Case of the Month July 2014, Page 3

ANSWER:  
A) Right heart enlargement and flattening of the interventricular septum
b) Regurgitation of contrast into the inferior vena cava and/or the hepatic veins

The first image above demonstrates asymmetrical enlargement of the right heart and leftward bowing the interventricular septum, an abnormal finding that indicates higher-than-normal right heart filling pressures.  

The second image demonstrates reflux of contrast into the inferior vena cava (IVC).  On a normal CT chest angiogram to evaluate for PE, contrast should not be seen in the inferior vena cava (IVC).  When it is seen, such as in the case above, it indicates that the pressure within the pulmonary artery and right heart high enough to cause retrograde flow of contrast material into the IVC.

Other things to look for:
• Normal right ventricle (RV)/left ventricle (LV) short axis ratio (at level of tricuspid valve) < 0.9 (severe right ventricular strain if > 1.5)
• Pulmonary artery diameter > 30 mm (= 20 mm Hg)
• Increased diameter of superior vena cava or azygos vein

What other radiological tests are helpful when evaluating a patient with pulmonary emboli?

A) Abdominal Xray
B) Vascular Doppler ultrasound of the lower extremities
C) MRI of the abdomen and pelvis


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