PULMONARY AVMs (521-D)

Abnormal vascular communication between pulmonary artery and vein (95%) or systemic artery and pulmonary vein (5%)

Change in size with Valsalva/Mueller maneuver/erect vs. recumbent position (decrease with Valsalva maneuver) Cordlike bands

AETIOPATHOGENESIS
ETIOLOGY

Congenital defect of capillary structure (common) Acquired

From mass to hilum (feeding artery + draining veins) Phleboliths Occasionally increased pulsations

Cirrhosis (hepatogenic pulmonary angiodysplasia) Cancer Trauma Surgery Infections

Of hilar vessels CT SCAN (98% detection rate) Mass/lesion

Homogeneous circumscribed non-calcified nodule/serpiginous mass up to several cm in diameter Vascular supply

Actinomycosis Schistosomiasis TB (Rasmussen aneurysm) PATHOGENESIS

Vascular connection of mass feeding artery & draining vein Enhancement

with

enlarged

It is hemangioma of cavernous type Low-resistance extra cardiac R-to-L shunt (which may result in paradoxical embolism)

CLINICAL SCENARIO
AGE & GENDER

MRI Indications

Sequential enhancement of feeding artery, aneurysmal part & efferent vein on dynamic CT

3 4
rd

th

decade (hereditary

If contraindication to contrast material

Manifest in adult life, 10% in childhood ASSOCIATIONS Rendu Osler Weber syndrome hemorrhagic telangiectasia) CLINICAL FEATURES

If flow slow due to partial thrombosis For follow-up Intensity Signal void on standard spin echo High signal intensity on GRASS images or

ANGIO

Asymptomatic in 56% (until 3rd-4th decade) if AVM single and <2 cm Orthodeoxia (Increased hypoxemia with PaO2 <85 mm Hg in erect position due to gravitational shift of pulmonary blood flow to base of lung) Cyanosis with normal-sized heart (R-to-L shunt) Clubbing Bruit over lesion (increased during inspiration) Dyspnea on exertion, palpitation, chest pain Hemoptysis No CHF Simple type (79%)

Mostly obviated by MR/CT unless surgery embolization contemplated 100% sensitive for detection of vessels >2 mm COMPLICATIONS Pulmonary Hemoptysis

Most common presenting symptom Secondary to rupture of PAVM into bronchus Secondary to rupture of sub pleural PAVM

Hemothorax

CNS

TYPES

Single feeding artery empties into a bulbous nonseptated aneurysmal segment with a single draining vein Complex type (21%)

Are commonly the initial manifestation Cerebrovascular accident Stroke (18%)

Transient ischemic attack (37%) secondary to paradoxical bland emboli Brain abscess

RADIOLOGICAL FEATURES
LOCATION

More than one feeding artery empties into septated aneurysmal segment with more than one draining vein

Secondary to loss of pulmonary filter function for septic emboli

Others Polycythemia

Lower lobes (65-70%) > middle lobe > upper lobes Bilateral (8-20%) Medial third of lung

SPECTRUM OF CHEST DISEASES IN IMMUNOCOMPROMIZED/AIDS STATE (23-P)

Nodules Kaposi sarcoma Usually associated with skin lesions Septic infarcts Rapid size increase Fungal Cryptococcus Aspergillus Large opacity

In 2/3 single lesion & in 1/3 multiple lesions PLAIN RADIOGRAPHY SPN/Coin lesion

Sharply defined, lobulated oval/round mass (90%) of 1 to several cm in size Size changes Enlargement with advancing age

Maj Amer Hayat Haider-Senior Resident Radiology-MH Rawalpindi (13-05-2011) MISC -01

Consolidation, Pneumonia

Mass Hemorrhage NHL Linear or interstitial opacities PCP Atypical mycobacterium Kaposi sarcoma Lymphadenopathy Mycobacterium infections Kaposi sarcoma Lymphoma Reactive hyperplasia, rare in thorax Pleural effusion Kaposi's sarcoma Mycobacterium, fungal infection Pyogenic empyema

Abnormal accumulation of fluid in the extra-vascular compartments of the lung

CAUSES OF PULMONARY EDEMA

VQ SCAN DEFECTS (29-DD)

