Medical Image of the Month: Double Aortic Arch

Figure 1. A chest radiograph performed after endotracheal intubation of the patient demonstrated prominence of the upper mediastinum in the region of the right paratracheal strip (red arrow).

Figure 2. A non-contrasted CT of the chest demonstrates a complete vascular ring secondary to the patient’s double aortic arch (outlined in red) surrounding the trachea (T) and esophagus (E).

Case Presentation: A 78-year-old gentleman presented to the hospital via EMS with altered mental status. An urgent CT of the head performed in the emergency room demonstrated a large, right intraparenchymal hemorrhage with intraventricular extension into the right lateral ventricle. His Glascow Coma Scale score was 6, and he was intubated for airway protection.  A chest radiograph performed to verify placement of the endotracheal tube demonstrated prominence of the upper mediastinum in the region of the right paratracheal strip (Figure 1). A CT of the chest (Figure 2) demonstrated a double aortic arch corresponding to the upper mediastinal abnormality noted on the chest radiograph. In speaking with the patient’s family after acquiring the CT of the chest, they stated that the patient had long-term issues with dysphagia – specifically choking with solid foods. Unfortunately, the patient passed away from complications of his large intraparenchymal hemorrhage.

A double aortic arch results from persistence of both the right and left embryonic arches with each arch giving rise to the ipsilateral, separate carotid and subclavian arteries (1). A double aortic arch is the most common cause of a symptomatic vascular ring with the trachea and esophagus being compressed by the two arches (1). Symptoms usually arise in childhood with good outcomes with surgical repair of this abnormality in pediatric populations. A few case series exist describing repair of this anomaly in adult populations (2).

Kelly Wickstrom DO, Steven P. Sears DO, and Laura Meinke MD

Division of Pulmonary, Critical Care, Allergy and Sleep Medicine

University of Arizona College of Medicine

Tucson, AZ USA

References

1. Hanneman K, Newman B, Chan F. Congenital variants and anomalies of the aortic arch. Radiographics. 2017 Jan-Feb;37(1):32-51. [CrossRef] [PubMed]
2. Noguchi K, Hori D, Nomura Y, Tanaka H. Double aortic arch in an adult. Interact Cardiovasc Thorac Surg. 2012 Jun;14(6):900-2. [CrossRef] [PubMed]

Cite as: Wickstrom K, Sears SP, Meinke L. Medical image of the month: Double aortic arch. Southwest J Pulm Crit Care. 2019;18(5):120-1. doi: https://doi.org/10.13175/swjpcc019-19 PDF 

May 2019 Imaging Case of the Month: Asymptomatic Pulmonary Nodules and Cysts in a 47-Year-Old Woman

Michael B. Gotway, MD

Department of Radiology

Mayo Clinic Arizona

Scottsdale, AZ USA

Clinical History: A 47-year-old previously healthy woman presented to her new physician for a routine physical examination. The patient had no complaints. The patient’s physical examination showed normal vital signs and clear lungs; the physical examination was essentially unremarkable. The patient’s past medical history included a brief smoking history, having quit over 20 years earlier, as well as seasonal allergies. Her past surgical history included an appendectomy nearly 20 years earlier and a hysterectomy for bleeding related to uterine leiomyomas approximately 12 years prior to presentation. The patient was not taking any prescription medications.

Basic laboratory data, including a complete blood count, electrolyte panel, and liver function studies were all within the normal range. An electrocardiogram revealed normal findings. Frontal and lateral chest radiography (Figure 1) was performed.

Figure 1. Frontal (A) and lateral (B) chest radiography.

Which of the following statements regarding the chest radiograph is most accurate? (click on the correct answer to be directed to the second of eleven pages)

1. The chest radiograph shows mediastinal and hilar lymph node enlargement
2. The chest radiograph shows multifocal nodular pulmonary consolidation
3. The chest radiograph shows multiple, bilateral cavitary nodules
4. The chest radiograph shows multiple, bilateral circumscribed nodules
5. The chest radiograph shows nodular interstitial thickening

Cite as: Gotway MB. May 2019 imaging case of the month: Asymptomatic pulmonary nodules and cysts in a 47-year-old woman. Southwest J Pulm Crit Care. 2019;18(5):106-19. doi: https://doi.org/10.13175/swjpcc022-19 PDF