CARDIAC RADIOLOGY

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crapeanglr
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13890
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CARDIAC RADIOLOGY
Updated:
2010-04-12 13:27:48
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cardiac heart imaging radiology
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Cardiac imaging differentials and pearls for the oral radiology boards
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  1. DDx: contour abnormality in the upper mediastinum at the level of the aortic arch on chest film
    • "3 Sign" = knob above aorta and aorta
    • Reverse 3 is made on frontal view during barium esophagram because of mass effect on the esophagus

    • Nonvascular
    • -lymphadenopathy,
    • -abscess,
    • -mesenchymal tumor,
    • -neurofibroma
    • Vascular–aneurysm/ pseudoaneurysm,
    • -coarctation of aorta (rib notching),
    • -pseudocoarctation of aorta (no rib notching, not real stenosis; only a kink of the aorta)
  2. Don't see any findings on chest radiograph???
    • RIBS - notching (aortic coarctation) and posterior fractures (child abuse / NAT)
    • TRACHEA - deviation, etc
  3. DDx: Normal pulmonary blood flow on chest film with cardiac problems
    Think "AORTIC / AV PROBLEMS"

    • •Coarctation of Aorta
    • •Pseudocoarctation of Aorta
    • •Aortic valve disease
  4. 50-80% of people with coarctation / pseudocoarctation also have:
    Bicuspid aortic valve
  5. People with bicupsid aortic valve are at increased risk for ____?
    Aortic dissection
  6. Calcification on plain film of the a cardiac valve is diagnostic of:
    Stenosis
  7. DDx: Dilated Ascending Aorta
    4 A's and a D

    • Aortic valve disease (AS > AI) - (including Bicuspid aortopathy - 50-80% of people have coarctation)
    • Atherosclerotic aneurysm
    • Annuloaortic ectasia: Marfan’s
    • Aortitis (syphilis, Takayasu’s)
    • Dissection (rapid Δ)
  8. DDx: Increased blood flow on chest film WITHOUT cyanosis
    • PAPVR - LA NOT enlarged
    • and
    • Left to right shunts
    • -Atrial septal defect - LA NOT enlarged
    • –Ventricular septal defect - LA is enlarged
    • –Patent ductus arteriosus - LA is enlarged
    • –Atrioventricular septal defect (AVSD endocardial cushion defect)
  9. 3 Types of atrial septal defects
    • Primum - seen in endocardial cushion defect, basically with AVSD, rare
    • Secundum - most common, mid ASD
    • Sinus venosus - high ASD near SVC entry; assoc with PAPVR
  10. Pulmonary veins drain into SVC
    Partial Anamolous Pulmonary Venous Return
  11. RV, LA, LV enlargement, acyanosis, increased blood flow
    VSD
  12. Global chamber enlargement R>L, acyanotic with increased pulm flow
    AVSD
  13. Pure left sided cardiac enlargement with increased blood flow on chest film
    Patent Ductus Areteriosis
  14. DDx: Increased pulmonary blood flow with cyanosis
    "5 T's"

    • Transposition
    • TAPVR w/o obstruction
    • Truncus
    • Tricuspid Atresia
    • "Tingle" Single Left Ventricle - Hypoplastic Left Heart
  15. "Egg on a String" chest film with cyanosis and increased blood flow, cyanosis
    D-Loop Transposition of the Great Vessels

    Superior mediastinum narrowed due to aorta anterior to PA and thymic involution
  16. Snowman appearance of the mediastinum on chest film in a cyanotic kid with increased blood flow
    TAPVR - Total Anomalous Pulmonary Venous Return
  17. Pure right sided enlargement on a chest film with increased pulm. blood flow
    • •If acyanotic:
    • -ASD
    • -PAPVR (look for abnormal vein)
    • •If cyanotic:
    • -TAPVR w/o obstruct (snowman)
    • -D-loop TGA (egg-on-a-string)
  18. Increased Blood flow with prominent right mediastinum "truncal arch" on chest film
    Truncus arteriosis - aorta and PA arise off of same vessel

    Always have VSD
  19. Boot shaped heart with decreased blood flow
    Tetralogy of Fallot

    Upturned cardiac apex on chest film

    • 1. VSD
    • 2. Overriding aortic arch
    • 3. Pulmonary stenosis
    • 4. RVH
  20. Congenital causes of decreased blood flow on chest film
    • •Tetralogy of Fallot
    • •Ebstein’s anomaly
    • •Pulmonary atresia w/ intact ventricular septum and TR
  21. Decreased blood flow with narrow upper mediastinum and cardiomegaly
    Ebstein's Anomaly
  22. Cyanotic newborn with decreased blood flow and massive cardiomegaly
    Ebstein's (newborn to adult) versus Pulmonary Atresia w/ Intact Septum and Incompetent TV (newborn only)
  23. Acquired causes of decreased blood flow with right heart enlargement on chest film
    • •Tricuspid Insufficiency–with RV failure - (Think endocarditis because of IV drug abuse)
    • •Carcinoid heart syndrome - TR and PS
  24. Cyanotic newborn with diffuse edema
    • •TAPVR with obstruction - normal size heart - confluence of pulmonary vessels drain into portal circulation (high resistance circuit)
    • •Hypoplastic left heart - big right heart
  25. Acyanotic newborn with edema on chest film
    • •Noncardiogenic causes of edema–sepsis, transient tachypnea, lymphangiectasia, etc…
    • •Systemic AV fistula: LV failure–vein of Galen, hepatic hemangioendothelioma
    • •Left sided obstruction
    • •In uterine myocarditis (TORCH infections)

