Age 31-60 – ChestDB.com

Case 60

ICU/Surgery / Age 31-60, Cholecystectomy, Clavicle, Claviculectomy, Stent, Subclavian Vein Stent, Thoracic Outlet Syndrome

This radiograph shows a patient with a left claviculectomy for venous thoracic outlet syndrome. This is an uncommon surgical treatment for this condition, with first rib resection being more common. In some cases a clavicle fracture with subsequent malunion or nonunion can case thoracic outlet syndrome and can be treated with claviculectomy or corrective clavicle osteotomy. A left subclavian venous stent is also in place, another possible treatment for venous thoracic outlet syndrome.

Surgical clips are seen in the right upper quadrant, most likely from cholecystectomy. Two surgical clips are also present in the left breast. The exam is otherwise unremarkable.

Case 60 Read More »

Case 59

Emergency & Trauma / Age 31-60, Dialysis, Peritoneal Dialysis, Pneumoperitoneum, Rigler's Sign

This radiograph shows pneumoperitoneum in the form of free air under both hemidiaphragms. Under the left hemidiaphragm, air is seen on both sides of a GI tract structure (bowel or stomach). This is known as Rigler’s sign, though typically this is most useful on supine abdominal radiograph where air under the diaphragm is not a reliable finding due to patient position. The lungs are clear.

The differential for pneumoperitoneum includes the emergent finding of perforated bowel and should always be suspected in a patient with abdominal pain. Pneumoperitoneum can also be seen in a few more benign settings. One is a history of abdominal surgery in the past few days, particularly laparoscopic surgery, as it takes time for the air introduced to the peritoneal space to be absorbed. The other is air that is inadvertently introduced by patients on peritoneal dialysis. This patient had an unremarkable abdominal exam and was on peritoneal dialysis, so the air was attributed to the dialysis.

Case 59 Read More »

Case 57

Normal/Variants & Congenital / Age 31-60, Clavicle, Cleidocranial Dysplasia, Congenital, Nerve Stimulator, Unfused Spinous Process

This radiograph shows a patient with cleidocranial dysplasia. The right clavicle is entirely absent and the left clavicle is severely hypoplastic. The shoulders are depressed bilaterally due to lack of articulation with the axial skeleton. Metallic foreign objects projecting of the left acromion process are most likely retained nerve stimulator leads. Unfused spinous processes are seen in the lower cervical and upper thoracic spine.

The remainder of the exam is unremarkable.

Case 57 Read More »

Case 54

Infectious/Inflammatory / Age 31-60, Consolidation, Pneumonia, Silhouette Sign

Discussion This radiograph shows a right lower lobe pneumonia. A focal opacity with indistinct margins is seen in the right lung base. The opacity silhouettes the right hemidiaphragm but not the right heart border, which localizes it to the right lower lobe. Along with a corroborating clinical history, this appearance is consistent with a lobar

Case 54 Read More »

Case 53

Emergency & Trauma / Age 31-60, Artifact, Dislocation, Elastic Band, Ponytail

This radiograph shows a left anterior shoulder dislocation in a trauma patient. The humeral head projects inferior and medial to the glenoid. No associated fracture is evident, though dedicated shoulder imaging should be performed to evaluate for Bankart and Hill-Sachs lesions. The patient’s hair is in a ponytail with an elastic band which can be seen projecting over the cervical spine and should not be confused with a foreign body. The remainder of the exam is unremarkable.

Case 53 Read More »

Case 51

ICU/Surgery, Lines/Tubes/Devices / Age 31-60, Chest Tube, Emphysema, Lung Volume Reduction Surgery, LVR, Pleural Effusion, Pleural Tent, Staple Line, Surgical Lung Volume Reduction

This radiograph demonstrates the expected postoperative appearance of a pleural tent following lung volume reduction surgery in the right upper lobe (note the visible staple line), though this can be done after upper lobectomies for any cause. The anatomy of upper lobectomies in particular is unfavorable for post-operative pleura-pleura apposition, increasing the risk for air leaks from the staple line. In this procedure, the visceral pleura is peeled from the chest wall and draped over the staple line. This promotes apposition and decreases the chance of an air leak. A chest tube is placed under the tent intraoperatively, as seen here, and will eventually be removed. The cavity will eventually fill with fluid, just like a pneumonectomy cavity.

There is marked emphysema in the left lung. Incidentally, this patient also has a small left effusion which is chronic and unrelated to the procedure.

Case 51 Read More »

Case 48

Lines/Tubes/Devices / Age 31-60, Bravo Device, Gastroesophageal Reflux Disease, GERD, Wireless pH Monitoring Device

This radiograph demonstrates an in situ wireless pH monitoring device, also called a Bravo device. It is placed by an endoscopist and continuously monitors the pH level in the esophagus, wirelessly transmitting the data to an external receiver worn around the patient’s waist for up to 96 hours. This allows for quantification of gastroesophageal reflux disease (GERD) over the recording interval. The device is designed to eventually detach, pass through the digestive tract, and be flushed down the toilet.

Case 48 Read More »

Case 46

Emergency & Trauma, Infectious/Inflammatory / Age 31-60, Consolidation, Infection, Lobar Pneumonia, Pneumonia

This radiograph demonstrates a right upper lobe consolidation most consistent with lobar pneumonia in this patient with a cough and elevated white count. The consolidation has poorly defined margins with the exception of the inferior margin, which is sharp and linear. This is due to the consolidation abutting the minor fissure. The position of the consolidation superior to the minor fissure definitively localizes it to the right upper lobe. Uncomplicated community acquired lobar pneumonia does not typically cross fissures. While malignancy is not entirely excluded, a mass would be unlikely to respect the fissural boundary without exerting mass effect.

The exam is otherwise unremarkable.

Case 46 Read More »

Case 45

Lines/Tubes/Devices, Normal/Variants & Congenital / Age 31-60, Dual Chamber Pacemaker, Pacemaker, Persistent Left SVC

This radiograph demonstrates unusual but ultimately inconsequential pacemaker lead positioning. A dual chamber pacemaker generator pack projects over the left hemithorax. The right ventricular lead takes the expected course through the left brachiocephalic vein, superior vena cava, right atrium, and tricuspid valve and terminates in the expected position of the right ventricle. The right atrial lead, however, courses to the left of the aorta. There are no secondary signs to suggest an inadvertent extravascular course. The best explanation for this appearance is a persistent left superior vena cava. This is a normal variant and connects the left subclavian vein to the coronary sinus. Ultimately, the lead ends up in the right atrium. It is not clear in this case why this positioning was chosen rather than placing both leads in the right (normal) SVC.

The exam is otherwise unremarkable.

Case 45 Read More »

Case 44

Malignancy / Age 31-60, Atelectasis (Lobar), Juxtaphrenic Peak Sign, Left Upper Lobe Collapse, Post-Obstructive Collapse, Silhouette Sign

This radiograph demonstrates left upper lobe collapse. This is one of the more challenging lobar collapse patterns to recognize on AP or PA radiographs as the left upper lobe collapses anteriorly and superiorly and ends up superimposed over the inflated left lower lobe. Other than the increased opacity over the left hemithorax, other notable features present on this radiograph are a left juxtaphrenic peak sign and silhouetting of the left heart border and hilum by the collapsed left upper lobe.

When this finding is identified, the cause of the collapse should be further investigated with CT. This case was post-obstructive collapse secondary to a central obstructing mass. The mass is not well visualized on this radiograph.

Case 44 Read More »