Archive | September, 2013

Massive cardiomegally…

September 30, 2013

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Patient with acromegally has this xray:

Massive cardiomegally 1 Massive cardiomegally 2 Massive cardiomegally 3

These images show some serious cardiomegally.  He incidentally has what appear to be retained metallic fragments that look suspicious for bullets.  Apparently his estimated cardiac “girth” is 2 liters!

Author:  Russell Jones, MD

Image Contributor:  Jay Williams, MD

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ROCKIN!

September 26, 2013

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A patient told me the other day that he swallowed a rock.  He had a psych history and we initially didn’t believe him.  However…

Rockin! 1 Rockin! 2

This acute abdominal series shows a radioopaque object strikingly similar to a rock in the right lower quadrant with obstructive changes (dilitation and air-fluid levels) of the small bowel.  Our fellow surgeon colleagues found a rock at the illeocecal junction when they opened him up!

Author:  Russell Jones, MD

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WWWTP #10 Answer…

September 22, 2013

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This patient came in with trauma to the face after an altercation, here was his head CT:

WWWTP 10

The patient’s left eye is somewhat proptotic in comparison to the right and he has high density fluid consistent with blood in the retrobulbar space.  This is a retrobulbar hemorrhage.  Turns out clinically he had a proptotic eye, intraocular pressures were 27 and he was having difficulty seeing.  After a lateral canthotomy and cantholysis his vision returned, his pressures dropped to the low 20s.  Here is the rest of his CT imaging:

WWWTP 10.1 WWWTP 10.2 WWWTP 10.3

What is even more interesting about this patient is that he had a inferior orbital wall blowout fracture.  The retrobulbar space should be communicating with the maxillary sinus (as you can see there is a lot of blood in the sinus as well) and orbital compartment syndrome usually doesn’t occur with these type of fractures. 

Image Contributor:  Nathan Parker, MD

Author:  Russell Jones, MD

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What’s Wrong With This Picture #10

September 18, 2013

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This person came in after an altercation.  What is wrong with this CT head:

WWWTP 10

Image Contributor:  Nathan Parker, MD

Author:  Russell Jones, MD

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Big stone…

September 14, 2013

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Middle-aged male came in with left flank pain…

Staghorn Calculi 1 Staghorn Calculi 2

This patient has a large staghorn calculi with stranding around the area of the expected renal calyx.  This is highly suspect for a calyceal rupture.

This is an excerpt taken from the American Urological Association’s 2005 guidelines on the management of staghorn calculi:

Staghorn calculi are branched stones that occupy a large portion of the collecting system. Typically, they fill the renal pelvis and branch into several or all of the calices. The term “partial staghorn” calculus designates a branched stone that occupies part but not all of the collecting system while “complete staghorn” calculus refers to a stone that occupies virtually the entire collecting system. Unfortunately, there is no consensus regarding the precise definition of staghorn calculus, such as the number of involved calices required to qualify for a staghorn designation; consequently, the term “staghorn” often is used to refer to any branched stone occupying more than one portion of the collecting system, ie, renal pelvis with one or more caliceal extensions. Furthermore, the designation of “partial” or “complete” staghorn calculus does not imply any specific volume criteria.

The guidelines can be found here:

AUA REPORT ON THE MANAGEMENT OF STAGHORN CALCULI (2005)

Although all types of stones can grow to staghorn calculi, most are composed of struvite and/or calcium carbonate apatite.  These stones have a strong association with urinary tract infection from organisms that produce urease.  These stones are often causative agents in calyceal rupture, as in the patient above.  Management is dependent on the patient’s symptoms, signs of urosepsis, and multiple other cofactors.  Per the report above, percutaneous nephrolithotomy is the first-line procedure of choice for most patients.  Sometimes shock-wave lithotripsy is required as well as percutaneous nephroscopy.  Please refer to the above guidelines for more information if desired.

