Cardiac Flashcards
prev of angina
2% population
Information is obtained about: - CT cardiac
Cardiac morphology and chamber size
Coronary anatomy and disease
when in cardiac cycle to do the scan
late diastole
optimal heart rate
<60s - ideal 55 - 60
Benefit of retrospective imaging
evaluate myocardial wall motion and EF
CT cardiac - contrast delivery parameters
During a single breath-hold, 25 ml of IV contrast is injected at a rate of between 4-6 ml/s.
dosing of metroprolol
5- 75mg but really up to 40mg
which is worse calcified or non calcified
Non-calcified plaque may be more unstable and prone to acute rupture leading
what kind of HU are plaques going to be
Soft 14
intermediate 91
Calcified 419
when is CT CA used?
if cant do the procedure due to anatomy - large aortic root
or pathology such as dissection
why is calcium scoring dubious
may have limited impact due to effects of remodelling
if no calcium then unlikely to have any plaque
if calcium - likely underestimates amount of plaque
Coronary calcium load has been found to progress over time, increasing by
15-25% per year
Agatston scoring system for calcium
3 mm slice thickness is a product of the area of calcification per coronary segment and a factor rated 1 through 4 dictated by the maximum calcium CT density within that segment
minimum density to be considered a plaque on the scoring system
130HU
What is a step artefact
Step artefact are forms of reconstruction artefact which may occur particularly as a consequence of cardiac arrhythmia. This results in visible ‘step’ increments on a single image which is reconstructed from several data sets.
CT CA artefacts
motion artefact
step artefact
partial voluming next to calcium
IV contrast timing or poor output in cardiomyopathy
what is ectopic origin of the artery - why is it important
exclude it in the young
second commonest cause of sudden death in young
.
.
Ao
Aorta
LA
left atrium
LCA
left coronary artery
Max intensity projection
MIP
PA
pulmonary artery
RVOT
right ventricle ouflow track
what is the difference between normal variant and anomaly?
Normal variant - seen in more than 1% of the population
Anomaly - seen in less than 1% of population
An anomalous coronary artery origin is considered when the ostium is located
not within the sinus
patients with clinically significant anomalies will usually present when
before midlife
the most common major congenital malformation of the coronary circulation
Anomalous origin of the left coronary artery from the pulmonary trunk is the most common major congenital malformation of the coronary circulation (~1:300 000 live births), but this manifests itself in infancy.
anomalies of intrinsic coronary arterial anatomy
number of anomalies of intrinsic coronary arterial anatomy such as
ostial stenosis,
atresia,
single, absent or hypoplastic coronary arteries,
What is myocardial bridging?
most common place
epicardial segment of a coronary artery that courses through the myocardium.
mid LAD
aetiology of spontaneous dissection is unknown; however, SCAD has been reported, especially in
young women during the peripartum period or in association with oral contraceptive use
Features of Kawasaki
Conjunctivitis
Erythematous
Lips
Oral cavity
Palms and soles
Polymorphous exanthema of the body trunk
Swelling of the cervical lymph nodes
Kawasaki - Acute/early phase complications
Include: pericarditis, myocarditis, endocarditis, inflammation of the conduction system and coronary artery involvement with 1-2% of patients presenting with sudden death due to cardiac failure.
Myocardial infarction is also a potential complication that usually occurs in the first year. At post-mortem, these infants are found to have coronary arteritis with associated thrombosis and aneurysm formation. In a large Japanese study 25% of patients with acute Kawasaki disease were shown by coronary angiography to have coronary aneurysms.
Kawasaki - chronic complications
Chronic/long-term phase
In the chronic phase, the long-term complications relate to the persistence of these aneurysms, the development of thrombotic occlusion, the risk of ischaemic heart disease and premature atherosclerosis. Aneurysms detected after the acute stage regress in about 50% of cases with small (<5 mm) to moderate (5-8 mm) sized aneurysms more likely to regress with approximately 1% of patients who recover from acute Kawasaki disease developing giant coronary artery aneurysms (>8 mm in diameter) or coronary artery obstruction due to thrombosis or stenosis. Giant coronary aneurysms have the lowest regression rate, the highest risk of stenosis and strongest association with myocardial infarction.
