Thoracic manifestations of IgG4-related disease

Immunoglobulin G4-related disease (IgG4-RD) is a recently described rare systemic fibroinflammatory disease with an estimated incidence of less than 1 in 100,000 persons per year. The disease can affect virtually any organ and is characterized by unifying histopathological findings. Recently, four subgroups of patients have been characterized: hepatobiliary, head and neck, Mikulicz syndrome and retroperitoneal fibrosis, who illustrate the mainly abdominal and ENT tropism of the disease. Yet, thoracic involvement is not uncommon. It can be detected in up to 30% of patients with systemic IgG4-RD and is the exclusive manifestation of the disease in about 10% of cases. Clinical symptoms are nonspecific and may include dyspnoea, cough or chest pain. Chest CT findings are heterogeneous and primarily include peribronchovascular thickening, nodules, ground-glass opacities and lymphadenopathy. There is no specific diagnostic test for IgG4-RD thoracic involvement, which may mimic malignancy or vasculitis. Therefore, a cautious approach is needed to make an accurate diagnosis: a search for extra-thoracic manifestations, elevated serum IgG4 levels, circulating levels of plasmablasts and pathologic evidence of disease is warranted. Although very suggestive, neither the presence of a polyclonal IgG4 lymphoplasmacytic infiltrate, storiform fibrosis or obliterative phlebitis are sufficient to confirm the histological diagnosis. Steroids are recommended as first-line therapy. Rituximab or disease-modifying antirheumatic drugs may be used in relapsed or rare cases of steroid-refractory disease. In this review, we summarize current knowledge regarding the pathophysiology, epidemiology, diagnostic modalities (clinical-biological-imaging-histopathology) and treatment of IgG4-RD thoracic involvement.

Stereotactic body radiation therapy (SBRT) as salvage treatment for early stage lung cancer with interstitial lung disease (ILD): An observational and exploratory case series of non-asian patients

Interstitial lung disease (ILD) can coexist with early-stage lung cancer (LC) and may compromise surgery and worsen patients' outcomes. Stereotactic body radiation therapy (SBRT) is the gold standard treatment for medically inoperable early-stage lung cancer, but radiation therapy is contra-indicated for patients with ILD because of the higher risk of severe radiation-induced pneumonitis. SBRT may spare healthy lung tissue, but data are scarce in this rare population. Our exploratory case series aimed to retrospectively identify patients treated with SBRT in this setting: 19 patients were diagnosed with early-stage LC-ILD over the past 6 years and 9 received SBRT. Most of them were smokers with a median age of 71, 4 had no pathological documentation. After SBRT, 5 patients had grade I-II respiratory adverse events (AEs), but none had treatment-related grade III-IV respiratory AEs. Two patients died within 6 months of SBRT, and for both, death was related to metastatic relapse. In this case series, the radiological evolution of ILD before radiotherapy and the evolution of the radiotherapy scar on CT-Scan were also explored with different evolutionary models. This exploratory study shows available data that could be studied in a larger retrospective cohort to identify risk factors for SBRT in the LC-ILD population. The use of dosimetric data as a risk factor for SBRT should be done with cautiousness due to heterogeneous and complex dose delivery and different fractionation schedule.

Pulmonary IgG4-related disease with favourable response to rituximab: A case report

Pulmonary involvement of IgG4-associated disease is a rare condition with no codified treatment apart from steroid administration. We report here the case of a patient with pulmonary involvement of IgG4-RD successfully managed with Rituximab, in induction and maintenance therapy. This original case could support the use of Rituximab in rare situations of steroid-resistant or steroid-dependent pulmonary IgG4-RD.

CIRSE Standards of Practice on Bronchial Artery Embolisation

This CIRSE Standards of Practice document is aimed at interventional radiologists and provides best practices for performing bronchial artery embolisation to effectively treat haemoptysis. It has been developed by an expert writing group established by the CIRSE Standards of Practice Committee.

Thoracic involvement and imaging patterns in IgG4-related disease

OBJECTIVE

Immunoglobulin G4-related disease (IgG4-RD) is a rare orphan disease. Lung, pleura, pericardium, mediastinum, aorta and lymph node involvement has been reported with variable frequency and mostly in Asian studies. The objective of this study was to describe thoracic involvement assessed by high-resolution thoracic computed tomography (CT) in Caucasian patients with IgG4-RD.

