Bruce Maycher

Radiological imaging in pneumonia: recent innovations.

Purpose of review Pneumonia is one of the major infectious diseases responsible for significant morbidity and mortality throughout the world. Radiological imaging plays a prominent role in the evaluation and treatment of patients with pneumonia. This paper reviews recent innovations in the radiologic diagnosis and management of suspected pulmonary infections. Recent findings Chest radiography is the most commonly used imaging tool in pneumonias because of availability and an excellent cost–benefit ratio. Computed tomography is mandatory in unresolved cases or when complications of pneumonia are suspected. A specific radiologic pattern can suggest a diagnosis in many cases. Bacterial pneumonias are classified into four main groups: community-acquired, aspiration, healthcare-associated and hospital-acquired pneumonia. The radiographic patterns of community-acquired pneumonia may be variable and are often related to the causative agent. Aspiration pneumonia involves the lower lobes with bilateral multicentric opacities. The radiographic patterns of healthcare-associated and hospital-acquired pneumonia are variable, most commonly showing diffuse multifocal involvement and pleural effusion. Summary Combination of pattern recognition with knowledge of the clinical setting is the best approach to the radiologic interpretation of pneumonia. Radiological imaging will narrow the differential diagnosis of direct additional diagnostic measures and serve as an ideal tool for follow-up examinations.

Imaging techniques in chronic thromboembolic pulmonary hypertension.

Purpose of review Chronic thromboembolic pulmonary hypertension (CTEPH) can affect up to 4–5% of patients with acute pulmonary embolism. It is likely an underdiagnosed entity. Misdiagnosis is common because patients often present with nonspecific symptoms of pulmonary hypertension. Early diagnosis may help improve the outcome, as CTEPH is potentially curable with pulmonary thromboendarterectomy (PEA). Imaging is central to an accurate diagnosis, and for assessing correctly the technical feasibility of PEA. This review examines the findings of various imaging techniques in CTEPH and their contribution in the diagnostic and therapeutic evaluation of the disease. Recent findings Ventilation–perfusion scintigraphy remains a sensitive method for excluding CTEPH. Multidetector computed tomography angiography (MDCTA) depicts directly changes of CTEPH, provides a surgical ‘road map’, and should be used for the diagnostic assessment of all suitable patients with pulmonary arterial hypertension. In many centers, the role of conventional pulmonary angiography is gradually being replaced by cross-sectional methods. MRI has a role in preoperative and postoperative assessment of right ventricular function and can depict vascular abnormalities up to segmental level. Summary MDCTA in combination with MRI represent the main techniques for the diagnosis and management of CTEPH. Newer techniques such as dual spectrum computed tomography may further improve preoperative and postoperative assessment of CTEPH patients.

Comparative manifestations and diagnostic accuracy of high-resolution computed tomography in usual interstitial pneumonia and nonspecific interstitial pneumonia.

Purpose of reviewOf the idiopathic interstitial pneumonias, the differentiation between idiopathic pulmonary fibrosis (IPF) and nonspecific interstitial pneumonitis (NSIP) raises considerable diagnostic challenges, as their clinical presentations share many overlapping features. IPF is a fibrosing pneumonia of unknown cause, showing a histologic pattern of usual interstitial pneumonia (UIP), and has a poorer prognosis than does NSIP. This review examines whether the radiographic features of IFP and NSIP as assessed by high-resolution computed tomography (HRCT) can be used to distinguish between these two entities. Recent findingsThe diagnostic accuracy of HRCT for UIP and NSIP has been reported to be approximately 70% in various studies. Disagreement between the HRCT diagnosis and the histologic diagnosis occurs in approximately one-third of the cases. The predominant feature of honeycombing on HRCT yields a specificity of approximately 95% and sensitivity of approximately 40% for UIP. In contrast, a predominant feature of ground glass opacities (GGOs) gives a sensitivity of approximately 95% and specificity of approximately 40% for NSIP. SummaryThe finding of honeycombing as the predominant HRCT feature suggests the diagnosis of UIP and may exclude the need for biopsy. Predominant features of GGOs are not specific enough to distinguish between NSIP and UIP.

Mycotic pulmonary arterial aneurysms in an intravenous drug user

A case of mycotic pulmonary artery aneurysm (PAA) in an intravenous drug user in whom resolution occurred with conservative therapy is described. The natural history of PAA is not well described in the literature. Although PAA is potentially fatal, resolution may occur in patients who do not have hemoptysis. Clinical presentation, diagnosis and management of PAA are reviewed.

