Four Radiology Cases
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These are 4 cases seen on my month on radiology chosen for teaching value: Endoleak, Aortic Dissection, Pneumobilia, Portal venous gas. Download for complete transitions & notes.
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Four Radiology Cases
- 2. Case 1: How to Evaluate for Endoleak? https://www.aafp.org/afp/2002/0415/p1565.html
- 3. Case 1: RS • 82 M 2017 • 2017 - P/W asymp. Infrarenal AAA, 5.5 cm • Aortobi-iliac endovascular aneurysm repair using a Gore stent graft https://surgery.ucsf.edu/conditions--procedures/endovascular-aneurysm-repair.aspx
- 4. Case 1: Imaging • Regular check-ups for leak • Check HU to look for extravasation • 07/2018 • “no CTA evidence of endoleak on arterial-phase imaging, but evaluation for potential endoleak is limited…in the absence of delayed-phase imaging” • 2/12/19 • Got repeat CTA with delayed films • Why is delayed phase so important?
- 11. Case 1: What’s Next? • Evidence of Type II • Without an increase in sac size • Asymptomatic • Observe and F/U in 3-6 mo
- 12. Case 1: Takeaways • Type ____ Endoleaks are the most common • Retrograde flow usually arises from ______ • Requires what kind of CT imaging?
- 13. Case 2: JS • 81 yo F with Hx of HTN and Afib • P/W with sudden CP radiating to the back, stable • Study? • CT Chest, Abdomen, Pelvis W/ & W/O Contrast
- 14. Case 2: Acute Aortic Syndrome 1. Most Common 2. Shearing forces False Lumen & Intimal Flap 3. +/- Enhancing (Thrombus) 1. Rupture of vaso vasorum in media 2. Overlooked because it’s non- enhancing 3. Delayed mortality up to 25% 1. Ulceration of plaque 2. Outpouchings of contrast 3. Often multiple, rarely rupture Rx
- 15. Case 2: AAS Imaging • http://www.radiologyassistant.nl/en/p441baa8530e86/thoracic-aorta-the-acute-aortic-syndrome.html
- 16. Case 2: Imaging
- 18. Case 2: Imaging
- 19. Case 3: From Imaging Note VASCULAR: • Type A intramural hematoma … extends from the aortic … all the way through the abdominal aorta • At the level of the diaphragmatic hiatus, there is a small penetrating ulcer … allows contrast to pass into the mural wall. • No dissection flap is identified.
- 20. Case 2: Findings & F/U • Type A intramural hematoma • Ascending aortic & Transverse hemi-arch replacement • Known residual descending/abd dissection • Penetrating ulcer at diaphragmatic hernia Rx
- 21. Case 2: Takeaways • Have to check for all 3 types of acute aortic syndromes • Variability in management and prognoses • Requires attention to spiraling, enhancement, calcifications, flap, etc
- 22. Case 3 & 4: Air in the Liver • Pneumobilia vs. Portal Vein Gas
- 23. Case 3: AH • 60 yo M • Hx of acute cholecystitis, deferred surgery • P/W generalized abdominal pain with N&V • CT Abd, Pelvis with contrast
- 32. Case 3: Discussion • Pneumobilia is air in the biliary tree • Air stays Central • Etiology often benign • Recent biliary instrumentation, ERCP • Gallstone ileus • DDx is limited but includes… • Portal venous gas https://radiopaedia.org/articles/pneumobilia?lang=us
- 33. Case 4: DH • 80 yo M with Hx of vascular disease • P/W blood-tinged diarrhea, LLQ pain • Had N/V & not been able to eat or drink AKI • CT Abdomen, Pelvis without contrast
- 37. How does gas reach the liver? Ischemia causes necrosis of bowel wall Bacteria releases gas into bowel wall & vessels Gas travels through portal vein system
- 40. Case 4: Take-away • Portal venous gas • Usually reaches the Periphery of the liver • Very concerning for intestinal ischemia
- 41. Summary 1. Endoleak Evaluation with CTA Delayed Phase Imaging 2. 3 Types of Acute Aortic Syndromes 3. Two Cases of Air in the Liver
Editor's Notes
- https://www.aafp.org/afp/2002/0415/p1565.html Coronal CT angio & axial CT with con of AAA Point out renals and thrombus Left: FIGURE 5A. Reconstructed computed tomographic angiogram in the frontal projection demonstrating the bilobed infrarenal aortic aneurysm (arrow heads). The renal arteries are well visualized (small arrows), revealing a severe stenosis of the proximal right renal artery (outline arrow) and the proximity of the aneurysm neck to the renal arteries. The relationship of the aneurysm to the iliac arteries and the aneurysmal dilatation of the right common iliac artery (outline arrow head) are also well displayed.
