Richard B. Jaffe

Septic Pulmonary Emboli

The cases of 17 patients with septic pulmonary emboli, a radiologically significant manifestation of right-sided bacterial endocarditis or septic thrombophlebitis, are reviewed. Characteristic radiologic features may permit early, correct diagnosis. The emboli may present as small, scattered areas of consolidation simulating bronchopneumonia and extending rapidly or as round or wedge-shaped peripheral opacities. Quickly excavating, they often produce thin-walled cavities simulating pneumatoceles. Coalescence of necrotic infarcts may result in formation of large lung abscesses. Lesions may extend to involve the pleura, causing empyema, bronchopleural fistula, and pneumothorax. Following therapy, lesions resolve completely or leave residual pleural thickening or areas of pulmonary fibrosis.

CT assessment of tracheobronchial anomaly in left pulmonary artery sling

BackgroundThe left pulmonary artery sling (LPAS) is a rare vascular anomaly where the left pulmonary artery arises from the right pulmonary artery, passes over the right bronchus, and goes posteriorly between the trachea and esophagus. The LPAS is frequently associated with cardiac and non-cardiac defects including tracheobronchial abnormalities.ObjectiveTo evaluate the utility of multislice CT (MSCT) and helical CT (HCT) in diagnosing and defining the tracheobronchial anomaly and anatomic relationships between the trachea and aberrant left pulmonary artery.Materials and methodsMSCT or HCT was performed in 27 children to determine the tracheobronchial anatomy and identify tracheobronchial stenosis. Eighteen children underwent surgery.ResultsAccording to the Wells [6] classification of LPAS, which includes two main types and two subtypes, there were eight cases of type 1A, five cases of type 1B, six cases of type 2A and eight cases of type 2B in this group. Twenty-four of the 27 children had substantial tracheobronchial stenosis. Four died before surgery; the 18 had reanastomosis of the left pulmonary artery. Five children also had tracheoplasty; three died after surgery.ConclusionCT, especially MSCT, is an ideal modality for simultaneously identifying aberrant left pulmonary artery and any associated tracheobronchial anomaly. The Wells classification is useful for operative planning.

Popliteal Cysts: Presentation as Thrombophlebitis

Synovial-lined cysts in the popliteal space associated with rheumatoid arthritis or meniscal tears may compress the popliteal vein and produce signs and symptoms suggestive of thrombophlebitis. Because of a presumptive diagnosis of thrombophlebitis, venography may be performed initially and demonstrate compression of the popliteal vein by an extrinsic mass. The correct diagnosis of a popliteal cyst can easily be made with B-mode ultrasonography, and, if desired, confirmed by arthrography. Four cases are presented which emphasize these features.

Mycotic aneurysms of the pulmonary artery and aorta.

The clinical presentation and characteristic radiographic and angiographic findings in 6 patients with mycotic aneurysms of the pulmonary artery of aorta are presented. Radiographic findings that may suggest a mycotic aneurysm of the pulmonary artery include a rapid change in its coutour, which may be aneurysmal in character, and multiple septic pulmonary emboli or bacterial pneumonia. Patients with mycotic aneurysms of the descending thoracic aorta may have a middle or posterior mediastinal mass in close association with the aorta, and a pulmonary infiltrate may be seen surrounding the aneurysm. A barium swallow will often demonstrate esophageal displacement by the extrinsic mass.

Roentgenographic Evaluation of Bronchial Size Following Pulmonary Embolization

Estimates of the changes in bronchial dimensions following pulmonary embolization have largely been derived from measurements of total lung resistance, anatomic dead space, lung compliance, and other parameters that are assumed to change with bronchoconstriction. Surprisingly, only one group, Jesser and de Takats (6), has attempted to visualize the bronchial response directly by instilling radiopaque material into the bronchial tree prior to embolization. With the use of bronchography, these investigators believed that they could demonstrate bronchoconstriction with pulmonary embolization by the appearance of radiopaque material “squeezed into the terminal radicals.” They did not measure any changes in bronchial dimensions, however, nor can any be definitely recognized in the published roentgenograms. Also, their report that these changes could be prevented by vagotomy, a procedure more recently shown to have no effect in preventing embolism-induced bronchoconstriction (1, 4, 8), suggests that their metho...

Contrast-enhanced magnetic resonance angiography of persistent fifth aortic arch in children

BackgroundCine angiography and echocardiography have been utilized to diagnose congenital aortic arch anomalies. However, the visualization of great vessels by echocardiography is limited, while cine angiography requires cardiac catheterization with ionizing radiation. Contrast-enhanced magnetic resonance angiography (MRA) is a noninvasive modality suitable for visualization of congenital aortic arch anomalies.ObjectiveTo evaluate the utility of contrast-enhanced MRA in the diagnosis of persistent fifth aortic arch, a rare congenital aortic arch anomaly, and to compare the diagnostic accuracy of MRA with that of echocardiography and cine angiography.Materials and methodsIn four pediatric patients, contrast-enhanced MRA studies were performed for diagnosing persistent fifth aortic arch. The findings of MRA were compared with echocardiographic findings and confirmed by cine angiography and operation.ResultsTransthoracic surface echocardiography noted an aberrant vessel arising from the ascending aorta in two of four patients; the etiology of this vessel was uncertain. In the other two patients a diagnosis of coarctation was made. Of the four patients, only one was diagnosed with interruption of the aortic arch. Contrast-enhanced MRA clarified uncertain echocardiographic findings, enabling the correct diagnosis of persistent fifth aortic arch with fourth aortic arch interruption in all four patients.ConclusionContrast-enhanced MRA is a safe, accurate, and fast imaging technique for the evaluation of persistent fifth aortic arch and may obviate the need for conventional cine angiography. Cardiac catheterization may be reserved for some types of complicated congenital heart disease and for obtaining hemodynamic information.