Should CTCA be done on low to intermediate trop rises
debated
How to prepare patients for CT CA
Heart rate control
- aim less than 60
- B block
- GTN
how does GTN work?
smooth muscle relaxant
severe aortic stenosis contraindicated
contraindicated in phosphodiasterase inhibitors
How long do patients need to breath hold for?
10 - 15 seconds
how to get the contrast into the coronary at the right time?
ROI to define a peak enhancement of the arteries
left atrial appendage should be looked for what>
clots
LV thickness can only be reviewed in relation to what?
Diastole or systole.
how to tell systole or diastole
based on whether the mitral valve is open or closed
third branch of the left stem
ramus or intermeidate branch
obtuse marginal come from
circumflex
diagnosal branches come from
LAD
dose of CTCA
often as low as 1mSv
what views do you need to show?
2 3 4 chamber views
plaques are classififed as
calcified
non clafieid
mixed morphology
CAD RADS uses what to measure the plaques?
3 - 50% stenosis
4 - 70 - 99%
presence of contrast distally implies what
doesn’t necessarily mwan there is NOT complete occlusion.
Can still have complete occlusion
What are the distincive features of the right ventricle?
APICAL MODERATOR BAND
papillaries attached to interventricular septum and free wall
course trabeculae
What are the distinctive features of the left ventricle?
Papillary muscles attached ONLY to ventriclar free wall
thin and delicate trabeculae
Hypoplastic left heart? what is it?
born with a crap left heart
small ascending aorta, retrograde flow to the great vessels
Flow from pulmonary trunk into aorta
Hypoplastic left heart surgery outcomes?
Palliative option. 3 stage process to protect the lungs and avoid right heart overload
Hypoplastic surgeries - what are they?
Norwoord - days
Glenn - 6 months
Fontain - 5 years
NOrwood surgery
Creat less restriction the systemic blood flow
Anastomose the aorta to the right ventricle.
Increase the size of the arch
increase the size of the VSD
shunt between the right subcalvian ARTERY and right PA to get blood into the lungs
Glenn procedure
Goal: blood return to be passive rather than arterial
Vein to artery. SVC to right PA. Passive blood return.
Fontan procedure
GOAL: passive return of blood
Close ASD.
Shunt between RA and left PA
Transposition of arteries - what is it?
Different types.
Double issue swap is fine.
If loops are interconenct between each side of th ehart then needs surgery.
L type vs d type for transposition?
L type is on the left
D is on the right
Wayts to correct transposition of the arteries.
Senning and Mustard - RV is the systemic pump
Rastelli - LV is systemic pump. Uses a baffle.
Jatene - LV systemic pump. Direct switch
LeCompte manuever
switching of the aorta and pulmonary artery in transposition of the great arteries
Ross procedure
Performed in diseased aortic valve
Pulmonary is placed into the aortic valve
Aortic dilatation from marfans - what procedure is done?
Bentell procedure
replaces the valve and ascending aorta
Caridac MR - white is
dead
Cardiac MR sweet spot
scar enhances late - 10 minuetes to 30 minutes after contrast
how to seperate types of heart disease on MR
ischaemic (vascular distribution - sub endocaridal) vs non ischaemic
Cx is supply to which bit of the wall?
Lateral
subendocardial is the first to be seen in ischaemic injury - why?
wave of ischaemia goes from inside out base on hopw bad the ischaemia is
Viability - 50%
less than 50% myocardiam involved thickness then good result ith PCI
Normal vs akinesia vs dyskinesia
Normal - myocardium should thicken.
Akinesia - part doesnt contract at all
dyskinesia - bulges in the wrong direction
types of cardiac ventricular aneurysm?
