Cardiovascular

Radiology Rotating Exhibit

Pre-Session Version 2020

Steven Ostrow, M.D.

Lee Eisner, Ph.D.
With support from
John Amodio, M.D.
Louis
Salciccioli, M.D.

Stephen Waite, M.D.

 A 50 year old woman presented to the ER complaining of a racing heart and
palpitations, with the sensation that her heart would “burst out of” her chest.
She denies any chest pain, shortness of breath or dizziness.

Set A Case 1
Question 1A
Identify the numbered structures on this normal PA chest.

2 3

Set A Case 1 Normal PA

Question 1B
Identify the anatomic structures that contribute to the components of the
mediastinal contours which are outlined on this normal PA chest. (Different
colors mark different anatomical structures.)

2 3

Set A Case 1 Normal PA

Question 2
Identify the numbered structures.

Identify the anatomic structures that

contribute to the components of the
cardiac contours which are outlined
1
on this normal lateral chest.

Note that the “L” label on the image

indicates that the image was obtained
in left lateral projection.

Normal lateral
Set A Case 1
 Here is the PA image of our patient.
PA 50 year old patient
Question 3
Identify the same mediastinal
contours and numbered
structures. Compare this
image to the normal PA to
determine which contour(s)
is / are abnormal. Are any
other contours visible? What
does this tell you about the
patient’s heart?

Set A Case 1
Here is our patient’s lateral image.

Question 4 L
Identify the same cardiac
contours. Compare the image to
the normal lateral to determine
which contour(s) is / are abnormal.
Are any other contours visible?
What does this tell you about the
patient’s heart?

Lateral 50 year old patient

Set A Case 1
 Here is an echocardiogram image from another patient who has the same chamber
enlargement as our patient.
Question 5
Using the diagram for orientation, identify the numbered structures on this parasternal
long axis image. Which chamber(s) is / are enlarged?
Parasternal long axis 50 year old patient

2 3
5

2 4
LV

LV

Set A Case 1
A 55 year old woman with hypertension for many years has not been taking
her blood pressure medication for six months. She presented to the ER with
the sudden onset of shortness of breath and tearing chest pain radiating to
her back.

Set B Case 2
Question 1
Compare the patient’s AP CXR (taken while supine) with a normal AP supine
CXR. How do the heart and mediastinal shadows differ?

55 year old patient AP Normal AP

Set B Case 2
Question 2
Identify the numbered structures on the patient’s CT image, obtained in the
plane indicated on the scout image, after IV contrast was given. The IV
contrast was injected into the right median cubital vein.

Why are structures 1 and 2 opacified more than the other structures?

2 3 10
7 6 11
1
8 5

Set B Case 2
Question 3a
Here are more images from our patient’s CT. On each of the following images a-e
identical numbers have been assigned to the same structures previously visualized.
On each image identify the newly numbered structures. Anatomically localize and
describe the abnormality (if any). What is the patient’s diagnosis?

3 4 6
2 5
7
1 12
8

Set B Case 2
Question 3b
Here are more images from our patient’s CT. On each of the following images a-e
identical numbers have been assigned to the same structures previously visualized.
On each image identify the newly numbered structures. Anatomically localize and
describe the abnormality (if any). What is the patient’s diagnosis?

6
3
2 12

7
8
12

Set B Case 2
Question 3c
Here are more images from our patient’s CT. On each of the following images a-e
identical numbers have been assigned to the same structures previously visualized.
On each image identify the newly numbered structures. Anatomically localize and
describe the abnormality (if any). What is the patient’s diagnosis?

13 12

7
8

12

Set B Case 2
Question 3d
Here are more images from our patient’s CT. On each of the following images a-e
identical numbers have been assigned to the same structures previously visualized.
On each image identify the newly numbered structures. Anatomically localize and
describe the abnormality (if any). What is the patient’s diagnosis?

17 14

13
15

19 20 16
8

18

Set B Case 2
Question 3e
Here are more images from our patient’s CT. On each of the following images a-e
identical numbers have been assigned to the same structures previously visualized.
On each image identify the newly numbered structures. Anatomically localize and
describe the abnormality (if any). What is the patient’s diagnosis?

23

21 17

22

8
18

Set B Case 2
 Question 4
Here are two CT images from another patient, a 59 year old male. Why do
regions x and y differ in their attenuation values? What is the effect of this on
perfusion of the patient’s kidneys, as shown in the image on the right?

x
y

59 year old male patient

Set B Case 2
 A 58 year old man presented to the emergency room with the sudden onset
of sharp left upper quadrant pain. The pain is sharp, non-radiating, and 7 out
of 10 in intensity. He has a history of myocardial infarction four years ago
and an arrythmia which has been controlled by a pacemaker. Physical exam
revealed a regular pulse, normal heart sounds, and a soft non-tender
abdomen.

