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We describe a 61-year-old male patient at our institution who was being reviewed by the heart team for consideration of transcatheter aortic valve intervention. Gated cardiac computed tomography revealed extensive eccentric calcification of the left ventricular outflow tract (LVOT) extending into the mitral valve leaflet and a large aortic annulus (33 mm; mean annular diameter/area, 854 mmsup2;). This is larger than all recommended manufacturer annular size limits, although observational data support the use of both Edwards Sapien 3 and Medtronic Evolut R in such annuli.

Coronary artery fistulae are a rare congenital abnormality. If such fistulae drain directly into a cardiac chamber, they are termed coronary-cameral fistulae. Such fistulae are usually congenital in origin or, occasionally, may arise as an iatrogenic complication of a cardiac procedure such as cardiac catheterization or surgery. We present a highly unusual case in which a patient presented to cardiac services on two occasions-nearly a decade apart-and was found to have coronary aneurysms initially, the largest of which expanded further and into the right atrium, thus creating a coronary-cameral fistula.

Funding Acknowledgements Type of funding sources: None. Background Adenosine stress perfusion has been shown to be of minimal incremental benefit in distinguishing between ischaemic and non-ischaemic aetiology of severe left ventricular systolic dysfunction (LVSD) over and above that obtained from Cardiac Magnetic Resonance (CMR) with Late Gadolinium Enhancement (LGE). Stress CMR has, however, been shown to be effective in risk-stratifying LVSD patients, with ischaemia being an independent predictor of cardiovascular death or myocardial infarction (MI) and associated with higher rates of further intervention. Purpose Evaluate real world data from a single tertiary UK cardiac MRI centre to determine the characteristics and long-term clinical outcomes of patients with LVSD referred for stress CMR. Methods As part of an ongoing registry, all consenting patients with Ejection Fraction (EF) ≤40% and a completed adenosine stress perfusion CMR between January 2015 and December 2019 were included with prospective baseline data collection. All-cause mortality and cardiac hospitalisation, coronary angiography/revascularisation was determined from electronic hospital records. Outcomes were compared between the inducible ischaemia vs. no ischaemia groups, and LGE present vs. no LGE groups using chi square. Results The sample included 86 patients. The mean EF was 32 ± 6%. Median follow up was 3.8 years (range 41-2222 days). The indications for CMR were: 30 (35%) assess ischaemia, 35 (41%) assess LVSD aetiology and 21 (24%) LVSD assess viability. Inducible ischemia was present in 30 (35%) patients and absent in 56 (65%). Patient characteristics and outcomes are shown in Table 1. Baseline characteristics were similar between the groups but there was a higher rate of hypertension and ischaemic heart disease in the ischaemia group. There was a non-significant difference in combined mortality and cardiac hospitalisation rates between the groups (40% vs. 27% p = 0.20). LGE was present in 69 (80%) patients (28 with ischaemia; 41 without) and absent in 17 (20%, 2 with ischaemia, 15 without). The event rate was 23 (33%) vs. 4 (24%) between LGE vs. No LGE groups (p = 0.44). Of the 15 patients (17%) with no LGE or ischaemia; 2 died and 1 was hospitalised, there were no MI"s and no Percutaneous Coronary Intervention (PCI). The lack of statistical difference in event rates between ischaemia and no ischaemia groups may be due to our relatively small sample size or could reflect the effectiveness of contemporary disease modifying treatment for Heart Failure with reduced EF. Conclusion This real-world data supports published findings that in patients with LVSD and no LGE on CMR, ischaemia is very uncommon and stress CMR is unlikely to increase diagnostic yield. Conversely, if stress CMR is performed and ischaemia is absent, incidence of subsequent angiography and revascularisation is very low, which is reassuring in clinical practice. In those patients without ischaemia and LGE, likelihood of MI is low.