True ventricular
False ventricular aneurysm
False ventricular aneurysm - what happens
doesn’t go through all layers
body wider than the mouth
posterolateral position
takes 3- 7 days after MI
myocarditis will affect which part of the wall
mid wall or epicardial
favours lateral free wall
myocarditis caused by what virus
coxsackie virus
what will MR amyloid look like
circumferential
sub endocardial distribution
myocardium hard to null (long inversion time)
eosinophilic cardiomyopathy causes what?
bilateral ventricular thrombus
MR dose some bouncing of the septum. Sigmoidization
Constrictive pericarditis.
calcified pericardium
Causes of constrictive pericarditis
CABG or radiation
Causes of contsrictive vs restrictive pericarditis
Restrictive is amyloid or esoinophils IN THE MUSCLE
What causes HCM?
cardiac sarcomere is retarded
What does HCM look like?
thickened myocardium
What is SAM stand for in HCM
Systolic anteriror movement of mitral valve
MR distribution of pathology is subendocardial and circumferential
Amyloidosis
MID wall MR cardiac spots of apthology
HOCM
Midwall, epicardialCardiac MR pathology
myocarditis, sarcoidosis
thrombus vs tumour? Which imaging to tell the difference
Cardiac MR with contrast. Tumour will enhance
most common caridac tumour?
What about kids?
Primary is a myxoma
Mets is pericardial
kids - tubosclerosis. Rhabdomyeloma
ischaemic or scarred cardiac tissue will behave how with Nuclear studies?
They wont take up the tracer.
How do you work out the difference between ischaemic or scar?
cold on only stress - ischaemia
cold on stress and normal - scar
Cardiac Nuc med - how much stenosis do you need to see it?
50% with stress
90% if no stress
so it increases the sensitivity of the test
What drug to give in Cardiac Nuc med
Regadenson
Ragadenson does what?
Vasodilator
No bronchospasm
What use is dipyridamole in Cardiac nuc med?
inhibits the breakdown of adenosine
so adenosine builds up and causes vasidilation
List the left to right shunts
ASD
VSD
AVSD
PDA
how many adults have an unsealed formane ovale
25%
Tetrology of fallot consists of
he other components are pulmonary stenosis (valvular or infundibular), dextroposition of the aorta (the aortic root overrides the defect) and right ventricular hypertrophy.
and VDD
Types of atrial septal defects
secundum
primum
superior sinus venosus
inferior sinus venosus
coronary sinus defect
common atrium
ASd - secundum
Secundum: Defects within the oval fossa
ASD - primum
Partial atrioventricular defect - the defect lies low in the septum and is associated with abnormal development of one or both of the atrioventricular valves. This will be discussed under the section on AVSDs.
ASD - Superior sinus venosus
: The superior vena cava (SVC) terminates in such a way as to drain into both atria. Commonly, the pulmonary veins from the right upper lobe are also involved draining in an anomalous fashion to the SVC.
Inferior sinus venosus
ASD
IVC drain into both atria
ASD
Common atrium
confluence of one type of defect with another
size of a left to right shunt is realted to what
compliance of the ventricles
(not the size of the defect)
How to measure shunt flow on MRI
difference between aortic and pulmonary blood flow
how can invasive catheter monitor demsontrate shunting
measure oxygen level in the SVC and atrium. Atrium will have higher oxygen concerntration.
Associated abnormalities with ASD
partial anomalous pulmonary venous drainage,
pulmonary valve stenosis, mitral stenosis,
mitral valve prolapse,
VSD,
PDA and coarctation of the aorta.
which is better for right ventricle volumes - echo or MRI
MRI
Types of VSD
Perimembranous VSD - most common
Muscular ventricular septal defects
Doubly committed sub-arterila ventricular septal defects (between aortic and pulmonary valves)
What are goals of therapy for VSDs?
prevent infective endocarditis
preserve left sided heart function
close it if there is pulmonary htn, (Eisenmenger physiology)
Types of VSD at risk of infection
small
if the pressure gradient across the VSD remains high what does this imply
pulmonary hypertension hasn’t happened yet
What are the types of AVSD
Partial
Complete
Partial AVSD
ostium primum ASD, common valve is divided into two orifices
Complete AVSD - classified how
common valve guards a common orifice
AVSD - CXR findings
massive pulmonary artery
small aorta
Pulmonary artery calcification in a native vessel indicates
longstanding pulmonary arterial hypertension - consider PDA
cardiomyopathy is what kind of process?
