imaging modality to evaluate for pulmonary embolism. Careful analysis of plain x-rays in the appropriate clinical setting can occasionally yield classic radiologic signs described in the literature, [3],[4] which may lead to confirmatory investigations.

A 62-year-old male with no significant medical history presented to the Emergency Department with progressive dyspnea on exertion for 3 weeks; on initial assessment, his vital signs were within normal limits. His physical examination was unrevealing. His chest X-ray [Figure 1] showed focal, demarcated oligemia in the upper right lung (circle, Westermark's sign), in contrast to a prominent right descending pulmonary artery (arrow, Palla's sign). Pulmonary embolism was strongly suspected, and the patient was started on intravenous unfractionated heparin. A computed tomography (CT) pulmonary angiogram was obtained, which confirmed the presence of extensive, saddle emboli at the right pulmonary artery [Figure 2], with eccentric shape, along with smaller thrombus on the left pulmonary artery, consistent with acute and chronic pulmonary embolism.
Figure 1: Chest x-ray on a PA projection that shows focal relative oligemia of the right upper lung (Westermark's sign, circle), in contrast to significantly dilated right descending pulmonary artery, with a "sausage-like" appearance (Palla's sign, arrow)

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Figure 2: CT pulmonary angiogram, coronal view, maximum intensity projection (MIP) series, with evidence of a large sized, saddle pulmonary embolus at the right pulmonary artery (arrow), with eccentric appearance suggestive of chronic thromboembolism; there are also smaller filling defects on the left pulmonary artery (ellipse), consistent with acute emboli

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The concurrence of Westermark's and Palla's signs has been reported in cases of acute pulmonary embolism; [5] we documented their presence in a patient with acute and chronic pulmonary embolism. Individuals with chronic hypoxemia, secondary erythrocytosis, and a positive Westermark's sign have a 2.3 times higher probability of being diagnosed with chronic pulmonary embolism, as compared to those in whom this radiologic sign is absent. [6] Despite the superior sensitivity of multi-slice CT angiogram for the diagnosis of acute and chronic pulmonary embolism, we should not neglect the diagnostic information provided by more modest techniques, including plain chest x-rays, as they continue to be the most common radiologic tests ordered in Emergency Departments around the world.

 
   References Top

1.Tapson VF. Acute pulmonary embolism. N Engl Med J 2008;358:1037-52.  Back to cited text no. 1
    
2.Pipavath SN, Godwin JD. Acute pulmonary thromboembolism: A historical perspective. AJR Am J Roentgenol 2008;191:639-41.  Back to cited text no. 2
[PUBMED]    
3.Westermark N. On the roentgen diagnosis of lung embolism. Acta Radiol 1938;19:357-72.  Back to cited text no. 3
    
4.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;141:513-7.  Back to cited text no. 4
[PUBMED]    
5.Sreenivasan S, Bennett S, Parfitt VJ. Images in cardiovascular medicine. Westermark's and Palla's signs in acute pulmonary embolism. Circulation 2007;115:e211.  Back to cited text no. 5
[PUBMED]    
6.Ristic L, Rancic M, Pejcic T. Pulmonary embolism in patients with chronic hypoxemia. Med Pregl 2010;63:492-6.  Back to cited text no. 6
    

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Correspondence Address:
Jorge A Brenes-Salazar
Department of Medicine, Division of Cardiovascular Diseases, 200 First St SW Rochester MN, 55905
United States
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0974-2700.125645

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