Incidental coronary and cardiac calcification are frequent findings on non-gated thoracic CT. We recommend that the heart is reviewed on all CT scans where it is visualised. Coronary artery calcification is a marker of coronary artery disease and it is associated with an adverse prognosis on dedicated cardiac imaging and on non-gated thoracic CT performed for non-cardiac indications, both with and without contrast. We recommend that coronary artery calcification is reported on all non-gated thoracic CT using a simple patient-based score (none, mild, moderate, severe). Furthermore, we recommend that reports include recommendations for subsequent management, namely the assessment of modifiable cardiovascular risk factors and, if the patient has chest pain, assessment as per standard guidelines. In most cases, this will not necessitate additional investigations. Incidental aortic valve calcification may also be identified on non-gated thoracic CT and should be reported, along with ancillary findings such as aortic root dilation. Calcification may occur in other parts of the heart including mitral valve/annulus, pericardium and myocardium, but in many cases these are an incidental finding without clinical significance.

Aim To evaluate the diagnostic utility of additional whole-chest computed tomography (CT) in identifying otherwise unheralded COVID-19 lung disease as part of an acute abdominal pain CT imaging pathway in response to the COVID-19 pandemic. MATERIALS AND METHODS Consecutive patients (n=172) who underwent additional whole-chest CT via a COVID-19 acute abdominal pain CT imaging pathway between 27 March and 3 May 2020 were evaluated in this retrospective single-centre study. Chest CT examinations were graded as non-COVID-19, indeterminate for, or classic/probable for COVID-19. CT examinations in the latter two categories were further divided into one of three anatomical distributions (lung base, limited chest [below carina], whole chest [above carina]) based on location of findings. Reverse transcriptase-polymerase chain reaction (RT-PCR) results and clinical features of COVID-19 were assessed to determine if COVID-19 was clinically suspected at the time of CT referral. RESULTS Twenty-seven of the 172 (15.7%) patients had CT features potentially indicative of COVID-19 pneumonia, 6/27 (3.5%) demonstrating a classic/probable pattern and 21/27 (12.2%) demonstrating an indeterminate pattern. After correlation with clinical features and RT-PCR 8/172 (4.7%) were defined as COVID-19 positive, of which only 1/172 (0.6%) was clinically unsuspected of COVID-19 at the time of CT referral. All COVID-19 positive cases could be identified on review of the lung base alone. CONCLUSION Whole-chest CT as part of an acute abdominal pain CT imaging pathway has a very low diagnostic yield for the present cohort of patients. All COVID-19-positive patients in the present cohort were identified on review of the lung bases on the abdominal CT and this offers an alternative imaging approach in this patient group., Highlights • Low unheralded COVID-19 diagnostic rate for whole chest CT for acute abdominal pain. • Alternative CT strategies for COVID-19 diagnosis in acute abdominal pain are viable. • Mean radiation dose burden of 3.4mSv for additional whole chest CT for COVID-19.

Background One of the most important techniques of cardiac magnetic resonance in assessment of coronary heart diseases is adenosine stress myocardial first-pass perfusion imaging. Using this imaging method, there should be an adequate response to the drug adenosine to make an accurate evaluation. The conventional signs of drug response are not always observed and are often subjective. Methods based on splenic perfusion might possess limitations as well. Therefore, T1 mapping presents as a novel, quantitative and reliable method. There are several studies analyzing this newly discovered property of different T1 mapping sequences. However most of these studies are enrolling only one of the techniques. Aims To compare modified look-locker inversion recovery and shortened modified look-locker inversion recovery sequences in terms of T1 reactivity and to determine the relationship between T1 reactivity and conventional stress adequacy assessment methods in adenosine stress perfusion cardiac magnetic resonance. Study Design A cross-sectional study using STARD reporting guideline. Methods Thirty-four consecutive patients, who were referred for adenosine stress perfusion cardiac magnetic resonance with suspect of myocardial ischemia, were prospectively enrolled into the study. Four patients were disqualified, and thirty patients were included in the final analysis. Using both modified look-locker inversion recovery and shortened modified look-locker inversion recovery, midventricular short axis slices of T1 maps were acquired at rest and during peak adenosine stress before gadolinium administration. Then, they were divided into six segments according to the 17-segment model proposed by the American Heart Association, and separate measurements were made from each segment. Mean rest and mean stress T1 values of remote, ischemic, and infarcted myocardium were calculated individually per subject. During adenosine administration, patients’ heart rates and blood pressures are measured and recorded every one minute. Adenosine stress perfusion images were examined for the presence of splenic switch-off. Results There was a significant difference between rest and stress T1 values of remote myocardium in both modified look-locker inversion recovery and shortened modified look-locker inversion recovery (p

