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An Unusual Benign Cause of an Alarming Finding on Chest-X ray: A Case Report of Widened Mediastinum due to Rare Congenital Abnormality (Azygos Vein Continuation of Inferior Vena Cava). Case Rep Crit Care 2019; 2019:3457495. [PMID: 31885936 PMCID: PMC6925908 DOI: 10.1155/2019/3457495] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2019] [Accepted: 09/03/2019] [Indexed: 11/18/2022] Open
Abstract
Acute widened mediastinum is an alarming finding. It has many possible differential diagnoses; aortic dissection (AD) is considered one that carries catastrophic outcomes. AD is relatively uncommon; it requires early and accurate diagnosis and treatment for better patient survival. However, acute mediastinal widening also can be present in more benign conditions. We report a case of a 50-year-old African American female with postoperative shortness of breath; initial imaging studies revealed an acute widened mediastinum, but on further management with diuresis and follow-up imaging, she was diagnosed with azygous vein continuation of the Inferior vena cava (IVC). This is considered as a rare benign cause of wide mediastinum. Clinicians must be aware of the presence of such a benign cause when dealing with acute wide mediastinum.
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To reduce routine computed tomographic angiography for thoracic aortic injury assessment in level II blunt trauma patients using three mediastinal signs on the initial chest radiograph: a preliminary report. Emerg Radiol 2018. [PMID: 29536276 DOI: 10.1007/s10140-018-1596-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
PURPOSE CTA is routinely ordered on level II blunt thoraco-abdominally injured patients for assessment of injury to the thoracic aorta. The vast majority of such assessments are negative. The question being asked is, Does the accurate interpretation of the three mediastinal signs permit reliable determination of which patients need CTA for aortic assessment? The purpose of this investigation was to evaluate the role of three specifically selected mediastinal anatomic signs on the initial supine chest radiograph (CXR) of adult level II blunt thoraco-abdominally injured patients for the presence or absence of a mediastinal hematoma. The presence of a mediastinal hematoma is typically used as an indicator for computed tomographic angiography (CTA). The three mediastinal signs are the right para-tracheal stripe (RPTS), left para-spinal line (LPSL), and the left apical extra-pleural area (LAPA). MATERIALS AND METHODS The patient triage designation (level II trauma) was made by the attending physician at the time of admission. The initial CXR image and the CTA report of the 197 adult blunt level II thoraco-abdominally injured patients obtained on the day of admission were compared. The CXR of each of the 197 patients was independently assessed by each of four observers specifically for the status of the three mediastinal signs. Each observer was blinded to the CTA report until after the status of the three mediastinal sign evaluation had been determined. Two or three of the mediastinal signs being positive were required to determine that the CXR was positive for a mediastinal hematoma. RESULTS Two or three of the selected mediastinal signs were normal in 192 (97.5%) patients. None of these patients had either a mediastinal hematoma or a major aortic injury on CTA. In each of the remaining five (2.5%) patients, two or three of the mediastinal signs were abnormal. Each of these patients had a mediastinal hematoma and a major thoracic aortic injury on CTA. CONCLUSIONS This preliminary study suggests that the accurate interpretation of the three specifically selected mediastinal signs on the initial supine CXR of adult level II blunt thoraco-abdominally injured patients could reduce the need for routine CTA for thoracic aortic injury assessment, and requires verification by an additional study.
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Aboukhoudir F, Rekik B, Rica O, Aboukhoudir I, Pansieri M, Rekik S. [Massive intraatrial mass?]. Ann Cardiol Angeiol (Paris) 2016; 65:359-362. [PMID: 27697300 DOI: 10.1016/j.ancard.2016.09.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2016] [Accepted: 09/04/2016] [Indexed: 06/06/2023]
Abstract
Posterior mediastinal hematoma in a rare and potentially lethal disease and is frequently consecutive to a traumatism. We report the original case of a 88-year-old male admitted to our department for lipothymia and syncope related to a severe compression of the left atrium by an important mediastinal hematoma mimicking in transthoracic echocardiography an obstructive intraatrial mass.
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Affiliation(s)
- F Aboukhoudir
- Service de cardiologie, centre hospitalier d'Avignon, 84000 Avignon, France; EA4278, laboratoire de pharm-écologie cardiovasculaire, université, 84000 Avignon, France
| | - B Rekik
- Service de cardiologie, centre hospitalier d'Avignon, 84000 Avignon, France
| | - O Rica
- Service de cardiologie, centre hospitalier d'Avignon, 84000 Avignon, France
| | - I Aboukhoudir
- Service de cardiologie, centre hospitalier d'Avignon, 84000 Avignon, France
| | - M Pansieri
- Service de cardiologie, centre hospitalier d'Avignon, 84000 Avignon, France
| | - S Rekik
- Service de cardiologie, hôpital de Belfort, centre hospitalier Nord-Franche-Comté, 14, rue de Mulhouse, 90000 Belfort, France.
