Drs. Daniel Escobar, Angela Pikus, and Alex Blackwell are Emergency Medicine Residents and interested in medical education. They are joined by Marianne Dannemiller, PA who is an APP for Sanger Heat & Vascular Institute. With the guidance of Dr. Michael Gibbs, a notable Professor of Emergency Medicine, they aim to help augment our understanding of emergent imaging. Follow along with the EMGuideWire.com team as they post these educational, self-guided radiology slides. This set will cover: - Aortic Aneursym - Endovascular Aortic Repair (EVAR) - EVAR Endoleak - Right Sided Aortic Arch - Tension Pneumothorax - Thyroid Mass

1. Adult Chest X-Rays Of The Month
Daniel Escobar, MD1, Angela Pikus, MD1,
Alex Blackwell, MD1, Marianne Dannemiller, PA2
1Department of Emergency Medicine
2Sanger Heart & Vascular Institute
Carolinas Medical Center & Levine Children’s Hospital
Michael Gibbs, MD - Faculty Editor
CMC Imaging Mastery Project
November 2021

2. Disclosures
 This ongoing chest X-ray interpretation series is proudly sponsored by the
Emergency Medicine Residency Program at Carolinas Medical Center.
 The goal is to promote widespread mastery of CXR interpretation.
 There is no personal health information [PHI] within, and ages have been
changed to protect patient confidentiality.

3. Visit Our Website
www.EMGuidewire.com
For A Complete Archive Of Imaging Presentations And Much More!

4. Airway
Bones
Cardiac
Diaphragm
Effusion
Foreign body
Gastric
Hilum

5. It’s All About The Anatomy!

6. Healthy 26-Year-Old
Male Presents To
The Emergency
Department With
Two Days Of Chest
Pain.
T-98, BP 165/55, HR 75,
SAO2 99%
His Physical Exam Is
Normal.
• CBC, CMP are normal
• HS-Troponin 441 ng/L
• BNP 875 pg/ml
• d-Dimer <0.27 ug/ml
Emergency Department Chest X-Ray

7. An ECHO Reveals A Dilated Aortic Root And A Chest CT Is Then Ordered.
Aneurysm Of The Ascending Aorta With A Maximal Diameter Of 93.7 mm.

8. Chest CT Reconstructed Images

9. Aneurysm In Situ Aneurysm Resection Graft Placement
Images Courtesy of: Marriane Dannemiller, PA &

10. Let’s Take Another Look At The 1st Chest X-Ray.
Healthy 26-Year-Old
Male Presents To
The Emergency
Department With
Two Days Of Chest
Pain.

11. Notice The Fullness Along The Right Cardio-Mediastinal Boarder.
Healthy 26-Year-Old
Male Presents To
The Emergency
Department With
Two Days Of Chest
Pain.

12. Post-Operative CXR Reveals A “Normal” Mediastinal Width.
Aortic
Valve
Replacement

14. Once A Thoracic
Aneurysm Reaches A
Diameter Of 6 cm The
Risk Of Complications
Increases Dramatically!

15. Law Of Laplace

16. 84-Year-Old Presents Following A Syncopal Episode. Ten Years Prior He Was Diagnosed With A Thoracic Aneurysm
(58 mm) And Refused Surgery. On Presentation A Ruptured Aneurysm Of The Ascending Aorta, Arch, And
Descending Aorta Measured 98 mm In Maximal Diameter. The Patient Died Shortly After Admission.

17. Our Patient Had A Normal (Tricuspid) Aortic Valve.
Patients With Congenital Bicuspid Aortic Valves
Are Physiologically Predisposed To Developing
Aneurysmal Dilatation Of The Ascending Thoracic
Aorta Over Time.

20. 52-Year-Old Male
Presents To The ED
Following A Witnessed
Syncopal Episode. On
Arrival The Patient Is
Cool, Clammy And
Diaphoretic.
HR 111, BP 74/55
Resuscitation Begins
And The Team
Performs A Bedside
Ultrasound
Immediately.

