This is Barry Bellosis, one of the musculoskeletal radiology fellows at Stanford University. 20-year-old female presents a training room complaining of dyspnea, midline chest, and left-sided rib pain, concern for pulmonary embolism. The patient in this case presented with this PA and lateral chest radiograph. In patients with pulmonary embolism, radiographs are usually normal. There are described radiographic findings that are neither sensitive nor specific. The patient's radiograph demonstrates blunting of the left costrophrenic angle, which is nonspecific and may represent small atelectasis or pleural effusion. On a different patient, here the chest radiograph show a described finding called Hampton hump. It is a dome-shaped, pleural-based peripheral opacification that we can see here on the right mid-lung as a rounded opacification. This raised concern for pulmonary embolism. However, this finding is nonspecific and may represent an organizing pneumonia. Hampton hump on CT pulmonary arteriogram. In our coronal reformat, we can see a pleural-based opacity in the right mid-lung. Approximately, we can see a feeling defect within the pulmonary artery consistent with pulmonary embolism. On our axial imaging here, we can see feeling defect in both the right main pulmonary artery and the left lower lobe pulmonary arteries. Just peripherally, we can see this pleural-based rounded opacification consistent with pulmonary infarct associated with pulmonary embolism. Additional radiographic findings described are the Fleischner and Westermark sign as in this different patient's chest radiograph. Fleischner sign is a prominent central pulmonary artery as seen here, but this finding is not specific for PE and could be seen in patients with pulmonary arterial hypertension. Westermark is relative oligemia on the periphery consistent with decreased caliber of the pulmonary arterial markings. We can see here that there is decreased pulmonary arterial markings than expected. The patient in this case underwent CT and demonstrating a saddle pulmonary embolism. Saddle pulmonary embolism is a large PE straddling the main pulmonary arterial bifurcation. There is a small rounded opacity in the periphery, which is not well depicted on the radiograph, and this is consistent with a developing pulmonary infarct. Important additional assessment that we do in patients with pulmonary embolism is looking at the size of the main pulmonary artery to look for evidence of increased pulmonary arterial pressure. Additionally, we look at the right heart to look for any evidence of right heart strain. This could be seen by enlargement of the right heart ventricle compared to the left or any bowing of the intraventricular septum to the left.

2nd Edition, CASE 42

2nd Edition

Pulmonary