Emergency #12 – Flashcard

31-year-old male:
* With flank pain
* Increased inflammatory parameters
* Decreased kidney function

Why is the right kidney less dense than the left?

Click here to see the answer

Obstructive kidney stone in the right proximal ureter (arrow) with secondary hydronephrosis

The increased pressure in the collecting system slows the ultrafiltration of urine and causes a slower enhancement of the right kidney in comparison with the left kidney, reflecting the impaired kidney function

Cáceres’ Corner Case 206

Dear Friends,

Now that Game of Thrones is ending, a new series is planned: Game of Thorax, in which either you diagnose or you die.

As you can see in today’s radiograph, the Iron Throne has been replaced by the Chest Throne.

What would your diagnosis be?

Come back on Friday to see the answer.

Dr. Pepe’s Diploma Casebook: CASE 142 – Art of interpretation – SOLVED

Dear Friends,

today I am presenting another “Art of interpretation” case. I like them and think they have good teaching value.
Radiographs were taken for preoperative knee surgery in a 21-year-old man.

What is the most likely diagnosis?

Diagnosis:
1. Swyer-James-McLeod syndrome
2. Congenital hypoplasia of left lung
3. LUL collapse
4. None of the above

Click here to see the images

Click here to see the answer

Findings: PA radiograph shows a hyperlucent left lung with a small elevated hilum (A, white arrow). The trachea is deviated towards the left and the left main bronchus is curved upward (A, blue arrow). There is a small peak in the left hemidiaphragm (A, red arrow). And there is a triangular-shaped paraspinal opacity (A, circle), better seen in the cone down view (B, white arrow), with two linear metallic opacities inside (B, red arrows).

The lateral view (C) is unremarkable. Although the PA findings suggest loss of volume of the LUL, there are some negative findings: no anterior displacement of the left major fissure and no opacity indicative of LUL collapse.

Analysis of the findings

There are four obvious findings:

1. Hyperlucent left lung with small left hilum
2. Tracheal deviation to the left
3. Upward curving of left main bronchus
4. Juxtaphrenic peak (*)

All these findings are indicative of LUL volume loss with compensatory overinflation of the LLL.

There are two less obvious findings, which are diagnostic:

Paramediastinal opacity with surgical staples
No signs of LUL collapse in the lateral view

The first indicates previous surgery and the second excludes LUL collapse. Taken together, these findings lead to the obvious conclusion that the patient had undergone a previous lobectomy.

(*) The juxtaphrenic peak sign was described by my late friend Kenneth Kattan as an indirect sign of LUL collapse. Semin Roentgenol 1980; 15:187-193

LOSS OF VOLUME OF LUL + SURGICAL STAPLES = LUL LOBECTOMY

In the past, the patient had embryonal carcinoma of the testicle with a metastatic nodule in the LUL (A and B, arrows). He had undergone LUL lobectomy by video-assisted thoracic surgery one year before.

Final diagnosis: LUL lobectomy for metastasis of embryonal testicular carcinoma

I’m showing this case to emphasize the importance of identifying metal sutures in the chest radiograph. Nowadays, most surgical procedures are done by video thoracoscopy which doesn’t leave any telltale signs other than surgical staples. These are difficult to see because of their small size and because high kV “burns” metal density.

Staples are visible as a faint longitudinal ring chain somewhat denser than the surrounding tissues. It’s very important to be familiar with their radiographic appearance because they offer valuable information about previous surgery.
When staples are detected, our interpretation of associated findings may change, as occurred with the case presented.

To familiarize you with the radiological appearance of surgical staples, I’m showing three more cases.

CASE 1:

88-year-o.ld man with dementia and moderate dyspnea. Chest radiographs show a nodule in the RUL (A and B, arrows). PA view shows post-surgical changes at the left 6th and 7th ribs and a hyperlucent left lung with a small hilum. There are surgical clips in the mediastinum (A and B, red circles). These findings suggest a previous LUL lobectomy and a second primary tumor. The patient’s records disclosed a LUL lobectomy for carcinoma twenty years earlier. The second primary tumor was confirmed by needle biopsy.
The radiographic findings are typical of “old” chest surgery.

CASE 2:

PA radiograph of a 23-year-old woman with a nondescript LUL infiltrate (A, arrow). Close-up view reveals a longitudinal ring chain of staples within the infiltrate (B, arrows), pointing to a man-made opacity secondary to video thoracic surgery.