21. 52-Year-Old Male
Presents To The ED
Following A Witnessed
Syncopal Episode. On
Arrival The Patient Is
Cool, Clammy And
Diaphoretic.
HR 111, BP 74/55
Resuscitation Begins
And The Team
Performs A Bedside
Ultrasound
Immediately.
Pericardial Effusion (*) With Right Ventricular Diastolic Collapse (→)
*
*
*
* *
*
*

22. The Chest CT Scout Film Reveals Mediastinal Widening
A STAT Chest CT Is
Ordered.

24. *
Type A Aortic Dissection (→) With Pericardial Effusion (*)
*
*
*
*

25. The Patient Was
Then Taken To The
Operating Room
For Surgical Repair
Of A Type A Aortic
Dissection
Chest X-Ray On Post-Operative Day 2

26. Aortic Dissection And Pericardial Tamponade

27. Tamponade No Tamponade
Hypotension 20.8% 15%
Syncope 37.5% 13.8%
Altered Mental Status 27.6% 7.8%
Hospital Mortality1 32.6% 12.8%
1Peri-operative mortality in patients surviving to surgical repair.

28. On Presentation
1 Month Ago
80-Year-Old With A Thoracic EVAR Presents With Chest Pain. Chest X-Ray Shows Aneurysmal Enlargement.
EVAR = Endovascular Aortic Repair

29. 80-Year-Old With A Thoracic EVAR Presents With Chest Pain. Chest X-Ray Shows Aneurysmal Enlargement.
Asterisks (*): Contrast Extravasation At The Proximal Endograph Attachment Site [Type Ia Endoleak]
* * * L *
*
L = Endograph Lumen
L L

30. Understanding Endovascular
Aortic Repair (EVAR) Graft Leaks
“Endoleaks”

31. This Classification Scheme Should Be Used For Both Abdominal And Thoracic Endoleaks.

32. Anatomy
• Poor apposition between a graft site and the adjacent arterial wall
• Blood leaks through this defect into the aneurysmal sac
• “High-pressure” endoleak with a significant risk of aneurysm sac rupture
Type IA: proximal endoleak
Type IB: distal endoleak
Imaging Findings
• Associated with a visible increase in aneurysmal sac size
• Hyperdense acute hemorrhage within the aneurysm
• Central contrast that is continuous with the involved attachment site
Management
Prompt endovascular repair

33. Anatomy
• Account for 40% of all endoleaks
• Retrograde flow of blood into the aneurysmal sac via an aortic branch
• Most commonly the inferior mesenteric artery or a lumbar artery
Type IIA: one branch vessel involved
Type IIB: two or more branch vessels involved
Imaging Findings
• Peripheral hemorrhage or contrast material within the aneurysm sac
• Change in aneurysm sac size the best indicator
• Larger sac size at greater risk for rupture
Management
Conservative if aneurysm sac size remains stable, embolization if aneurysm expands

34. Anatomy
• Leakage of blood through the body of the stent graft
• “High-pressure” endoleak with a significant risk of aneurysm sac rupture
Type IIIA: modular disconnection, or leak at the junction with a visceral stent
Type IIIB: fabric tear and leak
Imaging Findings
• Associated with a visible increase in aneurysmal sac size
• Collection of central contrast, usually distant from the proximal and distal graft
attachment sites
Management
Prompt replacement (or stenting) of leaking graft components

35. Anatomy
• Graft porosity – causing transient peri-procedure leakage across the graft into the
aneurysm sac without any discernable discrete anatomic defect
• Typically resolves after the discontinuation of anticoagulation
Imaging Findings
• Modest increase in the size of the aneurysmal sac without any visible focal contrast
extravasation
Management
Observation with repeat imaging

36. 75-Year-Old Female With A History Of Thoracic Aneurysm

37. 75-Year-Old Female With A History Of Thoracic Aneurysm
Maximal Diameter 54.5 x 41.3 mm

38. 75-Year-Old Female With A History Of Thoracic Aneurysm
Successful Endovascular Aortic Repair (EVAR)

39. Type 1b Endoleak 26 Months Later
Arrows Show Distal Contrast Extravasation

40. 67-Year-Old Male With A History Of Thoracic Aneurysm

41. 67-Year-Old Male With A History Of Thoracic Aneurysm
Successful Endovascular Aortic Repair (EVAR)

42. Type 1b Endoleak 18 Months Later
Arrows Show Distal Contrast Extravasation

43. 23-Year-Old Male
Being Evaluated
After A Car Crash

44. 23-Year-Old Male
Being Evaluated
After A Car Crash
Wide
Mediastinum

45. 23-Year-Old Male
Being Evaluated
After A Car Crash
Wide
Mediastinum
Is There An Aortic Injury?

