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Stephanie Christina


Repoting male patient, 71 years old

Referrred from ENT Department
With clinical information Vocal Cord Tumor pre-operative assessment
Asked for Chest X-ray PA projection

The patient has undergone Chest MSCT examination on September 17th 2015, and the results
- Supporting aortic dissection at aortic knob with the length approximately 4,08 cm
- Bilateral multiple renal cysts

Chest x-ray PA projection :

Chest X-ray seems asymmetrical
Heart : size and shape are normal
Lung : there is no infiltrate / nodule
Right and left costophrenic angles are sharp
There is mediastinal widening projected at the level of 3th to 6ththoracal vertebrae, round-
shaped, well-circumscribed, size approximately 6 x 6 cm, silhouette sign (-), with multiple

Conclusion :
Supporting aortic knob aneurysm with multiple aortic wall calcifications
Stephanie Christina
Stephanie Christina


The mediastinum is an area whose lateral margins are defined by the medial borders of each
lung, whose anterior margin is the sternum and anterior chest wall, and whose posterior
margin is the spine, usually including the paravertebral gutters.
The mediastinum can be arbitrarily subdivided into three compartments: the anterior, middle,
and posterior compartmentsand each contains its favorite set of diseases.
The superior mediastinum, roughly the area above the plane of the aortic arch, is a division
that is now usually combined with one of the other three compartments mentioned above.
Stephanie Christina

The anterior mediastinum is the compartment that extends from the back of the sternum to
the anterior border of the heart and great vessels.

The middle mediastinum is the compartment that extends from the anterior border of the
heart and aorta to the posterior border of the heart and contains the heart, the origins of the
great vessels, trachea, and main bronchi along with lymph nodes.
Lymphadenopathy produces the most common mass in this compartment. While Hodgkin
disease is the most likely cause of mediastinaladenopathy, other malignancies and several
benign diseases can produce such findings.
Other malignancies that produce mediastinal lymphadenopathy include small cell lung
carcinoma and metastatic disease such as from primary breast carcinoma.
Benign causes of mediastinal lymphadenopathy include infectious mononucleosis and
tuberculosis, the latter usually producing unilateral mediastinaladenopathy.
Stephanie Christina

The posterior mediastinum is the compartment that extends from the posterior border of the
heart to the anterior border of the vertebral column. For practical purposes, however, it is
considered to extend into the paravertebral gutters.
It contains the descending aorta, esophagus, and lymph nodes and is the site of masses
representing extramedullary hematopoiesis. Most importantly, it is the home of tumors of
neural origin(neurofibroma, schwannoma (neurilemmoma), ganglioneuroma, and

On conventional radiographs look for :

- cervicothoracic sign
- widening of the paravertebral stripes

Beda tumorparudengantumormediastinum :
Tumor Mediastinum TumorParu
Batas Tegas / reguler, kadang Tidaktegas / ireguler
Sudutterhadapparenkimparu Tumpul Tajam
Silhouette sign Bisa (+), padatumor Biasanya (-)
mediastinum anterior /
Pendesakan Menimbulkanpendesakan Jarangmenimbulkanpendesakan
organ2 mediastinum organ2 mediastinum

Stephanie Christina

Thoracic aortic aneurysms are relatively uncommon compared to abdominal aortic aneurysms.
There is a wide range of causes and the ascending aorta is most commonly affected. CTA and
MRA are the modalities of choice to image this condition.

The term aneurysm is used when axial diameter of the thoracic aorta is > 5 cm and when it
measures 4-5 cm the term dilatation is used.

Most commonly occur in 50-60 year old age group and incidence is estimated at ~7.5 per
100,000 patient years. There is a male predominance (M:F=3:1).

Clinical presentation
Thoracic aneurysms are often identified incidentally on imaging of the chest. Symptomatic
presentation may be due to mass effect on airway or oesophagus. Alternatively they may
present due to a complication, including rupture, aorto-bronchial or aorto-oesophageal
Pseudoaneurysms of the thoracic aorta are usually the result of significant thoracic trauma,
both penetrating and blunt, and carry a very high mortality, with 80-90% of patients dying
prior to reaching hospital.