A 48-year-old man was admitted as a Level 1 trauma after attempting suicide by jumping 28 m into a river. He was haemodynamically stable with unremarkable physical examination except for bilateral periorbital bruising. Trauma-protocol CT demonstrated an isolated T5 vertebral fracture. Despite being pain free, serial ECGs showed dynamic anterior ST-elevation. Review of the trauma CT identified a subtle perfusion defect in the left anterior descending artery (LAD) territory in keeping with a recent infarct, but motion artefact made assessment of the aortic root challenging. In view these findings, …

Objective: To assess the frequency and impact of incidental findings (IF) on CT during work-up for transcatheter aortic valve intervention (TAVI). Methods: A consecutive cohort of patients referred for consideration of TAVI who underwent a CT scan between 2009 and 2018 were studied retrospectively. CT reports were reviewed for the presence of IFs and categorised based upon their clinical significance: (a) insignificant—findings that did not require specific treatment or follow-up; (b) intermediate—findings that did not impact on the decision-making process but required follow-up; (c) significant—findings that either required urgent investigation or meant that TAVI was clinically inappropriate. Results: A total of 652 patients were included, whose median age was 82 years. One or more insignificant IF was found in 95.6% of patients. Intermediate IFs were documented in 5.4%. 91 (14%) patients had at least one significant IF. These included possible malignancy in 67 (74%). The ultimate decision to offer aortic valve intervention was only changed by the presence of an IF in 3.5% of cases. Conclusion: Clinically significant IFs are detected in more than 1 in 10 of patients undergoing CT as part of a TAVI work-up, although just over half of these patients still receive aortic valve intervention. Advances in knowledge: This study is the largest UK cohort, which, when combined with a review of existing literature, provides a clear picture of the frequency and clinical impact of IFs found at CT for TAVI assessment.

Background COPD patients have increased risk of developing pneumonia, which is associated with poor outcomes. It can be symptomatically indistinguishable from exacerbations, making diagnosis challenging. Studies of pneumonia in COPD have focused on hospitalised patients and are not representative of the ambulant COPD population. Therefore, we sought to determine the incidence and aetiology of acute exacerbation events with evidence of pneumonic radiographic infiltrates in an outpatient COPD cohort. Methods One hundred twenty-seven patients with moderate to very severe COPD aged 42–85 years underwent blood and sputum sampling over one year, at monthly stable visits and within 72 h of exacerbation symptom onset. 343 exacerbations with chest radiographs were included. Results 20.1% of exacerbations had pneumonic infiltrates. Presence of infiltrate was highly seasonal (Winter vs summer OR 3.056, p = 0.027). In paired analyses these exacerbation events had greater increases in systemic inflammation. Bacterial detection rate was higher in the pneumonic group, with Haemophilus influenzae the most common bacteria in both radiological groups. Viral detection and sputum microbiota did not differ with chest radiograph appearance. Conclusions In an outpatient COPD cohort, pneumonic infiltrates at exacerbation were common, and associated with more intense inflammation. Bacterial pathogen detection and lung microbiota were not distinct, suggesting that exacerbations and pneumonia in COPD share common infectious triggers and represent a continuum of severity rather than distinct aetiological events. Trial registration Trial registration Number: NCT01360398. Electronic supplementary material The online version of this article (10.1186/s12931-018-0842-8) contains supplementary material, which is available to authorized users.