Is HRCT the best way to diagnose idiopathic interstitial fibrosis

Purpose of review High-resolution computed tomography (HRCT) has been the major advance in the diagnosis of idiopathic interstitial pneumonias in the last two decades. In diffuse lung diseases, HRCT now has a central role in routine diagnostic evaluation, and a major impact on the utility of other diagnostic tests, especially bronchoalveolar lavage and surgical lung biopsy. Recent findings Numerous published studies have evaluated the accuracy of HRCT. The clinical information was not always utilized to generate a noninvasive diagnosis, however. Despite failure to identify idiopathic pulmonary fibrosis on HRCT in a significant minority of cases, given compatible clinical data, characteristic HRCT appearances justify noninvasive diagnosis in most patients. The limitations of the published studies highlight importance of integrating HRCT data with baseline clinical information and, in selected cases, histopathologic findings. Summary When HRCT and clinical findings are both typical of an individual diffuse lung disease, i.e. ‘pathognomonic’, it is generally appropriate to institute management based on a confident noninvasive diagnosis. When clinical and HRCT data are divergent, or when HRCT features are ‘indeterminate’, however, histologic evaluation continues to play an essential role. Integration of histology with radiologic and clinical data is the best way to formulate the final diagnosis in these cases.

Multimodality Imaging of a Coronary Artery Fistula After Septal Myomectomy in Hypertrophic Cardiomyopathy

![Figure][1] ![Figure][1] [Video 1][2] Parasternal Long-Axis View on Transthoracic Echocardiography Demonstrating Diastolic Blood Flow on Color Doppler Originating From the Interventricular Septum to the Left Ventricular Chamber Incidental note is made of mild to moderate aortic

Case of the Month #166: Carcinoid Heart Disease

A previously healthy 60-year-old woman presented with a 3-week history of fatigue and exertional dyspnea. Over the past year, she had experienced episodic wheezing, facial flushing, diarrhoea, and an unintentional 40-lb weight loss. On physical examination, she demonstrated venous telangiectasia in the malar region, mild peripheral cyanosis, and an elevated jugular venous pressure with a dominant V wave. On cardiac auscultation, there was a holosystolic murmur at the left lower sternal region of grade III/VI intensity that increased on inspiration. Transthoracic echocardiography was performed to confirm the valvular abnormalities detected on physical examination (Figure 1A). Cardiac magnetic resonance imaging (CMR) was performed to quantify right ventricular systolic function and computed tomography of the abdomen was performed as shown Figures 1B and C.

Musculoskeletal Radiology / Radiologie musculo-squelettique Things That Go Bump in the Body: Musculoskeletal Sports Medicine Magnetic Resonance Imaging Cases: Part 2 of 2

Department of Medical Imaging, University of Saskatchewan, Royal University Hospital, Saskatoon, Saskatchewan, Canada Pan Am Medical Clinic, Winnipeg, Manitoba, Canada Department of Radiology, Health Sciences Centre, Winnipeg, Manitoba, Canada C/o The Radiology Consultants of Winnipeg, Winnipeg, Manitoba, Canada Department of Diagnostic Imaging, St Boniface General Hospital, Winnipeg, Manitoba, Canada Canadian Association of Radiologists Journal 60 (2009) 238e247 www.carjonline.org

An Unusual Case of a Malpositioned Transvenous Pacemaker Wire via a Persistent Left-Sided Superior Vena Cava

The presence of a persistent left-sided superior vena cava is a rare venous return anomaly. There have been numerous reports in the literature describing placement of central venous catheters and transvenous pacemaker wires successfully into the right side of the heart through a persistent left-sided vena cava and the coronary sinus. An 84-year-old male developed acute cardiogenic pulmonary edema resulting in respiratory failure requiring assisted ventilation. His electrocardiograms revealed findings consistent with left ventricular hypertrophy. Subsequently, he developed cardiogenic shock complicated by asystolic cardiac arrest from which he was quickly resuscitated with epinephrine and atropine. A pulmonary artery catheter was placed via the right internal jugular vein without any complications. A transvenous pacemaker was successfully inserted through the left internal jugular vein for complete heart block. The postprocedure chest radiograph demonstrated a normally placed pulmonary artery catheter and the presence of the pacemaker wire along the left side of the heart. Thoracic computed tomography (CT) confirmed that the pacemaker wire extended through a persistent left-sided superior vena cava into a superficial cardiac vein. We present an unusual and previously unreported case of malposition of a temporary transvenous pacemaker wire into a superficial cardiac vein via a persistent left-sided superior vena cava. Critical care physicians should be aware of this congenital anomaly while placing central venous catheters from the left side, particularly in patients with other congenital cardiac defects. When the position is uncertain, imaging modalities, particularly CT, will be helpful in defining the course of central venous catheter.