Medical Image of the Month: Large Complex Cerebral Arteriovenous Malformation

Figure 1. Computed tomography angiography of the head showing the large complex arteriovenous malformation near the midline of the brain. A: sagittal plane the malformation is fed predominantly by the anterior circulation more on the right and the left. B: coronal plane.

A 70-year-old woman with a history of hypertension presented with left-sided weakness, headache, nausea, and vomiting. She denied loss of consciousness or seizure activity. On examination, she had receptive aphasia. Pupils were equal, round and reactive. She had neck pain on flexion. Her left upper extremity was plegic. Computed tomography of the brain showed acute hemorrhage involving the right thalamus, extending into the ventricular system, and a midline mass. She underwent a computed tomography angiogram, which showed a large, complex arteriovenous malformation (AVM) with a dilated branch of the right suprasellar internal carotid artery feeding the AVM, which then drained into the vein of Galen and straight sinus (Figure 1). She was monitored in the intensive care unit without worsening neurological deficit. She was discharged to a rehabilitation facility, having had no intravascular or surgical intervention.

AVMs are intracranial vascular anomalies which occur in 0.1% of the population (1). Clinical presentations include intracranial hemorrhage, seizures, headaches and neurological deficits, with hemorrhage being the most common and significant manifestation (2). The gold standard imaging modality is conventional cerebral angiography (1). Treating an AVM is a challenging clinical problem, as the risk of treatment has to be weighed against the natural history of the condition. Treatment modalities include observation with medical management, surgical resection, stereotactic radiosurgery, and endovascular embolization (1,2).

Vedhapriya Srinivasan MD, Piruthiviraj Natarajan MD, Reuben De Almeida, Safal Shetty MD, and Kulothungan Gunasekaran MD.

Bridgeport Hospital

Yale New Haven Health

New Haven, CT USA

References

1. Ajiboye N, Chalouhi N, Starke RM, Zanaty M, Bell R. Cerebral arteriovenous malformations: evaluation and management. ScientificWorldJournal 2014;2014:649036. [CrossRef] [PubMed]
2. Geibprasert S, Pongpech S, Jiarakongmun P, Shroff MM, Armstrong DC, Krings T. Radiologic assessment of brain arteriovenous malformations: what clinicians need to know. RadioGraphics. 2010;30:483-501. [CrossRef] [PubMed]

Cite as: Srinivasan V, Natarajan P, De Almeida R, Shetty S, Gunasekaran K. Medical image of the month: large complex cerebral arteriovenous malformation. Southwest J Pulm Crit Care. 2019;19(3):97-8. doi: https://doi.org/10.13175/swjpcc027-19 PDF 

Medical Image of the Week: Paget-Schroetter Syndrome

Figure 1. Venous contrast study demonstrating thrombosis and flow obstruction at the thoracic outlet (arrow). 

A 22-year-old right-handed man developed acute swelling of his right upper extremity following a weekend of vigorous physical military training. There was no associated pain or numbness. Physical examination demonstrated edema of the right arm. Radial and ulnar pulses were intact, and neurological exam was normal. Venous doppler examination demonstrated thrombus in the subclavian-axillary venous system. A confirmatory venous contrast study was performed (Figure 1), followed by catheter directed lysis.  Effort related thrombosis of the subclavian vein secondary to mechanical compression at the thoracic outlet is known as Paget-Schroetter Syndrome (1). Current treatment commonly includes catheter directed clot lysis and an arbitrary three-month period of systemic anticoagulation, followed by surgical resection of the first rib (2). Post-operative balloon angioplasty of the involved venous segment improves long-term results (3). This patient underwent successful lysis, was discharged on oral rivaroxaban, and has been referred to thoracic surgery for consideration of rib resection.

Charles Van Hook MD and Ken Hirasaki MD

Longmont United Hospital

Longmont, Colorado USA

References

1. Kucher N. Deep-vein thrombosis of the upper extremities. N Engl J Med. 2011;364:861-9.[CrossRef] [PubMed]
2. Engelberger RP, Kucher N. Management of deep vein thrombosis of the upper extremity. Circulation. 2012;126:768-73. [CrossRef] [PubMed]
3. Illif KA, Doyle AJ. A comprehensive review of Paget-Schroetter syndrome. J Vasc Surg. 2010;51:1538-47. [CrossRef] [PubMed]

Cite as: Van Hook C, Hirasaki K. Medical image of the week: Paget-Schroetter syndrome. Southwest J Pulm Crit Care. 2018;16(3):156. doi: https://doi.org/10.13175/swjpcc031-18 PDF 

October 2017 Imaging Case of the Month

Paul J. Conomos, MD¹

Michael B. Gotway, MD²

¹Arizona Pulmonary Specialists

Phoenix, AZ USA

²Mayo Clinic Arizona

Scottsdale, AZ USA

Clinical History: An 18-year-old man with no known previous medical history presented with complaints of intermittent cough persisting several months. No hemoptysis was noted.

