CT

Initial Management and Recognition of Aortoiliac Occlusive Disease, A Case Report

Ashley Hope, BA^*, Alisa Wray, MD, MAEd^* and Graham Stephenson, MD^*

DOI: https://doi.org/10.21980/J87M0Z Issue 7:1 No ratings yet.

Computerized tomography with angiography (CTA) of the entire aorta demonstrated an occluded distal infrarenal aorta with extension into the bilateral common femoral arteries (red outline), lack of flow through femoral arteries (yellow outline) and trickle flow reconstituted distally consistent with aortoiliac occlusive disease (blue outline). Some small segments of the proximal celiac axis showed signs of occlusion (purple outline). A short segment of non-specific bowel wall thickening, which may have been related to ischemic changes, was also seen (not seen on images). The included coronal slice shows the extent of the bilateral occlusive burden, with three-dimensional reconstruction emphasizing the same findings.

Cardiology/Vascular Visual EM

Case Report: It’s a Small Whirl Afterall

Lisa M Schwartz, MD^*, Ryan M Perdomo, MD^* and Jason An, MD^*

DOI: https://doi.org/10.21980/J83S8G Issue 7:1 No ratings yet.

The CT imaging of the abdomen and pelvis demonstrated multiple loops of dilated small bowel with a whirl sign (red arrow) within the mid abdomen and a transition point (green arrow), suspicious for closed loop bowel obstruction and internal hernia.

Abdominal/Gastroenterology Visual EM

Ovarian Juvenile Granulosa Cell Tumor Case Report

Jasmine Lemmons, MD^*, Kim Little-Wienert, MD, MEd^* and Alia Hamad, MD^*

DOI: https://doi.org/10.21980/J8035H Issue 7:1 No ratings yet.

A focused assessment with sonography in trauma (FAST) exam was performed initially to evaluate for intra-abdominal injury given the clinical picture. A phased-array ultrasound transducer was placed in sagittal orientation along the patient’s right and left flank, demonstrating extensive heterogenous fluid collections in Morrison’s pouch (red arrow), subphrenic space (solid green arrow), and splenorenal recess (dashed green arrow). To further evaluate, a phased-array transducer was placed over her pelvic area in transverse orientation, demonstrating, a large, heterogeneous mass (outlined in yellow arrows). The surgical team was promptly consulted and blood products were ordered. Although there was concern for impending hemorrhagic shock due to patient’s presenting tachycardia, the patient was hemodynamically stable enough for a CT scan of her chest, abdomen, and pelvis. The CT scan showed large-volume ascites, which exerted mass effect on all abdominal organs with centralization of bowel loops. Additionally, there was a large, 6.4 x 6.8 x 10.9-centimeter, midline pelvic mass (outlined in blue arrows).

Ob/Gyn Visual EM

A Case Report of Aortic Dissection Involving the Aortic Root, Left Common Carotid Artery, and Iliac Arteries

Miguel Angel Martinez-Romo MD^* and Christopher Eric McCoy MD^*

DOI: https://doi.org/10.21980/J8V93K Issue 7:1 No ratings yet.

Computed tomography angiography (CTA) of the thoracic and abdominal aorta revealed an aortic dissection of the ascending aorta, with a dissection flap starting from the aortic root/aortic annulus (yellow arrows), extending into the aortic arch (light blue arrowhead) and involving the left common carotid artery (purple arrow), left subclavian artery (pink arrow), extending to the descending aorta (red arrows), and into the bilateral iliacs (green arrows). The true lumen (red star) and false lumen (blue star) created by the dissection flap can best be seen in the axial views.

Cardiology/Vascular Visual EM

A Case Report of Epiglottitis in an Adult Patient

Savannah Tan, BS^*, Kyle Dornhofer, MD^*, Allen Yang, MD^*, Shadi Lahham, MD, MS^* and Lindsey C Spiegelman, MD^*

DOI: https://doi.org/10.21980/J8QM09 Issue 7:1 No ratings yet.

At the time of presentation to the ED, laboratory results were significant for leukocytosis to 11.8 x 109 white blood cells/L and a partial pressure of carbon dioxide of 52 mmHg on venous blood gas. Computed tomography (CT) of the soft tissue of the neck with contrast showed edematous swelling of the epiglottis and aryepiglottic fold with internal foci of gas (blue arrow) and partial effacement of the laryngopharyngeal airway and scattered cervical lymph nodes bilaterally (Figure 1). Findings were consistent with epiglottitis containing nonspecific air. Additionally, the pathognomonic “thumbprint sign” (yellow arrow) was found on lateral x-ray of the neck (Figure 2). The CT findings as shown in figure 3 illustrate lateral view of the swelling of the epiglottis, gas, and blockage of the airway.

ENT Visual EM

An Atraumatic, Idiopathic Case Report of Intraperitoneal Bladder Dome Rupture

Kylie Prentice, BS^*, Alisa Wray, MD, MAEd^* and Danielle Matonis, MD^*

DOI: https://doi.org/10.21980/J85S83 Issue 6:4 No ratings yet.

