April 2017 Imaging Case of the Month

Michael B. Gotway, MD and John K. Sweeney, MD

Department of Radiology

Mayo Clinic Arizona

Scottsdale, Arizona USA

Clinical History: An 86-year-old man with a previous history of transcatheter aortic valve implantation 1 year earlier, coronary artery disease status-post coronary artery bypass grafting surgery 12 years earlier, atrial fibrillation on warfarin, and pacemaker placement 8 years earlier presented with altered mental status.

The patient’s white blood cell count was borderline elevated at 10.3 x 10³/mcl (normal, 4.8 – 10.8 x 10³/mcl)  and hyponatremia was noted (serum sodium = 129 mEq/L, normal =  136 – 145 mEq/L). The patient’s anticoagulation profile was within the therapeutic range (INR = 1.4), and the platelet count was normal. Oxygen saturation on room air was normal. The patient’s medication list included warfarin, digoxin, aspirin, metoprolol, montelukast, and atorvastatin.

Frontal chest radiography (Figure 1) was performed.

Figure 1. Frontal (A) and lateral (B) chest radiography.

Which of the following statements regarding the chest radiograph is most accurate? (Click on the correct answer to proceed to the second of eight pages)

1. Frontal chest radiography shows a cavitary lung mass
2. Frontal chest radiography shows focal consolidation suggesting aspiration pneumonia
3. Frontal chest radiography shows increased pressure edema
4. Frontal chest radiography shows malposition of the patient’s left subclavian pacemaker
5. Frontal chest radiography shows rib fractures

Cite as: Gotway MB, Sweeney JK. April 2017 imaging case of the month. Southwest J Pulm Crit Care. 2017;14(4):141-52. doi: https://doi.org/10.13175/swjpcc042-17 PDF

Medical Image of the Week: Atherosclerotic Aneurysm of Aortic Arch and Descending Thoracic Aorta

Figure 1.  Chest radiograph displays mild CHF, prominent vascular markings, and a large thoracic aneurysm.

Figure 2. Panel A: Computerized tomography angiography (CTA) with contrast displays an aneurysm of the aortic measuring 6.8 cm with eccentric thrombi. Panel B: CTA also shows an aneurysm of the descending aorta measuring 6 cm across with eccentric thrombi. Panel C: CTA demonstrates a tortuous descending aorta displayed by the curving of the descending aorta as it transitions to the abdominal aorta.

A 94-year-old Spanish-speaking woman presented to the hospital with intermittent episodes of dyspnea and abdominal pain for one week. Her past medical history was notable for 30 pack-year smoking history and hypertension, which was reportedly controlled with medical therapy.  Physical exam showed trace peripheral edema bilaterally, intact peripheral pulses, and a mild abdominal bruit. Work up at the emergency department revealed a non-ST elevation myocardial infarction with troponin T of 0.34 ng/mL but no ST-wave abnormality on electrocardiography. Chest x-ray displayed an incidental thoracic aneurysm (Figure 1). Chest computed tomography with contrast demonstrated a continuous aneurysm of the aortic arch and descending thoracic aorta with diameters measuring 6.8 cm and 6 cm, respectively (Figure 2A and 2B). Eccentric thrombi are noted in the aortic arch and the descending aorta. Interestingly, the distal descending thoracic aorta curves as it transitions to the abdominal aorta, which is evidence of a tortuous descending aorta (Figure 2C). The patient declined both invasive and non-invasive treatment and left the hospital against medical advice one day after admission.     

Melvin Parasram MS¹, Lea McKinnon MD², Iwan Nyotowidjojo MD³, and Kareem Ahmad MD⁴

¹Midwestern University: Arizona College of Osteopathic Medicine, Glendale, AZ USA

²Departments of Radiology, ³Internal Medicine and ⁴Pulmonary and Critical Care, Banner University Medical Center - Tucson, Tucson, AZ USA

Cite as: Parasram M, McKinnon L, Nyotowidjojo I, Ahmad K. Medical image of the week: atherosclerotic aneurysm of aortic arch and descending thoracic aorta. Southwest J Pulm Crit Care. 2016;12(2):46-7. doi: http://dx.doi.org/10.13175/swjpcc155-15 PDF 

Medical Image of the Week: Vascular Occlusion

Figure 1. Left arm angiogram showing complete occlusion of ulnar artery (red arrow).

Figure 2. Angiogram showing left radial artery complete occlusion (red arrow).

Figure 3. Left hand with necrotic fingers.

The patient is a 39 year-old woman with no significant past medical history presenting with progressive left hand pain for five days. The patient denied a history of Raynaud’s phenomenon or clotting disorders. She had no radial pulse on presentation and angiogram showed severe complete occlusion of the radial and ulnar arteries (Figures 1 and 2). She had an initial partial response with intra-arterial verapamil and nitroglycerin but her hand ischemia did not improve on heparin or with intra-arterial tissue plasminogen activator. Autoimmune and coagulation work-ups were negative. Her left hand finger necrosis at time of discharge is shown (Figure 3).  Further evaluation is ongoing for coagulation disorders.

Allison Shapiro MD, Carmen Luraschi-Monjagatta MD, Matthew Schreiber MD.

Department of Internal Medicine, Pulmonary and Critical Care, University of Nevada School of Medicine, Las Vegas, NV

Reference as: Shapiro A, Luraschi-Mongagatta C, Schreiber M. Medical image of the week: vascular occlusion. Southwest J Pulm Crit Care. 2014;9(1):36-7. doi: http://dx.doi.org/10.13175/swjpcc093-14 PDF