Aneurysmal dilatation can affect any part of the thoracic aorta. Relative frequencies are (with
some involving more than one segment):
aortic root/ascending aorta: 60%
aortic arch: 10%
descending aorta: 40%
thoraco-abdominal segment: 10%

Thoracic aortic aneurysms can be divided pathologically according to their relationship to the
aortic wall:
true aneurysm
o atherosclerotic aneurysms (most common)
o inflammatory/aortitis
rheumatoid arthritis (RA)
ankylosing spondylitis
Takayasu arteritis
giant cell arteritis (GCA)
o structural: cystic medial necrosis
Marfan disease
Stephanie Christina

Ehlers-Danlos syndrome
o bicuspid aortic valve
false aneurysm
o trauma
o mycotic aneurysms

Radiographic features
The location and shape of thoracic aortic aneurysms is variable. Aortic aneurysm,
asaneurysms elsewhere, can be described as saccular or fusiform. In the case of fusiform
dilatation, the term aneurysm should be applied when the diameter is >4 cm 1.

Plain film
The thoracic aorta can usually be seen on both frontal and lateral chest radiographs, and
aneurysms are often obvious. However, it is difficult to assess size accurately (due to
magnification effects and often poor visualisation or on side of the artery).
Additionally, mediastinal masses may mimic aortic aneurysms.
Mural calcification is seen both in atherosclerotic disease as well as various causes
ofaortitis (see causes of ascending aorta calcification).

Unlike abdominal aneurysms that can usually be readily assessed and monitored with
ultrasound, thoracic aortic aneurysms are encased in bone and air making transthoracic
ultrasound of no use.
Transoesophageal echocardiography can visualise much of the descending aorta, but due to its
invasive nature is not routinely used.

CTA is the work-horse of aneurysm assessment able to rapidly image the relevant vascular
territory with high resolution. It is able to visualise both the sac and the lumen and detect
potential complications.
Typically aneurysms appear as dilatations of the lumen. The walls may be thin or thickened by
presence of mural thrombus (circumferential or more frequently eccentric).
Calcified atherosclerotic disease is often identified not only in the wall of the aneurysm but in
adjacent arteries.
If rupture or leak has occurred haematoma/fluid may be seen adjacent to the aorta, in the left
pleural cavity or in the pericardium.

MRI has the advantage of not requiring ionising radiation or large volumes of iodinated
contrast. This is particularly advantageous in young patients with connective tissue disorders.
However, there are limitations in patients with pacemakers, and those with reduced renal
Acquisitions capable of being reformatted in three dimensions are essential to allow for
accurate luminal measurement.
Stephanie Christina

Digital subtraction angiography (DSA)

Although angiography has long been considered the gold standard for vascular imaging, it has
largely been superseded by CTA and MRA, which are able to obtain 3D volumetric data, and
able to assess the extraluminal soft tissues.
Angiography is however used during endovascular repair.

Treatment and prognosis

Mild to moderate aneurysmal dilatation can usually be treated conservatively and monitored.
When the diameter reaches 5-6 cm intervention is usually considered as the risk of rupture is
significantly elevated 1. Treatment options include:
open repair
endovascular repair
In general, when possible, endovascular repair is the treatment of choice, with reduced
morbidity and mortality.The majority of patients with thoracic aortic aneurysms either die of
direct complication of the aneurysm (rupture most frequently) or other cardiovascular
complications. The main predictors of rupture are size and speed of growth. Average growth of
thoracic aneurysm appears to be lower than that of abdominal aneurysms, typically in the
order of 1-2 mm/year, and correlates with a better prognosis for thoracic aneurysms when
controlled for size.

distal embolisation
fistula formation
o aorto-oesophageal fistula
o aorto-bronchial fistula
Differential diagnosis
aortic dissection
o widened mediastinum
o double aortic contour
o irregular aortic contour
o inward displacement of atherosclerotic calcification
penetrating atherosclerotic ulcer
intramural aortic haematoma
Kommerell diverticulum
Kommerell diverticula occur in a number of anomalies of the aortic arch
system. It usually refers to the bulbous configuration of the origin of an
aberrant left subclavian artery in the setting of a right sided aortic arch.
However, it was originally described as a diverticular outpouching at origin of
an aberrant right subclavian artery with a left sided aortic arch.
Plain photo : A small rounded density may be seen laterally towards the left of the
mediastinal mass