Set A Case 2
Question 1
Describe the course of the pacemaker leads. The place where they enter the
vascular system is indicated on the PA by the asterisk. What vessels do they
pass through to enter the heart? What is the anatomic location for each of the
lead tips? (Hint: use both projections to localize the lead tips in 3 dimensions.)

58 year old patient PA 58 year old patient lateral

Set A Case 2
Question 1
Describe the course of the pacemaker leads. What vessels do they pass through to
enter the heart? The place where they enter the vascular system is indicated on the PA
by the asterisk. What is the anatomic location for each of the lead tips? (Hint: use both
projections to localize the lead tips in 3 dimensions.)
58 year old patient PA 58 year old patient lateral

2 2

L subclavian v. L brachiocephalic v. SVC

The tip of lead 1 is in the RA. The tip of lead 2 is in the RV.
Set A Case 2 Answer
Question 2
Comment on the patient’s heart size and heart shape / contour.
Describe the radiographic appearance of the most obvious abnormality, which
is visualized on both views. What three-dimensional shape and composition
does it indicate?

Set A Case 2
58 year old patient PA 58 year old patient lateral
Question 2
Comment on the patient’s heart size and heart shape / contour. Describe the
radiographic appearance of the most obvious abnormality, which is visualized on
both views. What three-dimensional shape and composition does it indicate?
The heart is markedly enlarged. The contours indicates that the LV is the
most prominent of the chambers. There is a large spherical rim of
calcification related to the LV. The rim shape indicates calcification of the
wall of a structure with a hollow center / lumen.

58 year old patient PA 58 year old patient lateral

Set A Case 2 Answer
 Question 3
Identify the numbered structures on this CT performed after IV contrast was given.

Question 4
Identify the abnormality you previously described on the CXRs. What specific
pathologic lesion does it indicate?
Question 5
What additional abnormality is
visualized on this image that
was not evident on the CXRs?

2
1
4

Set A Case 2
Question 3
Identify the numbered structures on this CT performed after IV contrast was given.
1 lead in RA 3 LA 5 descending aorta
2 lead in RV 4 LV

Question 4
Identify the abnormality you previously described on the CXRs. What specific pathologic
lesion does it indicate?
There is an outward bulge of the
anterolateral wall of the LV which
is calcified in the pattern seen on
the CXRs ( ). This is a large * *
left ventricular aneurysm. 2
Question 5 1
What additional abnormality is 4
visualized on this image that
was not evident on the CXRs?
3
There is a crescent shaped region
of soft tissue density between the
5
wall of the LV and the contrast-
enhanced blood in its lumen. It is a
mural thrombus * in the LV.
Set A Case 2 Answer
 *

Set A Case 2 CT 55 year old patient

 CT 55 year old patient

Set A Case 2 Answer

Here is an image from the patient’s abdominal CT performed after IV contrast
was given.
Question 7
Identify, anatomically localize and
describe the appearance of the
major abnormality that is causing
the patient’s left upper quadrant
pain. How is it related to the
cardiac abnormality?

There is a low attenuation

wedge – shaped region * in the
spleen, compatible with a
splenic infarct. The thrombus in
the LV is a source of emboli that
can travel into systemic arteries
and lodge in (splenic, for
example) arterioles, causing
acute obstruction and absence
of blood perfusion, resulting in
tissue death.
Set A Case 2 Answer
 Ventricular Aneurysm
• Ventricular aneurysms develop in regions of weakened myocardium
damaged by myocardial infarct. The wall in this region typically contains
scar and necrotic muscle and occasionally viable muscle. Intraventricular
pressure stretches the non-contracting infarcted myocardium, causing it
to bulge outward with each contraction. They are an uncommon
complication of MI, seen in <5% of transmural MIs.

• Ventricular pseudoaneurysms result from a rupture in the ventricular wall

with hemorrhage into the pericardial sac. The clot is localized and
contained by pericardial adhesions. While a true ventricular aneurysm is
bounded by weakened myocardium, a pseudoaneurysm is bounded by
connective tissue or pericardium. Pseudoaneurysms are more likely than
true aneurysms to rupture.

• Complications from ventricular aneurysms include: interference with

ventricular performance thereby diminishing cardiac output, thrombus
formation in 10-40% of cases with risk of embolization, increased
incidence of ventricular tachyarrythmias leading to sudden death, and
more rarely, rupture of a true ventricular aneurysm.
Set A Case 2 Answer
 Ventricular Aneurysm
•CT, MR, echocardiogram, and angiography can all diagnose ventricular
aneurysm.