AERIS study subject inclusion and exclusion criteria and supplementary methods. (DOCX 58Â kb)

Table S1. Radiological findings at exacerbation. Table S2. Exacerbation treatment stratified by the presence or absence of radiographic pneumonic infiltrate. Table S3. Bacterial identification by culture and PCR in all exacerbation sputum samples and those exacerbation sputum samples with fewer than 30% squamous cells (considered high quality). Table S4. Bacterial and viral identification at exacerbation by culture (bacteria) and PCR (bacteria/viral). Table S5. Levels of inflammatory markers at paired stable and exacerbation visits. Table S6. Changes in levels of serum inflammatory markers between stable (pre-exacerbation) and exacerbation samples. Table S7. Levels of serum inflammatory markers at paired stable and exacerbation visits. The occurrence of the first infiltrate-associated exacerbation where available was prioritised, or first non-infiltrative exacerbation if not (subjects are therefore only represented once). Table S8. Lung function changes between nearest stable-state and exacerbation visits, stratified by the presence/absence of pneumonic infiltrate. Figure S1. The proportion of bacterial positive sputum samples at exacerbation by both culture and PCR. Figure S2. The lung microbiome (phylum) of exacerbations stratified by the presence or absence of pneumonic infiltrate. Figure S3. Area under the receiver operator curve analysis for CRP, fibrinogen and neutrophil count. (DOCX 232Â kb)

Aortic coarctation is a disease that usually presents in infancy; however, a proportion of patients present for the first time in adulthood. These lesions generally require repair with either surgery or interventional techniques. The success of these techniques means that increasing numbers of patients are presenting for follow-up imaging in adulthood, whether their coarctation was initially repaired in infancy or as adults. Thus, the adult presenting to the radiologist for assessment of possible coarctation or follow-up of coarctation repair is not an uncommon scenario. In this review, we present details of the MRI protocols and MRI findings in these patients so that a confident and accurate assessment can be made.

Objective: To evaluate the technical and oncological efficacy of an image-guided cryoablation programme for renal tumours. Patients and Methods: A prospective analysis of technical and radiological outcomes was undertaken after treatment of 171 consecutive tumours in 147 patients. Oncological efficacy in a subset of 125 tumours in 104 patients with >6 months' radiological follow-up and a further subset of 62 patients with solitary, biopsy-proven renal carcinoma was also analysed. Factors influencing technical success, as determined by imaging follow-up, and complication rates were statistically analysed using a statistics software package and logistic regression analyses. Results: No variables were found to predict subtotal treatment, although gender (P = 0.08), tumour size of >4?cm (P = 0.09) and central location of tumour (P = 0.07) approached significance. Upper pole location was the single variable that was found to predict complications (P = 0.006). Among the 104 patients (125 tumours), radiologically assessed at ?6 months and with a mean radiological follow-up of 20.1 months, we found a single case of unexpected late local recurrence. Conclusion: Percutaneous image-guided cryoablation, at a mean of 20.1 months' follow-up, appears to provide a safe and effective treatment option with a low complication rate. Anteriorly sited tumours should not be considered a contraindication for percutaneous image-guided cryoablation.

