Cardio-Imaging 1 Flashcards
Normal chest X-ray
Cardiothoracic ratio should be less than ——?
50%
What are 3 pathologies that can cause increased cardiothoracic ratio?
In order to have a good chest x-ray, one must follow RIPE. What does R stand for?
In order to have a good chest x-ray, one must follow RIPE. What does I stand for?
In order to have a good chest x-ray, one must follow RIPE. What does P stand for?
In order to have a good chest x-ray, one must follow RIPE. What does E stand for?
What is the most common cause of cardiomyopathy?
ischemic cardiomyopathy due to coronary artery disease
:notice that the image is not a full inspiration (doming in diaphragm, not enough ribs shown)
Pericardial effusion
or less likely a cardiomyopathy w/o congestive failure (the heart is enlarge but there is no congestion in the lungs)
Post contrast chest CT
Magnification differences PA and AP
Semi-erect is commonly performed for those in the or too sick to stand.
emergency room
Which one is inspiration and which is expiration?
Left is inspiration (diaphragm pushed down farther and higher volume)
Right is expiration (less desireable)
Which RIPE issue is apparent in this image?
Rotation
The clavicles ends are not equidistant from the spinous processes
Can cause heart to look enlarged and is most common cause of chest wall deformity
If passive cardiophrenic angle, most likely benign fat. Can confirm with a previous x ray
Mediastinal mass (thymolypoma)
Review Cardiac Chambers
Be mindful that no contour in this image is made up of the right ventricle
What contour of the heart is seen on a lateral chest X-ray that cannot be seen from an AP or PA view?
The right ventricle
What 3 things are wrong with this image?
- Left atrial appendage is bulging outward (not flat or concave, usually associated with rheumatic heart disease)
- Left atrium enlarged (double opaque part)
- Cardiomegaly
What 6 things do you notice in this image?
- mediasternal clips
- Prosthetic mitral valve
- Left atrial appendage
- Markedly enlarge left atrium
- Moderate cardiomegaly
- Prominant vascularture (probably due to HTN)
Probably associated with rheumatic heart disease
What is wrong with this image?
Common causes include chronic HTN, also notice enlargement of thoracic aorta
Retrocardiac airspace shoud be defined and should not extend to the posteriorly to overly spine
What happens to the retrosternal airspace with right ventricular enlargement in a lateral view?
It fills most of the airspace on lateral view. It is tricky to distinguish right atrial from right ventrical enlargement and so often called right heart enlargement.
What is the conditon in which the heart is unable to pump enough blood to meet the metabolic needs of the body?
congestive heart failure (CHF)
What is the most common diagnosis of hospitalized patients over the age of 65?
CHF
What are the 3 most common causes of CHF?
- coronary artery disease
- diabetes mellitus
- hypertension
CHF
How do we measure left atrial heart pressures or pulmonary edema pressures?
It can be indirectly measured by the pulmonary capillary wedge pressure.
What is happening during this Stage 1 - CHF?
A redistribution of blood flow into the upper lung fields (normally would find in base of lung) and widening of the vascular pedicle
How many stages in congestive heart failure?
3
In CHF Stage 2, fluid begins to leak out of vessels into the interstitial space, and can cause thickened interlobular septa that can be seen on imaging. What are these called?
Kerley B lines
How many different types of Kerley lines are there?
3, Kerley A, kerley B, kerley C
(the most important are Kerley B lines located posterolaterally)
What happens to the bronchi in the Stage II -Interstitial phase of CHF?
Peribronchial cuffing
They become thickened due to surrounding edema
(can cause expiratory wheezes, also known as cardiac asthma)
When the PCWP (peripheral capillart wedge pressure) increases to >25ml, fluid leaks into the alveoli, through pleura, and into the pleural space. What stage of CHF?
Stage 3- Pleural/Fissure effusions (usually bilateral)
Left
- Enlarged heart
- Fluid in upper lung (cephalization)
- Kerley B lines
- Fluid in minor fissure (yellow arrow)
- subpulmonic effusions on both sides directly beneath diaphragm (hyperdense area between fundus of stomach and base of the lung)
Right
- A more marked case of subpulmonic effusions
Stage III- Alveolar edema (classic appearance)
- Opacities (Bat-wing or butterfly appearance symmetric around hyla)
- Fluid leaked out to alveolar spaces
CHF alveolar edema can be resolved after treatment, what pathologies would not be resolved?
Tumors and pneumonia
How is this different than CHF and what is it?
Acute MI (left ventricle fails)
Pulmonary edema (butterfly distribution) secondary to acute MI, but no cardiomegaly or pleural effusions
CHF?
No, low lung volume (only 4 anterior ribs under clavicle and diaphragms curved upwards).
Name the 5 most prominant findings for CHF in this image
And widened vascular pedicle and subpulmonic effusion on right (right under diaphragm)
Which is cardiac and which is not cardiac pulmonary edema and what are the differences?
- heart not enlarged (or only mildly)
- No Kerley lines
- No effusions
What kind of scan is this?
