Michael J. Landay

Blunt traumatic rupture of the right hemidiaphragm: experience in 12 patients.

In a 9-year period (1972 to 1981), 35 patients with blunt traumatic rupture of the diaphragm were seen in our institution; 12 had involvement of the right hemidiaphragm, an incidence of approximately 34%. In 9 of these 12 patients, the right-sided diaphragmatic injuries were seen soon after the accident (acute), and in 3, late after the accident (chronic). A large diaphragmatic rent, usually 10 cm or more, without any predilection to a specific area of the right hemidiaphragm, was a frequent operative finding. Expectedly, the most common viscus that was injured or herniated through the defect was the liver. Total or nearly total herniation of the liver was noted in 5 patients and partial herniation, in 1. Injury to the juxtahepatic vena cava or hepatic vein, or both, was also encountered in 5 patients. This highly lethal injury accounted for the 3 deaths in the series, all of which were directly related to an uncontrollable exsanguinating hemorrhage from the injured vena cava or hepatic vein. The surgical approach for repair of a ruptured right hemidiaphragm is best individualized. The right thoracotomy approach through a right posterolateral incision is preferred for chronic diaphragmatic injury. It is also our choice in patients in whom acute right-sided injuries are definitively diagnosed and who are hemodynamically stable. This approach not only provided the best exposure of the defect, but also made the repair of associated retrohepatic caval injury surprisingly easy in at least 2 of our patients.(ABSTRACT TRUNCATED AT 250 WORDS)

Noncardiac Incidental Findings on Cardiac CT: A Step-by-Step Approach

Noncardiac incidental findings on cardiac CT are remarkably common and some of these may have a significant impact on patient management. Herein, we present a straightforward and cost-effective step-by-step approach for identifying and reporting noncardiac incidental findings. In Step 1, we discuss the ‘ABCDEFG’ search pattern for systematically reviewing noncardiac organ systems. The most prevalent and clinically significant incidental findings are highlighted with strategies for increasing their conspicuity. In Step 2, the importance of reviewing clinical history and prior imaging studies is discussed. In Step 3, we provide a classification scheme and follow-up recommendations for incidental findings based on their potential clinical significance.

Ultrasonic Differentiation of Right Pleural Effusion from Subphrenic Fluid on Longitudinal Scans of the Right Upper Quadrant: Importance of Recognizing the Diaphragm

Care in identifying the diaphragm on longitudinal sonograms through the liver allows differentiation of subpulmonic effusions from subphrenic fluid collections.

Lung penetration by thoracostomy tubes: imaging findings on CT.

We have analyzed the radiographic and computed tomographic (CT) appearance of thoracostomy (chest) tubes inadvertently placed into the lungs. We have studied the clinical sequela of such malpositioning and discussed treatment options. Cases were collected from chest CT log book reports between January 1998 and January 31, 2005 which indicated or suggested intrapulmonary thoracostomy tube placement. CT scans were reviewed by the authors. The chest radiographs and medical records—including thoracic surgical reports—of those patients whose scans demonstrated intrapulmonary tube placement or indeterminate tube location were reviewed. Fifty patients, in whom 51 thoracostomy tubes were placed into the lungs, are included in this series. None of these tubes were described as intrapulmonary on reports of chest radiographs done before CT scanning. In 13 patients (26%), thoracostomy tube placements produced immediate improvement in pleural abnormalities. Dramatic increase or development of chest wall emphysema or pneumothorax was noted in 4 (8%) patients after tube placement. Twenty-five patients (50%) demonstrated either abrupt or gradual increase in pulmonary or pleural opacity on postplacement chest radiographs. Twenty-one (42%) had no apparent clinical complications. Thirteen (26%) had either prolonged air leaks or recurrent pneumothorax. Ten (20%) developed pneumonia. Retained hemothorax or empyema occurred in 8 (16%). Twelve patients (24%) required subsequent thoracic surgery. Intrapulmonary placement of thoracostomy tubes is probably more common than previously reported. This possibility should be considered when radiographs and CT scans are evaluated.