    • If > 6 weeks add,
    • •Myocardial abnormalities
    • •aberrant left coronary artery (ALCAPA)
    • •glycogen storage disease
    • •Large L →R shunt
  26. Cardiogenic edema in older kids and adults
    "LAMP"

    • LV failure: ischemic, nonischemic
    • •(Atrial fibrillation / arrhythmias)
    • Mitral valve disease / obstruction
    • Pulmonary venous obstruction
  27. Edema or redistribution of flow on chest radiograph with normal LV, but LAE, RVE
    Mitral stenosis

    (Most common cause rheumatic heart disease) - Look for Ca2+ near mitral valve
  28. Causes of Mitral Insufficiency
    • •Mitral valve prolapse
    • •Rheumatic heart disease
    • •Ruptured chordae (MI, trauma)
    • •Dilated left ventricle
  29. Increased size of LA appendage
    Think mitral valve disease
  30. Causes of centralized increased in pulmonary blood flow (pulmonary HTN)
    • Chronic PE
    • COPD, lung disease
    • L →R shunt
    • Primary PAH
    • Chronic LVF
    • Mitral stenosis
  31. Lateralized blood flow on chest radiograph
    • •Acquired:
    • –Lobar collapse
    • –Swyer-James
    • –Stenosis of PA
    • –(Unilateral lung transplant)
    • •Congenital:
    • –Hypoplastic PA - smaller left hemithorax, insult after lung began to form
    • –Scimitar syndrome - smaller hemithorax usually with tubular structure (PV draining to IVC)
    • –Pulmonary valve stenosis - unilateral hilar enlargement (big main and left PA)
  32. DDx: right paratracheal opacity
    • •Nonvascular
    • –bronchogenic cyst
    • –lymphadenopathy
    • –mesenchymal tumor, etc
    • •Vascular
    • –aneurysm / pseudoaneurysm
    • –aortic arch anomaly (right aortic arch, etc.)
  33. Two types of right aortic arches
    • 1. Mirror image (normal lateral view, 95% association with CHD)
    • 2. Right aortic arch with abberant left subclavian (abnormal lateral view with some tracheal bowing, only 5% association with CHD)
  34. Situs inversus totalis with bronchiectasis on chest radiograph
    Kartagener's syndrome (also assoc with sinusitis)
  35. Left aortic arch and cardiac apex with right stomach bubble
    Situs ambiguous

    • Worry about polysplenia / asplenia (won't see asplenia because they die due to encapsulated organism infection)
    • Absent IVC with azygous continuation
  36. DDx: Globular enlargement of the cardiac silhouette
    • Myocardial:
    • -Dilated / ischemic cardiomyopathy
    • -Multivalvular dz--* rheumatic
    • -Ebstein’s (Rt; decreased flow)
    • Pericardial:
    • -Pericardial effusion (water bottle on frontal view and fat stripe sign on lateral view)
  37. Non-valvular cardiac calcifications: pericardial versus myocardial ?
    • Myocardial - usually involve LV apex and set back from the sternum (? prior infarct)
    • Pericardial - over RV, spares apex and abuts sternum (infection, uremia, XRT)
  38. Distal clavicular resorption, pericardial calcifications, rugger jersey spine
    Uremia
  39. Chest radiograph - Heart shifted to left, but upper mediastinum not shifted
    Congenital absence of the pericardium (heart not tethered to sternum, will droop posteriorly on supine CT)
  40. Enhancement patterns on delayed post-gadolinium images of the heart on MR
    • Myocardial infarction (Always involves subendocardium and then extends transmural)
    • Myocarditis (no focal subendocardial involvement)
    • - mid-myocardial = Myocarditis, Hypertrophic cardiomyopathy, Sarcoidosis
    • - epidardial = Sarcoidosis, Myocarditis
    • - circumferential diffuse subendocardial = Amyloid, sometimes post-transplant
  41. LV Failure - Ischemic vs Non-ischemic
    • Ischemic = revasc. will help if >50% of wall is viable
    • -RV not involved
    • -Focal wall thinning
    • -MR enhancment = subendocardial, transmural
    • Non-ischemic
    • -RV involved
    • -Uniform wall
    • -No enhancement
  42. LV aneurysm vs pseudoaneurysm
    • Aneurysm
    • -Prior MI
    • -Occur at apex
    • -Dyskinetic, wide neck, will calcify
    • -Stasis of flow increases risk of thrombus need anticoagulation
    • Psuedoaneurysm
    • -Prior MI vs trauma
    • -Occur inferior posterior wall
    • -Narrow neck
    • -Hole in heart contained only by thrombus, require surgery due to risk of rupture
  43. Bi-atrial enlargement with normal sized ventricles
    • Diastolic dysfunction
    • Restrictive vs Constrictive
    • •Clinically indistinguishable
    • •Both: non-compliant ventricles
    • Restrictive: progressive, fatal (amyloid)
    • Constrictive: cured surgically (calicifcation - usually cured by stripping)
  44. Restrictive vs Constrictive diastolic dysfunction
    BOTH: Bi-atrial enlargement with normal sized ventricles