Aim To determine whether patients undergoing transrectal ultrasound (TRUS)-guided prostate biopsy with increased sampling numbers are more likely to experience bleeding complications and whether warfarin or low-dose aspirin are independent risk factors. Materials and methods 930 consecutive patients with suspected prostatic cancer were followed up after biopsy. Warfarin/low-dose aspirin was not stopped prior to the procedure. An eight to 10 sample regime TRUS-guided prostate biopsy was performed and patients were offered a questionnaire to complete 10 days after the procedure, to determine any immediate or delayed bleeding complications. Results 902 patients returned completed questionnaires. 579 (64.2%) underwent eight core biopsies, 47 (5.2%) underwent nine, and 276 (30.6%) underwent 10. 68 were taking warfarin [mean international normalized ratio (INR) = 2.5], 216 were taking low-dose aspirin, one was taking both, and 617 were taking neither. 27.9% of those on warfarin and 33.8% of those on aspirin experienced haematuria. 37% of those on no blood-thinning medication experienced haematuria. 13.2% of those on warfarin and 14.4% of those on aspirin experienced rectal bleeding. 11.5% of those on no blood-thinning medication experienced rectal bleeding. 7.4% of those on warfarin and 12% of those on aspirin experienced haematospermia. 13.8% of those on neither experienced haematospermia. Regression analysis showed a significant association between increasing sampling number and occurrence of all bleeding complication types. There was no significant association between minor bleeding complications and warfarin use; however, there was a significant association between minor bleeding complications and low-dose aspirin use. There was no severe bleeding complication. Conclusion There is an increased risk of bleeding complications following TRUS-guided prostate biopsy with increased sampling numbers but these are minor. There is also an increased risk with low-dose aspirin use; however, there is no increased risk of bleeding complications with warfarin use. These results suggest that up to 10 cores during prostate biopsy remains acceptable safe practice and cessation of warfarin and low-dose aspirin is usually not necessary.

The case involves a 69-year-old female with severe, longstanding bronchiectasis secondary to childhood pertussis infection. She presented to the hospital and was thought clinically to have a pulmonary embolus. A CT pulmonary angiogram was performed, which was technically satisfactory. This revealed multiple, bilateral filling defects that were fairly convincing for pulmonary emboli. Further review of the CT scan not only revealed the extent of her bronchiectasis but also a number of enlarged bronchial arteries supplying the diseased lung. The pulmonary arterial filling defects arose suspiciously close to the bronchial arteries and the possibility of bronchial to pulmonary artery anastomoses was considered. Could the admixture of highly contrast-opacified pulmonary arterial blood with partially opacified systemic arterial blood cause the apparent filling defects? After further consideration, a second electrocardiography-gated CT angiogram was performed—this time in the systemic arterial phase but planned with two regions of interest sited over the main pulmonary artery and the aorta with the aim of triggering the scan with maximum contrast in the bronchial arteries, and as much contrast washout as possible in the pulmonary arteries. This study revealed a reversal of the CT pulmonary angiogram appearances with contrast now seen in the bronchial arteries and opacifying the sites of the previous filling defects in the pulmonary arteries. Thus, the filling defects were actually false positives caused by an admixture of highly opacified and part-opacified blood via bronchial artery anastomoses. In the context of a false-positive finding of pulmonary embolus on a background of severe bronchiectasis, unnecessary anticoagulation could have increased the risk of complications such as haemoptysis. This case report illustrates the importance of knowledge of potential false-positive findings in CT pulmonary angiography and describes a novel approach based on cardiac CT techniques to prove this.

Methods Sixteen healthy subjects and 35 patients with heart failure awaiting guideline indicated CRT or primary prevention ICD (16 non ischemic cardiomyopathy (NICM), 19 ischemic cardiomyopathy (ICM)) were scanned on a 1.5T Magnetom Avanto (Siemens Healthcare, Erlangen) using a MOLLI (investigational WIP#448, 5:3:3 acquisition scheme, motion correction and automatically generated T1 map). In all cases on the basal short axis slice, a single, slender ROI was placed in the mid wall of the septum with meticulous attention to avoid partial volume of blood. In addition, the T1 was measured within scar when present on the T1 map (confirmed on the corresponding basal LGE image). When a contemporaneous haematocrit was available (n=24), the extracellular volume (ECV) was calculated using standard bolus acquisition methods.

Background MRI Adenosine stress perfusion is a well-established method of evaluating myocardial ischaemia but we know from a number of studies that false negatives are a potential weakness of this modality. Assessment of splenic perfusion at stress and rest (splenic switch-off) has recently been suggested as a means of identifying true pharmacological stress response to adenosine [1]. This is a promising technique but can only be assessed after the stress procedure. The aim of this study was to compare symptomatic and haemodynamic response with visual assessment of splenic perfusion during stress and rest perfusion imaging to see if we could accurately predict those who would have absent splenic switch-off.

