0:00

The remaining cases that we'll discuss

0:02

of bronchopulmonary sequestration are different than the

0:05

first three and that these were not diagnosed prenatally.

0:09

Here I am showing you a chest radiograph of a young child

0:13

who came to the emergency department for cough.

0:16

It was noted at the time of interpretation

0:18

that there is this confluent retro cardiac opacity

0:23

and we can see on the lateral view more subtly

0:26

that it's hiding back in here somewhere.

0:30

And so given the patient's symptoms, the radiologist thought

0:33

that this was most likely going to be a pneumonia

0:35

and it is quite a typical look for pneumonia as well.

0:39

However, due to some clinical concerns, the patient went on

0:43

to get a CT scan.

0:46

And so we have here

0:49

an axial contrast enhanced ct

0:51

and this CT was actually

0:53

of the abdomen due to clinical concerns.

0:56

But we can see the lower chest

0:58

and that there is a subtle rounded structure

1:02

that seems a little bit separate from the pleural

1:04

fluid adjacent to it.

1:08

This corresponds with

1:09

that confluent opacity seen on the radiographs.

1:13

Because of this more focal appearance here,

1:15

this patient went on to have an MRI.

1:19

And so we have 3M RI

1:22

images, axial images.

1:25

The first one I'm showing here is the T two

1:30

fat SAT images and then we have T one fat SAT images without

1:34

IV contrast and then T one fat sat images with IV contrast.

1:39

Focusing on the T two we can see that same rounded structure

1:43

that's hypo intense on the T two

1:46

with some surrounding pleural fluid.

1:48

There's also some pleural fluid on the other side

1:50

and there's also some adjacent atelectasis on both sides.

1:54

But the main finding here is this hypo intense lesion

1:58

on T one images.

2:00

It's an intermediate intensity surrounded

2:04

by pleural fluid again.

2:06

And then on T one post contrast images, we can see

2:09

that there is no internal enhancement of the lesion.

2:12

There is enhancement of adjacent atelectatic lung,

2:16

so this turned out

2:17

to be an extra low bar bronchopulmonary sequestration

2:21

that had tourist

2:22

and when it tourist its blood supply was cut off

2:26

and hence there's no enhancement of the lesion.

2:30

And so this is an unusual

2:32

but possible complication of extra low bar sequestration.

2:36

This one happens to be intrathoracic

2:39

and this patient went on to surgery and had it resected

2:42

and it was proven at pathology

2:43

to be a tourist extra lobar sequestration.

2:47

This next case is of a baby who originally had radiographs,

2:52

which I'm not showing here, and also had an ultrasound.

2:57

The ultrasound showed

2:59

What looked like a supra renal mass

3:01

and so they went on to have a CT scan.

3:04

Here we have contrast enhanced

3:07

angiographic images in axial and coronal plane

3:11

and I'll start with the coronal plane.

3:13

You can see here nice opacification

3:15

of the aorta in the abdomen.

3:17

We can see the left kidney here

3:19

and the right kidney here and superior.

3:22

And separate from the left kidney is this

3:25

ill-defined lobular mass.

3:27

That would be easy to ignore if you weren't paying

3:29

attention, but it is not

3:32

a normal structure is not a normal adrenal gland.

3:35

And as we scroll, you'll note

3:38

that there are some prominent vessels centrally

3:41

that you can trace back to a systemic branch

3:46

of the aorta.

3:50

So this has a feeding artery coming off

3:53

of the systemic arterial supply going into this

3:57

non-specific lobular soft tissue mass.

4:01

But because we saw that large feeding artery,

4:04

the top differential here was an extra low bar

4:07

intraabdominal broncho pulmonary sequestration,

4:10

which this was proven to be at pathology.

4:13

I'm not showing the original ultrasound here,

4:16

but interestingly the normal adrenal gland was actually

4:20

found separately, which can be quite hard to do,

4:22

but it was found separately so it was not an adrenal mass.

4:26

The final case I will show is of an older child

4:30

who started out with a radiograph

4:33

and they came in for acute respiratory symptoms

4:36

and somewhat similarly to our first case,

4:39

we see a confluent retro cardiac opacity causing

4:43

silhouetting of the diaphragm.

4:44

We don't see the diaphragmatic margin very well

4:48

and so this was thought to be pneumonia at the time

4:50

of this interpretation.

4:52

The patient was treated and their symptoms resolved,

4:55

but then two years later they came back

4:57

and had a subsequent radiograph.

5:00

Here we have both frontal and lateral views

5:03

and we have a very similar picture.

5:05

So two years later, very similar confluent retro cardiac

5:09

opacity causing silhouetting

5:11

of the diaphragm all the way out here.

5:15

And we can see it's harder

5:16

to find its borders on the lateral,

5:18

but note the absence of the second diaphragmatic margin

5:22

so we can see the right diaphragm clear as day,

5:25

but you can't see the left diaphragm.

5:26

And the reason is it's silhouette out by this thing here.

5:30

So because of this, this patient went on to have a CT scan

5:35

and we have tri plaine images

5:39

and the axial have both soft tissue and lung windows.

5:41

So we'll focus on the soft tissue window axials first.

5:44

We can see in that left lower lung, many cystic

5:51

foci all clustered together

5:53

with some enhancing intervening sector.

5:57

And importantly, although we do not see an obvious

6:01

feeding artery coming directly from the aorta,

6:04

and we do see some vessels that seem to be communicating

6:08

with the pulmonary arteries in this case a pathology.

6:11

This also turned out to be a sequestration.

6:14

This was an intra lobar sequestration that was still cystic

6:20

and we can see on the lung windows,

6:24

but it's causing perhaps a little bit of ectasis.

6:28

And on the additional planes,

6:31

I'm gonna change the lung windows a little bit.

6:33

We can get a sense of its size

6:35

and relationship to the mediastinal structures.

6:39

And again, despite not being able

6:41

to see an obvious systemic feeding artery a pathology,

6:44

this was a broco pulmonary sequestration.

6:46

Just another look. So you can see the variety of appearances

6:50

that this type of lesion can have.