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?

Click here to see the see the images


NEW CLINICAL INFORMATION:

Pulses were weaker in the lower extremities.

Click here to see the see the answer

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.

    Like

  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

    Like

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

    Like

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

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

    Like

  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.

    Like

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

    Like

  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?

    Like

  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….

    Like

  9. 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?

    Like

  10. 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.

    Like

    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 🙂

      Like

Leave a Reply to Andy Cancel reply

Fill in your details below or click an icon to log in:

WordPress.com Logo

You are commenting using your WordPress.com account. Log Out /  Change )

Google photo

You are commenting using your Google account. Log Out /  Change )

Twitter picture

You are commenting using your Twitter account. Log Out /  Change )

Facebook photo

You are commenting using your Facebook account. Log Out /  Change )

Connecting to %s

This site uses Akismet to reduce spam. Learn how your comment data is processed.