L ventriculogram in RAO projection Echo shows a thrombus *

shows a large true aneurysm * of in a LV apical aneurysm.
the apical – anterior wall.
Catheter introduced via aorta.

Set A Case 2 Answer

 An infant born at full term developed episodes of cyanosis of the skin, lips
and nail bed while crying or feeding several weeks after birth. Blood test
revealed low arterial oxygen saturation.

Set B Case 1
 Here is an AP chest from a normal
neonate.

Set B Case 1
Here is an AP chest from a normal
neonate.

Set B Case 1 Answer

 Question 2
Compare the AP image of our patient (taken at age 4 months) with the normal image
you have just analyzed. On the patient’s image identify the structures which were
labeled on the normal image. How do they differ? What anatomic abnormalities do
these changes suggest? What imaging study should be performed next?

AP chest normal neonate

Set B Case 1 AP chest 4 month old cyanotic infant

 Question 2
Compare the AP image of our patient (taken at age 4 months) with the normal image
you have just analyzed. On the patient’s image identify the structures which were
labeled on the normal image. How do they differ? What anatomic abnormalities do
these changes suggest? What imaging study should be performed next?

Set B Case 1 Answer AP chest normal neonate AP chest 4 month old cyanotic infant
Question 3
Using the illustration to help with orientation, identify the labeled structures on the
patient’s parasternal long axis echocardiogram. What abnormality is indicated by the
arrow? Can you recognize the abnormality of structure 1? Hint: compare the two
regions labeled “1” on the illustration with the same regions on the echo. What is the
patient’s diagnosis?

1
A
2
D
1 B

parasternal long axis echo

Set B Case 1 4 month old cyanotic patient
Question 3
Using the illustration to help with orientation, identify the labeled structures on the
patient’s parasternal long axis echocardiogram. What abnormality is indicated by the
arrow? Can you recognize the abnormality of structure 1? Hint: compare the two
regions labeled “1” on the illustration with the same regions on the echo. What is the
patient’s diagnosis?
A is RV B is LV C is LA D is aorta 1 is ventricular wall 2 is interventricular septum
The thickness of the RV wall in our patient is greater than that of the LV, indicating that
it is hypertrophied. The aorta overrides both the LV and the RV. All of these findings
support a diagnosis of tetralogy of
points to a ventricular septal defect
Fallot.

1
A
2
D
1 B

parasternal long axis echo

Set B Case 1 Answer 4 month old cyanotic patient
 Tetralogy of Fallot (ToF)
Tetralogy of Fallot is a complex congenital heart defect with an incidence of 5/10,000
births. It affects males and females equally. Classically it includes four components:
1 Pulmonary Stenosis Narrowing of the right ventricular outflow tract which may be
valvular or infundibular.
2 Right ventricular hypertrophy This feature is now generally agreed to be a
secondary anomaly.
3 Overriding aorta The origin of the aorta is displaced over the IV septum and its
defect, and communicates with both ventricles.
4 Ventricular septal defect This is usually single and large and located at the superior
aspect of the septum.
• The degree of pulmonary stenosis (and thus the degree of right outflow obstruction)
varies among individuals with ToF and is the main determinant of symptoms and
severity by affecting the pressure gradient causing the shunt. The greater the
resistance to flow into the pulmonary vasculature,
the more significant will be the right to left shunt and
the more severe the cyanosis will be.

Set B Case 1 Answer

 Tetralogy of Fallot (ToF)
• Imaging findings for Tetralogy of Fallot include an uplifted and displaced cardiac apex
and the absence of the normal pulmonary arterial contour causing the mediastinum to
be shaped like a boot (a coeur en sabot).

• MR imaging provides good delineation of the aorta, right ventricular outflow tract,
VSDs, RV hypertrophy and the pulmonary artery. However, it requires sedating small
children to prevent motion artifacts and sick infants cannot be monitored when they
are within the MRI tunnel.

Set B Case 1 Answer https://www.youtube.com/watch?v=DrgUSGvL_4Q

 A 3 month old infant was brought to his pediatrician because of difficulty
with feeding and poor weight gain. Physical exam reveals no evidence of
cyanosis and a continuous murmur heard in the left infraclavicular region.
The physician ordered a CXR.

Set C Case 2
Question 1
Compare the patient’s PA CXR to one of a normal child. What is abnormal
about his heart and lungs? (Hint: assess both the size of the heart and the
mediastinal contours as well as the pulmonary vasculature.) What can you
deduce about the pattern of blood flow in the thorax?