METHODS

Thoracic CT scans before treatment were retrospectively collected through the French case registry of IgG4-RD and a single tertiary referral centre. CT scans were reviewed by two experts in thoracic imagery blinded from clinical data.

RESULTS

48 IgG4-RD patients with thoracic involvement were analysed. All had American College of Rheumatology/European League Against Rheumatism classification scores ≥20 and comprehensive diagnostic criteria for IgG4-RD. CT scan findings showed heterogeneous lesions. Seven patterns were observed: peribronchovascular involvement (56%), lymph node enlargement (31%), nodular disease (25%), interstitial disease (25%), ground-glass opacities (10%), pleural disease (8%) and retromediastinal fibrosis (4%). In 37% of cases two or more patterns were associated. Asthma was significantly associated with peribronchovascular involvement (p=0.04). Among eight patients evaluated by CT scan before and after treatments, only two patients with interstitial disease displayed no improvement.

CONCLUSION

Thoracic involvement of IgG4-RD is heterogeneous and likely underestimated. The main thoracic CT scan patterns are peribronchovascular thickening and thoracic lymph nodes.

Natural history of COVID-19 and therapeutic options

Introduction: COVID-19 presents benign forms in young patients who frequently present with anosmia. Infants are rarely infected, while severe forms occur in patients over 65 years of age with comorbidities, including hypertension and diabetes. Lymphopenia, eosinopenia, thrombopenia, increased lactate dehydrogenase, troponin, C-reactive protein, D-dimers and low zinc levels are associated with severity.Areas covered: The authors review the literature and provide an overview of the current state of knowledge regarding the natural history of and therapeutic options for COVID-19. Expert opinion: Diagnosis should rely on PCR and not on clinical presumption. Because of discrepancies between clinical symptoms, oxygen saturation or radiological signs on CT scans, pulse oximetry, and radiological investigation should be systematic. The disease evolves in successive phases: an acute virological phase, and, in some patients, a cytokine storm phase; an uncontrolled coagulopathy; and an acute respiratory distress syndrome. Therapeutic options include antivirals, oxygen therapy, immunomodulators, anticoagulants and prolonged mechanical treatment. Early diagnosis, care, and implementation of an antiviral treatment; the use of immunomodulators at a later stage; and the quality of intensive care are critical regarding mortality rates. The higher mortality observed in Western countries remains unexplained. Pulmonary fibrosis may occur in some patients. Its future is unpredictable.

COVID-19 impact assessment on the French radiological centers: a nationwide survey

PURPOSE

To determine the impact of the COVID-19 on the CT activities in French radiological centers during the epidemic peak.

MATERIALS AND METHODS

A cross-sectional prospective CT scan survey was conducted between March 16 and April 12, 2020, in accordance with the local IRB. Seven hundred nine radiology centers were invited to participate in a weekly online survey. Numbers of CT examinations related to COVID-19 including at least chest (CT_covid) and whole chest CT scan activities (CT_chest) were recorded each week. A sub-analysis on French departments was performed during the 4 weeks of the study. The impact of the number of RT-PCRs (reverse transcriptase polymerase chain reactions) on the CT workflow was tested using two-sample t test and Pearson's test.

RESULTS

Five hundred seventy-seven structures finally registered (78%) with mean response numbers of 336 ± 18.9 (323; 351). Mean CT_chest activity per radiologic structure ranged from 75.8 ± 133 (0-1444) on week 12 to 99.3 ± 138.6 (0-1147) on week 13. Mean ratio of CT_covid on CT_chest varied from 0.36 to 0.59 on week 12 and week 14 respectively. There was a significant relationship between the number of RT-PCR performed and the number of CT_covid (r = 0.73, p = 3.10^-16) but no link with the number of positive RT-PCR results.

CONCLUSION

In case of local high density COVID-19, CT workflow is strongly modified and redirected to the management of these specific patients.

KEY POINTS

• Over the 4-week survey period, 117,686 chest CT (CT_total) were performed among the responding centers, including 61,784 (52%) CT performed for COVID-19 (CT_covid). • Across the country, the ratio CT_covid/CT_total varied from 0.36 to 0.59 and depended significantly on the local epidemic density (p = 0.003). • In clinical practice, in a context of growing epidemic, in France, chest CT was used as a surrogate to RT-PCR for patient triage.

