Pulmonary embolism - Westermark and Fleischner signs

Case contributed by Sachi Hapugoda


Sudden onset of shortness of breath and hypoxia. Hypotension and tachycardia.

Patient Data

Age: 65 years
Gender: Male

The right pulmonary artery is enlarged, with subtle oligemia in the right lung compared to the left. This is may be due to a large pulmonary embolism.

Saddle pulmonary embolus is present, with extensive occlusive thrombus in the distal right pulmonary artery, extending into lobar, segmental, and subsegmental branches of the right upper, right middle and right lower lobes. Thrombus is also in the lobar, segmental and subsegmental branches of the left lower lobe, and the segmental and subsegmental branches of the left upper lobe and lingula.

The main pulmonary artery diameter is in the upper limits of normal, however, there is bowing of the interventricular septum, and enlargement of the right ventricle suggesting right ventricular strain.

An ovoid region of consolidation is in the right posterior costophrenic angle, which may reflect a Hampton’s hump/areas of ischemic lung. Minor bibasal atelectasis.

Case Discussion

A case of Westermark and Fleischner signs of pulmonary embolism.  Early recognition of these findings on plain radiography can help facilitate early intervention, which is critical in cases of central pulmonary emboli.

Acknowledgements: Dr Anne Williamson.

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