Idiopathic
4 categories of cardiomyopathy
Hypertrophic cardiomyopathy
Restrictive cardiomyopathy (RCM)
Dilated cardiomyopathy (DCM)
Arrhythmogenic right ventricular cardiomyopathy (ARVC)
IS there a 5th category of cardiomyopathies?
Which conditions are in it?
Unclassfied category.
Left ventricular non-compaction and takotsubo cardiomyopathy
Does HCM cause outflow obstruction?
no, this is an old consideration
what part of the lv is affected by HCM
base
Classical HCM affect the mitral valve leaflet in what way
classical HCM is systolic anterior motion of the anterior leaflet of the mitral valve
What kind of gad sequence is used for reviewing scarring in MRI cardiac
late gad enhancement
does myopathy scarring involve the subendocardium
no
define restrictive cardiomyopathy
disease that restricts diastolic filling of ventricles
restrictive cardiomypathies differential
amyloid
sarcoid
haemachromatosis
What will restrictive cardiomypathies look like
The diastolic filling is stiff and non-compliant and there is often systolic dysfunction, particularly as the disease process progresses
Echo vs MRI in reviewing for restrictive cardiomyopathy
benefit of MR is its ability to sometimes define an underlying cause by, for example, looking for evidence of mediastinal and hilar lymphadenopathy (sarcoid) or iron deposition in the myocardium with T2W imaging (haemochromatosis).
Late gad enhancement in amyloid shows what?
enhances in thickened ventricular walls/atria/interatrial septum
white heart sign
normal heart is what colour on late gad enhancement
black
what is the definition of dilated cardiomyopathy?
Dilated cardiomyopathy is the term used to refer to ventricular dilatation of unknown cause and specifically there must be no evidence of underlying ischaemia.
Diagnosis of exclusion
Arrhythmogenic right ventricular cardiomyopathy affects which venTricle most?
rIGHT
Arrhythmogenic right ventricular cardiomyopathy
WHAT HAPPENS TO CAUSE IT?
DISORDER OF intercellular adhesion molecules between the myocytes
infiltrating fat is typically of high signal on T1W images and the fibrous material can be seen on LGE imaging.
What condition is this ?
Arrhythmogenic right ventricular cardiomyopathy
Left ventricular non compaction - what is it?
recently identified cardiomyopathy characterised by a very prominent pattern of trabeculation within the LV.
What is Takotsubo Cardiomyopathy
isease of transient apical ballooning seen usually in post-menopausal female patients
Normally an overwhelming psychological event
due to sympathetic or catecholamine overdrive.
Hypoplastic left heart syndrome anatomy at birth?
Pulmonary venous return is via a patent foramen ovale or atrial septal defect (ASD) to the right atrium (RA).
Cardiac output is supplied by the single right ventricle (RV) to the pulmonary arteries, and via the PDA to the aorta.
In the aorta, antegrade blood flow passes to the lower body, with retrograde blood flow to the head and neck vessels and coronary arteries (via the hypoplastic ascending aorta).
Outcome for hypoplastic left heart syndrome?
without treatment death within 90 days
hypoplastic left heat syndrome - treatment options
compassionate care
staged palliative surgery
cardiac transplantation
hypoplastic left heart surgery in staged palliative surgery - three operations - what are they?
Norwood
Bi-dirctional glenn
Fontan
hypoplastic left heart - bi-directional glenn - what is the main complication
branch pulmonary artery narowing from fibrosis/scarring or compression from other vascular structures
What is a fontan operation ?
Cavopulmonary connection.
pulmonary venous return is now solely to the systemic right ventricle
What is the main complication of the Fontan circulation?
dilatation of the right atrium and resultant atrial arrhythmias
What is the issue in tetrology of fallot?
anterior displacement of the conal septum.
