Ather Anis

Enormous Right Atrial Hemangioma in an Asymptomatic Patient: A Case Report and Literature Review

We report the case of an enormous right atrial hemangioma in an asymptomatic 42‐year‐old woman. The diagnosis was made by echocardiogram after the patient was found to have an abnormal EKG during a routine medical exam. The hemangioma is the largest described in English literature. The tumor was surgically resected and the patient did well postoperatively. In this case report, we discuss the discovery of the tumor and treatment of our patient. A brief discussion of cardiac hemangiomas follows.

Aortic rupture: comparison of three imaging modalities.

We report a case of a 56-year-old man with traumatic aortic rupture (TAR) sustained in a motor vehicle accident diagnosed by helical computed tomography, aortography, and transesophageal echocardiography. A large majority of patients with TAR never make it to the hospital, and for those who do, a timely diagnosis is critical for survival. We discuss the merits and pitfalls of the three imaging modalities.

Radiological Reasoning: Pulmonary Embolism—Thinking Beyond the Clots

OBJECTIVE We discuss the CT findings in a case of pulmonary embolism complicated by paradoxical embolism in a patient with a patent foramen ovale and atrial septal aneurysm. CONCLUSION When confronted with a case of pulmonary embolism on CT, besides evaluating the extent of pulmonary artery occlusion, the radiologist should examine the cardiovascular system to identify any unsuspected underlying or associated conditions.

Renal cell carcinoma with extension to the heart

A 59-year-old woman with hypertension presented with right flank pain. Magnetic resonance imaging of the abdomen revealed a 9 cm × 8 cm right renal mass and a filling defect (tumour extension) in the inferior vena cava (IVC), with protrusion into the right atrium (Figure 1). Figure 1) Magnetic resonance imaging of the abdomen showing a 9 cm × 8 cm right renal mass and a filling defect (tumour extension) in the inferior vena cava (thin arrow) with protrusion into the right atrium (thick arrow) Transthoracic echocardiography showed a large mobile mass (Figure 2) protruding from the IVC into the right atrium. The patient underwent radical right nephrectomy and excision of the mass from the IVC and right atrium. Microscopic examination of the renal mass and its intracaval and intracardiac extension demonstrated renal cell carcinoma of clear cell type. The patient remained stable on follow-up examination. Figure 2) Transthoracic echocardiogram showing a large mobile mass (arrow) protruding from the inferior vena cava (IVC) into the right atrium. Ao Ascending aorta; RV Right ventricle Malignant renal tumours represent approximately 2% of all malignant neoplasms (1). Patients with renal cell carcinoma and extension into the atrium have a significantly worse prognosis than those with other levels of vena caval involvement (2). Echocardiography plays an important role in diagnosing tumour clot extension into the right heart through the IVC.

CT appearance of isolated dextroversion

We present the multidetector CT appearance of a case of isolated dextroversion. Dextroversion is a rare anomaly characterized by extreme right-sided rotation of the heart resulting in dextrocardia with the left ventricle anterior and to the left of the right ventricle. The diagnosis is easily made with ECG-gated multidetector CT.

LUPUS MYOCARDITIS TREATED WITH INTRAVENOUS IMMUNOGLOBULIN UNDER HEMODYNAMIC MONITORING

demonstrated reactive lymphadenopathy. It was complicated by transient post-procedural hypotension. Transthoracic echocardiography revealed pulmonary hypertension (right ventricular systolic pressure 69 mmHg), with right ventricular dysfunction, dilatation and hypertrophy. Chest CT scan with pulmonary embolism protocol showed no pulmonary emboli. Subsequently, paroxysmal nocturnal dyspnea, orthopnea and peripheral edema developed. She was a never smoker from Wisconsin, without occupational exposures, HIV risk factors or history of substance abuse. Examination showed respiratory distress, blood pressure 118/70 mmHg, heart rate 115 beats/min, 84% oxygen saturation on room air, elevated jugular venous pressure, crackles in the right lung base, accentuated P2, 2/6 systolic murmur and 1 pitting lower extremity edema bilaterally. The patient was hospitalized and bronchoscopy with transbronchial needle aspiration of subcarinal lymphadenopathy showed edematous mucosa but was otherwise non-diagnostic. Hypoxemia and hypotension during and following the bronchoscopy required ICU admission, mechanical ventilation and vasopressor support. Chest radiograph revealed pulmonary edema. Histoplasmosis titer by complement fixation was 1:8. Hemodynamic assessment disclosed: pulmonary artery pressure of 89/45 mmHg, wedge pressure of 38 mmHg, and cardiac index of 1.3 L/min/m2. Epoprostenol, nitric oxide and dobutamine were carefully administered, but ineffective. Transesophageal echocardiography and chest CT with contrast showed obstruction of the right inferior and left superior pulmonary veins, severe stenosis of the right superior and a patent left inferior pulmonary vein.(FIG.1C-E) Only the 90% stenosed right superior pulmonary vein was accessible to balloon angioplasty. Successful recanalization via right heart catheterization resulted in initial hemodynamic improvement but the patient continued to require vasopressors and died on the ninth hospital day. Autopsy confirmed severe pulmonary edema with venous infarcts and pulmonary venous obstruction caused by dense fibrosis consistent with fibrosing mediastinitis. Old necrotic granulomas with fungi consistent with Histoplasma (evaluated with silver stain) were also identified. (FIG.2A-C). DISCUSSIONS: In the US, most cases of fibrosing mediastinitis are attributed to histoplasmosis and considered to represent late complications in susceptible individuals[1,2]. In the absence of a tissue diagnosis, Histoplasmosis associated fibrosing mediastinitis is clinically diagnosed in patients presenting with slowly progressive invasion and/or compression of mediastinal structures by localized, almost universally calcified mediastinal mass lesions[1,2]. Diffuse non-calcified mediastinal infiltration is typically encountered in the less common idiopathic form of fibrosing mediastinitis which is associated with retroperitoneal fibrosis, orbital pseudotumor, Riedel’s thyroiditis and methysergide therapy[2]. Our case illustrates that Histoplasmosis associated fibrosing mediastinitis may present as rapidly progressive diffuse infiltration of the mediastinum compromising vital structures even in the absence of radiographic calcifications and convincing serologic evidence of Histoplasmosis. In the absence of effective medical therapy, percutaneous and surgical interventions to relieve mechanical obstructions remain the most beneficial interventions[2]. CONCLUSION: Current clinical criteria used to separate fibrosing mediastinitis associated with Histoplasmosis from idiopathic variants do not reliably distinguish between these entities.