Radiofrequency ablation of stage IA non-small cell lung cancer in patients ineligible for surgery: results of a prospective multicenter phase II trial

Background

A prospective multicenter phase II trial to evaluate the survival outcomes of percutaneous radiofrequency ablation (RFA) for patients with stage IA non-small cell lung cancer (NSCLC), ineligible for surgery.

Methods

Patients with a biopsy-proven stage IA NSCLC, staging established by a positron emission tomography-computed tomography (PET-CT), were eligible. The primary objective was to evaluate the local control of RFA at 1-year. Secondary objectives were 1- and 3-year overall survival (OS), 3-year local control, lung function (prior to and 3 months after RFA) and quality of life (prior to and 1 month after RFA).

Results

Of the 42 patients (mean age 71.7 y) that were enrolled at six French cancer centers, 32 were eligible and assessable. Twenty-seven patients did not recur at 1 year corresponding to a local control rate of 84.38% (95% CI, [67.21–95.72]). The local control rate at 3 years was 81.25% (95% CI, [54.35–95.95]). The OS rate was 91.67% (95% CI, [77.53–98.25]) at 1 year and 58.33% (95% CI, [40.76–74.49]) at 3 years. The forced expiratory volume was stable in most patients apart from two, in whom we observed a 10% decrease. There was no significant change in the global health status or in the quality of life following RFA.

Conclusion

RFA is an efficient treatment for medically inoperable stage IA NSCLC patients. RFA is well tolerated, does not adversely affect pulmonary function and the 3-year OS rate is comparable to that of stereotactic body radiotherapy, in similar patients.

Trial registration

ClinicalTrials.gov Identifier NCT01841060 registered in November 2008.

Imaging of acquired coronary diseases: From children to adults

Acquired coronary diseases include aneurysms, fistulae, dissections, and stenosis. Aneurysms may occur secondarily to Kawasaki disease, a childhood vasculitis, the prognosis of which depends on the coronary involvement, or they may be degenerative, infectious, inflammatory, or traumatic in origin. Fistulae develop between the coronary arterial system and a pulmonary or bronchial artery, or cardiac cavity. Dissections may occur spontaneously or may be post-traumatic. These coronary abnormalities may be found incidentally or may present as complications, infarction or rupture. The goals of this article are to understand acquired childhood and adult coronary diseases and their usual means of presentation, the ways of investigating them, and the principles of their treatment.

Early experience with the DJUMBODIS system: what did we observed, what can we expect? Part 2

The authors describe their experience with the Djumbodis system, reporting the findings of a comparative study focussing on the outcomes of surgical management of patients presenting with real type I aortic dissection. The most common feature observed in patients receiving a 9 or 14 cm stent into the proximal descending aorta was stabilization of the dissected thoracic segments. Clinical outcomes were, however, comparable between the groups of stented patients and controls. This clinical result is to be shared with other endovascular devices used in acute dissections and which might require a hybrid operating room, since they might compromise blood flow in collateral arteries. Carefully analysing our data and current literature we propose to consider real type I aortic dissections complicated by dynamic malperfusion symptoms or for which the diameter of the proximal descending aorta is already noticeably dilated as justified indications according to the current knowledge about stenting of acute dissections.

Early experience with the DJUMBODIS system: what did we observed, what can we expect? Part 1

PURPOSE

In order to remodel or to stabilize the dissected descending aorta following conventional replacement of proximal aorta for real type I acute dissection, the deployment of a bare-metal stent that expand the true lumen and compress the false lumen has been proposed. To date results have been insufficiently assessed through comparative studies. We conducted this study to compare midterm results according to the optional deployment of an antegradely inserted balloon inflated stainless steel stent at the level of the proximal descending aorta during conventional aortic surgery in real type I aortic dissections.

METHODS

Control study including a consecutive series of patients operated on conventionally for real type I aortic dissection involving descending aorta between 2006 and 2011. For stented patients, an optimal inflation volume was determined a priori according to the measured diameter of landing zone and a bare stent 90 or 140mm long was deployed antegradely during circulatory arrest. Endpoints were mid-term aortic event free survival and the evolution of the indexed (body surface area) diameter of descending aorta.

RESULTS

We included 19 and 26 patients in the stented and control group respectively. Aortic event free survival at 4 years was 57% and 43% (p=0.37) in the stented and control group respectively. The proximal descending aorta remained remodeled or stabilized during follow-up for 11 stented and only 9 control patients (p=0.05). After a mean follow up of 2 years, the mean indexed diameter of the upper third aorta was 4 mm wider in the control group due to false lumen enlargement (p=0.01).