Microvascular obstruction (MVO) is usually seen in a proportion of patients with acute myocardial infarction following reperfusion therapy of an occluded coronary artery. It is characterized by damage and dysfunction of the myocardial microvasculature with a no-reflow phenomenon within the infarct zone. While MVO may be demonstrated via a number of different imaging modalities, cardiac MR (CMR) enables accurate identification of MVO and also permits assessment of infarct extent and overall left ventricular function during the same imaging examination. We present a pictorial review of the characteristic appearances of MVO on CMR and highlight the importance of this imaging diagnosis for patient outcome following acute myocardial infarction.

Cardiac myxomas are the most common benign primary cardiac tumour to present in adulthood. While most patients present with symptoms of cardiac obstruction, embolic phenomena or constitutional impairment, up to a fifth of patients remain asymptomatic and are incidentally diagnosed on imaging. Although echocardiography is usually the initial imaging modality used to evaluate these patients, cardiac MRI (CMR) has emerged over the past decade as the primary imaging modality in the assessment of patients with cardiac tumours. The superior tissue characterization capability of CMR means that it is able to determine the nature of some tumours pre-operatively and performs well in differentiating myxomas from thrombus. We present a pictorial review highlighting the key CMR features of myxomas and show how these lesions can be differentiated from thrombus and other cardiac masses.

The term “acute aortic syndrome” (AAS) encompasses several non-traumatic life-threatening pathologies of the thoracic aorta presenting in patients with a similar clinical profile. These include aortic dissection, intramural haematoma and penetrating atherosclerotic ulcers. These different pathological entities can be indistinguishable on clinical grounds alone and may be confused with other causes of chest pain, including myocardial infarction. Multidetector-row CT (MDCT) is the current modality of choice for imaging AAS with a sensitivity and specificity approaching 100%. Early diagnosis and accurate radiological classification is associated with improved clinical outcomes in AAS. We review the characteristic radiological features of the different pathologies that encompass AAS and highlight the vital role of MDCT in determining the management of these life-threatening conditions.

Classic chest radiograph signs of pulmonary emboli include regional oligaemia (‘Westermark sign’), right descending pulmonary artery enlargement (‘Palla sign’), central pulmonary artery enlargement (‘Fleishner sign’) and abrupt pulmonary artery tapering (‘knuckle sign’).1 We present a case highlighting the importance of recognising these unusual radiological signs in patients presenting with haemodynamically unstable pulmonary emboli (box 1). Box 1 ### CXR appearance of Westermark and Palla signs Westermark sign: regional pulmonary oligaemia Palla sign: enlargement of the descending pulmonary artery A 78-year-old lady presented to the emergency department with collapse and pleuritic chest pain. On examination, the patient was in respiratory distress and haemodynamic …

Mesenteric panniculitis is a rare, complex disorder characterized by a chronic, idiopathic fibro-inflammatory process of mesenteric adipose tissue. Due to its protean clinical presentation, mesenteric panniculitis poses a significant diagnostic challenge to the clinician, radiologist and pathologist alike. We present an extremely rare case of mesenteric panniculitis with disease progression associated with retroperitoneal fibrosis. This report identifies the need for increased awareness of this rare condition and for mesenteric panniculitis to be considered in the differential diagnosis of patients presenting with recurrent episodes of unexplained abdominal pain. Our case also highlights the importance of computed tomography imaging in the diagnosis, and the follow-up of patients with mesenteric panniculitis as disease progression may occur in the absence of symptoms.

Pulmonary lacerations are an uncommon injury typically associated with high-impact trauma. Most cases occur as a result of high-speed road traffic collisions. Although chest wall and pleural injuries are commonly associated with sports-related thoracic trauma, pulmonary injuries are far less common. There are only a few reported cases of significant pulmonary trauma associated with sports injuries, the majority of which have described pulmonary contusions occurring as a result of thoracic injury sustained while playing high-impact contact sports such as American football. Pulmonary laceration occurring as result of soccer-related thoracic trauma has never previously been reported.