Learning Radiology
Stephanie Christina

Aneurysms are defined as enlargement of a vessel greater than 50% of its original size.
Atherosclerosis is the most common cause of a descending thoracic aortic aneurysm. The
majority of patients with aortic aneurysms are also hypertensive.
Most patients with aneurysms are asymptomatic, and the aneurysm is discovered
When an aneurysm of the descending thoracic aorta expands, it may cause pain that
classically, but not always, radiates to the back.
As measured on CT or MRI scans, the ascending aorta is usually <3.5 cm in diameter and the
descending aorta is <3 cm.
An aneurysm of the thoracic aorta is usually defined as a persistent enlargement of >4 cm.
In general, aneurysms of 5 to 6 cm are at risk to rupture and will require surgical intervention.
The rate of growth of an aneurysm is also important in determining the need for surgical
intervention and repair. Annual aneurysm growth rates should be <1 cm/year or elective
resection is considered.

Recognizing a Thoracic Aortic Aneurysm

The appearance of a thoracic aortic aneurysm will depend, in part, from which portion of the
thoracic aorta it arises.
Aneurysms of the ascending aorta may extend anteriorly and to the right. Aneurysms of the
aortic arch produce a middle mediastinal mass. Aneurysms of the descending aorta project
posteriorly, laterally, and to the left.
Contrast-enhanced CT is the modality most often used to diagnose a thoracic aortic aneurysm;
MRI is also excellent at demonstrating aneurysms but is usually less available and more
On CT, aneurysms can appear as fusiform (long) or saccular (globular) in shape.
Their anatomy will be more readily delineated on CT studies using iodinated contrast material
injected intravenously as a bolus, but they may be visible on non- contrast (unenhanced)
studies as well. Often, both unenhanced and contrast-enhanced CT studies are obtained to
fully evaluate the aneurysm and its contained clot.
Frequently calcification is seen in the intima, which may be separated from the contrast-filled
lumen by varying amounts of clot.

Thoracic Aortic Dissection

Aortic dissections most often originate in the ascending aorta (Stanford type A) or may
involve only the descending aorta (Stanford type B).
They result from a tear that allows blood to dissect in the wall for varying lengths of the aorta,
usually along the media.
In general, patients with aortic dissection have been hypertensive and may have an
underlying condition that can predispose to dissection, such as cystic medial degeneration,
atherosclerosis, Marfan syndrome, Ehlers- Danlos syndrome, trauma, syphilis, or crack cocaine
In many patients, abrupt onset of ripping or tearing chest pain, which is maximal at its time
of origin, is the characteristic history.
Stephanie Christina

Conventional radiographs are not significantly sensitive to be diagnostically reliable, but they
may point to the diagnosis when several imaging findings occur together, especially in the
proper clinical setting.
Widening of the mediastinum is a poor means of establishing the diagnosis because it is
commonly overinterpreted on portable supine radiographs while, on the other hand, it occurs
in only about 1 in 4 cases of aortic dissection.
Left pleural effusion (which frequently represents a transudate caused by pleural irritation,
although transient hemorrhage from the aorta can also produce a hemothorax).
Left apical pleural cap of fluid or blood
Loss of the normal shadow of the aortic knob
Increased deviation of the trachea or esophagus to the right
MRI is probably more sensitive than CT at detecting a dissection, but CT is usually more
readily available. Transesophageal ultrasound is also used to establish the diagnosis.
On both MRI and CT, the diagnosis rests on identification of the intimal flap that separates
the true (original) from the false lumen (canal created by the dissection).
In general, type A (ascending aortic) dissections are treated surgically, whereas type B
(descending aortic dissections) are treated medically.

Thoracic Radiology The Requisites

Aortic Aneurysm
A thoracic aortic aneurysm (Box 16-13) is an abnormal dilation of the aorta. The aortic lumen
usually is larger than 4 cm in diameter.
Stephanie Christina

