Archive | April, 2014

Tearing abdominal pain…

April 24, 2014

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This is a 60 year old male who presented with tearing abdominal pain…

SMA dissection 1

This CT angiogram of the abdomen shows a superior mesenteric artery dissection.  The aorta was normal.  On the above CT image you can see a flap dissecting the SMA.

SMA dissection is a rare pathology in the abdomen.  It can lead to localized mesenteric ischemia and presents with severe abdominal pain.  It is treated various ways including medical management and observation, endovascular repair, or surgical revascularization (1).  Many times it is associated with aortic dissection with a dissection flap extending into the SMA.

Image contributor:  James Chenoweth, MD

Author:  Russell Jones, MD

References

1.  Gobble RM, Brill ER, Rockman CB et-al. Endovascular treatment of spontaneous dissections of the superior mesenteric artery. J. Vasc. Surg. 2009;50 (6): 1326-32.

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Further images of interesting central line complication…

April 19, 2014

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Last post was concerning an uncommon central line complication with the line passing into the mediastinum through the inferior brachiocephalic vein.  One astute observer asked for more information about the case, see the comments posted (very interesting fluoro experience with this type of  complication).  Here are some further images of the traversing the mediastinum very close to the aorta and the tip ends up near a pleural effusion on that side. 

Abberrent central line Aberrent Central line 1

Interestingly this patient had a vascular surgery consult.  The line actually passed through the IJ near the line insertion, tracked down the neck near the IJ and brachiocephalic,  and into the mediastinum.  The pleural effusion was from another process.  Fortunately the line was removed and no further problems were encountered. 

Unfortunately this was another team that placed the line so I don’t have information on the actual difficulty in placing the line, confirmation of venous flow once placed, etc. 

Thanks for the comments.

Author:  Russell Jones, MD

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Central line complication…

April 14, 2014

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Central line mishap 1

Central line mishap 2 Central line mishap 3 Central line mishap 4

Central lines are often necessary and performed quite frequently.  With frequent procedures sometimes we get comfortable performing them and we minimize possible dangers.  This case demonstrates, however, that there are real complications that can occur from our invasive procedures.  Thus it is important to weigh the risks and benefits.

This central line decided to go through the caudal portion of the brachiocephalic vein and into the mediastinum.  The first xray shows the end of the catheter kinked near the aortic root.  CT of the chest shows the distal tip of the catheter puncturing through the vein and into the mediastinum.  Obviously this is a very rare complication!

Image Contributor:  Aaron Hougham, MD

Author:  Russell Jones, MD

 

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Reasons not to try relocation of hips…

April 7, 2014

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Dislocated hip

On this pelvis Xray you can see two hip replacements, the left one is dislocated.  If you look closely you can also see a fracture line just superior to the prosthesis near the greater trochanter.  Be careful reducing these without obtaining orthopedics input. 

The other prosthesis is interesting.  It is a hip replacement with a constrained acetabular liner.  You can see a radioopaque ring around the femoral head component of the arthroplasty.  This is a ring that functions to hold the hip in place.  If this dislocates (not in this case), then this requires open surgical intervention for relocation.  Don’t try to put one of these back in!

Image Contributor:  Hollis “Tag” Hopkins, MD

Author:  Russell Jones, MD

References

1.  THR: Constrained Acetabular Liners.  http://www.wheelessonline.com/ortho/12698

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Multiple masses chest..

April 3, 2014

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Late 20s male presents with shortness of breath…

Chest masses Chest masses CT

This Xray and CT show a phenomena called “Cannonball Metastases.”  This refers to innumerable descreet masses in the chest.  Two tumors are highly suspected in this case: renal cell carcinoma and choriocarcinoma.   Others that have a higher prediliction to multiple lung mets are prostate, endometrial, and synovial sarcoma (1). 

This patient ended up having a choriocarcinoma of the testes. 

Image Contributors:  Kevin Murphy, MD and Mary Bing, MD

Author:  Russell Jones, MD

References:

1.  Knipe H, Bickle I, et al.  Cannonball Metastases. www.radiopaedia.org

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