Holly leaf sign - refers to the typical chest radiograph appearance of calcified pleural plaques. The well-defined but irregular thickened edges simulate the appearance of a holly leaf. ‘Geographic density’ is another common term used to describe their appearance. Pleural plaques are the most common form of asbestos related disease.
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Left atrial enlargement - while echocardiography has emerged as the preferred tool for assessing cardiac chamber size, recognising the features of left atrial enlargement on chest radiography remains worthwhile.
- The double density sign (left image) occurs when the right side of the dilated left atrium is visible next to the normal right heart border (right atrium). It may even extend out beyond the right heart border, an appearance known as atrial escape.
- Oblique measurement of greater than 7cm (right image, blue arrow).
- Convex left atrial appendage - normally it is flat or concave.
- Splaying of the carina to greater than a 90 degree angle (right image, yellow lines).
- Posterior displacement of the left main stem bronchus on lateral radiographs forming an upside down ‘V’ known as the walking man sign.
Inferior rib notching - refers to a remodeling deformity of the lower aspect of the ribs, usually induced by dilated intercostal vessels. Arterial dilatation most commonly occurs when there is obstruction of the aorta such as in coarctation, while venous dilatation may occur in the setting of SVC obstruction. In both settings the intercostal vessels act as collaterals to bypass the primary vascular obstruction with the rib notching being a secondary effect. Nerve sheath tumours are the major non-vascular cause of inferior rib notching.