- https://surgery.ucsf.edu/conditions--procedures/endovascular-aneurysm-repair.aspx Goal is to dec blood flow to the aneurysmal parts and prevent rupture
- If you see something in the arterial phase, don’t know if it’s acute enhancement in the thrombus Delayed phase – looking for change in thrombosed portion, that it’s not a chronic calcification
- Type II endoleaks account for approximately 40% of all endoleaks encountered in clinical practice and are the most common [3]. They occur when there is retrograde flow of blood into the aneurysm sac via an excluded aortic branch, most commonly the inferior mesenteric artery or a lumbar artery. Many type II endoleaks close spontaneously over time [3] https://www.ajronline.org/doi/pdf/10.2214/AJR.08.1593
- At level of renal arteries, no graft – infrarenal
- Graft starts
- Bi-iliac graft, see it as it splits Can also see the anuerysm
- Look for difference in enhancement
- Can see possible lumbar artery feeding into it
- II Lumbar, IMA arteries CTA with delayed phase imaging
- What are we thinking of here? What’s the best study to get? Ok so ‘ve always thought of classical AD, but have to know about other 2 Clinically presentation and Tx can be very similar with different pathophysiologies and different prognoses Often you can have multiple types have to look for all 3
- 3 Types of Dissections Small subtle IMH often not seen with contrast IMH – why you get non-contrast http://www.radiologyassistant.nl/en/p441baa8530e86/thoracic-aorta-the-acute-aortic-syndrome.html#i441d7719eda9d Many details about calcification, spiraling, etc I’m not getting into
- Always have to check where the dissection is in relation to LSCA
- Can start to see a little at start of aortic outlet Can see it clearly in the descending
- Can see No intimal flap or false lumen (not classic AD) No fenestration (not PAU) Not fully enhancining – not aneurysm
- Still have IMH Now also have PAU
- Unless it involves aortic root, may also be conservative mgmt
- http://www.radiologyassistant.nl/en/p441baa8530e86/thoracic-aorta-the-acute-aortic-syndrome.html
- https://www.sciencedirect.com/science/article/pii/S0736467905004154
- Gall bladder wall thickening Air in the GB 1. Inflammation of the gallbladder compatible with chronic cholecystitis with a definite fistula to the adjacent duodenum. Minimal fluid is present in the gallbladder fossa and tracks around the anterior surface of the liver. Minimal associated pneumobilia. No biliary obstruction.
- Small amount of pneumbilia 1. Inflammation of the gallbladder compatible with chronic cholecystitis with a definite fistula to the adjacent duodenum. Minimal fluid is present in the gallbladder fossa and tracks around the anterior surface of the liver. Minimal associated pneumobilia. No biliary obstruction.
- Fistula
- 2. Gallstone ileus. Multiple prominent dilated loops of mid jejunum. Large 31 x 16 mm calculus obstructs the bowel on image 73 series 5. Administered oral contrast material shows transit to the colon indicating incomplete obstruction.
- 2. Gallstone ileus. Multiple prominent dilated loops of mid jejunum. Large 31 x 16 mm calculus obstructs the bowel on image 73 series 5. Administered oral contrast material shows transit to the colon indicating incomplete obstruction.
- Why does it localize centrally? Image credit: https://jonbarron.org/article/healing-liver-and-gallbladder
- https://radiopaedia.org/articles/pneumobilia?lang=us
- Intestinal ischemia pneumatosis, intestinalis Wall thickening Air, subserosal Incidental umbilical hernia w/o evidence of SBO . Extensive portal venous gas with multiple distal small bowel loops which demonstrate wall thickening and scattered pneumatosis concerning for bowel ischemia. There is a loop of small bowel which protrudes into an umbilical hernia without upstream dilatation or surrounding soft tissue stranding to suggest current or recent obstruction.
- Bubbles of Air in subserosa eventually forms ring around stool
- Air of liver in peripheray, all the way to edge
- https://radiopaedia.org/articles/intestinal-ischaemia?lang=us
- Axial views, following mesenteric vessels
- https://www.pinterest.com/pin/686024955708326255/