0:00

We'll move on to the next case.

0:03

a 71 year old man with acute chest

0:06

pain

0:07

and the four images that we see here

0:10

from top to bottom and left

0:13

to right or

0:15

from an

0:17

Axial, I'm sorry from a routine non-ecgated CT

0:21

with contrast.

0:26

Look over these images and see if you

0:29

can.

0:29

identify findings and render a

0:32

diagnosis

0:40

Okay.

0:43

The pathology here is something that we really don't

0:46

want to miss.

0:48

But it's a little confusing to identify what the abnormal findings

0:51

are here.

0:53

Starting at the top on the

0:56

left.

0:57

where the level of the aortic valve and we can see

1:00

that there is a pericardial effusion.

1:03

Remember the normal pericardium is paper thin and

1:06

here we clearly have it. Looks

1:09

like it's fairly homogeneous fluid.

1:13

Moreover although it's difficult to see on

1:16

a contrast study. It looks like

1:19

that fluid.

1:20

Is intermediate density maybe

1:23

even higher density that's hard to tell.

1:26

the the clear thing is that there's pericardial

1:29

fluid, but it may be higher density then we

1:32

look at

1:34

The cardiac Chambers. Well, we're not

1:37

seeing very much of the right atrium right ventricle. They kind of

1:40

look normal on a limited Imaging we see of them

1:43

the left atrium looks normal in size,

1:46

but the right sorry the left ventricle.

1:49

Is clearly abnormal?

1:53

What's abnormal about it? That's a little bit hard to describe

1:56

admittedly, but it

1:59

looks like

2:01

the mid and distal

2:04

portions of the left ventricle are misshapen. They kind

2:07

of Bulge out.

2:09

especially laterally

2:12

towards the Apex.

2:14

And then there's this very funny.

2:17

low density structure

2:19

that seems to be in the cavity but

2:22

then I I don't see the interventricular septum

2:25

very well and this low density structure

2:28

seems to go right up to the pericardium something

2:31

funny is happening here.

2:35

And this is something that should at least raise your

2:38

attention for serious pathology

2:42

and potential morbidity

2:45

and this is myocardial rupture.

2:50

So this is something we don't want to miss because there's a very

2:53

high association with rapid

2:56

fatality. If this

2:59

is missed. In fact, most of the time these patients don't reach the

3:02

CT scanner, but when they do we want to

3:05

do our best to make sure we don't miss the diagnosis.

3:10

Myocardial rupture when we see it is because of

3:13

the slow leakage of blood into the pericardium. You

3:16

can result in tamponade or just rapid exangglation

3:19

to the pericardium. It occurs

3:22

in up to about 3% of all

3:25

myocardial infarctions and up

3:28

to about 10% of anterior myocardial infarctions.

3:33

And this is key.

3:35

It usually occurs in the third to fifth

3:38

day following myocardial infarction. So if

3:41

a patient who had a recent Mi presents

3:44

three to five days back into

3:47

the emergency room have this potential

3:50

outcome as a serious consideration.

3:54

myocardial rupture