PA of 3 month old patient Normal PA

Set C Case 2
Question 1
Compare the patient’s PA CXR to one of a normal child. What is abnormal about his heart
and lungs? (Hint: assess both the size of the heart and the mediastinal contours as well as
the pulmonary vasculature.) What can you deduce about the pattern of blood flow in the
thorax? PA of 3 month old patient Normal PA

The heart is enlarged. The contour of the pulmonary artery is abnormally prominent /
convex. The pulmonary blood vessels are more prominent than normal – they are
visualized farther into the periphery of the lungs as they taper. Together these three
findings indicate a left – to – right shunting of blood within the circulation of the thorax;
oxygenated blood from the left side of the heart shunts back to the pulmonary circulation
rather than being delivered via the aorta to the systemic circulation. The abnormally
large volume of shunted blood engorges some of the heart chambers, pulmonary artery
and the pulmonary blood vessels.
Set C Case 2
 The patient was lost to follow-up.
At age 30 he presented with severe lower extremity edema and cyanosis. His
upper extremities, head and neck were not affected.

Question 2
Compare the patient’s PA CXR with a normal (female) PA. Which abnormalities
that were present on his previous CXR are still present? Are there any new or
different findings? (Hint: note the pulmonary vasculature.)

PA 30 year old patient Normal PA

Set C Case 2
 The patient was lost to follow-up.
At age 30 he presented with severe lower extremity edema and cyanosis. His
upper extremities, head and neck were not affected.
Question 2
Compare the patient’s PA CXR with a normal (female) PA. Which abnormalities
that were present on his previous CXR are still present? Are there any new or
different findings? (Hint: note the pulmonary vasculature.)

The heart is still enlarged. The pulmonary artery contour is now normal. The
L and R pulmonary arteries are now prominent and most of their branches are
small; there is very little tapering. The vessels are no longer prominent out to
the periphery of the lungs. The changes indicate increased pulmonary
vascular resistance causing pulmonary hypertension.

Set C Case 2 Answer PA 30 year old patient Normal PA

Question 3
Compare the patient’s lateral CXR with a normal (female) lateral. Which contour and
chamber of his heart is abnormal? Which abnormality visualized on the PA is also seen
here?

Lateral 30 year old patient Normal lateral

Set C Case 2
Question 3
Compare the patient’s lateral CXR with a normal (female) lateral. Which contour
and chamber of his heart is abnormal? Which abnormality visualized on the PA is
also seen here?

Lateral 30 year old patient Normal lateral

The anterior contour of the heart at its superior aspect is displaced

anteriorly, indicating that the RV is enlarged. RV hypertrophy resulted from
the chronic pulmonary hypertension. The hila are enlarged due to the
prominence of the L and R pulmonary arteries, which was seen on the PA.
Their shadows are superimposed on this projection. This change is also
caused by the pulmonary hypertension. He has right heart failure causing his
lower extremity edema. Set C Case 2 Answer
Question 4
Here is an image from the patient’s echocardiogram, and an image from his
CT performed after IV contrast was given. The white arrows indicate his
congenital abnormality. What is it? How does it explain the findings on the
CXR taken when the patient was an infant? (Hint: remember his murmur.)
What happened to the patient subsequently to explain his adult symptoms and
the findings on his adult CXR?
superior
a ascending
aorta
n arch
desc
PA
t asc
aorta
aorta SVC
e
r
i descending
o aorta

30 yo patient echo suprasternal view 30 yo patient CT

Set C Case 2
 Question 4
Here is an image from the patient’s echocardiogram, and an image from his CT
performed after IV contrast was given. The white arrows indicate his congenital
abnormality. What is it? How does it explain the findings on the CXR taken when the
patient was an infant? (Hint: remember his murmur.) What happened to the patient
subsequently to explain his adult symptoms and the findings on his adult CXR?
superior
a ascending
aorta
n arch
desc
PA
t asc aorta
aorta SVC
e
r
i descending
o aorta

30 yo patient echo suprasternal view 30 yo patient CT

The patient has a large patent ductus arteriosus (PDA) between the
pulmonary artery and the descending aorta. This caused the left to right
shunt when the patient was an infant, allowing oxygenated blood to pass from
the high resistance systemic circulation to the low resistance pulmonary
circulation. Subsequently he developed pulmonary hypertension and the shunt
became a right to left shunt. Set C Case 2 Answer
 Eisenmenger’s syndrome (ES)
• ES occurs when a left to right shunt caused by a congenital heart defect leads to
increased flow through the pulmonary vasculature resulting in pulmonary
hypertension. The increased pressure that develops in the right side of the heart
eventually causes reversal of the shunt into a right to left shunt:

congenital left to increased increased

right to
cardiac right shunt pulmonary pulmonary
left shunt
defect blood flow vascular
resistance
• The incidence of moderate to severe congenital heart defect (CHD) is about 6 – 19
per 1,000 live births. About 11% of those with left to right shunting develop ES.
The likelihood depends on the size and the location of the CHD. The larger the
defect the greater the likelihood. ASD, VSD, PDA and truncus arteriosus are some
of the CHDs that can lead to ES.

