Drs. Breeanna Lorenzen and Daniel Escobar are Emergency Medicine Residents and interested in medical education. 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: - Disconnect VP shunt - PFO Closure Device - Implanted Baclofen Pump - Pnuemobilia - Common Bile Duct Stent - Dextrocardia - Implantable Cardioverter Device - Left Ventricular Assist Device (LVAD)

1. Adult Chest X-Rays Of The Month
Daniel Escobar, MD & Breeanna Lorenzen, MD
Department of Emergency Medicine
Carolinas Medical Center & Levine Children’s Hospital
Michael Gibbs, MD - Faculty Editor
CMC Imaging Mastery Project
October 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. 38-Year-Old With
A History Of
Seizure And A VP-
Shunt Presents
With Altered
Mental Status.
What Do You See?

7. 38-Year-Old With
A History Of
Seizure And A VP-
Shunt Presents
With Altered
Mental Status.
Disconnected VP Shunt.

8. 58-Year-Old With
A History Of
Season allergies
Presents With
Right-sided
Deficits and
Aphasia. Imaging
Is Post
Intervention.
Notice Anything Unusual?

9. 58-Year-Old With
A History Of
Season allergies
Presents With
Right-sided
Deficits and
Aphasia. Imaging
Is Post
Intervention.
Notice Anything Unusual?
???

10. 58-Year-Old With
A History Of
Season allergies
Presents With
Right-sided
Deficits and
Aphasia. Imaging
Is Post
Intervention.
Look Closer!
Properly Positioned
PFO Closure Device

11. 58-Year-Old With
A History Of
Season allergies
Presents With
Right-sided
Deficits and
Aphasia. Imaging
Is Post
Intervention.
Lateral View

12. When A Patent Foramen
Ovale (PFO) Is Present,
The Right-To-Left Shunt
Passage Of A Clot May
Occur - Leading to An
Embolic Stroke.
Patent Foramen Ovale (PFO) Pathophysiology

13. J Intern Med 2020. 288(4): 400– 409.

14. doi: 10.1111/ joim.13143
T
he role of device closure of patent foramen ovale in
patients with cryptogenic stroke
M
. Fukutomi, B. W
ilkins & L. S
øndergaard
From the Heart Center, Rigshospitalet, Copenhagen, Denmark
Content List – Read more articles from the symposium: “The 99th Berzelius symposium: The Cardiac Patient from Birth to Adulthood”.
A
bstract. Fukutomi M, Wilkins B, Søndergaard L
(Rigshospitalet, Copenhagen, Denmark). The role
of device closure of patent foramen ovale in
patients with cryptogenic stroke (Review-
Symposium). J Intern Med 2020; 288: 400–409.
One of the most frequent causes of cardiac
embolism in cryptogenic stroke is a paradoxical
embolus, which originate from systemic venous
source though an unidentified patent foramen
ovale (PFO). PFO is a common finding in the
general population with a prevalence of 25% to
30%. Transcatheter PFO device closure is known
to be feasible and safety treatment for such
patients. In recent years, several randomized
controlled trials (RCTs) have been conducted to
address the superiority of PFO closure over
medical therapy alone in the prevention of stroke
recurrence in patients with PFO. In contrast to
findings from early 3 RCTs, recent 4 RCTs could
successfully show the benefits of PFO device
closure compared with medical therapy, with less
peri- and postprocedural complication. Based on
these data, PFO device closure is recommended
to carefully select cryptogenic stroke patients
aged from 18 to 65 years, with a high probability
of a causal role of the PFO in stroke events.
However, it is still uncertain whether PFO closure
is superior to oral anticoagulants therapy in
these patients. Therefore, further prospective
randomized trials are needed to address the
efficacy of PFO device closure to oral anticoagu-
lants therapy.
K
eywords: cryptogenic stroke, persistent foramen
ovale, transcatheter device closure.
Introduction
More than one million people suffer a stroke
every year in Europe, and this numbers is
estimated to rise to 1.5 million due to the ageing
population. In general, hypertension, diabetes,
smoking and atrial fibrillation (AF) are considered
as conventional independent risk factors for
(ASA) or substantial right-to-left interatrial shunt
[9-12].
The foramen ovale is a part of the fatal blood
circulation, and in the majority of infants, closure of
the foramen ovale occurs soon after birth. However,
in some cases the primum and secundum atrial
septum remains incomplete closure with a contin-
Review Symposium
doi: 10.1111/ joim.13143
T
he role of device closure of patent foramen ovale in
patients with cryptogenic stroke
M
. Fukutomi, B. W
ilkins & L. S
øndergaard
From the Heart Center, Rigshospitalet, Copenhagen, Denmark
Content List – Read more articles from the symposium: “The 99th Berzelius symposium: The Cardiac Patient from Birth to Adulthood”.
A
bstract. Fukutomi M, Wilkins B, Søndergaard L
(Rigshospitalet, Copenhagen, Denmark). The role
of device closure of patent foramen ovale in
patients with cryptogenic stroke (Review-
Symposium). J Intern Med 2020; 288: 400–409.
One of the most frequent causes of cardiac
embolism in cryptogenic stroke is a paradoxical
embolus, which originate from systemic venous
source though an unidentified patent foramen
ovale (PFO). PFO is a common finding in the
general population with a prevalence of 25% to
30%. Transcatheter PFO device closure is known
to be feasible and safety treatment for such
patients. In recent years, several randomized
controlled trials (RCTs) have been conducted to
address the superiority of PFO closure over
medical therapy alone in the prevention of stroke
recurrence in patients with PFO. In contrast to
findings from early 3 RCTs, recent 4 RCTs could
successfully show the benefits of PFO device
closure compared with medical therapy, with less
peri- and postprocedural complication. Based on
these data, PFO device closure is recommended
to carefully select cryptogenic stroke patients
aged from 18 to 65 years, with a high probability
of a causal role of the PFO in stroke events.
However, it is still uncertain whether PFO closure
is superior to oral anticoagulants therapy in
these patients. Therefore, further prospective
randomized trials are needed to address the
efficacy of PFO device closure to oral anticoagu-
lants therapy.
K
eywords: cryptogenic stroke, persistent foramen
ovale, transcatheter device closure.
Introduction
(ASA) or substantial right-to-left interatrial shunt
[9-12].

