0:00

Okay, this next case is a 45 year

0:03

old man who came to the Ed with chest pain after recently

0:06

having used crack cocaine.

0:09

And this is an example of cocaine-related vasospasm.

0:12

You'll notice as you go

0:15

through the case on ombra that it doesn't have the

0:18

same series as you're used to seeing and that's because this

0:21

is actually quite an old case.

0:23

from the institution where I did my fellowship

0:26

and I say we don't really see this

0:29

diagnosis very often.

0:31

I'm not saying it's an uncommon diagnosis, but I

0:34

think it's an uncommon diagnosis to come to cardiac CT.

0:37

So this actually was is one of

0:40

the best examples I've seen.

0:43

So let's take a look.

0:45

You can see here's the left Main in this patient, which looks free

0:48

of disease.

0:50

But then when we get into the LED, you can see this big house by plaque.

0:54

LED also has a diagonal Branch here.

0:57

And another diagonal Branch here looks like that

1:00

diagonal has some mild calcified black.

1:02

And then this mid LED has some

1:05

mild calcified black as well.

1:10

a few other scattered cost by plaques and the the distal LED

1:13

and then

1:14

Then it looks looks good out towards the Apex.

1:18

Kind of just Fades away.

1:21

If we look at the RC, I'm going to save the circumflex from

1:24

for last if we look at the RCA we can see there's mild

1:27

calcified plaque there.

1:29

We have a nice.

1:31

Column of contrast passing the calcium in

1:34

the same goes for that calc there.

1:37

And then more mild disease

1:40

here with a good size Lumen getting past

1:43

the disease.

1:45

There's this sort of tortuous segment of the

1:48

mid-rca, which is not

1:50

An uncommon finding this has a name. It's

1:53

actually called this Shepherd's crook appearance.

1:56

And it's not really relevant. It doesn't necessarily put the patient

1:59

risk for anything except for one thing. It can make it more difficult

2:02

for them to perform cardiac cath on

2:05

the distal RCA.

2:07

Some other small flecks of calcium here and there in the RCA

2:10

but no significant disease.

2:12

So now let's look at the circumflex.

2:15

You can see compared to all the other vessels of certain flux is

2:18

very small.

2:20

And you can see it comes down.

2:23

A little bit of calcium there and then we kind of lose it and

2:26

just disappears.

2:28

And then later on you see this you see

2:31

an obtuse marginal and you see the circumflex

2:34

continuing.

2:36

I'm going to zoom up just to show that one more time if I'm

2:40

going backwards we have obtuse marginal.

2:44

And circumflex and as we March backwards.

2:47

We get to their Origins.

2:50

And then we don't see anything.

2:52

And then further backwards it comes back.

2:56

And let's take a look at that on the NPR.

2:59

So one trick for looking at the circumflex on

3:02

the nprs is to start with the axial image

3:05

and find the part of the circumflex. That's at

3:08

the top of the AVG Groove.

3:10

Drop your crosshairs on that and then rotate clockwise so

3:13

that you're lined up with a long axis of the vessel in

3:16

the AV Groove.

3:19

Find the other.

3:21

Long axis image and rotate clockwise here

3:24

so that you're going through the AV groove,

3:27

right? This is the

3:29

Atrium ventricle and the space between

3:32

the AV Groove

3:33

so once you've done that if you've done it correctly,

3:36

then you should have

3:38

A plane through the AV Group which we see here on

3:41

the short axis images.

3:43

And what you can see is we've got.

3:46

left Main

3:47

LED circumflex coming down

3:52

And then this is letting up this is the spot where

3:55

the circumflex comes down.

3:57

And then just disappears right here.

4:00

And then you can see the reconstitution of the

4:03

circumflex right here and the obvious Marshall Branch

4:06

here if we do a MIP.

4:10

The mips going to show this really nicely.

4:12

You can see circumflex a little

4:15

spot of calcium and then just kind of tapers away and

4:18

disappears and then comes back again.

4:22

and so this degree of diffuse vessel

4:25

narrowing

4:27

and you don't really see plaque here. You just

4:30

see that the vessel kind of Narrows Narrows and disappears and then comes back

4:33

again. That's a really good picture for vasospasm. So

4:36

basically, you know, the vessels just clamped down.

4:40

So when you see vessels that are tiny and clamped

4:43

down and there's no plaque to really explain that

4:46

in the right clinical setting then you definitely want to think about

4:49

vasospasm one other thing to point out in this

4:52

case, which is pretty interesting.

4:54

And you don't see this very often at all. But if you have somebody

4:57

with a cute chest pain

4:59

And you see a significant lesion you can sometimes pick

5:02

up areas of perfusion abnormalities.

5:06

in The myocardium

5:08

so in this case

5:10

if we window

5:12

you can see that this region.

5:15

of the LV myocardium

5:19

is lower in signal

5:21

than the rest.

5:23

And if I go and do a more kind

5:26

of long access for chamber of you, I think I can make

5:29

it even a little more convincing that this area right here.

5:33

shows reduced perfusion

5:36

And so it's the sub-endocardial region of the left ventricular

5:39

free wall.

5:41

It has lower signal which tells you there's less contrast

5:44

there which tells you there's less perfusion, which is explained by

5:47

the fact that area of The myocardium is

5:50

supplied by this abnormal circumflex. So

5:53

in this case, we have high grades stenosis

5:56

of the proximal circumflex accompanied by

5:59

some sub-indocardial. Ischemia in

6:02

the latter wall in the circumflex territory.

6:05

And all of it was actually most likely secondary to

6:08

invasive spasm. They actually didn't even take this patient to Cath.

6:11

They just treated them symptomatically because of the history of cocaine use