Diagnosis: changes after endoscopic LUL bullectomy for recurrent pneumothorax.

CASE 3:
I saw this case three weeks ago and it is still unproven. A 44-year-old woman from another country came for a routine cardiac checkup. The PA chest radiograph shows a serpiginous opacity in the LLL (A, arrow) with a ring chain of staples in the periphery, better seen in the cone down view (B, arrows). On questioning, the patient mentioned previous endoscopic surgery for a nodule in the left lung two years ago. Enhanced CT shows a solid lesion with staples in the periphery (C, arrow).

As the patient could not provide previous medical records, we were unable to ensure that the changes were attributable to scar tissue. A follow-up CT has been scheduled.

Final words: Staples are difficult to reproduce on the computer screen, and I have done my best. I assure you that they are easily visible on a 14 by 17 reading console, provided that you see and recognize them 🙂


Follow Dr. Pepe’s teaching points:

1. Surgical staples are visible as a faint longitudinal ring chain.

2. They indicate previous surgery and help to interpret the chest findings under a new light.

Abdominal #1 – Long case

A 47-year-old female presented to the Emergency Room with bilateral upper extremity paresthesia, redness and edema. Her symptoms were not position-dependent. The patient was otherwise healthy, and did not take any medication. There is no pertinent surgical history.

An MR angiogram was ordered. The following images were obtained during bolus tracking:

Click here to see the images
Coronal MRV

MRA

T1-weighted images with fat saturation, following contrast administration


Click here to see the diagnosis

Diagnosis:

Superior vena cava (SVC) syndrome from right apical lung mass

Discussion:

In this patient with bilateral neurological deficits and edema, the suspicion of SVC syndrome must be addressed. This can be done using either an MRI or a CT protocol. In this case, the MRI scout bolus images (Image 1 & 2) revealed a pathognomonic sign for SVC occlusion:

Please note the marked collateral circulation following contrast administration to the right upper extremity with dilation of multiple intercostal and lateral thoracic veins. These collateral vessels then pool into the liver’s quadrate (segment 4 of the liver), giving the characteristic “hot spot sign”. This name originates from terminology in nuclear medicine, where it was occasionally seen in the case of SVC syndrome. Nowadays, it is more likely to be noticed on a CT or MR. This image also reveals the complete occlusion of the SVC.

Following fat-saturated T1-weighted axial image acquisition with contrast, the cause of the obstruction is evident. There is an infiltrative right apical mass which obstructs the SVC, as well as bilateral pleural effusions. Additionally, there is tumor thrombus noted in the left innominate vein, likely secondary to stasis.

Please review the following video and identify all these pertinent findings:

Cáceres’ Corner Case 205

Dear Friends,

Today I am showing preoperative radiographs for hand surgery in a 53-year-old man.

What do you see?

More images will be shown on Wednesday.

Click here to see the images

Dear Friends,

showing today chest radiographs taken one year earlier.

Do they help?

Click here to see the new images

Click here to see the solution

Findings: PA chest radiograph shows an ill-defined opacity in the left middle lung field (A, arrows). It is located in the anterior clear space in the lateral view and has a stippled appearance (B, arrows). In addition, there is a flat irregularity in the dome of the left hemidiaphragm in the PA view which appears to be calcified (A, red arrow).

Previous radiographs one year earlier show the same findings, unchanged (C-D, arrows).

The clue to the diagnosis lies in the irregularity of the dome of the left hemidiaphragm, that looks like a calcified plaque. This finding suggests that the apparent pulmonary opacity in the PA view may be a pleural plaque see “on face”. It is not seen as a line in the lateral view because the curvature of the anterior thoracic wall does not offer a straight interface to the X-ray beam.

CT confirms calcified anterior pleural plaques in both hemithoraces (E-F, arrows).

Coronal and sagittal CT confirm the calcified plaque in the diaphragmatic dome (G-H, red arrows).

The patient was found to have a history of asbestos exposure.
 
Final diagnosis: Asbestos-related pleural disease simulating pulmonary infiltrate.

Congratulations to S, who was the first to make the diagnosis. Silver medal to VL.
 
Teaching point: remember the deceitful appearance of pleural plaques shown in Diploma case 140. Some of you were fooled by it!