To evaluate the technical and oncological efficacy of an image-guided cryoablation programme for renal tumours.A prospective analysis of technical and radiological outcomes was undertaken after treatment of 171 consecutive tumours in 147 patients. Oncological efficacy in a subset of 125 tumours in 104 patients with6 months' radiological follow-up and a further subset of 62 patients with solitary, biopsy-proven renal carcinoma was also analysed. Factors influencing technical success, as determined by imaging follow-up, and complication rates were statistically analysed using a statistics software package and logistic regression analyses.No variables were found to predict subtotal treatment, although gender (P = 0.08), tumour size of4 cm (P = 0.09) and central location of tumour (P = 0.07) approached significance. Upper pole location was the single variable that was found to predict complications (P = 0.006). Among the 104 patients (125 tumours), radiologically assessed at ≥6 months and with a mean radiological follow-up of 20.1 months, we found a single case of unexpected late local recurrence.Percutaneous image-guided cryoablation, at a mean of 20.1 months' follow-up, appears to provide a safe and effective treatment option with a low complication rate. Anteriorly sited tumours should not be considered a contraindication for percutaneous image-guided cryoablation.

Introduction Although first described in 1866, ALCAPA was recognised with a clinical description and correlation with autopsy findings by Bland and colleagues in 1933. ALCAPA accounts for approximately 0.25–0.5% of all congenital heart defects and exists predominantly in two forms; infant type and adult type. Infants present with features of myocardial ischaemia and heart failure and very rarely can be associated with other cardiac anomalies. Mortality rate approaches 90% in infants if ALCAPA is left untreated. Adult cases are unusual and but can present with unusual ischaemic symptoms. Although historically ALCAPA was diagnosed at conventional angiography, the development of gated CT and MRI imaging allows assessment with non-invasive means. Learning Objectives: To describe and illustrate radiological findings and characteristics in patients diagnosed with having an ALCAPA anomaly. Imaging Findings We describe our case series of patients with characteristic findings on electrocardiography, CT and MRI seen in patients with ALCAPA. The left coronary artery arises from the pulmonary trunk and branches into dilated LAD and circumflex vessels. Collaterals are usually seen between the right and left coronary arteries with retrograde flow through the left coronary artery into the pulmonary trunk. The right coronary artery is often also dilated due to high volume flow. Identification of these dilated collaterals is often the first indication of this pathology. Conclusion It is important for radiologists to be aware of the typical imaging findings in this relatively rare anomaly as prognosis is good with early diagnosis and surgical correction.

Malignant peripheral nerve sheath tumours are rare and aggressive soft-tissue sarcomas of ectomesenchymal origin. These tumours commonly occur in patients with neurofibromatosis Type 1 with a cumulative lifetime risk of 10%. The vast majority of cases present with clinical evidence of a soft-tissue mass with or without features of nerve irritation and loss of function arising from the lesion of origin. The primary presentation of a malignant peripheral nerve sheath tumour with a pneumothorax in the absence of widespread metastatic disease in a patient with no medical or family history of neurofibromatosis has never been reported in the literature. We present a unique case of a systemically well 34-year-old male who presented with clinical evidence of a right-sided pneumothorax. The chest radiograph identified the right-sided pneumothorax and revealed an apical pleural mass that was confirmed by intravenous contrast-enhanced CT of the thorax. The patient was referred for video-assisted thorascopic surgical pleurodesis and biopsy of the lesion. Histopathology analyses confirmed the diagnosis of malignant peripheral nerve sheath tumour. To the best of our knowledge, no such case reports have been published in the literature. A diagnosis of malignant peripheral nerve sheath tumour should be considered as one of the rarer possibilities in patients presenting with pneumothoraces in association with apical pleural lesions.