(the septum which divides pulmonary outflow tract (the infundibulum) from the left ventricle)
4 hallmarks of Fallot
Pulmonary outflow tract stenosis
VSD
Over-riding aorta (over the VSD)
Right ventricular hypertrophy (as a consequence of high right heart pressures)
commonest cause of right sided arch ?
Fallot tetraology
Blalock-Taussig shunt (BT shunt)?
, anastomosing the subclavian artery down onto the pulmonary artery.
An adult patient presents for cardiac MRI, having undergone correction of tetralogy of Fallot during childhood. Which structure is the most likely to be dilated?
RV
Post MI risk in 1 month and 1 year of death
Post hospitalisation, the risk of death in the first month is 10-15%, with a further risk in the subsequent year of 10%.
On angiograms - which type stenoses are the ones that will rupture and cause MI
the mild stenoses
Describe the graph of lesion length and % stenosis for rest / excercise.
1mm length - 60% stenosis to cause excercise angina. 85% to cause unstable angina.
10mm - 30% stenosis to cause excercise angina, 60% to cause unstable angina.
Ie the longer the lesion the less narrowed it has to be to cause issues. Overall need at least 60% to cause unstable angina symptoms.
inferior MI - commonest complication?
bradyarhthmia and complete heart block
what kind of pacemakers are used for bradycardias post MI
dual lead
atrio and ventricular
VF or Vt need what?
AICD
artifical implantable cardiac defibrillator
The following are all seen in which part of the muscle and what phase?
End diastolic wall thinning
Wall motion abnormality
Absence of wall motion
Paradoxical wall motion
Systolic left ventricular wall motion abnormalities
paradoxical motion (dyskinesis) - what is it ?
Mi causes thin muscle to balloon out rather than contract
left ventricle pseudo aneurysm will form how long after an MI
3-5 days
Rupture through the ventricular septum causing acute ventricular septal rupture occurs in
what kind of MI
both inferior and in anterior MI.
Symptoms of cardiac failure tend to develop when over WHAT of the LV myocardial mass becomes damaged from an MI.
20-25%
Right heart failure XR features
Chext x-ray: Prominent systemic veins – prominent azygos vein
Left sided heart failure
normal LVF venous pressure?
8-12mmHg
12-18 mmHg LVF chest xr sign
Blood flow is redirected to the upper lobes (erect)
> 18 mmHg LVF chest xr sign
interstitial oedema
sub pleural effusions
loss of peribronchial definition
> 25 mmHg LVF chest xr sign
alveolar oedema
alveolar shadwoing due to fluid in alveoli
late post mi pericarditis is called what
dresslers syndrome
There are three common causes of a single ventricle.
Tricuspid atresia
Double inlet left ventricle
Hypoplastic left heart syndrome
What is a Blalock-Taussig Shunt
subclavian artery to the superior aspect of the pulmonary artery
what is a fontan circulation ?
systemic venous shunts, ie IVC/SVC straight to the PA.
Glen shunt is what?
When the IVC or SVC is put into the PA
Which condition can only have a single ventricle repair?
Tricuspid and mitral atresia - failure of ventircle to develop.
Hypoplastic left heart syndrome
double inlet left ventricle.
common complications of single ventrivle patients?
arrythmias
sinus node dysfunction
You should be able to make a definite diagnosis for shunt stenosis using:
ECG-gated CT
Magnetic resonance imaging
Invasive angiography
A PDA will allow some mixing and can be kept open by xxxx
prostacyclin
moderator band exists in which ventricle
the right ventricle
Congenitally Corrected Transposition of the Great Arteries
what is it?
TGa, but also have discordant atrium to ventricles.
IVC to left atrium, mitral valve, left ventricle, pulmonary artery
examples of conditions that can give right ventricle dysfunction
COPD and myocardial dysfunction
when is reflux of contrast into the IVC not an actual useful sign for PE
Tricupsid regurgiation
injection of contrast at greater than 3ml / second
What can you do to improve the quality of the CTPA?
breathing from start of contrast adminsitration. Deep breaths. Long and gentle inspiration.
Avoid valsalva maneouver.