Aneurysms may be classified based on several features, including integrity of the aortic wall,
aneurysm shape, and aneurysm location. Based on the integrity of the aortic wall, aneurysms
may be classified as true aneurysms, characterized by an intact aortic wall, and as false
aneurysms, characterized by a disrupted aortic wall, in which case the aneurysm is contained
by surrounding tissues.
Aneurysms may be further classified by their shape as fusiform or saccular. Fusiform
aneurysms are characterized by cylindrical dilation of the entire aortic circumference, whereas
saccular aneurysms are characterized by a focal area of outpouching of the aorta. By location,
aneurysms may be classified as occurring within the ascending, trans- verse, and descending
Aneurysms that classically involve the ascending aorta include those related to cystic medial
necrosis and syphilis. The latter, previously a common cause of ascending aortic aneurysms, is
infrequently seen today. Aneurysms that commonly involve the descending thoracic aorta
include atherosclerotic, posttraumatic, and mycotic aneurysms. The transverse aorta, usually
involved by processes similar to those in the descending thoracic aorta, is uncommonly
affected by cystic medial necrosis.
Most thoracic aortic aneurysms are atherosclerotic and are true aneurysms. Because
atherosclerosis usually affects long segments of the aorta, atherosclerotic aneurysms are
usually fusiform. They most commonly affect the aortic arch and descending thoracic aorta.
Atherosclerotic aneurysms typically contain mural thrombus and calcification.
Aneurysms resulting from connective tissue disorders such as Marfan syndrome and Ehlers-
Danlos syndrome most often affect the ascending aorta and are caused by cystic medial
necrosis. Complications of ascending aortic aneurysms include rupture, dissection, aortic
insufficiency, and pericardial tamponade.
Posttraumatic aneurysms are usually the result of a rapid deceleration injury and often caused
by a motor vehicle accident. Among patients who survive the initial injury, most aortic
transections (80%) occur at the level of the ligamentous arteriosum, which is located just distal
to the origin of the left subclavian artery. Posttraumatic aneurysms are classified as false
aneurysms and are an acute surgical emergency, because the associated mortality rate is very
high. Most patients who sustain a traumatic transection of the aorta do not survive the initial
injury; for those who do survive, prompt diagnosis and treatment are critical. Uncommonly, a
patient may present with a chronic false aneurysm from previous trauma; as in acute
posttraumatic aneurysms, the most common location is at the level of the
Infectious aneurysms are also known as mycotic aneurysms. They are classified as false
aneurysms and are usually saccular. Mycotic aneurysms may be associated with periaortic
inflammation and abscess formation.
On chest radiographs, an aortic aneurysm should be suspected whenever a mediastinal mass is
immediately adjacent to the aorta, particularly if a border of the mass is indistinguishable from
the aortic contour. Peripheral calcification within such a mass is supportive evidence of a
vascular cause, particularly in atherosclerotic aneurysms. The diagnosis can be confirmed by
contrast-enhanced CT, MRI, or angiography. Important information provided by these studies
includes the precise location and size of the aneurysm, the relationship of the aneurysm to the
great vessels, and the presence of complications, including aortic rupture and dissection. It is
important to accurately mea- sure the maximal diameter of an aortic aneurysm, because the
Stephanie Christina

incidence of rupture correlates with the size of the aneurysm and increases significantly for
aneurysms greater than 5 cm in diameter. Aneurysms can dilate at a mean rate of
0.12cm/year. For these reasons, elective surgical repair has been recommended for ascending
aortic aneurysms of 5 to 5.5 cm and for descending thoracic aortic aneurysms of 5.5 to 6.5 cm
in diameter.
Contrast-enhanced CT and MRI play an important role in imaging aortic aneurysms. The
location of the abnormality and the expected cause should be considered when deciding which
imaging modality to use for further evaluation. For abnormalities of the ascending aorta, MRI is
usually preferred over CT, but MRI has less of an advantage in the current era of multidetector
CT scanners. The direct multiplanar capability of MRI, including the ability to image in sagittal-
oblique (LAO) and coronal projections, allows for precise measurement of an ascending aortic
aneurysm; MRI can accurately identify associated effacement of the sinotubular junction by an
aortic root aneurysm. Contrast- enhanced CT usually is sufficient for the evaluation of
aneurysms of the aortic arch and descending thoracic aorta. CT can accurately demonstrate
aortic dilation, intramural thrombus, and perianeurysmal hemorrhage or infection. However, a
tortuous aorta occasionally courses obliquely on a transaxial CT image and may be difficult to
measure accurately. Sagittal-oblique and coronal reformation images should be obtained to
accurately measure and characterize aortic aneurysms using CT. Although catheter
angiography was historically the method of choice for the evaluation of acute posttraumatic
aortic transection (Fig. 16-23), CT angiography has largely replaced catheter angiography for
this indication at most institutions.