A 17-year-old man presented to the emergency department after being ejected from a motorbike following a high-speed road traffic collision. The secondary trauma survey revealed a high lying and tender right testes. Ultrasound of the scrotum showed a fixed right …

(CHEST 2009; 135:1684–1687) A 27-year-old man presented to the emergency department with a 24-h history of dyspnea and right-sided chest pain. The pain was acute in onset, sharp in nature, worse on deep inspiration, did not radiate, and was not reproducible with palpation. There was no associated fever, cough, hemoptysis, or calf pain. The patient denied any history of recent trauma. His medical history included a left-sided acromioclavicular joint dislocation sustained in a road traffic accident that required open reduction 8 months prior to this presentation. The patient was not receiving therapy with any medications and denied smoking or illicit drug use.

Background Adenosine as a stress agent is well tolerated and has a good safety profile but occasionally when administered at 140mg/kg/min it fails to produce a haemodynamic or symptomatic response. Studies have reported that between 4 18% patients do not respond to the standard dose . Splenic switch-off is a novel way of assessing adequacy of hyperaemic response, to adenosine. The aim of this study was to assess the number of patients that required an increase in dose to either 175 mg/kg/min or 210 mg/kg/min over a 12-month period and the adequacy of this response using splenic switch-off.

Methods 9 healthy volunteers and 7 patients with no evidence/ history of disease were scanned on a Siemens Avanto 1.5T scanner and a 32 channel coil using the Siemens modified look locker inversion recovery (MOLLI) WIP version 448B (5:3:3 acquisition with inline motion correction and T1 map generation). All subjects had a 4 chamber, basal and mid ventricular short axis acquisition performed. In all slices, a single, slender ROI was placed in the mid wall of the left ventricular septum with meticulous attention to avoiding partial volume of blood pool. In addition, the mid ventricular short axis slice was segmented (with aggressive endo and epicardial border pruning) into 6 AHA segments to allow regional T1 analysis.

Superior vena cava (SVC) obstruction leads to a constellation of symptoms and signs that encompass the SVC syndrome. Today, malignancy accounts for 65% of all cases. The most common neoplastic causes are non–small cell lung cancer (50%), small cell lung cancer (25%), lymphoma, and metastasis. Primary cardiac tumors are an extremely rare cause of SVC obstruction. We describe the case of a 48-year-old man who presented with dyspnea, confusion, and facial swelling with cyanosis. The patient developed life-threatening airway obstruction after administration of anxiolytic. The diagnosis of SVC obstruction secondary to a primary cardiac sarcoma was established based on clinical, radiologic, and post-mortem findings. This is one of very few reported cases of a primary cardiac sarcoma causing SVC obstruction.

A 42-year-old man presented to the emergency department with a 6-week history of knee pain that had increased in severity …

A 26-year-old male presented with a 2-week history of increasing left-sided otalgia and discharge. Examination revealed a left-sided neck swelling with an enlarged cervical lymph node. Otoscopy of the left ear revealed tympanic membrane retraction with posterior perforation and granulation. A deep …

Background Sudden cardiac arrest has a significant global health burden with an estimated incidence of 95.9 per 100 000 person-years. The causal malignant ventricular arrhythmia may arise secondary to myocardial ischaemia, infarct, oedema, fibrosis or infiltration and survivors are at significant risk for recurrent events. Coronary revascularization procedures have a significant associated morbidity/mortaility in this patient popuation and hence identifying those patients who are most likely to benefit from therapeutic intervention is vital. The aim of this study was to evaluate the role and safety of cardiac MR (CMR) in the investigation of patients successfully resuscitated from out of hospital sudden cardiac arrest.

Background Cryptococcosis refers to a spectrum of infections caused by the encapsulated yeast Cryptococcus neoformans. In the immunocompromised host cryptococcus may disseminate resulting in significant mortality and morbidity. Case presentation We report the case of a 49-year-old homosexual male presenting with an atypical skin lesion associated with an asymptomatic pulmonary nodule. A subsequent diagnosis of disseminated cryptococcosis was made on India ink staining of cerebrospinal fluid. Conclusion A diagnosis of cryptococcosis should be considered in all patients at risk of immunocompromise that present with asymptomatic pulmonary nodules in the presence of extrapulmonary manifestations, as exemplified by the unusual skin ulceration in our case.