Pearls and Pitfalls in Thoracic Imaging


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A summary of the imaging findings which should be interrogated on CT angiography when traumatic aortic injury is suspected. Additional imaging findings which aid further management planning are also described. Interrogate aorta at a workstation using multiplanar reformatting aortic injury is most conspicuous in the sagittal-oblique plane left anterior oblique; degrees.


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Arch anatomy variants: direct vertebral artery origin, aberrant subclavian artery. Pictorial Review. Published by the British Institute of Radiology. Anatomy and Mechanism of Injury. Imaging Features. Figure 1. There is increased density at the right apex in keeping with a right apical pleural cap. Figure 2.

There is an intimal flap a; arrows as evidenced by a thin, linear filling defect at the level of the aortic isthmus. Associated traumatic injuries including left first rib b; solid arrow and left scapula fracture b; dashed arrow are indicative of a high velocity trauma which should prompt closer assessment for thoracic aortic injury TAI. Figure 3. There is an intimal flap a; arrow at the level of the aortic isthmus in keeping with aortic injury. Axial image b demonstrates high density periaortic haematoma b; dashed arrows within the mediastinum.

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The sagittal view is more definitive in comparison with the axial image for the visualisation of TAI. TAI, thoracic aortic injury. Figure 4. A 7 mm wide-necked thoracic aortic pseudoaneurysm arises distal to the left subclavian artery at the level of the aortic isthmus arrow. Figure 5. Cyclist hit by car on a main road.


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There is a right rib fracture a; arrow and sternal fracture b; arrow head indicating a high velocity trauma. In the coronal plane a pseudoaneurysm is appreciated b; dashed arrow.

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The patient went on to digital subtraction angiography c and subsequent stent insertion d. Figure 6. Restrained passenger with seatbelt involved in road traffic accident. CT reveals a large pseudoaneurysm a at the level of the aortic isthmus.

Common Problems in Thoracic Imaging

Extensive haemomediastinum is appreciated in the coronal plane b; dashed arrows. Note is also made of splenic injury b; solid arrow. Figure 7. The patient presented with chest pain. The aneurysm demonstrates peripheral calcification in keeping with its chronicity. Figure 8. Sagittal-oblique a and axial b images demonstrate a linear filling defect arrows which extends across the width of the aortic lumen arrows consistent with transection. Figure 9. There is an aortic transection a; solid arrow involving the thoracic aorta at the aortic isthmus.

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There is arterial blush of contrast in keeping with active haemorrhage at the left lateral aspect of the aortic arch b; dashed arrow as well as large volume mediastinal haematoma. Axial CT images a; arrows demonstrate periaortic haematoma which is adherent to the aortic arch.

This is an indirect sign prompting further evaluation of the thoracic aorta. Left anterior oblique reformatted image b; arrow demonstrates intimal flap and small pseudoaneurysm in the aortic arch distal to the origin of the left subclavian artery consistent with traumatic aortic injury. Type I Arch. The great vessels originate at the same level of the arch peak.

Type II arch. The distance between the aortic arch peak superior white line and the brachiocephalic artery origin inferior white line is approximately two to three times the diameter of the left common carotid artery black line. Angiographic image demonstrating a pseudoaneurysm at the level of the aortic isthmus a.

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A 21 mm Gore thoracic aortic stent Gore Medical, Flagstaff, AZ is subsequently deployed b via a right femoral approach with immediate exclusion of the pseudoaneurysm. Normal variants and Pitfalls. Gated a v s non-gated b CT angiographic studies. On the sagittal sections of the aorta, the fenestrations are more difficult to appreciate on the non-gated images.

There is a smooth outpouching along the inferior margin of the aorta at the level of the isthmus, which forms obtuse margins. Features are classical for a ductus diverticulum. There is a haematoma in the left supraclavicular fossa a; arrow heads which was subsequently determined to be a transected left dorsal scapular artery.

On further assessment of the thoracic aorta there is a smooth bulge distal to the left subclavian artery inthe region of the aortic infundibulum b; arrows with no periaortic haematoma. Features are of an incidental ductus diverticulum. Self reflection form. Grade 1: Intimal tear. Grade 2: Large intimal flap. Grade 3: Pseudoaneurysm. Prospective study of blunt aortic injury: multicenter trial of the American Association for the Surgery of Trauma. J Trauma ; 42 : — Effectiveness of regionalization of trauma care services: a systematic review.

Public Health ; : 92 — A new classification scheme for treating blunt aortic injury. J Vasc Surg ; 55 : 47 — Acute traumatic aortic injury: practical considerations for the diagnostic radiologist. J Thorac Imaging ; 30 : — Aortic injury in vehicular trauma. Ann Thorac Surg ; 57 : — Direct versus indirect signs of traumatic aortic injury revealed by helical CT: performance characteristics and interobserver agreement.

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Lung windows show bilateral nodular areas of ground-glass attenuation with associated interlobular septal thickening. CT abdomen coronal image with contrast in the same patient as in Figure This soft tissue is compatible with extrapulmonary Erdheim-Chester disease. Radiograph of the left tibia and fibula in the same patient as in Figures Lung windows shows bilateral areas of ground-glass attenuation with associated interlobular septal thickening.

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CT abdomen with contrast in the same patient as in Figure Although nonspecific, this soft tissue is compatible with extrapulmonary Erdheim-Chester disease. Similar soft tissue was seen surrounding the right kidney not shown. The lung bases are most commonly involved.

Pearls and Pitfalls in Thoracic Imaging Pearls and Pitfalls in Thoracic Imaging
Pearls and Pitfalls in Thoracic Imaging Pearls and Pitfalls in Thoracic Imaging
Pearls and Pitfalls in Thoracic Imaging Pearls and Pitfalls in Thoracic Imaging
Pearls and Pitfalls in Thoracic Imaging Pearls and Pitfalls in Thoracic Imaging
Pearls and Pitfalls in Thoracic Imaging Pearls and Pitfalls in Thoracic Imaging
Pearls and Pitfalls in Thoracic Imaging Pearls and Pitfalls in Thoracic Imaging
Pearls and Pitfalls in Thoracic Imaging Pearls and Pitfalls in Thoracic Imaging
Pearls and Pitfalls in Thoracic Imaging Pearls and Pitfalls in Thoracic Imaging

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