0:01

This case came in as a non-cardiac case,

0:04

but I thought it was just too interesting to exclude.

0:07

Um, this is a patient that came in in the setting

0:12

of no known disease, fairly young patient, uh,

0:15

had some risk factors, and at night was scanned in our

0:19

emergency department with the intent

0:21

to rule out aortic dissection.

0:23

But as you know, chest pain is a fairly wide differential.

0:27

And so while they didn't find any dissection,

0:29

they immediately went to the cardiac cath lab

0:31

where three vessel coronary disease was found.

0:33

So I don't expect anyone to be able to find, uh, the, uh,

0:37

coronary arteries all that well.

0:39

But you can see there's a lot of aroma.

0:40

So something that'll be nice to mention if you're reading

0:42

the ct now, within minutes, the right things happen

0:44

and the patient went to the cath lab.

0:46

Uh, the problem is with three vessels occluded

0:49

or severely stenotic, it's difficult to know what, uh,

0:52

vessel to, uh, intervene upon.

0:56

And there was some, uh, biomarkers consistent with an MI

0:59

and a very abnormal ECG.

1:01

I'm gonna flip back to my non-contrast scan, however,

1:04

and the thing that's important to pick up on this case is

1:07

that that pericardial effusion is actually hyperdense.

1:11

And if I were to put an ROI on it, if it my eye picked up,

1:15

I would see that that gets into the range of blood density.

1:18

And then you probably notice when I scan through it

1:21

that there were some very concerning features

1:24

along the inferior wall.

1:26

So let's go back and use our skills to make those, um,

1:29

cardiac planes, which again,

1:30

you can do without having ECG gating.

1:32

And let's dive in and make this a two chamber view.

1:37

Go perpendicular, define a four chamber view.

1:39

Uh, and in fact, we can make that a true four chamber view.

1:43

And then we've already defined the short axis.

1:45

And so as we look at the ventricle,

1:47

we're just gonna remember that we look at the anterior,

1:49

the lateral, the inferior, the septal.

1:50

We're kind of in the basal to mid layer here,

1:52

and it's discontinuous and a lot of contrast trapping.

1:56

And this is not ECG gated,

1:58

but you can already see that there is some hypoperfusion

2:01

of the, the myocardium surrounding this.

2:03

And the other interesting thing compared to the last case

2:05

where it was a true aneurysm, we see a narrow neck

2:08

and a long kind serpentine body.

2:11

And, uh, let's just turn on a touch of, um, MIP

2:14

for a minute just to show that.

2:16

But this is basically dead myocardium,

2:19

and this is a pseudo aneurysm

2:23

of the inferior wall of the heart.

2:25

So it's triple vessel disease,

2:26

but a transmural infarct, which led to a puncture.

2:30

Alright, so usually we get invasive

2:33

angiography as our gold standard.

2:35

In this case, we have the surgical photographs.

2:39

And so we're looking at the inferior wall of the heart.

2:41

I've kind of lined up a similar axial view.

2:43

And what you're looking at is very angry looking

2:47

and blood filled pericardium with the tip

2:49

of the pseudo aneurysm, which is a chronic scar,

2:52

and then a rupture with blood along it.

2:53

So, um, this was the pseudo aneurysm, which was about

2:57

to rupture and was immediately

2:58

Resected. And,

2:59

uh, patient did great.

3:01

But the important thing to remember is you had clues

3:03

of pericardial blood.

3:04

So hemo, pericardium, hypo, enhanced myocardium,

3:08

narrow neck wide body.

3:09

So then you should think pseudo aneurysm versus the much

3:12

more common true aneurysm, which is just dilatation

3:14

of all three layers of the wall, um,

3:16

even due to chronic scar.

3:17

Whereas this is a focal hole with a transmural leak.

3:20

And the only thing holding back this aneurysm from rupturing

3:23

was the pericardium, which wouldn't have lasted much longer.