0:00

Hello everybody. Thank you for joining me and

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I will.

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Go and share my screen so we can all.

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We can all look at the same thing here.

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right

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There you go. So

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what we're trying to do today is we're

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going to look at a few interesting cases that I would

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call. You should not miss. Those are

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the not to be missed cases and

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these are obviously not exhaustive, but

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those were a few that I accumulated and I

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thought were worthwhile sharing, please please

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feel free to

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Use the chat function because they're if there's

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questions arising I'd be

0:53

happy to discuss them on the Fly which brings

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us into the very first case and this

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is a 45 year

1:02

old gentleman who presented to an outside emergency

1:05

room with acute onset of shortness of

1:08

breath.

1:09

And they obtained a pulmonary CTP.

1:12

So CT for pulmonary

1:15

embolism exclusion, and I'm

1:18

going to share this PE study with you.

1:22

so it's running a little slow, but I think

1:25

that it just gives you time to assess the

1:28

images and I just want you to look at the images

1:31

really get an idea of what's going on mind you

1:35

this is a PE study that

1:37

we obtained or sorry the outside institutional

1:40

obtained.

1:43

and

1:45

I just want you to look at everything formulate your

1:49

opinion.

1:51

And I'm going to run it a couple times.

2:07

I'm going to go back up just to give you a second time to

2:10

look at it.

2:13

again, 45 year old gentleman presenting with

2:16

an acute onset of shortness of breath

2:20

I'm gonna speed it up a little bit so that you that we

2:23

don't waste too much time.

2:26

This is a PE study.

2:31

And there's no other known.

2:36

diseases or pre-existing conditions that this gentleman

2:39

has

2:40

so and with that I would like to get the

2:44

first polling.

2:46

What is your most likely diagnosis here and I

2:49

have this I have these four.

2:54

possibilities and I would like to

2:57

invite you to vote.

3:00

And the reason why I would like you to vote is because I would like to discuss what

3:03

we're seeing here, and I would like to get an

3:06

idea. So if you were to cast your vote, please

3:10

Okay, so this is wonderful.

3:13

So we have three participants who actually

3:16

we have four participants who think

3:20

that this is some form of vasculitis.

3:22

We have two participants who think this is a type A

3:25

dissection and fortunately we have nobody who thinks that's normal,

3:28

which is a good thing because obviously it's not normal and

3:31

so I would

3:34

like to submit to you that we need

3:37

to look at so the important thing with this one I

3:40

think are two things a the

3:43

history. So the history here in this case is really

3:46

critical. And remember I said, this is a

3:50

45 year old gentleman who presented with sudden onset

3:53

of shortness of breath and that's

3:56

really important. I know that as a radiologist we

3:59

often are not given information.

4:02

But in this case, we were actually given information that it was

4:05

sudden onset of shortness of breath. What are we seeing?

4:09

We're seeing opacific of the pulmonary arteries

4:12

because this was a PE study. And for once it's a very very good

4:15

piece study because it only opacifies the

4:18

right heart structures and the pulmonary arteries. But what else do

4:21

we see?

4:22

We see thickening of the

4:26

pulmonary arterial wall

4:28

As documented here and here and

4:31

here, but if you look closely.

4:34

The problem with that thickening is that it almost has a

4:37

waste it has a waste and it's

4:40

undulating. It's not circumferential and smooth. It's

4:44

not the same thickness all over the

4:47

place.

4:48

And if you continue further that thickening extends

4:51

into the periphery of the pulmonary arterial

4:54

branches in the long parenchyma.

4:58

So the thickening extends far out far out into

5:01

this. That's one thing that we need to

5:04

recognize.

5:06

and then so two of our participants thought that

5:09

this was a type A dissection and I salute them for thinking that

5:13

Because what else are we seeing here? Well, we're seeing

5:16

that there is a little bit of pericardial fluid but

5:19

then look at the ascending order always pay

5:22

attention to the ascending era when you have a patient come

5:25

in with acute onset of shortness of breath.

5:29

Because this is a very indistinct aorta

5:32

look at the fat here anterior to

5:35

the interventricular group. Look at the fat here

5:38

adjacent to the aorta.

5:41

Look at the fat.

5:45

Adjacent to this pulmonary arterial Branch because you

5:48

know, some people would say, well it's a vasculitis but

5:51

look at the fat here look at the fat here,

5:54

but the fat planes adjacent to the pulmonary

5:57

to the ascending era are really really gone. There's

6:00

some soft tissue attenuation in

6:03

the fat plane between the pulmonary artery and the ascending order.

6:07

And then last but not least look at

6:10

the size of the ascending order.

6:13

Look at the size and just get a Gestalt of

6:16

how big it is. And if you don't have a measurement, that's fine.

6:19

But you can Gestalt the

6:22

difference between the pulmonary artery and the ascending order.

6:25

And remember those should be approximately the

6:28

same size because what goes out has to

6:31

come in and vice versa and so they should match to

6:34

some degree and also you can compare the ascending ERA

6:37

with the descending order

6:40

and they should match also to some degree. So even

6:43

without any measurements we can see that the ascending

6:46

order is significantly larger than the descending order

6:49

and it is significantly larger than the pulmonary

6:52

artery the main pulmonary artery at that level. So putting all

6:55

of this together.

6:58

this patient actually had

7:01

A type aortic dissection so I applaud those

7:04

two people who were given that as an

7:07

answer and this is the same patient

7:10

on the same day. Just a few hours later.

7:14

And you can see that he has this dissection membrane

7:17

in his ascending era.