• Signs and symptoms of ES include:

cyanosis fainting and syncope
arrythmia finger clubbing or swelling
hemoptysis heart failure
polycythemia (elevated hematocrit) may cause hyperviscosity

Set C Case 2 Answer

 Eisenmenger’s syndrome (ES)
•ES can be prevented if the CHD is identified and surgically repaired before pulmonary
hypertension develops. Once it does, patients with reasonable functional status are
usually treated medically. Heart and lung or lung transplantation with CHD repair is the
final treatment option for those with poor prognosis.

Patent Ductus Arteriosus (PDA)

• The DA is a remnant of the sixth aortic arch. It provides a right to left shunt in utero,
allowing blood from the right side of the heart to detour around the high resistance
pulmonary circulation and flow directly into the aorta just distal to the origin of the L
subclavian artery. It normally closes several days after birth, stimulated by increased
oxygen levels, to become the ligamentum arteriosum.

• PDA is more common in premature infants whose lungs are poorly aerated due to
lack of surfactant. It is also more common in females and may be familial. Maternal
rubella infection may cause PDA. PDA causes a left to right shunt. Small shunts
may be asymptomatic; larger shunts may cause dyspnea and failure to thrive.

• When Eisenmenger’s syndrome develops from PDA the resulting cyanosis spares the
head, neck, and upper limbs because the right to left shunt occurs distal to the origins
of the brachiocephalic, L common carotid, and L subclavian arteries. There is no
such differential cyanosis in patients whose ES is caused by ASDs or VSDs.
Set C Case 2 Answer
 An 80 year old man presented to his physician because of several recent
episodes of loss of vision in his right eye (amourosis fugax), slurred speech
(dysarthria), left lower extremity weakness, and confusion. Each episode
lasted 5 -10 minutes and resolved spontaneously.

Set D Case 2
 This is a color Doppler US image from an exam of a normal common carotid
artery bifurcation in the sagittal plane.

Question 1
Identify the anatomic axes and the three main arteries in the image.

Normal color Doppler US carotid artery sagittal plane

Set D Case 2
 This is a color Doppler US image from an exam of a normal common carotid
artery bifurcation in the sagittal plane.

Question 1
Identify the anatomic axes and the three main arteries in the image.
Anterior

Inferior
2
Superior

1
*
3

Normal color Doppler US carotid artery sagittal plane

1 CCA 2 ECA 3 ICA
The ECA lies anterior to the ICA and normally has branches * in the neck.
The ICA has only intracranial branches.

Set D Case 2 Answer

 This is a color Doppler US image from an exam of a normal common carotid
artery bifurcation in the sagittal plane.

Question 2
What is the direction of the blood flow: from your left to right, or from your
right to left?

Normal color Doppler US carotid artery sagittal plane

Set D Case 2
This is a color Doppler US image from an exam of a normal common carotid artery
bifurcation in the sagittal plane.

Question 2
What is the direction of the blood flow: from your left to right, or from your right to left?
Transducer Transducer location is at
top (anterior) end of image
Blood is flowing
away from transducer Normal color Doppler US
carotid artery sagittal plane

The blood is flowing from our right to our left. There are two ways to arrive at
this answer:
1 The best way is to use the color graph. Red is assigned to flow away from
the transducer, so the blood is flowing away from the transducer toward the
bottom of the image. That is toward our left because of the angle of the long
axis of the vessels.
2 Since this is noted as a normal study, the blood in the carotid arteries must
be flowing superiorly, toward the head. For longitudInal images, superior is
always displayed toward the viewer’s left. However, you cannot assume that
a study is normal, and therefore the first method is the only valid one.
Set D Case 2 Answer
A spectral Doppler image is a graph displaying the velocity (cm/s) of the blood
flow from a particular point in a vessel's lumen (the y axis) versus time (the x
axis).
Question 3
Here are two normal spectral Doppler images. Decide which was obtained
from an ECA and which from an ICA.
Hint: consider the oxygen A
requirement / level of
metabolism of the organs
being perfused by branches
of these arteries.

Set D Case 2
A spectral Doppler image is a graph displaying the velocity (cm/s) of the blood flow
from a particular point in a vessel’s lumen (the y axis) versus time (the x axis).
Question 3
Here are two normal spectral Doppler images. Decide which was obtained
from an ECA and which from an ICA. Hint: consider the oxygen requirement /
level of metabolism of the organs being perfused by branches of these arteries.
A is ICA
B is ECA
beginning of systole

A end of diastole B

The ICA supplies the brain, an organ with high metabolic activity and oxygen
consumption. Thus flow within it is less pulsatile than the flow in the ECA;
there is relatively more flow in it during diastole than there is in the ECA.
This provides more constant perfusion of the brain. The organs supplied by
the ECA (mostly mucosa, muscles and glands of the upper aerodigestive
tract) do not have as high a demand for oxygen.
oThe pattern of flow in the ICA is a low resistance pattern.
oThe pattern of flow in the ECA is a high resistance pattern.
Set D Case 2 Answer
Here are gray scale and color Doppler images of our patient’s right ICA.

