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موضوع: Facebook Radiology الثلاثاء أبريل 30, 2019 9:55 pm

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What is the most likely diagnosis?

23year-old male with stabbing pain after being stabbed

Pulmonary Contusion
Tension Pneumothorax
Laceration of the Lung
Eosinophilic Granuloma
Simple Pneumothorax

Answer:

2. Tension Pneumothorax

Pneumothorax
Tension Pneumothorax

Presence of air in the pleural space

The above film shows a right sided tension pneumothorax with right sided lucency and leftward mediastinal shift. This is a medical emergency. Failure to place a right chest tube immediately could allow venous return to diminish and lead to possible death.
[rtl]https://www.med-ed.virginia.edu/courses ... chest.html[/rtl]

Anatomy

Visceral pleura is adherent to lung surface
There is no air in the pleural space normally
The introduction of air into the pleural space separates the visceral from the parietal pleura
In contradistinction, the visceral and parietal pleura usually do not separate from each other in obstructive atelectasis

Pathophysiology

Either from disruption of visceral pleura
Or, trauma to parietal pleura

Clinical findings

Acute onset of
Pleuritic chest pain
(Dyspnea (in 80-90%
Cough
Back or shoulder pain

Etiologies

Penetrating trauma
Blunt trauma
May be due to rib fracture
May be caused by increased intrathoracic pressure
May lead to bronchial rupture
“Fallen lung sign” (ptotic lung sign) -- hilum of lung is below expected level within chest cavity
Persistent pneumothorax with functioning chest tube
Iatrogenic
Tracheostomy
Central venous catheter attempt or insertion
Mechanical ventilation
May occur in up to 25% of patients maintained on PEEP
May be bilateral or under tension
Thoracic irradiation

************
A pneumothorax is defined as air inside the thoracic cavity but outside the lung. A spontaneous pneumothorax (PTX) is one that occurs without an obvious inciting incident.
Some causes of spontaneous PTX are;
idiopathic,
asthma,
COPD,
pulmonary infection,
neoplasm,
Marfan's syndrome,
and smoking cocaine.
However, most pneumothoraces are iatrogenic and caused by a physician during surgery or central line placement. Trauma, such as a motor vehicle accident is another important cause.
: A tension PTX is a type of PTX in which
air@ enters the pleural cavity
and is @ trapped during expiration usually by some type of ball valve-like mechanism.
This leads to a @ buildup of air increasing intrathoracic pressure.
Eventually the pressure buildup is large enough to @ collapse the lung
and @ shift the mediastinum away from the tension PTX.
If it continues, it can @ compromise venous filling of the heart and even death.

[rtl]https://www.med-ed.virginia.edu/courses ... chest.html[/rtl]

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Spontaneous pneumothorax

Most common etiology is
Rupture of subpleural blebs in apical region of lung
Age
20-40 years
Left is a supine view of a PTX, note the medial position of the air.
Right is an image demonstrating the deep sulcus sign (letter D in the image) in supine views of a PTX.
M:F = 8:1
Especially in patients who are tall and thin
Smokers

Left is a supine view of a PTX, note the medial position of the air.
Right is an image demonstrating the deep sulcus sign (letter D in the image) in supine views of a PTX.
Red arrows point to thin white visceral pleural line which
is the single best sign for a pneumothorax

Prognosis

Recurrence in 30% on same side
Recurrence in 10% on contralateral side

Treatment

(Simple aspiration (success in >50%
(Tube thoracostomy (effective in 90%

Other causes of a pneumothorax

Neonatal disease
Meconium aspiration
Respirator therapy for hyaline membrane disease
Malignancy
Primary lung cancer
Lung metastases, especially from osteosarcoma
Also pancreas, adrenal, Wilms tumor
Pulmonary infections
Tuberculosis
Necrotizing pneumonia
Coccidioidomycosis
Hydatid disease
Pertussis
Acute bacterial pneumonia
Staphylococcal septicemia
(AIDS (Pneumocystis carinii, Mycobacterium tuberculosis, atypical mycobacteria
Complication of pulmonary fibrosis
Histiocytosis X
Idiopathic
Cystic fibrosis
Sarcoidosis
Scleroderma
Eosinophilic granuloma
Interstitial pneumonitis
Rheumatoid lung
Idiopathic pulmonary hemosiderosis
Pulmonary alveolar proteinosis
Biliary cirrhosis
Asthma or emphysema
Produce a second peak incidence of pneumothorax from 45-65 years of age
Due to rupture of peripheral emphysematous areas
“Catamenial pneumothorax” is a recurrent spontaneous pneumothorax that occurs during menstruation and is associated with endometriosis of the diaphragm
R >> L
Marfan’s syndrome
Ehlers-Danlos syndrome
Pulmonary infarction
Lymphangiomyomatosis and tuberous sclerosis