Physical examination was largely unremarkable and the patient’s oxygen saturation was 99% on room air. The patient’s vital signs were within normal limits.

Laboratory evaluation was unremarkable.  Quantiferon testing for Mycobacterium tuberculosis was negative, and testing for coccidioidomycosis was unrevealing. Frontal and lateral chest radiography (Figure 1) was performed.

Figure 1. 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. The chest radiograph shows asymmetric reticulation and interlobular septal thickening
2. The chest radiograph shows bilateral reticulation associated with decreased lung volumes
3. The chest radiograph shows focal consolidation
4. The chest radiograph shows large lung volumes
5. The chest radiograph shows small cavitary pulmonary nodules

Cite as: Conomos PJ, Gotway MB. October 2017 imaging case of the month. Southwest J Pulm Crit Care. 2017;15(4):138-46. doi: https://doi.org/10.13175/swjpcc119-17 PDF

May 2017 Imaging Case of the Month

Prasad M. Panse, MD and Michael B. Gotway, MD

Department of Radiology

Mayo Clinic Arizona

Scottsdale, Arizona USA

Clinical History: Clinical History: A 32-year-old man presented for routine physical examination. His past medical history is unremarkable and the physical examination and basic laboratory data were within normal limits.

A frontal chest radiograph (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 nine pages)

1. The frontal chest radiograph shows an abnormal mediastinal contour
2. The frontal chest radiograph shows basal predominant fibrotic abnormalities
3. The frontal chest radiograph shows large lung volumes with a cystic appearance
4. The frontal chest radiograph shows multifocal small pulmonary nodules
5. The frontal chest radiograph shows no abnormal findings

Cite as: Panse PM, Gotway MB. May 2017 imaging case of the month. Southwest J Pulm Crit Care. 2017;14(5):201-12. doi: https://doi.org/10.13175/swjpcc055-17 PDF 

Medical Image of the Week: Fungus Ball

Figure 1. Panel A: Coronal view of thoracic CT scan shows a fungus ball (mycetoma) within a 4.7cm thin walled cavity, Panel B: Axial image of fungus ball and thin walled cavity.

Figure 2 Panel A. Prominent eosinophilic infiltration with epithelial-lined cavity containing fungus ball (orange arrow). Panel B: Higher magnification.

A 69 year-old Asian woman living in Arizona with a past medical history of nephrotic syndrome on high-dose steroids had worsening pulmonary symptoms. A computed tomography (CT) of the chest (Figure 1) showed a 4.7 cm thin walled cavitary lesion in the right middle lobe compatible with mycetoma. She underwent thoracotomy for mycetoma resection. Surgical pathology confirmed an epithelial-lined cavity containing dense mycelia (Figure 2). Given the patient lived in an endemic area; the cavity was thought to be likely due to coccidioidomycosis. However, the mycetoma was of unclear etiology. No spherules were noted on GMS stain and tissue culture was negative. While of unclear clinical significance which fungus colonizes a pre-existing cavity, a Coccidioides PCR was performed and no Coccidioides genes were amplified making a Coccidioides mycetoma very unlikely.

Pulmonary mycetoma or “fungus ball” consists of dense fungal elements and amorphous cellular material within a pre-existing pulmonary cavity. Classically presenting as an aspergilloma, other fungi can cause similar lesions. Patients with mycetoma rarely develop symptoms. When present, symptoms can include chest pain, cough, hemoptysis, fatigue, fever, or unintentional weight loss. If asymptomatic, no treatment is required. Surgical resection and/or embolization may be required in cases of severe symptoms including hemoptysis.

Scott Rosen MD, Bridget Barker PhD, Branden Larsen MD PhD, and Ishna Poojary MD

Department of Medicine and Pathology

University of Arizona Medical Center

Tucson, AZ

and

Tgen North

Flagstaff, AZ

References

1. Winn RE, Johnson R, Galgiani JN, Butler C, Pluss J. Cavitary coccidioidomycosis with fungus ball formation. Diagnosis by fiberoptic bronchoscopy with coexistence of hyphae and spherules. Chest. 1994;105(2):412-6. [CrossRef] [PubMed]
2. Sobonya RE, Yanes J, Klotz SA. Cavitary pulmonary coccidioidomycosis: pathologic and clinical correlates of disease. Hum Pathol. 2014;45(1):153-9. [CrossRef] [PubMed]
3. Sheff KW, York ER, Driebe EM, Barker BM, Rounsley SD, Waddell VG, Beckstrom-Sternberg SM, Beckstrom-Sternberg JS, Keim PS, Engelthaler DM. Development of a rapid, cost-effective TaqMan Real-Time PCR Assay for identification and differentiation of Coccidioides immitis and Coccidioides posadasii. Med Mycol. 2010;48(3):466-9. [CrossRef] [PubMed]

Reference as: Rosen S, Barker B, Larsen B, Poojary I. Medical image of the week: fungus ball. Southwest J Pulm Crit Care. 2015;10(4):182-3. doi: http://dx.doi.org/10.13175/swjpcc025-15 PDF