Cardiogenic pulmonary edema grade 1

Case contributed by Saneej Kanhirat
Diagnosis almost certain


Chest pain Shortness of breath

Patient Data

Age: 85 years
Gender: Male

Chest Xray PA


Heart is enlarged . CTR is 0.6

Blunting of right costophrenic angle suggestive of pleural effusion.

Fluid extending to right minor fissure.

Median sternotomy wires in situ with mediastinal surgical clips consistent with previous CABG

There is upper lobe venous diversion.

Coarsening of bronchovascular markings suggestive of COPD.

Air space opacities at both lung bases more on left

Annotated image

Annotated image

Dilated and branching upper zone pulmonary veins resemble the antlers of a stag

Case Discussion

Pulmonary edema is graded depending on chest x-ray and pulmonary capillary wedge pressure (PCWP) is as follows:

  • Grade 0: normal chest radiograph, PCWP 8-12 mmHg
  • Grade 1: upper lobe diversion on a chest radiograph, PCWP 13-18 mmHg
  • Grade 2: interstitial edema on a chest radiograph, PCWP 19-25 mmHg
  • Grade 3: alveolar edema on a chest radiograph, PCWP >25 mmHg

Our case is representing grade 1 pulmonary edema.

Upper lobe pulmonary venous diversion (cephalisation) reflects elevation of left atrial pressure and can occur with pulmonary edema

Stag antler sign: The prominence of upper lobe pulmonary veins resembles a stag's antlers. It is the earliest sign of pulmonary venous hypertension (grade 1 pulmonary edema). 

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