Tórax - Vascular RADIOUIT

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27/02/2016 
1 
Tórax - Vascular 
RADIOUIT 
Liga Acadêmica de Radiologia e Diagnóstico por Imagem 
Caso 01 
• 71 year-old with chest pain and syncope (perda súbita e 
transitória da consciência e consequentemente da postura, 
devido à isquemia cerebral transitória generalizada [redução 
na irrigação de sangue para o cérebro]) 
Qual o diagnóstico mais 
provável ? 
A. Mitral stenosis 
B. Pulmonic stenosis 
C. Aortic stenosis 
D. Mitral regurgitation 
E. Double aortic arch 
Aortic Stenosis- Clinical 
Findings 
•Asymptomatic for many years 
•Classical triad 
•Angina 
• Syncope 
• Shortness of breath (heart failure) 
Imaging Findings 
• In older children or young adults 
• Prominent ascending aorta 
• Poststenotic dilatation of ascending aorta 
• Due to turbulent flow 
• Left ventricular heart configuration 
• Normal-sized or enlarged left ventricle 
• Concentric hypertrophy of left ventricle produces a relatively 
small left ventricular chamber with thick walls 
• Heart size is frequently normal 
• In adults >30 years 
• Prominent ascending aorta 
• Poststenotic dilatation of ascending aorta 
• Due to turbulent flow 
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• Aortic 
Stenosis. Frontal 
radiograph 
demonstrates 
isolated 
enlargement of 
the ascending 
aorta 
(white arrow). 
The left ventricle 
is enlarged 
(yellow arrow) 
and the heart is 
mildly enlarged 
overall. The 
descending aorta 
is not enlarged 
(green arrow). 
Caso 02 
 
Qual o diagnóstico mais 
provável ? 
• A. Mitral Stenosis 
• B. ASD (Atrial septal defect) 
• C. Sarcoidosis 
D. Pulmonary Arterial Hypertension 
 
Pulmonary Arterial 
Hypertension (PAH) 
• · Diagnosis of exclusion 
• Clinically unexplained progressive pulmonary arterial 
hypertension without evidence for thromboembolic disease and 
pulmonary venoocclusive disease 
• Clinical 
• Age 
• 3rd decade; females > males 
• Dyspnea on exertion 
• Syncope 
• Easy fatigability 
• Hyperventilation 
• Chest pain 
 
Imaging findings 
• Main pulmonary artery usually prominent 
• Right and left pulmonary arteries large and taper rapidly 
• Peripheral pulmonary arteries are narrow and inconspicuous 
• No overinflation 
 
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• Frontal 
radiograph of 
the chest 
shows an 
enlarged main 
pulmonary 
artery 
and a markedly 
enlarged right 
and left 
pulmonary 
arteries. The 
peripheral 
vasculature is 
normal 
Caso 03 
 
Qual o diagnóstico mais 
provável ? 
 
A. Silicosis 
B. Pulmonary edema 
C. Sarcoidosis 
D. Idiopathic pulmonary hemorrhage 
E. Tuberculosis 
Pulmonary edema 
• General Considerations 
Increase in the fluid in the lung 
• Generally, divided into cardiogenic and non-cardiogenic 
categories. 
• Congestive heart failure is the leading diagnosis in hospitalized 
patients older than 65 
• Pathophysiology 
Fluid first accumulates in and around the capillaries in the 
interlobular septa (typically at a wedge pressure of about 15 
mm Hg) 
• Further accumulation occurs in the interstitial tissues of the 
lungs 
• Finally, with increasing fluid, the alveoli fill with edema fluid 
(typically wedge pressure is 25 mm Hg or more) 
 
Clinical Findings 
• Shortness of breath 
• Hemoptysis 
• Orthopnea 
• Dyspnea on exertion 
• Cough, wheezing 
• Anxiety and restlessness 
• Cyanosis 
 
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Imaging Findings 
• Radiographic findings can lag behind physiologic changes 
• The key findings of cardiogenic pulmonary edema 
• Kerley B lines (septal lines) 
• Seen at the lung bases, usually no more than 1 mm thick and 1 cm long, 
perpendicular to the pleural surface 
• Pleural effusions 
• Usually bilateral, frequently the right side being larger than the left 
• If unilateral, more often on the right 
• Fluid in the fissures 
• Thickening of the major or minor fissure 
• Peribronchial cuffing 
• Visualization of small doughnut-shaped rings representing fluid in thickened 
bronchial walls 
• Collectively, the above four findings comprise pulmonary interstitial edema 
• The heart may or may not be enlarged 
• When the fluid enters the alveoli themselves, the airspace disease is typically 
diffuse, and there are no air bronchograms 
 
