E1987. Critical Care Consult: Pictorial Review of Non-Coronary Thoracic Cardiac and Vascular Emergencies on CT
University of Florida
University of Florida
One of the most common complaints made by patients presenting to the emergency department is acute chest pain. The diagnosis of patients with acute chest pain is challenging and misdiagnosis can lead to serious adverse events for patients and considerable legal implications for the institution. For those reasons, computed tomography (CT) has become a mainstay for non-invasive evaluation of acute pain suspected to be cardiovascular in cause.
Educational Goals / Teaching Points
In this educational exhibit, we will review the CT imaging findings associated with non-coronary thoracic cardiac and vascular pathologies that may present in the emergency room setting. Review non-coronary vascular pathologies of the chest that result in chest pain separated into three main categories: aortic, non-coronary cardiac and pulmonary vasculature. Discuss the pathophysiology leading to the development of these pathologies. Identify key imaging findings associated with these pathologies and learn how to differentiate one pathology from another on CT.
Key Anatomic/Physiologic Issues and Imaging Findings/Techniques
We will use a case-based approach to discuss the following non-coronary thoracic cardiac and vascular emergencies identified on CT. Pathologies affecting the aorta and its branches include aortic dissection (Sanford Type A and B), penetrating ulcer, intramural hematoma, ruptured aortic aneurysm, injury to the internal mammary artery, aorto-enteric fistula, subclavian and carotid injuries, and vasculitis. Non-coronary pathologies affecting the heart include blunt cardiac injury leading to contusion or aneurysm, congenital left ventricular aneurysm, myocarditis, cardiomyopathy, endocarditis, neoplasia, acute cardiac dysfunction/failure, cardiac tamponade, and intracardiac thrombi and metastases. Pathologies affecting the pulmonary arteries/veins include pulmonary arterial embolism, pulmonary venous embolism, pulmonary arterial dissection, pulmonary arterial hypertension, pulmonary arterial invasion by malignancy, and Rasmussen’s aneurysm.
The etiology of chest pain is usually diagnosed through a combination of clinical history, physical exam, electrocardiography and laboratory evaluation. However, despite all these measures diagnosis can remain obscure. CT is a valuable tool in the work- up of emergency chest pathologies presenting with chest pain. It is important to recognize the various causes of chest pain that are non-coronary in origin and may result from cardiac or vascular insult elsewhere. It is crucial for the radiologist to recognize key imaging findings on CT associated with pathologies affecting the non-coronary vasculature in the chest to appropriately guide patient management in an expeditious manner.