Reiview the diagram
Name the arteries of this Arch DSA LAO:
Name the pathologies? And name the what the arrows are pointing to:
Aortic stenosis
Both are examples of Aortic Atherosclerotic Ectasia (dilation or distention of a tubular structure)
L: Aortic atherosclerotic ectasia with some tortuosity
R: A worse case with possible aneurysm and tortuosity
What type of aneurysm:
What type of aneurysm:
What type of aneurysm:
Can be a common frequent complication of angiography
What are the normal ascendig aorta sizes, rule of thumb
Ascending 3.5 cm, descending aorta 3 cm, abdominal aorta 2 cm
In general, a Thoracic Aortic Aneurysm (TAA) is generally defined as a persistent focal enlargement (varies based on gender, patient size, location, cause and imaging modality).
> 4 cm
Ascending TAAs run in some families, representing about 20% of all TAA cases. They are also linked to known genetic syndromes, Marfan Syndrome, Ehlers-Danlos Syndrome, LoeysDietz Syndrome and Syndrome.
Turner syndrome
Descending TAAs (thoracic aortic aneurysm) are usually secondary to which condition?
Atherosclerosis
Most thoracic aneurysms arise in the aortic root or ?
Ascending aorta (60%)
(40% descending aorta)
What type of aneurysm?
Interactive MRI
What are the DeBakey Aortic Dissection classifications for each?
DeBakey I: ascending, transverse, and descending
DeBakey II: Ascending aorta
DeBakey III: Descending aorta
What is the Standford classification for aortic dissections?
Stanford A includes the ascending aorta (may also include transverse and descending) - most common and usually fatal
Stanford B includes the descending aorta beyond the left subclavian artery
Which type of Stanford dissection?
Look at the extensive dissection flap in the 3rd frame
Which type of Stanford Dissection classification?
Stanford Type B dissection
Look at the dissection flap only in the descending aorta
Normally, you cannot distinguish the abdominal aorta from other soft tissue, however, these abdominal aneurysms have calcifications. The second frame is saccular, and the third frame is fusiform.
Abdominal ultrasound
Left frame is an axial view
Right fram is a longitudinal view
Look for vertebra to orient yourself
CT contrast enhanced abdominal aortic angiogram
Notice the thrombus on the outermost part of abdominal aorta
Massive AAA in non-contrast CT
Notice the calcifications on the outermost layer of AAA
CT angiogram with contrast
What refers to obstruction of the pulmonary artery or one of its branches by material (eg, thrombus, tumor, air, or fat) that originated elsewhere in the body?
Pulmonary embolism (PE)
What % of the PE originate from deep vein thrombosis of the proximal lower limbs and pelvis?
90%, most common from calf
What are the most common presenting symptom of acute pulmonary embolism?
most common presenting symptom is dyspnea, chest pain (classically pleuritic in nature), cough, and symptoms of DVT
What is the most appropriate imaging for a suspected pulmonary embolism?
CT pulmonary angiogram (CTPA)
Low specificity but can safely exclude PE
A pulmonary embolism is often associated with which condition?
DVT
What is a common blood test if a pulmonary embolism is suspected?
D Dimer
Which blood laboratory test is indicative of acute thrombosis, detdegradation product of fibrin, forms when plasma degrades fibrin clots, is 95-97% sensitive for PE?
D-dimer, however, lower specificity (35-40%)
Other conditions that can result in an elevated D-Dimer:
What are the 3 conditions that can create a false negative for a D-Dimer?
The chest x-ray is useful/not useful in making the diagnosis of acute pulmonary embolism; its role is in of alternative explanations for the patient’s presentation.
not useful; identification
What is this sign called and what is it looking for:
Westermark sign: vessel appearance disappears on one side compared to other due to lack of or diminished blood flow from thrombus in pulmonary artery
:suggestive but not diagnostic
What is this sign called and what is it looking for:
Hamptom hump: opacity due to occluded vessel that has resulted in infarction
:suggestive but not diagnostic of PE
What are the signs called and what are they looking for:
Fleischner sign (left pulmonary artery enlarged) and Westermark sign (diminished bloodflow or oligemia)
:notice the large thrombus in the right frame
Notice the multiple wedge shape defects on the right frame
Pulmonary angiogram not done much anymore due to invasivness
What is a doughnut sign?
Doughnut sign in CTPA (when the contrast surrounds the embolus)
What is a railroad track sign in CTPA with contrast?
A more longitudinal slice shaped embolus through a vessel with contrast on both sides
What type of clot in CTPA with contrast?
Eccentric clot
What is happening on the right and left frame?
Right is a mass obstructing the flow in the pulmonary artery and a railroad tract sign embolism on the left
This is an example of a PE: Cutoff sign- as the image goes lower the contrast filled vessel becomes smaller and non opacified (important to look at multiplanar images, especially with small emboli)
What level of pulmonary artery and what type of PE are we looking at?
Level of the main pulmonary artery bifurcation with a saddle embolus that cross into both the L and R
Where are the emboli?
Emboli on the left and right pulonary artery
Where are the emoboli?
Another example of emboli on both left and right pulmonary artery
What level and what kid of PE?
The level is below bifurcation in smaller branches of lobes and emboli found are called lobar PE
Even more distal are emoboli in the segmental branches called segmental PE
More segmental artery PE
Subsegmental PE
