Dr. Pepe’s Diploma Casebook 165 – SOLVED

Dear Friends,

showing today a preoperative AP chest of a 93-year-old man who broke his right femur after a fall.

What do you see?

Click here to see the answer

Findings: AP chest radiograph shows a poorly defined opacity in the RUL (A, circle).

Axial and coronal enhanced CT show that the opacity corresponds to a tortuous brachiocephalic artery (B and C, arrow). There is no pulmonary infiltrate.

Final diagnosis: Tortuous brachiocephalic artery simulating a pulmonary infiltrate.

The aim of this Diploma is to continue discussing chest imaging in the older population.

Today I will comment about the main manifestations of aging in the mediastinum and heart, discussing variants that may simulate disease, followed by the most common conditions affecting these regions in elderly patients.


The standard PA radiograph in aging adults usually shows a somewhat enlarged mediastinum, due to poor inspiratory effort combined with an elongated aorta and mediastinal fat accumulation (Fig. 1) .

Fig. 1. Normal chest in an 85-year-old man. Note the limited inspiration and increased width of mediastinum. The aorta is elongated, and the cardiothoracic ratio is 50%. A pacemaker is visible in the left hemithorax.

A common variant in older patients is a tortuous brachiocephalic artery, which may project into the lung, simulating a pulmonary lesion (Fig. 2), as was shown in the initial case.

Fig. 2. 88-year-old woman with vague chest complaints. PA radiograph shows an RUL opacity (A, circle). Unenhanced axial CT confirms that the opacity corresponds to a tortuous brachiocephalic trunk projecting into the lung (B, arrow).

Sometimes the tortuous artery simulates a mediastinal mass. In these cases, the diagnosis is easy because a mediastinal mass pushes the trachea toward the left (Fig. 3A), whereas an elongated artery does not; instead, the associated elongated aorta displaces the trachea to the right (Fig. 3B).

Fig. 3. 52-year-old man with a right thyroid mass pushing the trachea towards the left (A, arrow).
The second patient is an 83-year-old man with tortuous brachiocephalic vessels simulating a mediastinal mass (B, arrow). Note that the trachea is displaced towards the right by an elongated aorta.

The aorta is elongated in most older adults. A kink in the distal descending aorta often casts a posterior shadow in the lateral view that should not be confused with disease (Fig. 4).

Fig. 4. 73-year-old man with an elongated aorta (A). A kink in the descending aorta creates a posterior opacity superimposed on the lower spine (B, circle). Unenhanced sagittal CT confirms the kink as the cause of the opacity (insert, arrow).

Calcification of the annulus fibrosus of the mitral valve is common in elderly individuals. It does not cause symptoms and should not be confused with other conditions. It has a pathognomonic appearance in the chest radiographs (Fig. 5).

Fig. 5. 79-year-old man/woman with mitral annulus calcification. Note the typical “C” shape and location in the PA and lateral radiographs (A and B, circles).

A variant of calcified annulus fibrosus is a condition termed caseous necrosis of the mitral annulus. It appears as an ovoid intracardiac calcification, visible in chest radiographs (Fig. 6) and confirmed with CT. It is also symptomless.

Fig. 6. 73-year-old man, asymptomatic. PA and lateral radiographs demonstrate an ovoid calcification projected over the cardiac shadow (A and B, arrows). Axial CT confirms the calcification (insert, arrow), corresponding to caseous necrosis of the annulus.


The most common mediastinal pathology in the older population is hiatus hernia, easily identifiable when it contains air. An airless hernia should not be confused with a lower mediastinal mass. The best way to diagnose hiatus hernia is by looking at previous films (Fig. 7). If none are available, a barium swallow is sufficient (Fig. 8).

Fig. 7. 68-year-old woman with an airless hiatus hernia simulating a mediastinal mass (A, arrow). Previous film one year earlier shows a typical hernia with an air-fluid level (B, arrow).
Fig. 8. PA and lateral radiographs in a 65-year-old woman with a large airless hiatus hernia (A and B, arrows) . No previous films. Barium swallow confirms the hernia (insert, arrow).

At times, too much air in a hernia may be misleading, as occurred in the case below, which was initially diagnosed as a possible pneumopericardium (Fig. 9).

