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Radiology

Signs in Imaging
Andrew Kong, MD

The Deep Sulcus Sign1


APPEARANCE
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).

EXPLANATION
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.

DISCUSSION
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 com-

Index terms:
Pneumothorax, 66.73
Signs in Imaging
Published online
10.1148/radiol.2282020524
Radiology 2003; 228:415 416

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.

monly 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

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).

RSNA, 2003

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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Radiology

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

416

Radiology

August 2003

(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).
References
1. Gordon R. The deep sulcus sign. Radiology 1980; 136:2527.
2. Grainger RG, Allison DJ, Adam A, Dixon AK. Diagnostic radiology.
New York, NY: Churchill Livingstone, 2001; 254 257.
3. Brant WE, Helms CA. Fundamentals of diagnostic radiology. Baltimore, Md: Williams & Wilkins, 1994; 503506.
4. Camassa N, Boccuzzi F, Troilo A, DEttorre E. Pneumothorax in
severe chest injuries. Radiol Med (Torino) 1988; 75: 156 159. [Italian]
5. Armstrong P, Wilson AG, Dee P, Hansell DM. Imaging of diseases of
the chest. St Louis, Mo: Mosby, 2000; 770 771.
6. Tocino I, Armstrong J. Trauma to the lung. In: Taveras J, ed.
Radiology. Philadelphia, Pa: Lippincott-Raven, 1996; 1 8.

Kong

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