CONCLUSION

Anatomic evolution is favorable in the stented group. Increment of comparative followup data is mandatory before considering a revision of conventional approach of TAAD to influence mid- term aortic event free survival.

[Mechanisms of delayed myocardial enhancement and value of MR and CT contrast materials in the evaluation of myocardial viability]

The purpose of this article is to present a brief theoretical review of the models characterizing delayed myocardial enhancement applicable to both MR and CT imaging, review the different characteristics of commercially available gadolinium-based and iodinated contrast materials, and summarize the literature on the potential value of dedicated MR imaging contrast currently in development for the diagnosis of myocardial viability. The intensity of myocardial enhancement following infarction is related to two factors: expansion of the interstitial volume (15+/-2% in normal myocardium and 80+/-3% within necrosis) secondary to cell necrosis and perfusion abnormalities due to the absence of revascularization or lesions to the microcirculation. A kinetic model of contrast material properties within myocardium could be constructed from Kety's equation with regards to enhancement within the different myocardial tissues (viable myocardium, necrotic myocardium, fibrosis, no-reflow zones, stunned or hibernating myocardium). This model can be applied to both CT and MR since clinically available contrast agents are extracellular, inert and kinetically comparable. The development of dedicated contrast agents for viability and necrosis or molecular contrast agents open new horizons for preclinical research.

[Urokinase in the management of occluded PICC lines]

PURPOSE

To determine the efficacy and safety of urokinase in the management of occluded PICC lines.

MATERIALS AND METHODS

A total of 587 PICC lines were placed over an 11 month period. During this period, 28 PICC lines (4.8%) became occluded: 12 occluded PICC lines were successfully managed by simple flushing with normal saline while 16 PICC lines were thrombolyzed with urokinase.

RESULTS

After urokinase, 93.8% (15/16) of occluded PICC lines were completely patent. A single infusion of urokinase, 20,000 IU over 30 minutes, was used in all cases. No secondary occlusion or complication was noted after urokinase.

CONCLUSION

Urokinase is effective and safe to restore patency to occluded PICC lines. The procedure is simple, and could be performed at the bedside by nursing staff after medical prescription. It is an alternative to over the wire PICC line exchange, that could reduce the risk of complication related to manipulations, patient discomfort and cost.

[Cervical lymph nodes]

Imaging plays a chief role in the care and monitoring of patients in cervico-facial oncology. The radiologist must know the anatomy of different lymph nodes as well as signs of malignancy (hypertrophy, enhancement, necrosis, capsular rupture, etc.). CT is still the first-line examination because of its high reliability, its accessibility and its ability to make an assessment of the upper aero digestive ways at the same time. Ultrasound is very accuracy, and allows the realization of cytoponction, but does not provide a complete exploration of the neck. MRI does not appear to be indicated for the first intention, but the new rapid sequences (STIR, diffusion) seem interesting. The PET-CT is useful in post-therapeutic management of patients, and probably in the initial staging, but its accessibility is poor.

« Classification 2002 des pneumopathies interstitielles idiopathiques »

OBJECTIVES

Diagnosis of interstitial lung diseases was recently improved by the use of diagnostic tools, such as high-resolution Computed Tomography, and by new insights in their pathogenesis and histology. This led the American Thoracic Society and the European Respiratory Society to propose a new classification of these diseases, in the aim to facilitate early diagnosis and specific care.

CURRENT KNOWLEDGE AND KEY POINTS

Standard radiography gives the first suspicion of chronic diffuse infiltrative lung disease, and anamnesis and physical examination are essential steps of etiological diagnosis. High-Resolution computed tomography confirms the diagnosis of diffuse infiltrative lung disease. Longitudinal lung function tests are essential to assess the consequences of the lung disease. Lung biopsies are often, but not systematically, a useful tool. The 2000 classification consists of seven entities of idiopathic interstitial diseases which are defined on clinical, radiological and pathological criteria: idiopathic pulmonary fibrosis, non-specific interstitial pneumonia, cryptogenic organizing pneumonia, acute interstitial pneumonia, respiratory bronchiolitis associated interstitial lung disease, desquamative interstitial pneumonia and lymphoid interstitial pneumonia. The most frequent is Idiopathic Pulmonary Fibrosis, which has a poor prognosis.