Hyperdense aortic wall: potential pitfall in CT screening for aortic dissection.

Opacity of the aortic wall as compared with the nonopacified blood in the lumen has been utilized as one of the criteria for the diagnosis of aortic dissection. It has also been suggested that this finding may be indicative of severe anemia. We evaluated the frequency and implications of aortic wall hyperdensity in 107 consecutive chest CT examinations in patients with no indication of aortic dissection clinically or by other imaging modalities, and whose hematocrit was known. The density of the wall correlated with the patients age and presence of calcification. Presence or absence of anemia was not a statistically significant factor, although marked conspicuousness of the wall below the age of 60 years did suggest anemia. Atherosclerosis is the most likely explanation for wall visibility in nonanemic patients.

First-Line Use of Vemurafenib to Enable Thyroidectomy and Radioactive Iodine Ablation for BRAF-Positive Metastatic Papillary Thyroid Carcinoma A Case Report

Background. Patients with metastatic or radioactive iodine refractory papillary thyroid carcinoma (PTC) have poor prognosis due to ineffective therapy for this condition beyond surgery and radioactive iodine (RAI or 131I). BRAF mutation occurs in more than 44% of PCT. Tyrosine kinase inhibitors, the most commonly used agents for these patients, have weak BRAF inhibition activity. BRAF inhibitors have demonstrated promising efficacy in relapsed metastatic PCT after standard treatment, though they are not currently approved for this indication. Case Presentation. We present the case of a 48-year-old Hispanic male who initially presented with columnar-cell variant subtype of PTC and positive BRAFV600E mutation. The patient had widespread bulky metastases to lungs, chest wall, brain, and bone. Discussion. Initial use of vemurafenib demonstrated a 42% cytoreduction of targeted pulmonary metastases and facilitated thyroidectomy and RAI treatment. The patient achieved a durable response over 21 months in the setting of widely metastatic disease. Conclusion. Vemurafenib may be effectively used for cytoreduction in patients with bulky metastatic PTC to bridge them to thyroidectomy and RAI treatment.

Etiology of the Widened Mediastinum: Blunt Thoracic Trauma

Most centers continue to use conventional chest radiography as the principal screening modality for the detection of mediastinal hemorrhage and potential injury to the aorta or great vessels after blunt decelerating trauma. Of the many radiographic signs proposed to suggest potential injury, the mos

Chronic pulmonary embolism: diagnosis

Chronic thromboembolic pulmonary hypertension (CTEPH) is a complication of venous thromboembolic disease. Differently from other causes of pulmonary hypertension, CTEPH is potentially curable with surgery (thromboendarterectomy) or balloon pulmonary angioplasty. Imaging plays a central role in CTEPH diagnosis. The combination of techniques such as lung scintigraphy, computed tomography and magnetic resonance angiography provides non-invasive anatomic and functional information. Conventional pulmonary angiography (CPA) with right heart catheterization (RHC) is considered the gold standard method for diagnosing CTEPH. In this review, we discuss the utility of these imaging techniques in the diagnosis of CTEPH.

Cross-sectional imaging of sinus of Valsalva aneurysms: Lessons learned

Sinus of Valsalva aneurysm, dilatation of one or more of the aortic sinuses, is a rare but important aortic root defect, which can be a cause of some serious cardiac sequels. The purpose of this article is to review the etiopathogenesis, relevant anatomy, clinical manifestations, potential complications, multimodality imaging features, and management of this rare but important entity of sinus of Valsalva.

Histological Regression of Giant Cell Tumor of Bone Following RANK Ligand Inhibition

Lung metastases are a rare complication of giant cell tumors of bone. We herein describe an interesting case of histological regression and size reduction of lung metastases originating from a primary giant cell tumor of bone in response to the RANK ligand inhibitor denosumab.