Question 4
Describe the vascular abnormality on the gray scale image. What is its
etiology? What additional information does the color image provide?

80 y.o. patient sagittal gray scale 80 y.o. patient sagittal color Doppler

Set D Case 2
 Here are gray scale and color Doppler images of our patient’s right ICA.
Question 4
Describe the vascular abnormality on the gray scale image. What is its
etiology? What additional information does the color image provide?
There is a large mural structure protruding into the lumen of the ICA. Its
echogenic surface and anechoic shadow * likely indicate calcification. The
appearance is compatible with atherosclerotic plaque. The plaque causes
stenosis of the vessel lumen. The mottled color pattern in the narrowed
segment displays a wide variation in the flow direction, indicating turbulent flow.

80 y.o. patient sagittal gray scale 80 y.o. patient sagittal color Doppler
Set D Case 2 Answer
 Question 5
Using your knowledge of physics, predict the shape of the spectral Doppler
tracing in the narrowed segment of the ICA.

80 y.o. patient sagittal color Doppler

Set D Case 2
 Question 5
Using your knowledge of physics, predict the shape of the spectral Doppler
tracing in the narrowed segment of the ICA.
Bernoulli’s principle states that when a conduit carrying a fluid narrows, the
velocity of flow increases through the narrowed segment. Normal peak
velocity in the ICA should be < 125 cm/sec. In our patient the peak velocity is
367 cm/sec. The greater the velocity, the narrower the diameter of the vessel.
This value helps estimate the degree of stenosis in the artery. Turbulence
often accompanies the more rapid flow.

80 y.o. patient sagittal color Doppler Normal sagittal duplex Doppler ICA

Set D Case 2 Answer

 Carotid Artery Stenosis (CAS)
• CAS is one of several etiologic factors for stroke. A U.S. Preventive Task
Force estimated the prevalence of significant stenosis (60-99% of the
lumen) in the population older than 65 years to be about 1%.

• The major cause of CAS is atherosclerosis. Risk factors include:

hypertension, tobacco use, diabetes, hyperlipidemia, family history,
increasing age. Lack of exercise and obesity are indirect causes since
they increase the incidence of hypertension and diabetes.

• CAS may remain asymptomatic in its early stages. When it becomes more
advanced it causes decreased perfusion of the brain resulting in a transient
ischemic attack (TIA), characterized by reversible neurologic deficits, or
stroke which involves permanent neurologic deficits. These include
numbness or weakness in the face or limbs (often unilateral), difficulty
speaking and / or seeing, language deficit (aphasia), dizziness or loss of
balance. The onset of these symptoms is usually sudden.

• Ultrasound is usually the first imaging modality used to diagnose CAS. It is

noninvasive and does not require ionizing radiation or IV contrast. CT
angiography and MR angiography may also play a role.
Set D Case 2 Answer
 A 65 year old man presented to his physician complaining of episodes of
dyspnea during exertion sometimes accompanied by syncope. The physician
noted a systolic murmur on physical exam. The patient's vital signs are stable
at rest.

Set C Case 1
Question 1
Identify the numbered
structures on this
normal PA chest. 1

2 3

Normal PA

Set C Case 1
Question 1, continued

Identify the anatomic

structures that 1
contribute to the
components of the
mediastinal contours
which are outlined on
2 3
this normal PA CXR.
4

Normal PA

Set C Case 1
Question 1
Identify the numbered
structures.
1 trachea
2 right main bronchus 1
3 left main bronchus
4 carina

Identify the anatomic 2 3

structures that contribute
to the components of the 4
mediastinal contours
which are outlined on
this normal PA chest.
aortic knob
pulmonary artery
left atrium
left ventricle
superimposed
ascending aorta / SVC
right atrium Normal PA
descending aorta
Set C Case 1 Answer
Question 2
Identify some of the same numbered
structures you identified on the PA.

Identify the anatomic

structures that contribute 1
to the components of the
cardiac contours
which are outlined on
this normal lateral chest. 4

Note that the “L” label on the image

indicates that the image was obtained
in left lateral projection.