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Chawla A, Rajendran S, Yung WH, Babu SB, Peh WC. Chest radiography in acute aortic syndrome: pearls and pitfalls. Emerg Radiol 2016; 23:405-12. [PMID: 27282377 DOI: 10.1007/s10140-016-1415-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2016] [Accepted: 06/03/2016] [Indexed: 11/26/2022]
Abstract
Acute aortic syndrome is a group of life-threatening diseases of the thoracic aorta that usually present to the emergency department. It includes aortic dissection, aortic intramural hematoma, and penetrating aortic ulcer. Rare aortic pathologies of aorto-esophageal fistula and mycotic aneurysm may also be included in this list. All these conditions require urgent treatment with complex clinical care and management. Most patients who present with chest pain are evaluated with a chest radiograph in the emergency department. It is important that maximum diagnostic information is extracted from the chest radiograph as certain signs on the chest radiograph are extremely useful in pointing towards the diagnosis of acute aortic syndrome.
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Affiliation(s)
- Ashish Chawla
- Department of Diagnostic Radiology, Khoo Teck Puat Hospital, 90 Yishun Central, Singapore, 768828, Singapore.
| | - Surendran Rajendran
- Department of Diagnostic Radiology, Khoo Teck Puat Hospital, 90 Yishun Central, Singapore, 768828, Singapore
| | - Wai Heng Yung
- Department of Diagnostic Radiology, Khoo Teck Puat Hospital, 90 Yishun Central, Singapore, 768828, Singapore
| | - Suresh Balasubramanian Babu
- Department of Diagnostic Radiology, Khoo Teck Puat Hospital, 90 Yishun Central, Singapore, 768828, Singapore
| | - Wilfred C Peh
- Department of Diagnostic Radiology, Khoo Teck Puat Hospital, 90 Yishun Central, Singapore, 768828, Singapore
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Koksal V, Coskun S, Coskun PK. Rapid onset mediastinal hematoma due to vertebral fracture and review of relevant literature. Turk J Emerg Med 2016; 15:187-9. [PMID: 27239627 PMCID: PMC4882206 DOI: 10.1016/j.tjem.2014.09.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2014] [Revised: 09/03/2014] [Accepted: 09/12/2014] [Indexed: 11/09/2022] Open
Abstract
Patients with vertebral fractures are frequently encountered and those with thoracic and lumbar spine fractures are likely to have associated injuries. Detection of a widened mediastinum after trauma is very nonspecific and most of the time it is related to aortic injury or mediastinal hematoma. Vertebral or sternal fractures can also be the cause of mediastinal hematoma with or without aortic injury. This report reviews an unusual case of rapid onset mediastinal hematoma due to vertebral fracture after a fall. In the case, there was a mediastinal hematoma adjacent to a burst fracture of the T8 vertebral body. There was a rapid increase in identified hematoma during the emergency follow up and urgent erythrocyte transfusion was carried out. We would like to raise awareness of this infrequent presentation of mediastinal hematoma, as it is insidious and possibly fatal. In the evaluation of mediastinal hematoma, the detection of osseous injuries is a requirement.
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Affiliation(s)
- Vaner Koksal
- Department of Neurosurgery, Rize Training and Research Hospital, Recep Tayyip Erdogan University, Rize, Turkey
| | - Selcuk Coskun
- Department of Emergency, Ankara Ataturk Training and Research Hospital, Ankara, Turkey
| | - Pinar Koksal Coskun
- Department of Cardiovascular Surgery, Ankara Tobb-etu Hospital, Ankara, Turkey
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Pozek I, Hurt CJ, Stern EJ. The Wide Mediastinum: Don't Forget About Sternal Fractures. Curr Probl Diagn Radiol 2012; 41:124-5. [DOI: 10.1067/j.cpradiol.2011.07.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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7
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Posterior mediastinal hematoma after a fall from standing height: a case report. Case Rep Surg 2012; 2012:672370. [PMID: 22606603 PMCID: PMC3350289 DOI: 10.1155/2012/672370] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2011] [Accepted: 12/06/2011] [Indexed: 11/17/2022] Open
Abstract
Posterior Mediastinal Hematomas (PMHs) secondary to a fall from standing height are uncommon, with only one previous case reported in the literature. We describe a case of a 78-year-old male with multiple medical comorbidities, who was transferred to Montreal General Hospital (MGH) with a posterior mediastinal hematoma (PMH) after sustaining a fall from standing height. On initial assessment, the patient was hemodynamically stable and complained of mild chest pain, dyspnea, fatigue, and diaphoresis. The patient's airway was secured via endotracheal intubation fearing impending respiratory compromise secondary to an enlarging PMH. The patient was admitted to ICU where over the next 3 days he was managed conservatively via careful monitoring of his hemodynamic and hematologic indices. Repeat CT scanning indicated reduction in size of the PMH. The patient was discharged on hospital day eight. This case describes the assessment, evaluation, and conservative management of PMH in a complicated patient receiving prior anticoagulation. A review of the literature regarding the epidemiology of PMH and the management of both unstable and stable PMHs is also presented.
