Tan-Lucien H. Mohammed

Valsalva Sinus Aneurysms: Findings at CT and MR Imaging

Aneurysms of the Valsalva sinus (aortic sinus) can be congenital or acquired and are rare. They are more common among men than women and among Asians than other ethnic groups. Nonruptured aneurysms may be asymptomatic and incidentally discovered, or they may be symptomatic and manifest acutely with mass effect on adjacent cardiac structures. Ruptured Valsalva sinus aneurysms result in an aortocardiac shunt and may manifest as insidiously progressive congestive heart failure, severe acute chest pain with dyspnea, or, in extreme cases, cardiac arrest. Although both ruptured and nonruptured Valsalva sinus aneurysms may have potentially fatal complications, after treatment the prognosis is excellent. Thus, prompt and accurate diagnosis is critical. Most Valsalva sinus aneurysms are diagnosed on the basis of echocardiography, with or without angiography. However, both electrocardiographically gated computed tomography and magnetic resonance (MR) imaging can provide excellent anatomic depiction, and MR imaging can provide valuable functional information.

CT Findings of Pulmonary Nocardiosis

OBJECTIVE Nocardiosis is an opportunistic infection that primarily affects the lungs. Most infected patients have deficits in cell-mediated immunity such as those with AIDS, transplant recipients, and those receiving corticosteroid therapy. We review the various CT appearances of pulmonary nocardiosis and discuss the differential diagnosis. CONCLUSION Common CT findings include lung consolidation and nodules and masses. Cavitation may occur. Chest wall involvement develops in a small number of patients.

Vanishing Lung Syndrome (Giant Bullous Emphysema): CT Findings in 7 Patients and a Literature Review

Purpose we reviewed the imaging findings in 7 patients with idiopathic giant bullous emphysema. This is a chronic, progressive condition usually affecting young male smokers and is characterized by giant emphysematous bullae, which commonly develop in the upper lobes. Extensive paraseptal emphysema coalesces to form giant bullae, compressing the normal lung parenchyma and often displacing it centrally. These bullae occupy at least one-third of a hemithorax. Materials and Methods Seven patients with chest radiographic evidence of a bulla or bullae occupying at least one-third of a hemithorax, who had also been examined with high-resolution computed tomography (HRCT), were included in this retrospective study. On HRCT scans, the size, location, and distribution of the bullae were documented and categorized as either subpleural or central. Results The HRCT scan findings in all 7 study patients included numerous bullae ranging in size from a few centimeters in diameter to giant bullae nearly filling an entire hemithorax, mimicking a pneumothorax. Five of the 7 patients had extensive upper lobe predominant bullae, 4 of the 7 patients showed severe bilateral disease with asymmetric involvement, 2 of the 7 patients demonstrated left lung predominance and whereas 1 patient showed right lung predominant disease. All of our patients had subpleural bullae, had parenchymal fibrosis, another had extensive subcutaneous emphysema, and 1 had accompanying bronchiectasis. Conclusions The predominant findings on HRCT scans are extensive paraseptal emphysema coalescing into giant bullae. HRCT is helpful in confirming the diagnosis of VLS, assessing the degree of the disease, and providing information to guide treatment.

From the Radiologic Pathology Archives: Cardiac Lymphoma: Radiologic-Pathologic Correlation

Lymphoma of the heart and pericardium is usually present as one aspect of disseminated disease and rarely occurs as a primary malignancy. It accounts for 1.3% of primary cardiac tumors and 0.5% of extranodal lymphomas. Cardiac lymphomas are most commonly diffuse large cell lymphomas and frequently manifest as an ill-defined, infiltrative mass. Atrial location is typical; the right atrium is most often affected. Pericardial thickening or effusion is often a common early feature of disease. Infiltration of atrial or ventricular walls with extension along epicardial surfaces is also a notable feature. At computed tomography, the attenuation of cardiac lymphoma may be similar to or lower than that of normal myocardium. At magnetic resonance imaging, it has variable signal intensity and contrast enhancement. Clinical manifestations may include pericardial effusion, cardiac arrhythmias, and a variety of nonspecific electrocardiographic abnormalities, notably first- to third-degree atrioventricular block. Treatment most commonly includes anthracycline-based chemotherapy and anti-CD20 treatment. Chemotherapy has been used alone or combined with radiation therapy. Palliative surgery has been performed, mainly for tumor debulking. The prognosis for patients with either primary or secondary lymphomatous heart involvement is usually poor; late diagnosis is one of the major factors affecting outcome.

ACR appropriateness criteria® hemoptysis.