CTPA what ratio should always be measured.
RV / LV
Should be less than 1
Inspiratory CTPA - IVC should be what shape?
Ovoid.
Round measn hypertension.
myoxomas most often found where
Left atrium
arise from the interatrial septum close to the fossa ovalis and are often based on a small pedicle
On post-gadolinium images, myxomas mostly show enhancement which is
patchy and heterogeneous, but usually poor.
second most common benign cardiac tumour
lipoma
what percentage of caridac tumours are malignant?
where from?
25%
bronchus, breast and melanoma.
Mets to the cardiac - appear how on MRI
f low signal on T1W images, except melanoma metastases, which are of high signal.
Metastases tend to demonstrate high signal on T2W imaging
enhance post gad
main malignant cnacer of the heart is
Sarcomas
will invate wall and pericardium
three main types of coartation of the aorta are
tubular hypoplasia
localised coarctation
interrupted arch
Tubular hypoplasia of the aortic arch
presents in infancy and is often associated with other cardiac abnormalities.
The narrowed segment is of variable length and may be localised or involve the whole of the distal aortic arch
Localised coarctation
focal narrowing near the site of attachment of the ligamentum arteriosum distal to the left subclavian artery
Interrupted arch
his can occur beyond the left subclavian artery, between the left subclavian and left common carotid arteries or between the innominate and the left common carotid artery. In interrupted arch, the descending thoracic aorta is supplied from the pulmonary artery via a patent ductus arteriosus
The first and second ribs do not show notching in Coarctation
because the intercostals arise from the thyrocervical trunk proximal to the coarctation.
Associated cardiac abnormality for coarctation
bicuspid valve found in 85% of patients with CoA
but VSD, ASD, PDA also common
Associated intracranial pathology for a patient with CoA
berry aneurysm and sub arachnoid haemorrhage
coarctation is usually best seen on what view on echo?
Suprasternal notch
Adults presenting later in life will have coarctation of the aorta where?
Localised narrowings distal to the sublcavian artery
T or F
MRI can be safely used in patients with prosthetic aortic valves
T
All current valves are safe although there may be some artefact from the valve.
T / F
MRI is contraindicated in patients with coronary artery stents
F
It is advisable to wait for 2 weeks after stent insertion, although even this may not be necessary.
Intraaortic counterpulsation balloon pump is used for what?
treating postcardiotomy shock and as a bridge to either heart transplantation or implantation of a long-term device.
for an aortic dissection, what information should be included in your report?
Type A / Type B involves only the aorta distal to left subclavia
Branch vessel involvement (particularly coronary and carotid)
Pericardial effusion (and whether its simple or haemorrhagic)
Signs of mediastinal blood or haemorrhagic pleural effusion (indicating a contained rupture)
Involvement of the aortic valve cusps
Lowermost extent of the dissection (important for putting the patient on bypass)
An aortic dissection is secondary to a tear in the
intima of the vessel wall with subsequent extension through the media
Why do 75% of aortic dissection happen in the ascending
greatest pressure here
what causes Type B aortic dissection?
pre existing weakness in the wall
IMH or penetrating ulcer
how can you differentiate between the true and false lumen of the aortic dissection?
Signs.
False lumen shearing is never v clean - irregularities / cobweb sign.
False lumen often elliptical shape
in dissection what is an intramural haemaoms thought to be secondary to ?
a bleed in the media from vaso vasorum
reflection between the four pulmonary veins is called the
oblique sinus
reflection behind the ascending aorta is the
superior pericardial recess
pericardium is abnormal if size greater than
4mm
Pericardial cysts are
congenital outpouchings of the parietal pericardium.
what does dipyramidamole do?
inhibit the breakdown of adneosine
give some ddx for transudate or exudate cardiac effusoins
Congestive heart failure
Uraemia
Infectious (e.g. tuberculosis (TB))
Autoimmune (e.g. systemic lupus erythematosus (SLE))
Dressler’s syndrome (postoperative/post-infarction)
Neoplastic
Hypothyroidism
Sarcoid
Deep x-ray therapy (DXT)
Hypoalbuminaemia
give some ddx for CHYLOUS cardiac effusoins
Thoracic duct obstruction
Yellow nail syndrome
Trauma
Neoplasm
Surgery
igve some ddx for Haemorrhagic cardiac effusoins
Aortic dissection
trauma
cardiac rupture
aortic rupture
neoplasm
pericardial effusion on cxr - what are the signs?
crisp border
cardiomegaly
rapid change in size
density change of effusion to cardiac muscle
An effusion measuring >5 mm anterior to the RV is likely to be between ???
