February 2016 Imaging Case of the Month

Michael B. Gotway, MD

Department of Radiology

Mayo Clinic Arizona

Scottsdale, AZ

Imaging Case of the Month CME Information  

Members of the Arizona, New Mexico, Colorado and California Thoracic Societies and the Mayo Clinic are able to receive  0.25 AMA PRA Category 1 Credits™. Completion of an evaluation form is required to receive credit and a link is provided on the last panel of the activity.

0.25 AMA PRA Category 1 Credit(s)™

Estimated time to complete this activity: 0.25 hours

Lead Author(s): Michael B. Gotway, MD. All Faculty, CME Planning Committee Members, and the CME Office Reviewers have disclosed that they do not have any relevant financial relationships with commercial interests that would constitute a conflict of interest concerning this CME activity. 

Learning Objectives:
As a result of this activity I will be better able to:    

1. Correctly interpret and identify clinical practices supported by the highest quality available evidence.
2. Will be better able to establsh the optimal evaluation leading to a correct diagnosis for patients with pulmonary, critical care and sleep disorders.
3. Will improve the translation of the most current clinical information into the delivery of high quality care for patients.
4. Will integrate new treatment options in discussing available treatment alternatives for patients with pulmonary, critical care and sleep related disorders.

Learning Format: Case-based, interactive online course, including mandatory assessment questions (number of questions varies by case). Please also read the Technical Requirements.

CME Sponsor: University of Arizona College of Medicine at the Arizona Health Sciences Center.

Current Approval Period: January 1, 2015-December 31, 2016

Financial Support Received: None.

Clinical History: A 78 year-old woman presented to her physician for routine care. Her past medical history included hyperlipidemia, hypothyroidism, gout, hypertension, and arthritis.

Although she was asymptomatic, screening 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 proceed to the second of nine panels)

1. The frontal chest radiograph shows a poorly defined nodular opacity in the left upper lung
2. The frontal chest radiograph shows abnormal mediastinal contours
3. The frontal chest radiograph shows basal predominant fibrotic abnormalities
4. The frontal chest radiograph shows large lung volumes with a cystic appearance
5. The frontal chest radiograph shows no abnormal findings

Cite as: Gotway MB. February 2016 imaging case of the month. Southwest J Pulm Crit Care. 2016;12(2):48-58. doi: http://dx.doi.org/10.13175/swjpcc014-16 PDF

Medical Image of the Week: Atherosclerotic Aneurysm of Aortic Arch and Descending Thoracic Aorta

Figure 1.  Chest radiograph displays mild CHF, prominent vascular markings, and a large thoracic aneurysm.

Figure 2. Panel A: Computerized tomography angiography (CTA) with contrast displays an aneurysm of the aortic measuring 6.8 cm with eccentric thrombi. Panel B: CTA also shows an aneurysm of the descending aorta measuring 6 cm across with eccentric thrombi. Panel C: CTA demonstrates a tortuous descending aorta displayed by the curving of the descending aorta as it transitions to the abdominal aorta.

A 94-year-old Spanish-speaking woman presented to the hospital with intermittent episodes of dyspnea and abdominal pain for one week. Her past medical history was notable for 30 pack-year smoking history and hypertension, which was reportedly controlled with medical therapy.  Physical exam showed trace peripheral edema bilaterally, intact peripheral pulses, and a mild abdominal bruit. Work up at the emergency department revealed a non-ST elevation myocardial infarction with troponin T of 0.34 ng/mL but no ST-wave abnormality on electrocardiography. Chest x-ray displayed an incidental thoracic aneurysm (Figure 1). Chest computed tomography with contrast demonstrated a continuous aneurysm of the aortic arch and descending thoracic aorta with diameters measuring 6.8 cm and 6 cm, respectively (Figure 2A and 2B). Eccentric thrombi are noted in the aortic arch and the descending aorta. Interestingly, the distal descending thoracic aorta curves as it transitions to the abdominal aorta, which is evidence of a tortuous descending aorta (Figure 2C). The patient declined both invasive and non-invasive treatment and left the hospital against medical advice one day after admission.     

Melvin Parasram MS¹, Lea McKinnon MD², Iwan Nyotowidjojo MD³, and Kareem Ahmad MD⁴

¹Midwestern University: Arizona College of Osteopathic Medicine, Glendale, AZ USA

²Departments of Radiology, ³Internal Medicine and ⁴Pulmonary and Critical Care, Banner University Medical Center - Tucson, Tucson, AZ USA

Cite as: Parasram M, McKinnon L, Nyotowidjojo I, Ahmad K. Medical image of the week: atherosclerotic aneurysm of aortic arch and descending thoracic aorta. Southwest J Pulm Crit Care. 2016;12(2):46-7. doi: http://dx.doi.org/10.13175/swjpcc155-15 PDF