FUTURE PROSPECT AND PROJECTS

This new classification results from a multidisciplinary confrontation with chest physicians, radiologists and pathologists. A better characterization of anatomoclinical entities should lead to a better pronostic evaluation, more informative comparisons of published studies, and therefore to rational therapeutic approach.

[MR imaging and arrhythmogenic right ventricular dysplasia (ARVD)]

Arrhythmogenic right ventricular dysplasia (ARVD) is a cardiomyopathy of unknown etiology responsible for 20% of cases of sudden death in young adults secondary to arrhythmia. It is characterized histologically by fatty or fibro-fatty infiltration of the right ventricular myocardium. Diagnostic criteria have been proposed for diagnosing ARVD. Imaging, especially MRI, plays an important role. MR imaging must be performed using cardiac gating, and should include both cine-MR sequences for evaluation of segmental and global right ventricular function or any morphological change of the right ventricular shape, and anatomic sequences to detect fatty or fibro-fatty infiltration of the right ventricular myocardium.

Comment, quand et pourquoi réaliser une imagerie de l’aorte thoracique chez l’adulte ?

CT, MRI and transesophageal echocardiography have become the standard of reference for evaluation of the thoracic aorta. Angiography is mainly performed as a presurgical procedure. Congenital pathologies observed during adulthood include coarctation, patent ductus arteriosus, and aberrant retroesophageal subclavian arteries. Imaging plays a major role for diagnosis and management of patients with acute aortic syndromes: intramural hematoma, dissection, penetrating ulcer and nondissecting aneurysms. Cross sectional imaging of the thoracic aortic wall allows evaluation of inflammatory diseases of the aorta or aortitis.

[Radio-anatomy of the paranasal sinuses]

The imaging anatomy of the paranasal sinuses presents some complexity. The paranasal sinuses develop within facial and cranial bones. They communicate with one another and with the nasal cavity. Knowledge of normal anatomy is mandatory for accurate diagnosis of sinonasal pathology. The most frequent anatomical variants should be identified to decrease surgical risks. CT is the main imaging modality for the evaluation of sinonasal pathology.

LEARNING OBJECTIVES

to review the normal sinonasal anatomy and its frequent anatomical variants at CT imaging.

Radiological follow-up of inverted papilloma

The aim of this study was to describe cross-sectional imaging features of recurrent papilloma of the nasal fossa and paranasal sinuses and to evaluate the role of MR and CT in the postoperative follow-up of this lesion. Magnetic resonance imaging and CT of ten patients who presented recurrence of inverted papilloma were reviewed and correlated to initial imaging, endoscopy, and surgical reports. Imaging patterns of recurrent inverted papilloma are identical to those of initial tumors and recurrence location is closely related to the site of the former lesion. Magnetic resonance is more efficient than CT for the diagnosis and evaluation of extensions. Magnetic resonance supplies the deficiencies of endoscopy in case of extensions to the frontal sinus or the lateral recess of the antrum, especially if mucosal hyperplasia or sinusitis is associated. Magnetic resonance imaging is the first imaging modality to perform in the follow-up after removal of inverted papilloma.

Pulmonary arteriovenous malformations: lung transplantation as a therapeutic option

Multiple pulmonary arteriovenous malformations (PAVM) constitute an uncommon cause of respiratory disability. They may lead to severe hypoxaemia via right-to-left shunts and are sources of substantial mortality and morbidity. Conservative surgical resection has been proposed as the treatment of choice. More recently, percutaneous balloon or coil embolization of the feeding vessels offered an efficacious and safe alternative therapy for patients whose fistulas are too numerous to excise. This study reports an unusual case of respiratory disability in a patient with multiple and microscopic pulmonary arteriovenous malformations who failed to respond to embolotherapy and who received a double lung transplantation with good initial outcome.

Vanishing osteosclerotic lesion of the humeral head

We report on the spontaneous disappearance of a dense round lesion from within the greater tuberosity of the humerus. The patient was treated with oral non-steroidal anti-inflammatory agents for symptoms of subacromial bursitis. Symptoms resolved in 10 days and the lesion had vanished when radiographed 3 months later. We surmise the lesion to represent intraosseous crystal deposition.

Type A dissection of the thoracic aorta: use of MR imaging for long-term follow-up

PURPOSE

To evaluate routine magnetic resonance (MR) imaging for long-term follow-up in patients who undergo surgery for type A aortic dissection.

