Cáceres Corner Case 198 – SOLVED!

Dear Friends,

Today I’m presenting chest radiographs of a 28-year-old man with severe headache and high blood pressure (201/110 mmHg).

What do you see?

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Pulses were weaker in the lower extremities.

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Findings: Chest radiographs show a moderate cardiomegaly. There is pulmonary vascular redistribution, with the upper vessels (A, red circles) larger that the lower ones (A, blue circles), indicating an early stage of left cardiac failure.
The information of weak pulses in the lower extremities is important. This finding suggests impeded blood flow in the thoracic aorta, the most common cause being aortic coarctation. The small aortic knob and the lack of rib notching go against it, though.

CT angiogram shows narrowing and complete interruption of the distal thoracic aorta (C-E, circles), with abundant collateral circulation. The mid-aortic syndrome usually happens in children and young adults. The etiologies vary. In this particular case, biopsy confirmed Takayasu arteritis.

An aortic graft was placed to circumvent the obstruction (F-G, arrows).

Final diagnosis: Mid-aortic syndrome secondary to Takayasu arteritis
Congratulations to Ner, who made the correct diagnosis and to Krister A who was the first to suggest aortic obstruction.
Teaching point: in a young person with severe hypertension, distal pulses should be checked. If weak, aortic coarctation should be suspected. If the telltale signs of coarctation are missing, mid-aortic syndrome should be considered.

21 thoughts on “Cáceres Corner Case 198 – SOLVED!

  1. Good morning!

    Increased cardio-thoracic index in a well-inspired x-ray (cardiomegaly). The tip of the heart is directed to the diaphragm due to biventricular dilatation.
    Signs of vascular redistribution with pulmonary vessels from upper fields more evident than inferiors.
    Left pleural effusion more evidente than right.

    1. I just put new clinical information: pulses were equal in both arms and weaker in the lower extremities.
      Good luck!

  2. Obliteration left costo phrenic angle which associated with opacity in the posterior inferior aspect of the lateral chest view with triangular opacity seen.
    Relatively increased cardiac shadow
    Suggestive of cardiomegaly with mild left pleural effusion

  3. Narrow upper Mediastinum and hyperperfusion of the lungs, indicative of l/r shunt, possibly in context of transposition of great arteries.

  4. Cardiomegaly with slight left effusion in a relative young person with hypertension,

    Heart vitium?
    Hypertroph cardiomyopathy?
    Hypertroph obstructive cardiomyopathy?
    Pericard effusion?

  5. Hello,
    Rounding and lateral displacement of the left heart border on the PA view, and posterior displacement on the lateral view ( Hoffman-Rigler sign).
    Redistribution of the pulmonary vessels, no evidence of left atrial enlargement.

    Impression: left ventricular hypertrophy with grade 1 pulmonary edema.

  6. PA VIEW – Cardiomegaly, Left minimal pleural effusion.
    LATERAL VIEW – Left ventricular enlargement, Mild right ventricular enlargement, bilateral minimal pleural effusion

  7. So far, your answers are correct: cardiomegaly and vascular redistribution indicative of mild left cardiac failure in a patient with hypertension.
    Do you have any questions about the cause of the hypertension?

  8. ….scompenso del piccolo circolo con ipertrofia ventricolare sx e scarsa evidenza del bottone aortico…..la causa può’ essere una stenosi valvolare aortica, congenita(es. valvola bicuspide) od acquisita….

  9. I see rib notching in right costa 5. Could it be aortic coarctaion? Blood pressure different in left and right arm?

    1. I just put new clinical information: pulses were equal in both arms and weaker in the lower extremities.
      Good luck!

  10. Sorry! Of course, if it is coarctation the hallmark is high blood pressure in both arms and a low blood pressure in the legs, since the classical location is distal to the left subclavian artery.
    Any murmur?

    1. Don´t have information about any murmur. But the small aortic knob goes against coarctation.

  11. Oh, I’m late to the party!
    Enlargement of the heart, minimal pleural effusion.
    Small aortic knuckle, but no signs of chronic collateral enlargement (ribs seem fine). With clinical information I suspect some kind of arteritis (Takayasu?). Contrast enhanced CT needed.

    1. A left to right shunt would give increased pulmonary vascularity. In this particular case what we see is redistribution.

  12. Lateral view – Descending aorta is small in calibre – Coarctation of aorta to be ruled out

    1. I believe that what you call the descending aorta is the left pulmonary artery. In a young person it is difficult to see the descending aorta in the lateral view.
      However you may have a point. Wait and see the images tomorrow 🙂

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