7:19

The dissection membrane extends all the

7:22

way to the order guards. There's the tear.

7:26

And more importantly it's extending

7:29

to the right coronary artery ostium.

7:34

Now those of you who said vasculitis

7:40

I would submit to you. One of the most

7:43

important things again is the history vasculitis does

7:46

not tend to present with a sudden

7:49

onset for shortness of breath or

7:52

chest pain for that matter.

7:54

Patients with vascularities usually come and

7:57

they have these prodromy of malaise of

8:00

not feeling well, some of them lose weight. They're just

8:03

chronically ill. They don't

8:06

have a sudden event that they

8:09

can describe patients with aortic dissection

8:12

or intramural hematomas speaking with acute aortic

8:15

syndrome. They can tell you the second of the

8:18

hour when it happened they can tell you exactly what

8:21

they were doing when this happened because

8:24

it's such an inciting event. It's a sudden

8:27

event and that's that's one thing that is important and

8:30

and lastly

8:34

Um, why does it look so funny on the pulmonary artery

8:37

image? And this is from a publication

8:40

that that I did with a few of

8:43

my colleagues a couple years back.

8:46

When we did a video on rethinking mural

8:49

thickening and this is exactly what we're seeing here. So

8:52

number one, we have a significantly enlarged ascending

8:55

era. It measures 55 millimeter at the

8:58

time and we have this undulating mural thickening

9:01

of the pulmonary artery, which is

9:04

never smooth. It is never smooth. It is

9:07

Lumpy bumpy and extends along the pulmonary arterial tree.

9:10

Why is it that way because once we

9:13

have the dissection and the disruption of

9:16

the Integrity of the aortic wall, what

9:19

will happen is that the bleed will

9:22

invariably extend into the area of the lowest pressure

9:25

which in this case is actually the sheath

9:28

of the pulmonary artery because the aorta and

9:31

the pulmonary artery at their Inception share a

9:34

common sheath, which is just depicted here.

9:37

So if that tears,

9:39

The sheath is common. It bleeds into the in into

9:42

the at the surrounding saw into

9:45

the surrounding sheath, but rather than extending solely

9:48

within the aorta it extends into

9:51

the pulmonary arterial sheath because of the pressure differential.

9:56

How do you differentiate vascularities from?

10:02

type aortic dissections well again Clinic clinical presentation

10:07

Vasculinity is also are extremely rare to

10:10

happen only in the pulmonary arterial trees. You can

10:13

have vascularities of both the

10:16

aorta and the pulmonary artery, but it is extremely rare.

10:20

And then last but not least.

10:23

The extension of the mural thickening and

10:26

the nodularity or let's say the undulate undulating

10:29

nature. They're off going into the Peri

10:32

and extending all the way along the pulmonary arterio

10:35

branches whenever you see this you should at

10:38

least question with it. There is an dissection or

10:41

not. And if you're not sure.

10:44

then do what I did just get a gated

10:47

CTA chest if you can and proof

10:50

that it's not a dissection because

10:53

the point is also if you miss a

10:56

dice if you miss a vasculitis, the

10:59

patient is not going to instantly die. If you

11:02

miss a type A dissection that could

11:05

be a very critical Miss and the patient

11:08

could actually really have a very dire outcome in

11:11

that case. So I would submit to you if you're

11:14

not sure and if the clinical history is

11:18

Really saying that there was a sudden event and you have

11:21

such a beautiful study like we did here with little

11:24

to no opacification of the aorta.

11:28

Get a dedicated aortic study.

11:30

To rule out a type A dissection because if

11:33

the clinical presentation actually speaks about

11:36

the sudden and acute onset, you really

11:39

don't want to miss this.

11:42

and

11:45

there is

11:46

a chat box

11:49

that you're welcome to use. So I

11:52

guess there's a Q&A chat box. You can type questions into this

11:55

and I'd be happy to answer those questions on the

11:58

fly if I can or we can do this at the very end of the lecture. Just

12:01

wanted to bring that up again. So, please feel

12:04

free to use that good excellent.

12:07

So then I guess we will proceed to the next case.

12:12

Um, I just put that in there I had this on one of my prior

12:15

elections. I just like this because it's a

12:18

mnemonic for how you

12:21

should remember the dissection. So

12:24

and what you should report dissect them on

12:27

it. So you want to report the duration the

12:30

location the size the segmental extent

12:33

the potential complications and

12:36

ultimately from us, but you really

12:39

want to know how the patient presented

12:42

so again clinical information is critical to

12:45

differentiate what happened to the patient after the

12:48

second CT. How was he treated? Was there anything

12:51

to be done about the narrowing? That's a very good question. Thank you

12:54

for their question. The patient actually was taken emergently to

12:57

the or to undergo valve sparing

13:00

ascending aortic replacement for his type Ada section.

13:03

And the narrowing or

13:06

the bleed within the pulmonary arteries, there's not

13:09

much you can do about that. It will

13:12

be resorbed and quite frankly.

13:15

This is one of the reasons why patients die from

13:19

acute type A dissections because if

13:22

the bleed into the pulmonary arterial sheath is

13:25

to extensive it can lead to occlusions

13:28

of the pulmonary arterial tree and

13:32

the patient can can die on the spot.

13:35

So in this case, we're fortunate

13:38

enough that the bleeding had stopped at the

13:41

time, but the date patient underwent urgent

13:45

emergent. I mean instantaneous replacement of

13:49

his ascending ERA with a valsparing graft into

13:52

position. Thank you for the question.