Fig. 9. 66-year-old woman with known breast carcinoma admitted to the ER in shock. AP radiograph show right lung metastasis (A, arrow) and two lines outlined by air surrounding the heart (A, red arrows).

Pneumopericardium was suspected. Enhanced CT coronal and sagittal images
show that the apparent pneumopericardium was actually a large hiatus hernia (B and C, arrows). On retrospective review of the patient’s chest radiograph, bowel air can be seen projected over the heart.

Mediastinal mass in patients of advanced age are commonly due to metastasis. Lymphoma is an alternative diagnosis, as around 50% of non-Hodgkin lymphomas occur in patients older than 65 years (Fig. 10).

Fig. 10. 77-year-old woman with asthenia and weight loss. Chest radiographs show bilateral pleural effusion and an anterior mediastinal mass (A, arrows. B, asterisk). Axial CT confirms
the mass (insert, arrow). Diagnosis: B-cell lymphoma

Differentiating aortic aneurysm from a tortuous aorta is difficult in chest radiographs, because the medial aortic wall is obscured by the mediastinum. Sometimes the inner wall is outlined by air, allowing detection of aortic dilation in the plain film (Fig. 11).

Fig. 11. 73-year-old woman with chest pain and a tortuous aorta. The medial wall is outlined by air, allowing us to determine that the aorta is dilated (lines in A and B). Enhanced axial CT shows a type-B aortic dissection (insert, arrow).

The incidence of atrial fibrillation increases after the age of 65, and up to 9% of octogenarians are affected with this condition. Detecting a prominent left atrium in the chest radiograph of an elderly person should suggest this diagnosis (Fig. 12).

Fig. 12. 75-year-old woman with atrial fibrillation. Note the prominent left atrium in the PA and lateral radiographs (A and B, arrows).

Ventricular aneurysm is a complication of myocardial infarction. In an elderly patient, the aneurysm may calcify and appear as curvilinear calcium projected over the left heart (Fig. 13).

Fig. 13. 80-year-old man with a history of myocardial infarction ten years earlier. Chest radiographs show a thin curvilinear line projected over the heart, consistent with a calcified aneurysm (A and B, arrows). Unenhanced CT confirms the diagnosis (insert, white arrows). A calcified thrombus is also visible (insert, red arrow).

Follow Dr. Pepe’s advice:

1. Tortuous brachiocephalic artery and calcification of the mitral annulus are common variants in persons of advanced age.

2. Hiatus hernia occurs frequently in older individuals.

3. Enlarged left atrium in this age group should raise the possibility of atrial fibrillation.

This is the last case on 2020 and we will be back on January 11, 2021!

10 thoughts on “Dr. Pepe’s Diploma Casebook 165 – SOLVED

  1. A RUL opacity and other smaller opacities with a peripheral distribution.
    Enlarged hila, due to pulmonary arterial hypertension.
    Aortic knob enlarged, the descending aorta looks ectatic.
    I would say fat embolism.


  2. – opacity obscuring right lung apex
    – trachea pulled into the mentioned opacity
    – aortic knob & both hila seem enlarged but AP (lying?) can exaggerate
    Conclusion: possible carcinoma with apical pulmonary origin (Pancoast) and mets to the femur (low energy fracture)


  3. Rt upper zone linear opacities, showing parallel configuration.
    Abrupt cut off of right descending pulmonary artery. With broadening in proximal part. – to consider Pulmonary arterial thrombosis with fat embolism.
    The right uz might be due to prominent veins, in venous hypertension.


  4. Opacity Rt upper zone.
    Lt apical cap.

    Aortic knuckle prominent with unfolding of aorta seen through the heart shadow – age appropriate.


  5. Right upper medial lung zone opacity suspicious for mass.
    Irregularity of the left upper scapular cortical contour suspicious for destructive process with undisplaced pathologic fracture.
    Otherwise poor inspiratory effort, prominence of bronchovascular markings, widened hila and prominent aortic contours; relative hyperlucency of the right mid-lower lung zones (could be due to technical factors).
    CT chest indicated to evaluate right upper lung zone and left scapula.


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