MATERIALS AND METHODS

Ninety-two MR examinations were performed in 36 patients. Standard spin-echo images were obtained with electrocardiographic gating (n = 92) and rapid images with a fast low-angle shot sequence and intravenous administration of gadopentetate dimeglumine (n = 25). All segments of the native thoracic aorta were evaluated. Anastomoses of the prosthesis and periprosthetic hematoma were carefully analyzed.

RESULTS

Of 22 complications that occurred in 18 patients, 18 were diagnosed at MR imaging (nine false aneurysms and nine aneurysms distal to the graft). Nine patients underwent reoperation. The findings at MR imaging correlated with those at surgery.

CONCLUSION

Routine follow-up with MR imaging should improve long-term survival in patients who survive emergency surgical repair of type A aortic dissection.

Juvenile nasopharyngeal angiofibroma: comparison of blood loss during removal in embolized group versus nonembolized group

PURPOSE

This retrospective study was performed to assess the beneficial effect of preoperative embolization of juvenile nasopharyngeal angiofibromas (JNA) in terms of blood loss during surgery.

METHODS

Intraoperative blood loss in a group of 7 patients who underwent 10 procedures for JNA without preoperative embolization was compared with the blood loss of 13 patients who underwent 16 procedures after embolization of one or both external carotid arteries.

RESULTS

Mean blood loss was 5380 ml in patients without embolization and 1037.5 ml in those with embolization. This difference was not statistically significant because of the high standard deviation in the nonembolized group. However, when data were analyzed by tumor stage, a significant difference was noted between the embolized and the nonembolized patients with high-grade tumors but not between those with low-grade tumors.

CONCLUSION

Preoperative embolization of the branches of the external carotid appears to facilitate removal of high grade tumors. The benefit of embolization in those with low-grade tumors is less clear cut, probably because there is less vascularity in low-grade tumors and so removal is easier.

Right-sided aortic arch: surgical treatment of an aneurysm arising from a Kommerell's diverticulum and extending to the descending thoracic aorta with an aberrant left subclavian artery

The case of a 44-year-old black man who presented with severe dysphagia, cough and chest pain caused by a 12-cm aneurysm developing from a Kommerell's diverticulum at the origin of an aberrant retro-oesophageal left subclavian artery is reported. The aortic arch and descending thoracic aorta were right sided. Diagnosis was established before operation by computed tomography, magnetic resonance imaging and arteriography. The aneurysm extended a considerable distance down the descending aorta and therefore the risk of postoperative paraplegia was considered to be high. Accordingly selective arteriography was performed to locate the Adamkievicz's artery which arose only 2 cm below the end of the aneurysm. Resection grafting of the aneurysm including the upper third of the descending aorta via right thoractomy was performed. The patient made an uneventful recovery and was discharged 20 days later. This case appears to be the first successful operation for this pathology.

Dehiscence of the lamina papyracea of the ethmoid bone: CT findings

PURPOSE

To describe the CT findings characterizing dehiscence of the lamina papyracea.

METHODS

Axial and coronal CT scanning of the paranasal sinuses was performed on 783 patients.

RESULTS

Dehiscence of the lamina papyracea was noted incidentally in six patients. In all cases dehiscence was characterized by protrusion of orbital fat through a gap in the anterior ethmoid. The posterior limit of the dehiscence was always the basal lamella. The anterior limit varied.

CONCLUSION

CT scans are often taken to detect polyps or assess chronic sinusitis. Awareness of dehiscence of the lamina papyracea is important to avoid misdiagnosis as infectious or tumoral process and possible injury of the orbit during endoscopic surgery.

[Extrapleural hematoma]

The authors report a case of a voluminous extra-pleural hematoma in relation to a fracture of the body of the eleventh thoracic vertebra on a 74 year-old man after craniothoracic injury. Thoracic CT Scan showed a homogeneous posterior parietal mass of tissue density (40 HU) outlined by a fatty lining associated with a fracture of the eleventh thoracic vertebra. This allowed a modification in the diagnosis of a hemothorax established previously on conventional radiography. The authors insist on the gravity of this affection when the volume of the hematoma is important. But this is very rare (6 cases out of which 5 were autopsic findings). If present it requise an urgent surgical treatment without forgetting the fiability of CT Scan which relies on putting into evidence the pleural lining sign.