Medical Image of the Week: Pulmonary Arteriovenous Malformations

Figure 1. Cardiac ultrasound showing right to left shunting.

Figure 2. Thoracic CT scan showing arteriovenous malformations (AVM's, arrows).

A 34 year old woman presented to the clinic with exertional dyspnea since childhood. Oxygen saturations in clinic were 92% on room air. On review of systems she admitted to recurrent epistaxis and her daughter also suffered from frequent epistaxis. Bubble contrast echocardiography showed severe right to left shunting without evidence of intracardiac shunt (Figure 1). Computed tomography angiogram of the chest revealed multiple bilateral arteriovenous malformations (AVM’s), the largest measuring 9mm on coronal images (Figure 2). MRI of the brain was negative for AVM’s. She was referred to interventional radiology for microcoil embolization. She met two of four Curaçao criteria for the diagnosis of hereditary hemorrhagic telangiectasia (HHT), giving her “possible HHT”. She was referred for genetic testing to confirm the diagnosis.

Chris Strawter MD and Laura Meinke MD

University of Arizona

Tucson, Arizona

References

1. Lacombe P, Lacout A, Marcy PY, et al. Diagnosis and treatment of pulmonary arteriovenous malformations in hereditary hemorrhagic telangiectasia: an overview. Diagn Interv Imaging. 2013;94:835-48. [CrossRef] [PubMed]
2. Gossage JR, Kanj G. Pulmonary arteriovenous malformations. A state of the art review. Am J Respir Crit Care Med. 1998;158:643-61. [CrossRef] [PubMed]
3. Faughnan ME, Palda VA, Garcia-Tsao G, et al. International guidelines for the diagnosis and management of hereditary haemorrhagic telangiectasia. J Med Genet. 2011;48:73-87. [CrossRef] [PubMed]

Reference as: Strawter C, Meinke L. Medical image of the week: pulmonary arteriovenous malformations. Southwest J Pulm Crit Care. 2014;9(4):238-9. doi: http://dx.doi.org/10.13175/swjpcc131-14 PDF 

Medical Image of the Week: Aortic Ring

Figure 1. Post-intubation chest radiograph showing a widened right paratracheal stripe (arrow).

A 78 year old man presented with altered mental status and was found to have an intraventricular hemorrhage. He was intubated for airway protection. On the post-intubation chest radiograph (Figure 1), the patient was noted to have a widening of the right paratracheal stripe.

A CT chest (Figure 2) was obtained to characterize this finding and revealed an aortic ring which encircles the trachea and esophagus.

Figure 2. Axial (Panel A) and coronal (Panel B) of thoracic CT soft tissue windows showing the aortic ring.

Vascular rings are uncommon congenital abnormalities, accounting for approximately 1% of congenital heart disease. Complete vascular rings can occur with a right aortic arch with a ligamentum arteriosum or with a double aortic arch, such as with our patient (1). This ring can cause airway compression, stridor, esophageal compression, or no symptoms at all. As the embryo develops, the left fourth pharyngeal arch normally persists to become the aortic arch while the right fourth pharyngeal arch regresses. If both fourth pharyngeal arches persist, a right aortic arch can form and surround the trachea and esophagus (2).

Candy Wong MD¹, Tammer Elaini MD², Soyoung Park MD², Scott Rosen MD², and Sai Parthasarathy MD¹

¹Division of Pulmonary, Allergy, Critical Care, and Sleep Medicine. Department of Medicine

²Department of Medicine

University of Arizona

Tucson, AZ

References

1. Turner A, Gavel G, Coutts J. Vascular rings-presentation, investigation and outcome. Eur J Pediatr. 2005;164(5):266-70. [CrossRef] [PubMed]
2. Vatish J, McCarthy R, Perris R. A double aortic arch presenting in the 7^th decade of life. J Surg Case Rep. 2013.(10):pii:rjt081. [CrossRef] [PubMed]

Reference as: Wong C, Elaini T, Park S, Rosen S, Parthasarathy S. Medical image of the week: aortic ring. Southwest J Pulm Crit Care. 2014;9(4):121-2. doi: http://dx.doi.org/10.13175/swjpcc130-14 PDF