100 mls and 500 mls.
Constrictive pericarditis results from
thickening of the pericardium
subsequent constriction of the ventricular chambers
impaired diastolic ventricular filling
causes of constrictive pericarditis
Viral pericarditis
TB
Rheumatoid arthritis
SLE
Haemodialysis-treated renal failure
Mediastinal irradiation
Cardiac surgery
what is the differential for constrictive pericardiitis?
Restrictive cardiomyopathy
thickened pericardium might be the only tell tale sign
benign pericardial tumours
teratoma
fibroma
lioa
haeongioma
lymphangioma
hamartoma
malignant primary tumours of pericardium
mesothelioma
lymphoma
teratoma
angiosarcoma
fibrosarcoma
Which of the following features is most reliable in permitting a diagnosis of constrictive pericarditis?
Pericardial thickness up to 2 mm on CT
B. Septal flattening on real time cine MRI
C. Pericardial calcification identified on MRI
D. Atrial enlargement on CT
E. Rounding of the RV free wall on echo
b
Aorta, signs of injury are what?
intimal flap
false aneurysm
mediastinal haematoma
change in aortic calibre
how is an intimal falp different to a dissection?
Intimal flap is normally smaller
traumatic aorta - location?
just beyond the left subclavian origin
after an arotic ruputre where can the blood go?
mediastinum and haemothorax
pristine aorta but haemorrhage around it? Why?
venous bleeding. self limiting
minor injury causes massive damage for aortic injury
in which condition?
Elhoers Danlos
traumatic intramural haematoma is normally caused by….
catheters
A collar of adventitia surrounding the site of transection is called a
false aneurysm
What are the features of a right atrium
receives the IVC
atrial appendage
fossa ovals upper margin limbus
what is the main feature of a left atrium
narrow based finger like appendage
main features of a right ventricel
moderator band
coarse trabeculations
tricupsid papillalry attachements, free wall and septum
muscular infundibulum below the outlet valve
features of a left ventricle
fine trabeculations
two distinct papillary muscles
what does situs normally mean?
viscero atrial situs.
liver ivc and right atrium are on right side
another term of cardiac connections ?
concordant and discordant
what is situs ambiguous
complex situation of both atria the same, eg two left atria
bronchial situs is what
right bronchus is shorter and wider than the left
Differentials for completely dense hemi thorax
Pleural fluid (serous, chyle, blood, pus)
Atelectasis
Diaphragmatic hernia
Consolidation (but rare for whole lung to be involved)
Contusion/haemorrhage
Chest wall mass/tumour (look for rib erosion)
Post pneumonectomy
Pulmonary aplasia/hypoplasia
Congenital cystic adenomatoid
malformation (CCAM), sequestration
Mediastinal masses (i.e. lymphoma, foregut cysts)
The mediastinum:
Moves toward the opaque side: i.e. volume loss, usually due to XXX
collapse
Mediastinum Is shifted away from the opaque side: i.e. mass effect, usually due to XXXX
pleural fluid
segment collpase vs whole lung collapse by age
segment collapse more in older kids
whole lung in infants.
whole lung collapse often caused by
mucus plugging
trapped lung foreign body cases what appearance
Lucency of the affected lung portion
cystic fibrosis causes what kind of collapse?
subsegmental
paediatric air leaks - what are different typess?