    • Distinguished on MR =
    • Restrictive: LVH with abnormal enhancment (i.e. Amyloid)
    • Constrictive: Normal thickness and enhancment
  45. Causes of sudden cardiac death
    • Familial hypercholesterolemia
    • Aortic dissection
    • Anomalous coronary course
    • Cardiac sarcoid - arrhythmia, defib placed
    • Arrhythmogenic RV dysplasia - fibrofatty replacement best eval on MR, wall thinning and dyskinesis, RV enlargement, genetic, defib placed
    • Hypertrophic cardiomyopathy - no cause, genetic, arrhythmia - defib placed, LVOT obstr. from bulky septum - can have surgery to debulk
  46. Wall thickness to call hypertrophic cardiomyopathy
    >1.2-1.5cm

    • Septal location - in western world - must evaluate for LVOT obstruction - may see jet below aortic valve on MR, SAM (systolic anterior motion of the mitral valve leaflet)
    • Apical location - in Asia
  47. What is a "malignant" coronary artery anomaly?
    • When the coronary artery anomaly tracks between the aorta and PA, it can become compressed during states of high output leading to sudden death.
    • Treated surgically.

    Retroaortic and prepulmonic forms are benign anomalies and are incidental.
  48. Cutoffs when evaluating coronary CTA for stenosis
    (Always evaluate MIPs and cross sections of vessels)

    • < 50 % not hemodynamically significant - medical managment with statin to prevent rupture, etc
    • 50-75% go to stress test
    • >75% stenosis or occlusion with expansion (MI) go to cath
  49. DDx: coronary artery enlargement
    • •Aneurysm - >1.5 x normal (West - atherosclerosis, East - Kawasaki's)
    • •Pseudoaneurysm
    • •Fistula - to lower resistance to CS, chamber, MPA
    • •Dissection - mild ↑size
  50. Narrowed vessel diving into myocardium on CTA
    • Myocardial bridging
    • - normal vessels should always be surrounded by fat
    • - should do stress test to assess for ischemia
  51. Cardiac mass differential
    • Benign:
    • -thrombus - no enhancement, MC mass, atrial-usually from afib, ventricular - usually from aneurysm
    • -myxoma - MC benign neoplasm, left atrium, penduculated, stalk arises from IAS and can go through MV, variable enhance
    • -lipomatous hypertrophy IAS - signal follows fat on MR, doesn't involve fossa ovale like myxoma does, occ caval obst arryth
    • Malignant:
    • -mets - sessile, enhances, MC than primary malig
    • -primary sarcoma - usually in right atrium
  52. Hematogenous mets to heart
    • Lung,
    • Breast,
    • Lymphoma,
    • Melanoma
  53. Measurement to call pericardial effusion
    > 3mm of fluid
  54. Differential for enhancing pericardial effusion
    • -Infection (TB)
    • -Malignancy (Met vs Mesothelioma) - can be nodular
  55. If pacer lead or line seen left of the aorta
    Left SVC most likely
  56. Best indicator for sternal dehiscence
    Wire shift
  57. DDx: Right cardiophrenic angle mass
    • Pericardial cyst
    • Prominent fat pad
    • Lymphadenopathy
    • Solitary fibrous tumor
    • Loculated effusion
    • Morgagni hernia
  58. MR shows
    Tethered tricuspid valve
    Right cardiomegaly with hypokinetic RV
    Ebstein's Anomaly
  59. Big main and left PA
    RVH
    Lateralized blood flow pattern
    Pulmonic Valve Stenosis
  60. DDx: Left hilar enlargement:
    • -left hilar mass (?↑main PA)
    • -massive left PE (should be peripherally oligemic)
    • -valvular pulmonic stenosis
    • -small R hilum, redirect flow
  61. DDx: Small right hilum w / shift to R
    • -lobar collapse
    • -hypoplastic R PA
    • -scimitar syndrome
  62. DDx: Linear filling defect in left atrium with no turbulent flow around linear defect
    • Cor triatriatum
    • vs
    • Thrombus
  63. Multiple pulmonary emboli
    Right heart enlargement
    Straightening / convexity towards left of IV septum
    Pulmonary emboli with right heart strain

    Right heart strain changes management and lytics are used
  64. Left cardiac apex and aortic arch, right stomach bubble
    • Situs ambiguous
    • Polysplenia (die young if asplenic)
    • Interruption of IVC with azygous continuation
  65. VIEW?
    2 chamber view of the heart
  66. VIEW?
    3 Chamber view of the heart
  67. VIEW?
    4 Chamber view of the heart
  68. VIEW?
    Short axis view of the heart

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