0:00

Okay, for this next case, we're going to look at an embolic disease.

0:05

It is a 53-year-old female with a history of breast

0:09

cancer who came in with abdominal and

0:13

leg pain.

0:14

So again, we're going to start over.

0:16

We're going to look at all of our incidental

0:20

findings. And even starting out, this is one of the ones where we will look at

0:24

the incidental findings. We can see this hypo-enhancement

0:28

of the right kidney.

0:30

There's a large area that doesn't enhance, and then the rest of it enhances much

0:34

lesser compared to the left side. The appearance is highly

0:37

suggestive of a renal infarct. If we look at

0:41

it on the coronal view, we can see that it is wedge-shaped

0:45

and really quite characteristic of an infarct.

0:49

Now, going back to the artery.

0:52

So in the aorta, we see this large filling defect in that

0:56

juxtarenal aorta as a free-floating

1:01

filling defect that is suggestive of a thrombus.

1:03

And you can actually see this thrombus kind of propagated inside of that

1:07

right renal artery, and which is why

1:11

there's a thrombus, and it's extending into the renal artery, and

1:14

then unsurprisingly, there are resultant right renal infarcts.

1:20

Scrolling all the way down, we're going to look at one limb at a time.

1:24

So we're going to start off with the right lower extremity, and

1:28

we can see that up until now, external iliac, internal iliac,

1:32

common femoral, profunda, as well as superficial femoral

1:36

arteries, they're both patent.

1:40

They're all patent. And then coming to the popliteal artery and looking

1:44

at that popliteal artery now,

1:47

we can see its branches. And

1:50

as this vessel has branched in the anterior tibial artery, we can see that

1:54

there's a filling defect as well as in the tibial peroneal

1:58

trunk, there is a filling defect.

2:01

This defect is also extending into that ostium, and

2:05

so multiple occlusions at branch points.

2:08

You can see that this is the branch point of that tibioperoneal

2:12

trunk becoming the posterior tibial and peroneal artery right here.

2:16

Now, while it only caused a degree of stenosis in the

2:20

tibioperoneal trunk and the posterior tibial, there is definitely an

2:24

occlusion of this anterior tibial artery with intermittent

2:28

opacification and reconstitution of some vascular segments on this

2:32

right side.

2:34

Moving on to the left side over here, so common

2:37

iliac, external iliac arteries are all okay.

2:41

Coming into the thigh,

2:43

the superficial femoral artery is nice and wide and patent.

2:46

No significant atherosclerotic disease.

2:50

Coming down to the popliteal artery and then its branches.

2:53

So we have the anterior tibial, posterior tibial, and peroneal.

2:56

We're going to focus on the anterior tibial here, and you can see that there's this

3:00

filling defect here, and it's occluded, and there's intermittent

3:03

opacification. So multiple segments of occlusion

3:07

of the

3:10

anterior tibial artery

3:13

right here.

3:15

Even in the peroneal artery, while most of it was

3:19

patent, more distally, we can see that right here, there's severe

3:23

stenosis of it. So distal involvement,

3:26

multiple arterial segment involvement, involvements of branch

3:30

points, having other organ involvement like a

3:34

renal infarct, and then the more direct evidence that this is in

3:38

fact an embolic disease was the presence of a thrombus in the

3:42

aorta are all seen in this classic scan.

3:46

The one thing that we can highlight in this study as

3:50

well is

3:53

just the effect of spatial resolution when we're assessing the calf

3:56

arteries. So if we were looking at

4:01

the

4:02

calf arteries again

4:05

and

4:06

assessing its patency, looking at these small

4:10

field of view images, which are thinner in slice, you can really see how

4:14

much better

4:15

the spatial resolution is. So at that same slice

4:19

thickness

4:21

right here, right here, we can see how much crisper these

4:25

thinner slice thickness and the small field of

4:29

view where it's only the right leg that's reconstructed.

4:32

You can kind of really see how much better

4:36

the details and fine visualization of the vessels are on this

4:40

reconstruction.

4:42

Coming over to embolic disease, which is a lesser common cause

4:46

of thrombosis

4:48

compared to atherosclerosis. We consider that the

4:52

patient has an embolic disease when there are multiple occlusions typically seen at

4:56

branch points, if there are associated other organ findings.

4:59

So if there are renal infarcts, splenic infarcts,

5:02

and in a relatively young patient who doesn't have

5:05

atherosclerosis in other vascular beds as such, again, we think of an embolic

5:09

disease. We're always also looking for an imaging source.

5:13

So in addition to the abdomen pelvis angio that is typically

5:17

included as part of the runoff, you might have to image the chest because you

5:20

want to look at the whole aorta as the source of embolus.

5:24

The cardiac structures are often implicated as a source of embolus, so looking at

5:28

the chambers and valves, even at the base of the heart

5:32

is important. And the chest really should be imaged for a cardiac or an aortic

5:35

source of embolus either prospectively or retrospectively once

5:39

a concern is raised that this might be an embolic phenomenon.

5:43

So going over after looking at the case that we just did of

5:48

that embolic scan, this is just to show you

5:51

how quickly things can progress in an embolic disease.

5:54

So we just looked at the scan of the patient right now,

5:59

and what the imaging looks like, and this scan is from two days prior.

6:03

And so comparing both of these, you can see here how that's

6:07

the popliteal artery that gave rise to the anterior tibial artery, and

6:11

this anterior tibial artery is

6:15

occluded and multifocal occlusions in the mid and the

6:18

distal calf all the way through. But two days ago, that same

6:22

vessel, if you go all the way up, is widely patent.

6:26

So embolic

6:28

pheno-- like people can shower emboli and there can be

6:32

rapid progression of findings and symptoms.