19. 32-Year-Old With A
History Of GSW
Causing Anoxic
Brain Injury And
Chronic Spasticity.
What Do You See?

20. Implanted Baclofen Pump
32-Year-Old With A
History Of GSW
Causing Anoxic
Brain Injury And
Chronic Spasticity.

21. Implanted Baclofen Pump

25. 32-Year-Old With
A History Of ERCP
And
Sphincterotomy
Presenting With
Epigastric
Discomfort.
What Do You See?

26. 32-Year-Old With
A History Of ERCP
And
Sphincterotomy
Presenting With
Epigastric
Discomfort.
Common Bile Group Stent And Pneumobilia
CBD Stent
Pneumobilia
The CBD Stent Causes A
Direct Connection
Between The Small
Bowel And The Biliary
System.

27. What Do You See?
19-Year-Old With A
History Of
Congenital Heart
Disease Presenting
With Shortness Of
Breath.

28. Dextrocardia
19-Year-Old With A
History Of
Congenital Heart
Disease Presenting
With Shortness Of
Breath.

29. 19-Year-Old With A
History Of
Congenital Heart
Disease Presenting
With Shortness Of
Breath.
He is Found To Have
Aortopulmonary
Collateral Vessels
That Lead To A Left-
To-Right Shunt
Increasing
Pulmonary
Pressures.
What Do You See?

30. 19-Year-Old With A
History Of
Congenital Heart
Disease Presenting
With Shortness Of
Breath.
He is Found To Have
Aortopulmonary
Collateral Vessels
That Lead To A Left-
To-Right Shunt
Increasing
Pulmonary
Pressures.
Collateral Vessels Embolization Coils

31. 24-Year-Old With
A History Of
DiGeorge
Syndrome
Presenting After
Sensation Of
Multiple
Electrical Shocks
To The Chest.
What Do You See?

32. 24-Year-Old With
A History Of
DiGeorge
Syndrome
Presenting After
Sensation Of
Multiple
Electrical Shocks
To The Chest.
Dextrocardia
What About This?

33. 24-Year-Old With
A History Of
DiGeorge
Syndrome
Presenting After
Sensation Of
Multiple
Electrical Shocks
To The Chest.
Subcutaneous Implantable Cardioverter Defibrillator
S-ICD
Generator
What Happened?
Turns out her ICD was
oversensing and normal
depolarizations were sending
warning signs of ongoing life-
threatening dysrhythmia
leading to attempts to
cardiovert her normal
rhythm.
A quick call to Boston
Scientific and a small
adjustment did the trick and
solved the problem!
Sternum
Lead

34. S-ICD Versus TV-ICD
Unlike a TV-ICD, a S-ICD
is implanted in the side
of the chest below the
arm with a single lead
tunneled beneath the
skin ending at the
center of the chest near
the sternum. The Lead
is NOT placed within
the vasculature/heart.
Unlike a S-ICD, a TV-ICD
is usually implanted
subcutaneously along
the anterior left (most
common) or right chest
wall with the lead(s)
tunneling intravenously
to access the heart and
are designed to remain
in contact with the
endocardium.

36. What If The Pacemaker Or ICD
Brand Is Unknown?
This App And Others Like It Can Be Useful Aids. These Are Not Foolproof,
However And Sometimes Incorrectly Label Generators.
A Quick Online Search Will Help You Identify Standard Devices Features
That Can Often Be Seen If You Zoom In Close Enough To The Device.

37. 63-Year-Old With
A History Of Non-
Ischemic
Cardiomyopathy
Who Presented
with Altered
Mental Status
Can You Identify All Foreign Bodies Here?

38. 63-Year-Old With
A History Of Non-
Ischemic
Cardiomyopathy
Who Presented
with Altered
Mental Status
A Lot Can Go Wrong Here…
Left
Ventricular
Assist Device
(LVAD) Pump
with Inflow
Cannula
TV-ICD
Generator
ICD Leads
Red Arrows Top To Bottom
Right Atrial Lead
LV Coronary Sinus Lead
RV Lead (Extending
Towards The LVAD)
LVAD Drive line
LVAD Outflow Graft

39. A Different Example

40. 63-Year-Old With
A History Of Non-
Ischemic
Cardiomyopathy
Who Presented
With Altered
Mental Status.
Can You Identify All The Foreign Bodies Here?
Red Arrows Top to Bottom
Right Atrial Lead
LV Coronary Sinus Lead
(Bottom Two Arrows)
Left Ventricular Assist
Device (LVAD)
Blue Arrows
RV Lead
Purple Arrow
ICD Generator
Yellow Arrow
Sternotomy Wires
Green Arrow
LVAD Outflow Graft
(Connects Pump to Ascending
Aorta)
Orange Arrow
Driveline (Pump Cable Portion)

42. Summary Of Diagnoses This Month
 Disconnected VP shunt
 PFO Closure Device
 Implanted Chest Wall Baclofen Pump
 Pneumobilia
 Common Bile Duct Stent
 Dextrocardia
 Aortopulmonary Collateral Vessel Coil Embolization
 Subcutaneous Implantable Cardioverter Defibrillator
 Transvenous Implantable Cardioverter Defibrillator
 Left Ventricular Assist Device (LVAD)

43. See You Next Month!