Normal lateral
Set C Case 1
 Question 2
Identify some of the same numbered
structures you identified on the PA.
1 trachea
4 carina
1
Identify the anatomic
structures that contribute to the
components of the cardiac contours 4
which are outlined on this normal
lateral chest.
right ventricle
left atrium
left ventricle
Note that the “L” label on the image
indicates that the image was obtained
in left lateral projection.

Normal lateral
Set C Case 1 Answer
 Question 3
Assess our patient’s heart size by comparing it to the normal PA CXR.

PA 65 year old patient Normal PA

Set C Case 1
 Question 3
Assess our patient’s heart size by comparing it to the normal PA CXR.
On a non-rotated PA CXR taken in good inspiration the width of the heart at its
widest point should not exceed half the diameter of the thorax at its widest point
(measuring from the medial margins of the ribs). The normal cardiothoracic
ratio < 1:2. An easy way to estimate this ratio is to mentally add the width of
the heart in the R. hemi-thorax to the width of the heart in the L. hemi-thorax. If
the sum of these widths extends lateral to the inner margin of the left rib cage,
the cardiothoracic ratio exceeds 1:2 and the heart is enlarged.

PA 65 year old patient shows cardiomegaly Normal PA Set C Case 1 Answer

Question 3, continued
Assess our patient’s heart shape by comparing it to the normal PA to determine
which of the mediastinal contour(s) is / are abnormal. What does this tell you
about the patient’s heart?

PA 65 year old patient Normal PA

Set C Case 1
Question 3, continued
Assess our patient’s heart shape by comparing it to the normal PA to determine
which of the mediastinal contour(s) is / are abnormal. What does this tell you
about the patient’s heart?
The LV contour is prominent and the cardiac apex is displaced to the left. The
cardiac enlargement is due to enlargement of the LV. The contour of the
ascending aorta is also abnormally prominent.

PA 65 year old patient Normal PA

Set C Case 1 Answer
Question 4
Assess our patient’s heart shape by comparing it to the normal lateral to
determine which of the mediastinal contour(s) is / are abnormal. What does
this tell you about the patient’s heart?
What is the composition and location of the structure indicated by the arrow?
What pathology does it indicate? (Hint: consider the patient’s history and
physical finding.)

Lateral 65 year old patient - detail Normal lateral

Set C Case 1
 Question 4
Assess our patient’s heart shape by comparing it to the normal lateral to
determine which of the mediastinal contour(s) is / are abnormal. What does
this tell you about the patient’s heart?

The LV contour extends too far posteriorly, confirming the finding on the PA
that it is enlarged.

Another patient s/p mitral

Lateral 65 yo patient - detail Normal lateral (detail)
& aortic valve replacement
Set C Case 1 Answer
 Question 4
What is the composition and location of the structure indicated by the arrow?
What pathology does it indicate? (Hint: consider the patient’s history and
physical finding.)

This is a calcified aortic valve. On the lateral view the aortic valve lies above
a line drawn between the carina and the junction of the diaphragm and the
anterior chest wall. The mitral valve projects below this line. The history,
murmur, and imaging findings all support a diagnosis of aortic stenosis due to
a calcified aortic valve which is probably congenitally bicuspid.

Another patient s/p mitral

Lateral 65 yo patient - detail Normal lateral (detail)
& aortic valve replacement
Set C Case 1 Answer
 Aortic (Valve) Stenosis
• AS occurs in approximately 2% of people over 65 years, more often in men. It is the
most common valvular disease that requires valve replacement.

• The causes of aortic valve narrowing include a:

Congenital defect, a bicuspid aortic valve is the most common aortic valve
disease (1.3% worldwide)

Valve calcification, which develops with age and in many patients does not
interfere with valve function. It is more likely to do so in congenitally
deformed valves.

Rheumatic heart disease that causes scar tissue to form on the valves,
leading to valvular stenosis, insufficiency, or both. It may affect several
valves, most commonly the mitral valve.

• Symptoms and signs usually develop when aortic stenosis is severe and include:
1 angina or chest tightness
2 syncope on exertion
3 fatigue
4 palpitations
5 crescendo – decrescendo systolic murmur
Set C Case 1 Answer
 Aortic (Valve) Stenosis
• Complications: AS causes LV hypertrophy. Initially, this is a compensation allowing
the LV to eject an adequate stroke volume even when hindered by the stenotic
valve. Eventually hypertrophy leads to cardiac decompensation and heart failure.
Arrythmia and myocardial infarction may also occur.

• The following may be seen on CXR:

1 LV enlargement is initially caused by LV hypertrophy
2 As decompensation occurs, LV dilatation can cause LV enlargement on the CXR
3 Calcification of the aortic valve
4 Post-stenotic dilatation of the ascending aorta ( ) results from the pressure of a
high velocity jet of blood squeezed through the narrow valve pounding on the wall of
the aorta opposite the valve.