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Ursic C, Curtis K. Thoracic and neck trauma. Part three. Int Emerg Nurs 2010; 18:158-65. [PMID: 20542242 DOI: 10.1016/j.ienj.2008.11.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Previous parts to this series on thoracic and neck trauma discussed the anatomy and physiology of the thorax, assessment and initial nursing interventions, imaging and adjuncts to diagnosis. Part 2 describes specific chest wall and lung injuries, types of pneumothoraces and their diagnosis and management. This section, part 3 of 4, discusses other types of thoracic injuries and their management, such as trauma to the diaphragm and heart.
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Abstract
Sternal fractures are relatively common and range from simple unicortical cracks to displaced fractures associated with life threatening injuries. This paper describes the relevant anatomy, biomechanics, mechanism of injury, clinical presentation, investigation, treatment and complications and also includes associated and concomitant injuries. A management flow chart including criteria for discharge from the emergency department is presented.
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Affiliation(s)
- Rangan Raghunathan
- Selly Oak Hospital, University Hospital Birmingham NHS Trust, Selly Oak, Birmingham, West Midlands, B29 6JD, UK,
| | - Keith Porter
- Selly Oak Hospital, University Hospital Birmingham NHS Trust, Selly Oak, Birmingham, West Midlands, B29 6JD, UK
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Abstract
Mediastinal hematomas are the end result of numerous conditions ranging from the deadly traumatic aortic injury to the common changes after open heart surgery. The location of the hematoma, its relation with the surrounding structures, the clinical history, and associated findings can help narrow the differential diagnosis. Contrast-enhanced computed tomography is the imaging modality of choice because of its accessibility, noninvasiveness, rapid acquisition, and ability to evaluate the entire thorax at once.
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Paiva WS, De Amorim RLO, Tavares WM, Alho EJL, Jeng BP, Figueiredo EG. Horner's syndrome after blunt cervical and chest trauma: case report. ARQUIVOS DE NEURO-PSIQUIATRIA 2007; 65:1037-9. [PMID: 18094873 DOI: 10.1590/s0004-282x2007000600026] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/29/2007] [Accepted: 08/25/2007] [Indexed: 11/22/2022]
Abstract
Horner's syndrome is the triad of miosis, ptosis, and anhidrosis, resulting from disruption of the sympathetic pathways. This article describes an uncommon case of Horner's syndrome in a 22-year-old man after blunt trauma to the neck and chest without carotid artery dissection. The patient was brought to the emergency service after motorcycle fall. Neurologic examination revealed a patient presenting the score 15 at Glasgow Coma Scale. The left eyelid was 1-2 mm lower than the right. Carotid Doppler and angiotomography were undertaken and revealed no abnormalities of the carotid artery. CT disclosed a mediastinal hematoma extending to the left apex, compressing the left sympathetic chain. The understanding of this clinical entity may help the surgeon to make a better differential diagnosis in trauma patients in whom prompt diagnosis is critical to establish the correct treatment.
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Affiliation(s)
- Wellingson Silva Paiva
- Hospital das Clínicas, University of São Paulo, Rua Ovidio Pires de Campos 171/511, São Paulo, SP, Brazil.
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Ko SF, Ng SH, Fang FM, Wan YL, Hsieh MJ, Liu PP, Kung CT, Liu BM. Left brachiocephalic vein perforation: computed tomographic features and treatment considerations. Am J Emerg Med 2007; 25:1051-6. [DOI: 10.1016/j.ajem.2007.06.013] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2007] [Revised: 06/11/2007] [Accepted: 06/13/2007] [Indexed: 10/22/2022] Open
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