Pneumothorax
Pneumomediastinum
Pneumopericardium
Pneumoperitoneum
Pulmonary interstitial emphysema
most common causes of air leaks in children are
Foreign body aspiration
Neonatal disease including respiratory distress syndrome (RDS), meconium aspiration syndrome and complications of treatment, e.g. ventilator barotrauma
Asthma and bronchiolitis
Causes of pneumo-mediastinum
raised intra alveolar pressure (cough vomit)
extension from pneumoperitoneum
rupture
Asthma
infection
trama
Lung disease in neonates
Pneumothorax in this group is caused by:
Respiratory distress syndrome
Pulmonary interstitial emphysema
Meconium aspiration
Congenital bullous lesions
Lung disease in children
Pneumothorax in this group is caused by:
Asthma
Bronchiolitis
Pulmonary infections, such as staphylococcal pneumonia, tuberculosis (TB), pertussis and pneumocystis carinii
Diffuse lung diseases
Pneumothorax may occur in cases of:
Langerhans’ cell histiocytosis (LCH)
Marfan syndrome
Ehlers-Danlos syndrome
Tuberous sclerosis
The following can mimic pneumothorax:
Skin folds- traced beyond the lung edge
A large cystic lesion
A cavity from staphylococcal pneumonia
A congenital lesion
Risk factors for neonatal penumothorax
low birth weight and prematurity
espiratory distress syndrome, invasive and non-invasive ventilatory support
angels wings signs is what ?
elevated thymus from anterior pneumomediastinum
is pneumopericardium bengin
yes, normally
signs of cystic fibrosis are usually obvious on the radiograph:
Upper lobe bronchiectasis
Mucoid impaction
Parahilar densities
Evidence of infection
Central lines
how to define a lung nodule
The size of the nodule
The density of the nodule
Calcification
Cavitation
Feeding/draining vessels
Being well-defined or ill-defined
Solitary lung opacity
Causes
Round pneumonia
Granuloma
Hamartoma
Fungus
Contusion, haemorrhage
Metastasis or lymphoma
Vascular lesion; arteriovenous malformation (AVM)
Round atelectasis
Vasculitis
Bronchogenic cyst
Pulmonary blastoma
Sequestration/congenital cystic adenomatoid
Adenoma
Hydatid
Pulmonary abscess/infarct
Round pneumonia occurs because of
fee communication between adjacent air spaces via the pores of Kohn
Round pneumonia organisms
Haemophilus influenzae
Streptococcus (pneumococcus)
Round pneumonia differentials
Hamartoma
lymphoma
contusion
solitary met
granuloma
fungus
which paeds malignancies love the lung for mets
Wilms nephroblastoma
sarcomas of soft tissue and bone
osteosarcoma will usually have what in them
calcifications
fungal nodules tend to exist where
small (<5mm)
peripheral and subpleural locations
AVMs are associated with…
hereditary haemorrhagic telangiectasia
Hamartomas contain variable amounts of
fat, epithelial tissue, fibrous tissue and cartilage.
on CT fat and calcification is considred diagnostic
Drainage
Extralobar sequestrations usually drain into…
systemic veins (commonly the azygos and hemiazygos), whereas intralobar sequestrations usually drain into normal pulmonary veins.
There are a large number of non-infective causes of pulmonary opacities which may undergo cavitation, including ……………
Wegener’s granulomatosis, pulmonary contusion, septic embolism and infarction.
Pulmonary nodules
secondary features to look for
Pleural effusion
Mediastinal lymphadenopathy
Bone changes
mass vs nodule
> 3cm
multiple cavitating opacities nodules
Pyogenic abscess, TB, metastasis, fungus, vasculitis, infarction
Multipkle pulmonary nodules
Calcification suggests:
Granuloma, TB, hamartoma, osteosarcoma metastasis
Pulmonary masses
Ill-defined margins - causes
Infection, lymphoma, contusion, haemorrhage
which bug orgnaism
is a common cause of multifocal opacities with a propensity to undergo cavitation and pneumatocoele formation.
Staphylococcal pneumonia
multiple bilateral upper zone nodules less than 5 mm in diameter in both lungs
cause?
aspergillus
hamartomas are solitary or multiple
solitary