On CXR, a PTX appears as air without lung markings in the least dependant part of the chest. Generally, the air is found peripheral to the white line of the pleura.
In an upright film this is most likely seen in the apices.
A PTX is best demonstrated by an expiration film.
It can be difficult to see when the patient is in a supine position. In this position, air rises to the medial aspect of the lung and may be seen as a lucency along the mediastinum. It may also collect in the inferior sulci causing a deep sulcus sign.

يتبع

Types of pneumothorax

1- Closed pneumothorax = intact thoracic cage

Open pneumothorax = "sucking" chest wound - 2

Tension pneumothorax - 3

Accumulation of air within pleural space due to free ingress and limited egress of air

Pathophysiology:

Intrapleural pressure exceeds atmospheric pressure in lung during expiration (check-valve mechanism)

Frequency

In 3-5% of patients with spontaneous pneumothorax
(Higher in barotrauma (mechanical ventilation

Imaging findings in pneumothorax

Must see the visceral pleural white line
Very thin white line that differs from a skin fold by its thickness
Absence of lung markings distal or peripheral to the visceral pleural white line
Not evidence enough to say there is a pneumothorax only if there are no lung markings seen
No lung markings will be seen with bullous disease
Bullae have a concave surface facing the chest wall
Pneumothorax almost always has a convex surface facing the chest wall
Displacement of mediastinum and/or anterior junction line
Deep sulcus sign
On frontal view, larger lateral costodiaphragmatic recess than on opposite side
Diaphragm may be inverted on side with deep sulcus
Total / subtotal lung collapse
This is passive or compressive atelectasis
Collapse of SVC or IVC due to decreased systemic venous return and decreased cardiac output

Tension hydropneumothorax

Sharp delineation of visceral pleural by dense pleural space
Mediastinal shift to opposite side
Air-fluid level in pleural space on erect chest radiograph

Radiographic signs in upright position

White margin of visceral pleura separated from parietal pleura
Usually seen in the apex of the lung
Absence of vascular markings beyond visceral pleural margin
May be accentuated by an expiratory film in which lung volume is reduced while amount of air in pneumothorax remains constant so that relative size of pneumothorax appears to increase

Radiographic signs in supine position

Anteromedial pneumothorax (earliest location)
Outline of medial diaphragm under cardiac silhouette
Deep sulcus sign
Decubitus views of the chest may demonstrate a pneumothorax on the side that is non-dependent
Left lateral decubitus view for right-sided pneumothorax
Right lateral decubitus view for left-sided pneumothorax

يتبع

Newborn with cyanosis.
What's the diagnosis?

Ebstein’s Anomaly

Rare

POSTERIOR and SEPTAL cusps of tricuspid valve are displaced into the Right ventricle which makes Right ventricle smaller

o- Combined with tricuspid insufficiency or sometime tricuspid stenosis, the Right Atrial pressure is elevated producing a R to L shunt through the foramen ovale

o- Pulmonary vasculature is usually diminished

o- In those with large atrial septal defects, the pulmonary vasculature may appear prominent

o- There is an atrialized portion of the right ventricle between the AV groove and the tricuspid valve

o- The right ventricle and right atrium dilate

o The right heart border becomes prominent

· Think of Ebstein’s anomaly if:

o Pulmonary flow is decreased

o Cyanosis is present in the neonate

o One of the few conditions to produce cardiomegaly in the first few days of life

learningradiology.com

Hemangioma of the Spine

Case of the Week 587 is a 67 year-old complaining of low back pain who has an incidental finding on a lumbar spine series.
Hemangioma of the Spine. (Top) Close-up lateral radiograph of the lower lumbar spine shows the classical coarse linear striation in the body of L4 (white circle). (Bottom) An axial CT scan image of the lower abdomen demonstrates a vertebral body with a very prominent trabecular pattern characteristic of the corduroy or polka-dot appearance of a hemangioma of the spine (yellow circle). The cortex is not thickened and the surrounding soft tissues are normal.
For these same photos without the arrows, click here and here
For more information, click on the link if you see this icon

What's the diagnosis?