46. Not Today! Our Patient Has A Right-Sided Aortic Arch.

47. Not Today! Our Patient Has A Right-Sided Aortic Arch.

49. Right Sided Aortic Arch
• Rare congenital anomaly: 0.05% - 0.1% of radiology/autopsy series
• Several proposed classification schemes based on the arrangement of
arch vessels, relationship with the esophagus, and the presence or
absence of congenital heart disorders
• Asymptomatic in the majority of patients
• Clinical manifestations are uncommon, and these are caused by:
Tracheal Compression: Typically seen in children
Esophageal Compression: Typically seen in older adults

51. What do you see?
77-year-old-female
presents to the
Emergency
Department with
sudden onset of
chest pain and
shortness of
breath.
T-98, BP- 115/85, HR- 85,
SAO2- 100%
Physical exam is
unremarkable…
CBC, CMP normal

52. Arrows pointing to the collapsed lung
You can see lung
tissue expanded
throughout the entire
left lung, but when
you look at the right
lung, it has almost
completely collapsed.
Very surprising the
patient had equal
breath sounds, even
on repeat
examination!
Don’t be fooled!
Exams are to some
degree subjective.
What do you have to
worry about with a
pneumothorax?

53. Arrows pointing to the collapsed lung and
tracheal deviation
Tension
pneumothorax!
Tension physiology
is when the air
trapped in the
pleural space get so
large that is starts
to compress on
thoracic structures
and cause
cardiopulmonary
compromise

54. Signs and Symptoms:
-Chest pain
-Shortness of breath
-Shallow breathing
Physical Exam Findings:
-Decreased or absent
breath sounds
-Tracheal deviation
-Hypotension
-JVD
-Hypoxia
-Tachycardia
Treatment:
IMMEDIATE- Needle
decompression
DEFINITIVE- Chest tube

55. 71-Year-Old Male
With A History Of
Skin Cancer
Presents With
New-Onset Atrial
Fibrillation.
Vitals: BP 148/98,
HR fluctuating
104-118, Temp
99.6 F
Notice anything unusual?

56. 71-Year-Old Male
With A History Of
Skin Cancer
Presents With
New-Onset Atrial
Fibrillation.
Vitals: BP 148/98,
HR fluctuating
104-118, Temp
99.6 F
Still Don’t? Try Decreasing The Brightness (Density or Intensity)

57. 71-Year-Old Male
With A History Of
Skin Cancer
Presents With
New-Onset Atrial
Fibrillation.
Vitals: BP 148/98,
HR fluctuating
104-118, Temp
99.6 F
What’s Going On Here?!
Leftward Tracheal
Deviation

58. CT Imaging Shows A Thyroid Mass Displacing The Trachea

59. DIAGNOSIS
Toxic Multinodular Goiter
PATHOGENESIS
Iodine deficiency leads to increased TSH production. This leads to thyroid hyperplasia. With
time, this increased proliferation leads to DNA mutations due to free radical damage causing
increased growth factor expression. This eventually leads to formation of thyroid nodules that
contain self-stimulating activating mutations, forming these goiters
Endocrine Reviews,
Volume 26, Issue 4, 1
June 2005, Pages
504–524

60. EVALUATION & MANAGEMENT
Most of these will be performed in the Outpatient setting
- Obtain Thyroid Labs (TSH, Free T4 , total T3, TPO antibodies, TSH-receptor antibodies, etc)
- Thyroid Ultrasound; Thyroid Radionuclide Imaging (Assess for Hot & Cold Nodules; “Hot
nodules” aka hyperfunctioning nodules are rarely malignant)
- Plain Film, CT, MRI if concern for obstructive or substernal goiter
- Fine-needle aspiration (FNA) biopsy when suspicious findings for malignancy (rapid growth,
pain or tenderness, firmness in area of goiter, etc)
If concern for Hyperthyroidism -> Methimazole (Antithyroid agent, Thioamide)
Definitive Management -> Surgical Resection vs Radioiodine therapy
StatPearls Publishing,
January 2021
[Updated August
2021]
RAIU Scan

61. Summary Of Diagnoses This Month
 Thoracic Aortic Aneurysm
 Aortic Dissection + Pericardial Tamponade
 Endovascular Aortic Repair (EVAR) Endoleak
 Right-Sided Aorta
 Pneumothorax
 Thyroid Mass – Toxic Multinodular Goiter

62. See You Next Month!