0:00

next case 41 year old female hypertension

0:04

window this a little bit just an abdomen CT looks like

0:07

it's in an arterial phase.

0:10

Think about what are the things you're thinking about or?

0:13

And what would you be thinking about in a patient with?

0:18

With these demographics with this history.

0:35

Few people in chat box chiming in I'm gonna get to

0:38

that in a second scroll all the way down.

0:44

Be unfair for me to just give you.

0:47

some of the images and want to scroll slowly as

0:50

possible because

0:52

it's very tough when other people are scrolling. I'm

0:55

well aware of that.

0:57

I won't trade the long Windows here. I don't think they'll be relevant to the

1:00

case. Let's see what the chat box is showing requiring. So

1:04

some people are chiming in. Let me show you some other images in

1:07

this case.

1:11

It's a window a little bit. We did this at a lower. Kvp. I

1:14

think which is why.

1:15

Everything looks so bright. We do that

1:18

for some of our arterial face studies ctas.

1:34

All right, so we got a bunch of people chiming in so people are

1:37

talking about fibromuscular dysplasia. Which

1:40

side is the right fiber muscular dysplasia in

1:43

this case. Is it the right side the left side?

2:02

And people talking about the right side. Okay, that sounds great.

2:05

And so

2:07

maybe I'll ask the group then for another question is

2:10

what is the most common?

2:12

There's so many different types of fiber muscular displays it

2:15

what's the most common type does anyone in the group know?

2:24

Or type 2. I wish I knew which one was type 2 you're probably

2:27

around the person who said to.

2:30

And the medial type, okay so we can wrap it

2:33

up there. Yeah this patient. The other thing is some other

2:36

people talk about Triple A. This area looks pretty normal in size at the

2:39

very least. This person has it looks like a duplicated ride collecting system

2:42

to ureters are coming down. Some people talked about that or had

2:45

mentioned that as well. So I want to just be respectful of that and

2:48

I don't know if it's completely duplicated or we sort of

2:51

don't see it beyond that area. So I actually don't know much more than what

2:54

I'm showing you over here.

2:56

And so yeah, okay. So let's go through

2:59

this. So yeah, you know, I think the history sort of you know,

3:02

I could have provided a different history, but I think that would be unfair, you know,

3:06

and I think this is a 40 year old female with with hypertension.

3:09

There's a couple things you're looking for. Certainly you

3:12

want to look at the renal arteries other things. You

3:15

may want to think about just you know, before we go there is, you know, could this

3:18

person have a field chromocytoma, you know, so look

3:21

at the adrenal glands make sure there's no hypervascular Mass here could have

3:24

another pair of ganglioma one brought that up in our in our one over

3:27

our first case. So I want to scroll all the way down to look at

3:30

that organizer candle area no masks over there or anywhere in the Retro parenting

3:33

for that matter. So those are some of the things you can think about before you

3:36

approach the case, but you really do want to look at the renal arteries and I

3:39

find that.

3:41

I find that.

3:45

Looking for fibromuscular dysplasia is quite

3:48

challenging on the axial images. Now if

3:51

we look at this, maybe it helps look at the left one, which is relatively normally see

3:54

the smooth borders. Maybe I'll zoom up on this a little bit.

3:57

And you can see the smooth borders over

4:00

there and sort of branches out and looks pretty reasonable on

4:03

the right side can see it come out. It looks

4:06

pretty much okay till here and all

4:09

of a sudden you see start to see a little bit of lumpy bumpiness associated with it. You

4:12

can see a little bit of bumpiness hair as well associated with

4:15

it.

4:16

And then look at this thing, you know just so subtle areas of irregularity where

4:19

it's just not completely smooth and

4:22

for that I find the coronals and

4:25

we did look at these to be incredibly useful as I'm

4:28

sure most in the group would find them useful as

4:31

well though. I suppose most did diagnose it on the axials in

4:34

this case where you can see areas of focal dilatation

4:37

focal narrowing associated with this right

4:40

ureter.

4:41

And we can see it all the way even here a little aneurysm that's

4:44

coming up here and even more proximately so it's

4:47

really in this case sort of the mid to distal ureter that's

4:50

affected which is a common side for fiber muscular dysplasia. And so

4:53

that's what this turned out to be in in this in

4:56

this case as soon

4:59

as I have already still we still actually phase. Yeah, I probably was a

5:02

split those Techni. That's a great question. I mean now this was study was done a while back, so I'm

5:05

not really entirely sure but that's the only logical explanation.

5:08

So I appreciate the the audience answering

5:12

that there is a double ureter on the right side. It is duplicated. It's

5:15

not all the way down. I think autoimmune

5:18

pancreatitis not a great look for autoimming pecker Titus in

5:21

this case. We're looking for, you know rind of soft tissues

5:24

surrounding the pancreas. You may be looking for other things associated with

5:27

the paint grease include other things in the abdomencluding Retro

5:30

parent, you'll find roses, you know inflammatory pseudotumors of

5:33

the kidneys some biologicalities, I think

5:36

polyurethritis to do so, it would be a thing to consider if I saw issues with

5:39

more vessels, you know.

5:41

This is not just isolated adrenal arteries. Then I

5:44

think I would think of potentially something like polyaritis nodosa as

5:47

a possibility.

5:49

And so let's go through a brief teaching points in this case.

5:53

Fmd, it's not inflammatory. Not an atherosclerotic vasculopathy

5:56

involving the arteries the prime arteries

5:59

or the renal arteries and carotid arteries though. It happens more often

6:02

in the renal arteries and can cause stenosis and aneurysms and

6:05

capital dissection. So watch out for those and of course it can

6:08

cause hypertension and it's really classified based on

6:11

the involved layer of their true law. There's many many different types of

6:14

fmds. Most common medial displace anything that was

6:17

mentioned in a chat box and the classic appearance of string of

6:20

beads appearance classically mid to disturbino arteries. I find

6:23

it easiest to see on the reformats and gold standard

6:26

still is IR pertain of

6:30

transilinal Angie, you know angiogram and they can

6:33

do an angioplasties well to help out these patients and alleviate the

6:36

hypertension. So this was a nice case of

6:39

fmd.

6:42

This was a case of the main right real artery. I think somebody's asking

6:45

the chat box. There was an accessory by artery that looked fine.

6:48

Maybe there'd be some abnormalities with that. But I think was too small for

6:51

us to really detect those domain right real artery. That was that

6:54

was abnormal in this case.