The correct answer is at: [rtl]http://bit.ly/18ffU0O[/rtl]

General Considerations

Benign

Most often located in lower thoracic, upper lumbar spine
Skull is second most common location (spoke-wheel appearance)
Mostly asymptomatic
More frequent in females
Peak incidence in 40’s
Multiple in up to 1/3 of cases
Most often occur in the medullary cavity of bone
Microscopically, there is hamartomatous proliferation of vascular tissue
Classified as to cavernous, capillary, arteriovenous and venous
Spine hemangiomas are usually capillary type; skull are cavernous

Clinical Findings

Usually asymptomatic
Very slow growing
No known malignant potential
Over 40, patients may present with pain from compression fracture

Imaging Findings

Conventional radiography
is usually the first means of imaging hemangiomas
Prominent trabecular pattern from resorption of trabeculae by enlarged vascular channels produces
Vertical striations
Overall density of vertebral body is increased
Cortex is not thickened and vertebral body is not increased in size
Small hemangiomas will not be visible on conventional radiographs

CT
Corduroy (aka accordion, honeycomb, polka-dot) spine from coarse trabeculae seen in cross section
Thickened vertebral trabeculae produce a polka-dot appearance
Bone destruction and soft tissue extension may be present but are rare

MRI
Allows for diagnosis of soft-tissue extension
Increased signal intensity on both T1 (high fate content) and T2 (increased vascularity)
Nuclear medicine
Usually normal uptake on bone scan

Differential Diagnosis

Paget disease
Metastases
Lymphoma
Multiple myeloma

Treatment

Observation
Treatment is instituted only if they are symptomatic and may include
Vascular embolization prior to surgery
Surgical excision
Vertebroplasty
Ethanol injection

Complications

Pathologic fracture
Hemorrhage, when it occurs, is usually iatrogenic
Thrombosis
Displacement of adjacent nerves producing pain

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(Young heavy smoker with no leg pulse. Why? (hint: not atherosclerosis
تم تحجيم الصورة إلى : 92 % من الحجم الطبيعي لها [ 539 x 595 ]
Facebook Radiology Ruxrmr

ANSWER: [rtl]http://goo.gl/W61lA5[/rtl]

Buerger disease

Case contributed by: Dr G Balachandran

Presentation:
40 years old male was referred for evaluation of intermittent claudication in left lower limb.He was a chronic,heavy smoker.

Patient Data:
Age: 40
Gender: Male
Modality: CT

CTA shows total obstruction at left external iliac artery ,femoral.popliteal arteries.

Normal right side lower limb arteries.

Case Discussion:

Buerger disease is an obliterative arteritis found predominantly in heavy smokers. It most commonly affects medium and small vessels of the lower extremities.

VRs allow visualization of complex, overlapping arterial channels without the need for preliminary bone removal, providing an excellent overview of the complex anatomy.

Peripheral CTA provides complete delineation of both the femoropopliteal segment and inflow and outflow arteries, including lesion number, length, stenosis diameter and morphology, adjacent normal arterial caliber, degree of calcification, and status of distal runoff vessels.
These findings help in planning the procedure with respect to route of access, balloon selection, and expected long-term patency after femoropopliteal intervention.
Compared with catheter angiography, peripheral CTA provides better estimates of the effects of eccentric stenoses on luminal diameter reduction .
In addition, collateral vessels can be evaluated with MIP and VR images, and arterial segments distal to long-segment occlusions are well visualized peripheral CTA is more cost effective than digital subtraction angiog-raphy (DSA) for preprocedure evaluation of patients with claudication

[rtl]http://radiopaedia.org/cases/buerger-disease[/rtl]

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