• Linhas A de Kerley: opacidades lineares que estendem-se da 
periferia aos hilos; são causados por distensão dos canais 
anastomóticos entre linfáticos periféricos e centrais. 
• Linhas B de Kerley: linhas horizontais curtas, situam-se 
perpendicularmente à superfície pleural na base pulmonar; 
elas representam edema do septo interlobular. 
• Linhas C de Kerley são opacidades reticulares na base do 
pulmão, representando linhas B de Kerley na superfície. 
• Esses sinais radiológicos e achados físicos sugerem edema 
pulmonar cardiogênico. 
Linhas de Kerley 
Linhas A 
Linhas B 
Linhas C 
Edema 
pulmonar 
cardiogênico 
• Non-cardiogenic pulmonary edema 
• Bilateral, peripheral air space disease with air bronchograms or 
central bat-wing pattern 
• Kerley B lines and pleural effusions are uncommon 
• Typically occurs 48 hours or more after the initial insult 
• Stabilizes at around five days and may take weeks to completely 
clear 
• On CT 
• Gravity-dependent consolidation or ground glass opacification 
• Air bronchograms are common 
 
• Pulmonary 
Alveolar 
Edema. There is 
extensive, 
bilateral airspaces 
disease with fluid 
in the 
minor fissure 
(blue arrow) and 
bilateral pleural 
effusions (ref 
arrows). Although 
the heart is not 
enlarged, the 
cause was still on 
a cardiogenic 
basis. 
Caso 04 
• 57 year-old female with normal arm and leg pressures 
 
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Sagittal R
efo
rm
atted
 co
n
trast-en
h
an
ced
 C
T o
f ao
rta 
Qual o diagnóstico mais 
provável ? 
A. Hypertension 
B. Aortic stenosis 
C. Pseudocoarctation 
D. TAPVR 
E. Coarctation of the Aorta 
Pseudocoarctation of the 
Aorta 
• General Considerations 
• Congenital and relatively rare 
• Elongated and redundant descending aorta with 
kinking or buckling of the aorta distal to the origin of 
the left subclavian artery 
• No obstruction 
• Pressure gradient of less than 30 mmHg 
• No rib notching 
• May be caused by an abnormally long descending 
aorta 
• Clinical Findings 
• Asymptomatic 
 
Imaging Findings 
• Junction of arch and descending aorta just past ductus 
• Since there is no collateral flow needed, there is no rib 
notching 
• Differential Diagnosis 
• True adult coarctation of the aorta 
• Pressure differences and rib notching 
• Cervical aortic arch 
• Usually descends on the side opposite the arch 
 
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• Pseudocoarctation. Sagittal contrast-enhanced CT (above) 
shows kinking of aorta (white arrow) 
that produces a picture similar to coarctation without the 
significant pressure gradient seen in a true coarctation. 
A surface rendered 3D image below shows the same 
abnormality. 
Caso 05 
 
Qual o diagnóstico mais 
provável ? 
• A. Thymoma 
• B. Pulmonic stenosis 
• C. Pseudo-coarctation 
D. Coarctation of the aorta 
 