Author:  Russell Jones, MD

References:

1.  Preminger GM, et al.  AUA Report on the management of staghorn calculi.  2005.  http://www.auanet.org/education/guidelines/staghorn-calculi.cfm.  Accessed 9/2013.

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Is the shunt series a dinosaur?

September 10, 2013

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When a patient with a ventricular shunt presents to the ED, many times we will obtain a “shunt series.”  What is a “shunt series?”  Here is an example:
Shunt 1Shunt Series 2 Shunt series 3

The top image shows a lateral cranial view demonstrating the intracranial portion of the shunt (#1), the shunt reservoir and valve (#2), and a portion of the extracranial portion of the shunt catheter coursing down the lateral portion of the head.  The second image is an AP cranial radiograph.  This is another view of the shunt with the advantage of better imaging of the lateral extracranial catheter coursing down the neck and upper chest.  The third image is an AP abdomen which shows the rest of the catheter’s course into the abdomen.

How are these used?  Shunt series are used to look for kinks and breaks in the course of the catheter, most often the extracranial portion.

There is controversy whether we should use our time, expense, as well as the radiation to obtain shunt series.  Their yield is very low and CT imaging of the head or nuclear medicine shuntograms are much better at detecting shunt failure.  One series of 263 patients showed that less than 1% of shunt revisions were based on the findings on the shunt series (1).  Another study in 2011 demonstrated a lack of statistical significance in shunt series and surgical revision.  CT and nuclear medicine imaging, on the other hand, showed statistical correlation with shunt revision (2).

Kinda begs the question:  should we be obtaining shunt series at all?

References

1.  Griffey RT, Ledbetter S, Korasani R.  Yield and utility of radiographic “shunt series” in the evaluation of ventricle-peritoneal shunt malfunction in adult emergency patients. Emerg Radiol 2007; 13 (6): 307-11.

2.  Lehnert BE, et al.  Detection of ventricular shunt malfunction in the ED:  relative utility of radiography, CT, and nuclear imaging.  Emerg Radiol 2011; 18 (4): 299-305.

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20 year old male with wheezing…

September 6, 2013

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20 year old male presents with neck fullness and wheezing.  Had the sensation of “fullness” for about a year, worsening significantly over the past week.  Now he complains primarily of trouble swallowing and wheezing.

On exam the patient has a definite right sided neck mass, minimally mobile but unclear if associated with the thyroid.  Lungs with a biphasic wheeze and sats low 90s.  Positive Pemberton’s sign with facial plethora and JVD when he raised his arms above his head.  Here is his neck CT with IV contrast:

CT scout goiter CT goiter 1 CT goiter 2

The CT revealed a 4.9 x 4.2cm multi cystic mass occupying the right lobe of the thyroid with some tracheal compression.  TSH <0.02.  The patient was admitted and approximately 45ml of fluid was drained from his cystic lesion with significant improvement in his symptoms initially, although this fluid recurred over the subsequent month.  He is currently being worked up for thyroid pathology and may undergo a hemithyroidectomy in the near future.
On a side note, here is a NEJM article discussing “Pemberton’s Sign”:
Of note, there is some controversy surrounding the use of iodinated contrast in patient’s with suspected thyroid masses.  This iodine bolus may interfere with a subsequent radioiodine scan, and theoretically may delay a patient’s therapy with radioactive iodine, if ultimately indicated.
Image Contributor:  Aaron Hougham, MD

Author:  Aaron Hougham, MD

References

1.  Basaria S, Salvatori R.  Pemberton’s Sign.  N Engl J Med 2004; 350: 1338.

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Screw loose…

September 2, 2013

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Screw loosening 1 Screw loosening 2

This is an ankle XR demonstrating radiographic signs of hardware loosening.  The first XR is from several years ago, shortly after hardware placement.  The second XR is recent and it shows a radiolucent rim around the distal tibia screw.  This can be a sign that the screw is loosening in the bone and may fail. 

Author:  Russell Jones, MD

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