On regular CT scan imaging, the urinary bladder is partially distended with contrast with no focal wall thickening or intraluminal hematoma. There is an intraperitoneal bladder rupture with site of rupture likely at the dome of the bladder. The bladder is outlined in red, and the bladder rupture boundaries are outlined in yellow, showing the urine as free fluid escaping into the intraperitoneal space. We also provide these findings in an axial CT in video format. On CT cystography, there is a significant amount of contrast-enhanced urine noted within the visualized peritoneal spaces. The small amount of air present anteriorly is related to the catheterization because a Foley balloon is present within the bladder. These findings are annotated with the peritoneal spaces outlined in yellow, the air in the blue outline, and the bladder in the red outline. All of these CT cystography findings are also presented in an axial view in video format.

Urology Visual EM

Case Report of an Empyema Identified on Lung Ultrasound

Michelle Brown, DO^*, Carly Heffernan, BS^* and Alisa Wray, MD, MAEd^*

DOI: https://doi.org/10.21980/J8SH2N Issue 6:4 No ratings yet.

Using a curvilinear ultrasound probe, images of the patient were obtained from the left mix-axillary line. These images demonstrate a loculated left-sided pleural effusion (outlined in the attached ultrasound image in blue) that was moderate in size, concerning for an empyema. The diaphragm on the right (red) of the image outlines the inferior margin of the collection of pus, which is seen in the inferior aspect of the left lung. Unfortunately, rib shadows on the left side of the image prevent the full empyema from being captured in this single image. As a result of the bedside ultrasound, however, the patient was rapidly diagnosed with an empyema and was initiated on antibiotics, which is further discussed below. After his bedside ultrasound was completed, his chest x-ray revealed the expected left-sided pleural effusion. Additionally, a CT angiogram of the chest was ordered to rule out a pulmonary embolism, which was negative for an embolism but does redemonstrate the left-sided loculated pleural effusion (outlined on the CT axial and coronal images in blue).

Respiratory Visual EM

A Case Report of Neonatal Vomiting due to Adrenal Hemorrhage, Abscess and Pseudohypoaldosteronism

Raymen Rammy Assaf, MD, MPH^* and Mary Jane Piroutek, MD^{^}

DOI: https://doi.org/10.21980/J8QQ0B Issue 6:3 No ratings yet.

An ultrasound (US) of the abdomen was obtained to evaluate for possible pyloric stenosis (see US transverse/dopper imaging). While imaging showed a normal pyloric channel, it revealed an unexpected finding: a complex cystic mass arising from the right adrenal gland (yellow outline), measuring 5.8 by 4.0 by 6.4 cm with calcifications peripherally and mass effect on the kidney without evidence of vascular flow (blue arrow). Computed tomography (CT) of the abdomen/pelvis with IV contrast was subsequently obtained and measured the lesion as 2.8 by 4.6 by 4 cm without evidence of additional masses, lymphadenopathy or left adrenal gland abnormality (see CT axial, coronal, and sagittal imaging).

Endocrine Visual EM

Case Report of Unusual Facial Swelling in an 8-Month-Old

Amanda E Mulcrone, MD^*, Zobiya Z Momin, MD^{^} and Corrie E Chumpitazi, MD, MS^*

DOI: https://doi.org/10.21980/J8M06F Issue 6:3 No ratings yet.

Facial ultrasound revealed local inflammatory changes such as increased echogenicity and heterogeneity in the soft tissues of the right cheek, suggestive of soft tissue edema. There was evidence of a prominent right parotid gland with increased heterogeneity suggestive of a traumatic injury. Additionally, facial ultrasound demonstrated a 6mm ill-defined anechoic collection within the right cheek without increased doppler flow (green arrow), thought to represent a focal area of edema instead of an abscess.

Pediatrics Renal/Electrolytes Visual EM

Case Report: Thoracic Aortic Dissection in a Previously Healthy Male with an Unusual Inciting Factor

Peter L Vuong, DO^*, Edward J Durant, MD^*, and Christopher B Branham, DO^*

DOI: https://doi.org/10.21980/J8G92S Issue 6:3 No ratings yet.

A non-contrast computed tomography (CT) scan was negative for a suspected ureteral stone. However, there were aortic calcifications visualized at the infrarenal level that were notable given the patient’s age (red arrow). Given this finding in conjunction with the patient’s symptoms, bedside transabdominal ultrasonography was performed which revealed an intraluminal echogenic flap within the aorta near the common iliac arteries. CT angiography (CTA) with delayed contrast protocol revealed an extensive Stanford type A aortic dissection with involvement of the aortic root (purple arrow), brachiocephalic trunk, ostia of the left subclavian artery, descending aorta (blue arrow), bilateral common iliac arteries, and left internal iliac artery.

Cardiology/Vascular Visual EM