CORE Case 4 Workshop Petra Lewis MD Professor of Radiology and OBGYN Geisel School of Medicine at Dartmouth
Transcript
CORE Case 4 Workshop
Petra Lewis MD Professor of Radiology and OBGYN
Geisel School of Medicine at Dartmouth
What questions/difficulties did you have arising from the case?
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Note down areas that they had problems. If not covered in current session or planned sessions then will come back to at the end
COPD and emphysema
What are some of the CXR signs of COPD/emphysema
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Q: Slide question A: hyperinflation, flattening of hemidiaphragms, inc retrosternal airspace, bulla, attenuated vessels, etc. Clarify that COPD requires pulmonary function testing and is not a radiological diagnosis. COPD does not = emphysema Q: How sensitive do you think CXR is for COPD & Emphysema? A: Talk about poor sensitivity of radiographs,
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What do you see? (Flattening diaphragms, increased retrosternal space) How do you judge flattening of hemidiaphragms? What is normal?
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Show comparison normal on right with COPD on left
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Show comparison normal on right with COPD on left. Discuss height of hemidiaphragms (<3cm normal)
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What do they see here? What is going on. Large bulla in emphysema
What might we see on a CT?
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Bullae, blebs, enlarged airspaces etc. Subpleural, parasepta. Q: Where do we typically see the most severe changes? A: apices typically except in a1 antitrypsin deficiency
Patient 1 Patient 2
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Two different examples patients with emphysema. What do they see? How does this look different from normal lung? Which has the most severe changes? Q: What can CT be used for in patients with emphysema A: assessing severity/change, infection included infected bulla, small ptx. Severity air trapping. Screening for lung ca,
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What might be going on in this patient? What is unusual about about the distribution of the bulla in this patient? Basal Infected bulla in alpha 1 antitripsin deficiency.
Aortic dissection
What patients are at risk for aortic dissection?
How might they present?
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Q: Slide question 1? A: Marfans, hypertensives, smokers, aortic stenosis, Ehlers danlos and other connective tissue disorders, Q: Slide question 2? A: Hypertension, chest pain radiating to back, different BP in arms, often very non-specific
What are our imaging options?
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Q: Slide question? A: CT (only if +C), Mri (with or without gad) if stable, TEE. Q: What might affect your choice of exam? A: Patient’s ability to tolerate iodinated contrast for CTA Q: What patient factors (hemodynamic stability, renal function, contrast allergy etc). Q: What about doing a catheter angiogram? A: Little role for conventional angio currently outside of during therapy, because angio only shows the inside of the lumen. The real question is about the wall of the aorta when considering dissection.
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What do we see? Why is the blood denser in one lumen than the other? What do the terms ‘false’ and true’ lumen mean? Show how these may extend down into the pelvis Ask them about what organs might be affected depending on what vessels are involved (kidneys, brain, gut)
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True and False lumina clearly seen with some active arterial enhancement in the descending aortic false lumen
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What do they see? What might you be concerned about here? (Celiac and renal arteries involved but currently good perfusion)
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What might this patient have? Note dilated aorta – have them point it out. Marfans patient.
Pulmonary edema
What are some of causes of pulmonary edema?
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Get them to discuss cardiogenic and non-cardiogenic causes (neurogenic, ARDS, drowning, fluid overload etc)
How might we distinguish between the causes?
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History, Heart size, effusions, septal lines (much more specific for cardiogenic) peripheral location opacities in ARDs, asymmetry etc. Discuss the non-specificity of these findings often
Cardiothoracic ratio
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Confirm that they know how to measure CTR correctly and the significance of the <0.5 normal ratio What would be a normal CTR on a AP chest XR? (<0.6). Why is this larger (magnification)
Cardiothoracic ratio
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Confirm that they know how to measure CTR correctly
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Elderly patient with multiple cardiac issues, in acute pulmonary edema left, and after CABG, mitral valve replacement and pacemaker inserted right. Show intersitital markings, vascular haziness, peribronchial thickening
Interstitial Pulmonary Edema
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17 year old with post viral cardiomyopathy, acute (left) and baseline (right). Nice Kerly Bs, ‘shaggy’ heart
Kerley B lines
Peribronchial thickening
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Normal left, thickened on right
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Describe the image. Typical batwing. Acute MI
Baseline Admission
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Baseline 41year old man with dialysis dependent end stage renal disease who got shortness of breath from pulmonary edema. An image from a month before his acute onset of shortness of breath is the initial image Next image is 2 hours after admission Note the cardiomegaly
Admission 2 hrs later
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Same patient to show progression of edema
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What is different about this image? Note the assymetry (ruptured papillary muscle, severe pulmonary edema)
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9 yr old. s/p ATV accident with terminal hypoxic brain damage. What could this be due to? Neurogenic pulmonary edema.
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Compare and contrast prior cases with patient with ARDS. How is the distribution different? Peripheral rather than central
Pulmonary emboli
What are our diagnostic options in patients with suspected PE? What guides our choice?
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Discuss use of D-dimer in low risk patients, when might you do a lower extremity Doppler, CT pulmonary angiogram, VQ. Conventional PA angiogram D-dimer not helpful in ‘sick’ patients WELL’s criteria? Likelihood of PE, lower extremity symptoms, contraindications to CT (renal failure, allergy) etc Conventional PA probably only for treatment, occasional for indeterinatem CT, or with CO2 if contrast cannot be given (larger emboli) VQ: contrast allergy, renal failure
What do we look for on a CTPA for PE? How good is this test?
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Have them identify the PAs, draw on image if possible . Understand concept of ‘filling defects’ –Flowing blood white, clots is black . . Lack distal perfusion, signs infarct etc Good study >95% accuracy Depends on study quality (bolus, respiration, body habitus) as to what size PEs we can see ,
Patient 1 Patient 2
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Two different patients with PEs. See if they can see them.
Patient 3 Patient 4
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Two further examples
Patient 5
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What do you think happened here? RUL pulmonary infarct. Small occlusive RUL emboli Hampton’s Hump
Patient 6
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Have them trace out the ‘saddle embolus’ to understand the term What do you see here that might suggest that the patient is at cardiovascular risk from her PE? Signs RV strain – show vent dilatation, deviation of septum to left, triscupid valve plane larger than mitral
What do we look for on a VQ scan?
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Normal study shown. If wanted, discuss how we obtain the ventilation and perfusion images (Tc99m DPTA/MAA). Talk about matched and mismatched segments. Not important that they know the criteria, just that there are specific criteria that are used to standardize interpretations. Explain that CXR is needed for interpretation
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What do you see here? Normal CXR. High prob VQ See if they can find the multiple mismatches.