MISMATCHED DEFECTS
PERFUSION DEFECTS Perfusion defect is greater than the ventilation defect Causes Pulmonary embolus

CARDIOGENIC Adults LV failure from CAD (most common) Mitral regurgitation (common) Ruptured chordae Endocarditis Neonates TAPVC below diaphragm Hypoplastic left heart Cor triatriatum RENAL Renal failure Volume overload LUNG INJURY (Increased permeability & capillary leak) Shock Septic shock

Especially if multiple and segmental Embolus

Tumor embolus Fat embolus Vasculitis

Neurogenic shock Fat embolism Inhalation Sulphur dioxide Oxygen Chlorine Nitrous oxide Aspiration

Polyarteritis nodosa

Drowning RADIOLOGICAL FEATURES

TYPES Pulmonary edema can be classified according to its causes 03 types 1. Cardiogenic pulmonary edema 2. Renal pulmonary edema 3. Pulmonary edema associated with pulmonary injury

Systemic lupus erythematosus Bronchial carcinoma

But more commonly matched. Tuberculosis

Typically affecting an apical segment Post-radiotherapy Pulmonary hypertension VENTILATION DEFECTS

Bronchial obstruction with normal blood supply Ventilation defect greater than perfusion defect Chronic obstructive airways disease Pneumonia Carcinoma

DIFF FEATURES OF VARIOUS TYPES OF PULMONARY EDEMA

FEATURES Heart size Blood flow Distribution Kerley lines Air bronchogra m Pleural effusion GRADING OF CARDIOGE NIC Enlarged Inverted Basilar Common Not common RENAL Normal Balanced Central/Batw ing Common Not common LUNG INJURY Normal Normal Diffuse Absent Very common

The rarest appearance with bronchial carcinoma Lung collapse

Of any cause Pleural effusion

MATCHED DEFECTS
Chronic bronchitis Pulmonary infarct mismatched

Very Common Not common common CARDIOGENIC PULMONARY EDEMA

ventilation or

Do not confuse with the perfusion defect of embolus Asthma or acute bronchitis May also show mismatched perfusion defects Collagen vascular disease Lymphangitis carcinomatosa Pulmonary hypertension Sarcoidosis Intravenous drug abuse

Fluid accumulation in the lung due to cardiogenic causes (CHF, pulmonary venous hypertension) follows a defined pattern Grade 1: vascular redistribution (10-17 mm Hg)

Diameter of upper lobe vessels equal or increased over diameter of lower lobe vessels at comparable distance from hilum

Pulmonary veins in 1st intercostal space > 3 mm in diameter Grade 2: interstitial edema (18-25 mm Hg)

Peri-bronchiovascular cuffing & peri-hilar haziness Kerley lines

PULMONARY EDEMA (64-P)

Maj Amer Hayat Haider-Senior Resident Radiology-MH Rawalpindi (13-05-2011) MISC -01

Unsharp central pulmonary vessels (peri-vascular edema) Pleural effusion

Grade 3: alveolar edema (> 25 mm Hg) Air space disease Patchy consolidation

Air bronchogram ASYMMETRICAL PULMONARY EDEMA

Gravitational (most common) Underlying COPD (common) Unilateral obstruction of pulmonary artery (PE) Unilateral obstruction of lobar pulmonary vein (tumor)

CARDIAC PACEMAKERS (109-P)

A specialized bit of heart tissue that controls the heartbeat Natural pacemakers are SA node AV node Myocardium itself (In few cases) Artificial cardiac pacemaker is an instrument which is used to control the cardiac activity in case of any abnormality with the natural cardiac pacemakers Sinus (SA) node diseases AV blocks Reflux syncope Cardiac resynchronization therapy Few other specific conditions

INDICATIONS

LOCATION Typical location is in apex of RV

May be located in

Atrial appendage for atrial pacing Coronary sinus for atrial left ventricular pacing COMPLICATIONS
Displacement of electrodes Broken wires (Rare with modern pacemakers) Twiddlers syndrome (Rotation of pulse generator due to manipulation in a large pacemaker pocket) Perforation Infection Venous thrombosis Vascular obstruction

Maj Amer Hayat Haider-Senior Resident Radiology-MH Rawalpindi (13-05-2011) MISC -01