Coarctation Of the Aorta 
• l General 
• o 2X more common in males 
• l Common classification 
• o Infantile or preductal form 
• o Adult or juxtaductal form 
• l Adult Form 
• o Adult or juxtaductal (postductal) form is more common 
• o Usually localized 
• o Area of coarctation is just beyond the origin of LSCA at level of ductus 
• l Infantile Form 
• o Infantile, preductal form = diffuse type 
• o Long, tubular segment of narrowed aorta 
• § From just distal to innominate to level of ductus• o Intracardiac defects (VSD,ASD, deformed mitral valve) present in 50% of 
diffuse type 
• § Also patent ductus arteriosis 
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• l Clinical Findings–Infancy 
• o Severe CHF most common from 2nd to 6th week of life 
• o Weak or absent leg pulses 
• o Lower BP in the legs than in the arms 
• o EKG 
• § RV hypertrophy because RV assumes most of the 
cardiac output during fetal life in these patients 
• l Clinical Findings-Children and Adults 
• o Differential pulses in arms (bounding) and legs (weak) 
• o EKG 
• § LVH 
Imaging findings 
• o Rib Notching 
• § Single best sign 
• § Older the person, more likely to have rib notching 
• § Majority have it over 20 years of age 
• § Rib notching occurs in the high pressure circuit 
• § Most often involves 4th-8th rib 
• · Sometimes may involve 3rd and 9th 
• · Does not involve 1st and 2nd ribs 
• · Intercostals come off costocervical trunk and do not supply collateral flow to descending aorta 
• § 4th-8th do anastomose with internal mammary to form collaterals for descending aorta 
• § Rib Notching–Unilateral 
• · Isolated Right sided notching occurs when LSCA is involved in actual coarctation 
• · Isolated Left sided notching can occur if there is an aberrant RSCA which arises from below 
coarct 
• o Figure 3 Sign 
• § Caused by (in order) either a dilated LSCA or aortic knob, “tuck” of coarct itself, 
and poststenotic dilatation 
• § Occurs in 1/3–1/2 of patients with coarct 
• § Matched by “reverse 3” or “E” on barium-filled esophagus 
• o Convexity of left side of mediastinum just above aortic knob 2° to dilated LSCA 
• o Convexity of ascending aorta in 1/3 
 
• Close up of upper thorax in a patient with Coarctation of the Aorta. 
The red arrows point to rib notching caused by the dilated intercostal arteries. 
The yellow arrow points to the aortic knob, the blue arrow to the actual coarctation 
and the green arrow to the post-stenotic dilation of the descending aorta. 
Caso 06 
• A 64-year-old British white lady presented with sudden onset 
sharp central chest pain of one hour duration with non-
specific electrocardiographic findings and negative Troponin I 
test. She underwent Computed Tomography Aortography 
(CTA) and was sent for surgical management. 
Pacien
te (2009) 
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C
T scan
 sco
u
t view
 (2013) 
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Qual o diagnóstico mais 
provável ? 
Final Diagnosis 
• Thoracic aortic aneurysm 
Imaging Findings 
• CT Aortografia revelou alargamento do mediastino com 
calcificação periférica curvilinear, marginalmente aumentada 
em comparação com a radiografia de 3 anos antes. As imagens 
de CT sem contraste (NECT) confirmaram dilatação 
aterosclerótica da aorta descendente. A calcificação era 
cincunflexa sem evidência de hematoma ou trombo. CT axial 
com contrast (CECT) revelaram aorta ascendente dilatada. A 
aorta ascendente possuia aneurisma em forma fusiforme, 
espessa em meio de seu comprimento. Não havia evidência 
de ulceração, ruptura ou dissecção. 
Discussion 
• Um aneurisma é a dilatação irreversível de um vaso em 50% 
de seu tamanho normal. O formato do aneurisma pode ser 
sacular (localizado sobre a parede aórtica) ou fusiforme 
(simétrico, dilatação cística uniforme gerada pela 
fragmentação de fibras elásticas e perda de músculo liso). 
• A incidência da TAA é de 5-10%. É associada à aterosclerose 
em 80% dos pacientes e principalmente envolve as três 
camadas dos vasos, caracterizando um aneurisma verdadeiro. 
Trauma é a segunda causa mais comum de resultar em TAA. 
• CT Aortography é a investigação preferível. 
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Referências 
• BRANT, William E.; HELMS, Clyde A. (Ed.). Fundamentals of 
diagnostic radiology. Lippincott Williams & Wilkins, 2012. 
• COLLINS, Jannette; STERN, Eric J. (Ed.). Chest radiology: the 
essentials. Lippincott Williams & Wilkins, 2008. 
• JUHL, John H.; CRUMMY, Andew B.; KUHLMAN, Janet E. 
Interpretação radiológica. Interpretação radiológica, 2000. 
• PLANNER, Andrew; UTHAPPA, Mangerira C.; MISRA, Rakesh R. A–Z 
of Chest Radiology. Cambridge University Press, 2007. 
 
• GAILLARD, F. Appendicolith; Radiopaedia. org. 2014. 
• Sohail Iqbal, Zulfiqar Ali, Rana T Ahmad, Shagufta Jabeen, 
Muhammad Ahsan, Muhammad Zubair Hanif (2013, Aug. 14) 
Thoracic aortic aneurysm: case report & literature review {Online} 
• William Herring. LEARNING RADIOLOGY, 2014