Noninvasive Evaluation of Superior Vena Caval and Right Atrial Thrombosis Complicating Central Hyperalimentation

From the Departments of Pediatrics and Radiology, Primary Children’s Hospital and University of Utah, Salt Lake City, Utah. Address correspondence to: R. L. Bucciarelli, M.D., University of Florida, Department of Pediatrics, Box J296 JHMHC, Gainesville, FL 32610. Received for publication June 1982, revised August 1982, and accepted October 1982. RECENTLY, there have been several reports of ECENTL the occurrence of right atrial (RA) thrombosis with

Multi-slice computed tomography assessment of bronchial compression with absent pulmonary valve

BackgroundAbsent pulmonary valve is a rare cardiovascular anomaly that can result in profound tracheobronchial compression.ObjectiveTo demonstrate the advantage of multi-slice CT in diagnosing tracheobronchial compression, its severity as related to the adjacent dilated pulmonary arteries, and associated lung and cardiac lesions.Materials and methodsWe included children with absent pulmonary valve who were reviewed by multi-slice CT during a 17-year period. The number and locations of stenoses and lung lesions were noted and the severity of stenosis was categorized. The diameter of the pulmonary artery was measured and associated cardiac defects were demonstrated.ResultsThirty-one children (14 girls and 17 boys) were included. Of these, 29 had ventricular septal defect and 2 had an intact ventricular septum. Twenty-nine children (94%) had tracheobronchial compression, judged to be mild in nine children (31%), moderate in 10 (34%) and severe in 10 (34%). The different locations of the stenosis (carina, main bronchi, lobar and segmental bronchi) were observed. And the number and location of lung lesions demonstrated that the right middle and left upper and lower lobes were often affected. The diameter of the pulmonary artery in these children was well above normal published values, and Spearman rank correlation analysis showed a correlation between the size of the pulmonary artery and the severity of the tracheobronchial stenosis. Nineteen children (61%) underwent surgery and 4 of these children had a multi-slice CT post-operative follow-up study.ConclusionAbsent pulmonary valve can cause significant morbidity and mortality in children. Multi-slice CT can accurately depict areas of tracheobronchial compression, associated lung lesions and cardiac defects, helping to direct the surgeon.

Congenital complete heart block. Radiographic findings in 13 patients without associated defects.

The radiographic findings in 13 patients with congenital complete heart block without associated anomalies are presented to illustrate characteristic features. Findings related to the increased stroke volume in these patients include: (a) simulated shunt vasculature; (b) pulmonary venous pypertension with redistribution of blood flow to the upper lungs, and, in one patient, peribronchial edema; (c) cardiomegaly with right ventricular, pulmonary artery, left atrial, left ventricular, and aortic enlargement; and (d) variation in cardiac size on serial examinations. Less commonly seen were findings related to atrioventricular dissociation with transitory marked pulmonary venous hypertension present in one patient when left atrial contraction occurred during ventricular systole when the mitral valve was closed.

Treatment of traumatic pancreatic pseudocysts in children: the role of percutaneous catheter drainage

Six cases of successful percutaneous catheter drainage (PCD) of pancreatic pseudocysts in children ages 3–13 years are presented. All cases involved blunt abdominal trauma and presented with abdominal pain, vomiting, epigastric tenderness without a palpable mass, and elevated serum amylase. Indications for PCD were an enlarging pseudocysts and marked abdominal pain. Catheter placement was accomplished using CT guidance 15.3±1.8 days (mean ± SEM) following injury. Two patients had transgastric PCD. None of the pseudocysts were infected. Catheters were left in place until the drainage ceased, the serum amylase approached normal, the pseudocyst resolved on ultrasound, and the asymptomatic patient tolerated enteral feedings with the catheter clamped. The mean duration of catheter drainage was 18.3±3.7 days. At the time of catheter insertion, the range of serum amylase values was 242–2810 IU/l, while discharge values were 50–147 IU/l (normal: 16–108 IU/l). The mean hospital stay was 36.2±3.8 days and the mean length of total parenteral nutrition was 27.5±4.5 days. All pseudocysts were treated successfully without complication. PCD of traumatic pancreatic pseudocysts in children was performed safely and effectively in our study. Use of this therapeutic modality allowed earlier treatment, decreased the duration of symptoms, and avoided abdominal operation. PCD may prove to be the treatment of choice for pancreatic pseudocysts in children.