• Echocardiography is the test of choice to diagnose AS. It is sensitive, specific, and

noninvasive. It also allows evaluation of LV function and valve morphology.

Parasternal long axis

echo image obtained
during systole shows a RV
stenotic aortic valve ( ) LV * aorta
and hypertrophy of the
LV myocardium *. * LA
*
Set C Case 1 Answer
 A 50 year old man status post placement of a pacemaker several
years ago developed dyspnea. He was afebrile, had normal blood
pressure, and did not complain of chest pain.

Set D Case 1
Question 1
Identify the following structures on this normal PA chest x-ray.

left clavicle
right coracoid
anterior part of left third rib
posterior part of right eighth rib
left costophrenic angle
right atrial border
left hilum
cardiac apex
gastric air bubble

Normal PA
Set D Case 1
Question 1
Identify the following structures on this normal PA chest x-ray.

1 left clavicle 1

2 right coracoid 2

3 anterior part of left third rib

4 posterior part of right eighth rib
3
5 left costophrenic angle
6 right atrial border
7
7 left hilum
8 cardiac apex 4
9 gastric air bubble 6

Identifying/counting individual 6
ribs is necessary to determine
8
the degree of inspiration and to
localize lesions visualized in the 9
5
lungs.

Normal PA
Set D Case 1 Answer
Question 2
How does the size and shape of our patient’s heart shadow compare with that
of a different patient? Ignore our patient’s nasogastric tube projecting over his
mediastinum and abdomen.

AP portable different patient

AP portable 50 year old man with dyspnea

Set D Case 1
Question 2
How does the size and shape of our patient’s heart shadow compare with that of a
different patient? Ignore our patient’s nasogastric tube projecting over his
mediastinum and abdomen.

AP portable 50 year old man with dyspnea AP portable different patient

Both patients have markedly enlarged hearts. While the structures contributing to the
contours of the heart and mediastinum are recognizable on the right image (even though
some of them are enlarged), there are no normal contours discernible on our patient’s
image. His cardiac contour is globular.
Set D Case 1 Answer
Question 3
Identify the numbered regions on this subcostal view echocardiogram of our patient and
CT image (performed after IV contrast was given) from another patient with the same
condition. What is the composition and location of the areas marked by the asterisks?
What is the patient’s abnormality?

2
* 1 4
3 *
5

55

50 yo patient echocardiogram Another patient

Set D Case 1
Question 3
Identify the numbered regions on this subcostal view echocardiogram of our patient and
CT image (performed after IV contrast was given) from another patient with the same
condition. What is the composition and location of the areas marked by the asterisks?
What is the patient’s abnormality?

2
* 1 4
3 *
5

55

50 yo patient echocardiogram Another patient

1 RA 2 RV 3 LA 4 LV 5 descending aorta
The region with the asterisks is anechoic on the US image, compatible with simple
fluid. The gray scale value of this region on the CT is also compatible with fluid. The
fluid almost entirely surrounds the heart and is within the pericardial cavity. It is a large
pericardial effusion.
Set D Case 1 Answer
Here are the AP CXRs you evaluated previously, and coronal reformatted CT images from each
patient. The globular enlarged heart in our patient is due to the pericardial effusion. The
appearance is called a “water bottle heart” since it evokes a filled hot water bottle (like the one in
the illustration on the first slide) which bulges outward in all directions when distended. The
enlarged heart in the other patient is due to RA and LV dilation. 1 contrast in LV lumen
2 myocardium 3 pericardial effusion
3
1
2 3

Set D Case 1 Answer

 Pericardial Effusions
• Normally the pericardial space contains only a few mls of serous fluid. It serves as a
lubricant to reduce the friction between the visceral and parietal layers of the serous
pericardium lining the space as the two layers rub against each other during each
heartbeat.
• Many conditions can cause the accumulation of fluid in this space, resulting in a
pericardial effusion. Some of the most common are:
Infection Autoimmune (rheumatoid arthritis, lupus)
Uremia Hypothyroidism
Trauma (hemopericardium) Cancer (lymphoma or metastases)
Prescription drugs Radiation and chemotherapy
Dressler’s syndrome (pericarditis after heart surgery, myocardial infarction)
• Significant pericardial effusion may occur without signs or symptoms, especially if the
fluid accumulates slowly. Symptoms and signs include:
Dyspnea Orthopnea (dyspnea while supine)
Cough Tachycardia (rapid heart rate)
Low grade fever Diminished heart sounds during
ECG changes auscultation
Chest pain: typically retrosternal or on the left side, worse with breathing,
and better when sitting than when lying down
• Echocardiography is the imaging modality of choice. CXR, CT, and MR may also
play a role.
Set D Case 1 Answer