0:01

This is a companion case of a 42-year-old woman with, again,

0:06

acute shortness of breath, who comes to the ER.

0:09

CT of the chest with IV contrast was performed.

0:13

And in the scout view, again,

0:15

opportunity for us to take a survey of what's going on.

0:19

The lung fields are equally inflated.

0:22

There's no focal consolidation that we can

0:23

appreciate here. No large pleural effusion or pneumothorax.

0:27

The heart's a little prominent.

0:28

The bones themselves look intact.

0:30

They don't see anything that looks destructive or truly out of place.

0:34

We see that there are surgical clips

0:36

in the upper left quadrant, as well as in the upper right quadrant.

0:39

So there may have been some gastric surgery and a cold cystectomy.

0:43

We can make out here portion of the liver shadow, which looks a little enlarged.

0:49

Probably won't see it in its entirety,

0:51

but again, the scout view is a great way

0:53

to take a survey of the overall image area.

0:58

So we'll take a look at the axial images.

1:01

Let's just pull these up to the top.

1:04

And we went through a lot of the systematic approach in the last case.

1:07

So here we'll just really kind of focus on some of the salient issues.

1:10

But again, I like to start on soft tissue windows,

1:13

being able to look at it and assess the vasculature.

1:15

And if we come down, again,

1:18

paying attention, I try to clear the aorta first.

1:20

You can see the coronary arteries are really nicely identified here.

1:24

There's no aneurysmal dilatation,

1:27

nothing that looks like a dissection in the aorta, normal caliber.

1:32

And just taking it all the way down below

1:34

the diaphragm and you see, again, the first takeoff, which is the celiac artery.

1:39

On the way back up, we'll take a look at the pulmonary

1:42

arterial tree, and I usually will start on the left.

1:48

And you can see the a little filling defect

1:49

right here in a subsegmental branch, in the left lower lobe.

1:53

We'll see another one here.

1:59

We come back down on the main left, looks pretty good. But on the right side,

2:07

it's a large thrombus that's sitting right in here.

2:10

And you can see there's some contrast coursing around it.

2:13

So it's not completely occlusive, but it is a pretty large caliber.

2:16

And you can see it extends into some of the smaller branches as well.

2:21

Taking a look at the other portions

2:23

of the right, you know we're not getting good opacification here of the vessels.

2:27

And sometimes that happens.

2:28

And so, it's important for you to,

2:31

in your report, really identify to what level of confidence you're talking.

2:34

So sometimes you can only see centrally.

2:36

Sometimes it may be, you can see the lobar but not the subsegmental.

2:41

And so, it's helpful just to let the reader know what they can expect in terms of your

2:45

level of confidence or where we're talking.

2:47

So here, I think we can certainly say,

2:49

centrally, there's a large filling defect to large thrombus here.

2:52

So we want to make sure that we're looking for some of the other problematic issues.

2:56

So, again, looking at the caliber of the main pulmonary artery,

3:00

it's probably top limits of normal, just looking at it from my perspective.

3:04

But what we do notice, or what I do notice really nicely here,

3:08

is how compressed the left ventricle is compared to the right ventricle

3:13

and that you do have some degree of contrast refluxing into the intrapatic

3:17

IVC, and probably to some extent, some early hepatic veins here.

3:22

And so all of this suggests that there,

3:24

again, is right heart strain, secondary to the central thrombus obstruction,

3:31

causing increased pressures in a low pressure system.

3:34

So we want to make sure that we're looking for issues in the lungs themselves.

3:39

So, is there any evidence of pulmonary infarct?

3:41

And so you see some of this ground glass, hazy opacity here at the apices,

3:46

there is this focal opacity here.

3:48

As we move through the lungs,

3:50

there's definitely some degree of ground glass opacity scattered around the lungs.

3:57

You see them again down here.

3:59

You see some opacities that look more typical for atelectasis.

4:03

So sometimes it can be difficult to discern, you know, what is taking place.

4:07

So this is a patient who does have a significant thrombus load,

4:12

who obviously will be predisposed to having pulmonary infarcts.

4:15

But remember that patients can also have other things going on.

4:19

And so in many ways,

4:21

while not every entity reads the same textbook in terms of being classic, and we

4:25

think about pulmonary infarcts as being wedge-shaped peripheral opacifications or

4:32

consolidations, they may not always look that way.

4:36

And so some of these may be early and forming infarcts, the stuff that's more

4:40

central, could certainly be another process.

4:43

So, you know, I would certainly include in the differential or ask whether or not

4:47

there's any evidence of infection, kind of inflammatory infectious process that's

4:52

maybe atypical, or are we looking at early infarcts that are developing?

4:56

So sometimes it's not always clear,

4:58

but you want to check the boxes on things to consider.

5:01

So certainly with the patient with pulmonary emboli,

5:03

you want to consider, is there heart strain? Is there evidence of reflux

5:07

of contrast, elevation of pressures with an enlarged pulmonary artery?

5:11

Do we have evidence of pulmonary infarct?

5:13

And include that in your description.

5:15

So this is a companion case of a patient who does have left ventricular decreased

5:19

caliber, secondary to elevated pressures on the right.

5:23

You see that kind of moving throughout the system as well as precursors

5:27

in the intrahepatic IVC with a very central thrombus.

5:31

That is an explanation for the patient's shortness of breath.