Hemoptysis is defined as the expectoration of blood originating from the tracheobronchial tree or pulmonary parenchyma, ranging from 100 mL to 1 L in volume over a 24-hour period. This article reviews the literature on the indications and usefulness of radiologic studies for the evaluation of hemoptysis. The following recommendations are the result of evidence-based consensus by the American College of Radiology Appropriateness Criteria Expert Panel on Thoracic Radiology: (1) Initial evaluation of patients with hemoptysis should include a chest radiograph; (2) Patients at high risk for malignancy (>40 y old, >40 pack-year smoking history) with negative chest radiograph, computed tomography (CT) scan, and bronchoscopy can be followed with observation for the following 3 years. Radiography and CT are recommended imaging modalities for follow-up. Bronchoscopy may complement imaging during the period of observation; (3) In patients who are at high risk for malignancy and have suspicious chest radiograph findings, CT is suggested for initial evaluation; CT should also be considered in patients who are active or exsmokers, despite a negative chest radiograph; and (4) Massive hemoptysis can be effectively treated with either surgery or percutaneous embolization. Contrast-enhanced multidetector CT before embolization or surgery can define the source of hemoptysis as bronchial systemic, nonbronchial systemic, and/or pulmonary arterial. Percutaneous embolization may be used initially to halt the hemorrhage before definitive surgery.

Pulmonary nocardiosis after lung transplantation: CT findings in 7 patients and review of the literature.

Objective The purpose of this study is to review reported radiographic clues to the diagnosis of pulmonary nocardiosis, as well as to describe and illustrate the high-resolution computed tomography findings of 7 patients with pulmonary nocardiosis after lung transplantation. Conclusions Computed tomography findings of pulmonary nocardiosis after lung transplantation consist predominantly of nodules and cavitary lesions without any significant zonal or anatomic distribution. The diagnosis of pulmonary nocardiosis requires a high index of suspicion, as presenting symptoms are nonspecific, initial visualization is often not possible with routine stains, and identification requires prolonged cultures.

Inflammatory myofibroblastic tumor of the lung: recurrence after steroid treatment.

We report a case of a patient with inflammatory myofibroblastic tumor of the lung, which recurred after steroid treatment. The diagnosis of the tumor was confirmed by a core needle lung biopsy and pathology. The patient was initiated on steroid therapy, which on complete response was slowly tapered and discontinued. Few months later, the patient presented with dyspnea again. Chest radiography and computed tomography scans depicted recurrence at the tumor resection site in the right lobe of lung and a new tumor in the left lower lobe. Restarting the steroid therapy, led to regression of the tumors at both sites. This is a rare case of inflammatory myofibroblastic tumor recurring poststeroid therapy and adds to the current clinical knowledge about this peculiar manifestation of this disease entity.

Epipericardial fat pad necrosis: computed tomography findings and literature review.

Epipericardial fat necrosis is an unusual clinical condition of unknown etiology first reported in the literature in 1957. It presents as an acute onset of chest pain and a well-defined juxtacardiac mass. Computed tomographic findings of this condition demonstrate a fat-attenuation mass that resolves over time. We present a case of a 48-year-old man who presented with epipericardial fat necrosis followed over time with serial computed tomographic scans documenting resolution.

ACR Appropriateness Criteria® acute respiratory illness in immunocompetent patients.

Acute respiratory illness is defined as one or more of the following: cough, sputum production, chest pain, or dyspnea (with or without fever). The workup of these patients depends on many factors, including clinical presentation and the suspected etiology. This study reviews the literature on the indications and usefulness of radiologic studies for the evaluation of acute respiratory illness in the immunocompetent patient. The following recommendations are the result of evidence-based consensus by the American College of Radiology Appropriateness Criteria Expert Panel on Thoracic Radiology. Chest radiographs are usually appropriate in (1) patients with positive physical examination or risk factors for pneumonia, (2) for the assessment of complicated pneumonia, or (3) in cases of emerging infections and biological warfare agents such as severe acute respiratory syndrome, H1N1, and anthrax. Computed tomography, although having a more limited role, is usually appropriate (1) in the assessment of complicated pneumonia and (2) in patients with suspected severe acute respiratory syndrome, H1N1, or anthrax and a normal radiograph.

The American College of Radiology Lung Imaging Reporting and Data System: Potential Drawbacks and Need for Revision

&NA; Lung cancer screening using low‐dose CT scanning reduces lung‐cancer‐specific and overall mortality in high‐risk patients. A significant limitation of lung cancer screening is the false‐positive rate. The American College of Radiology Lung Imaging Reporting and Data System (Lung‐RADS) was designed to standardize reporting of low‐dose lung cancer screening results and to decrease the false‐positive rate without significantly compromising sensitivity. Implementing Lung‐RADS can also improve cost‐effectiveness. However, Lung‐RADS has never been studied in a prospective fashion. It also does not have a specific reporting category for patients with isolated hilar and mediastinal adenopathy or pleural effusion in the absence of lung nodules. We report four such cases from our lung cancer screening program. We believe that this is a significant limitation of Lung‐RADS and should be revised in its new version.