Pulmonary Vascularity Research Articles

Magnetic Resonance Imaging Assessment of Pulmonary Vascularity in Preterm Infants with Bronchopulmonary Dysplasia

Introduction: Pulmonary hypertension often complicates bronchopulmonary dysplasia (BPD) and infants with BPD plus pulmonary hypertension experience higher mortality rates. Current methods to evaluate pulmonary hypertension fail to evaluate the primary cause of this disease. We hypothesize that preterm infants with BPD experience altered pulmonary vascular growth and that magnetic resonance imaging (MRI) can be used to assess vascularity in BPD. Methods: In this observational cohort study, preterm infants with BPD (n = 33) and controls (n = 6) received a postnatal chest MRI that included a 2-dimensional time-of-flight acquisition. Semi-automatic segmentation was performed to measure vascularity parameters including vascular volume and density (vascular density = vascular volume/lung volume). Results: Vascular volume on MRI increases with post-menstrual age (877.2 mm3/week); however, the vascular density does not significantly change. Vascular volume is higher in infants with more severe BPD (p < 0.002), but vascular density did not significantly change when comparing mild, moderate, and severe BPD. Vascular density in infants with severe BPD requiring tracheostomy trended lower when compared to infants not requiring tracheostomy (0.18 mm3/mm3 vs. 0.27 mm3/mm3, p = 0.06). Vascular density increases with increasing days of inhaled nitric oxide (iNO) therapy in infants with severe BPD (0.02 mm3/mm3/week of iNO, rho = +0.56, p = 0.03). Conclusion: Neonatal MRI can be used to assess pulmonary vascularity in preterm infants with BPD. Infants with BPD experience altered vascular growth and while higher vascular volume is associated with more severe BPD, lower vascular density trends toward worse clinical outcomes. Vascular density increases with iNO therapy in severe BPD.

Pediatric three-dimensional quantitative cardiovascular computed tomography.

High-resolution, isotropic, 3-dimensional (D) data from pediatric cardiovascular computed tomography (CT) offer great potential for the accurate quantitative evaluation of pediatric cardiovascular and pulmonary vascular diseases. Recent pilot studies using pediatric 3-D cardiovascular CT have shown promising results in assessing cardiac function in conditions such as tetralogy of Fallot, cardiac defects with a hypoplastic ventricle, Ebstein anomaly, and in quantifying myocardial mass. In addition, the quantitative assessment of pulmonary vascularity is useful for evaluating differential right-to-left pulmonary vascular volume ratio, the effectiveness of pulmonary angioplasty, and predicting pulmonary hypertension. These initial experiences could broaden the role of pediatric cardiovascular CT in clinical practice. Furthermore, the current barriers to its widespread use, pertinent solutions to these problems, and new applications are discussed. In this review, the 3-D quantitative evaluations of cardiac function and pulmonary vascularity using high-resolution pediatric cardiovascular CT data are illustrated.

Predictors of therapeutic response to specific therapy in distal chronic thromboembolic pulmonary hypertension

Aim. To assess therapeutic response to specific therapy in patients with distal CTEPH who are ineligible for surgical management as pulmonary endarterectomy (PEA) or balloon pulmonary angioplasty (BPA).Materials and methods. The study included inoperable patients with CTEPH (n=53) who are ineligible for surgical management as pulmonary endarterectomy or balloon pulmonary angioplasty. The effectiveness of specific therapy were assessed after dividing the patients into improvement or nonimprovement groups based on the following indicators: functional class I-II (WHO), mean pulmonary artery pressure according to right heart catheterization ≤40 mm Hg, pulmonary vascular resistance ≤400 dyn×s×cm-5, cardiac index ≥2,5 L/min/m2 , decrease in N-terminal brain natriuretic peptide &gt;30%, and increase in 6-minute test distance &gt;30 m at 12th-month follow-up compared to baseline parameters.Results. There were no differences in groups by gender, age, and received specific therapy. Multiple logistic regression was performed, resulting in a model for predicting clinical improvement with sensitivity (57,1%) and specificity (87,1%), p=0,002. It was revealed, that the absence of the loss of pulmonary vascularity by X-ray at the time of verification of the diagnosis in patients with CTEPH by 5,91 times increases the chance of achieving clinical improvement after 12 months of the specific therapy, while the absence of signs of heart failure by 5,79 times, and degree of pulmonary valve insufficiency 0-1 according to echocardiography by 9,2 times, respectively.Conclusion. Early initiation of specific therapy in inoperable CTEPH patients due to distal lesions with the absence of severe vascular remodeling and heart failure symptoms leads to the better therapeutic response after 12 months of treatment.

Cardiac magnetic resonance imaging in patients with history of COVID-19

BACKGROUND: Myocarditis is among the most common complications arising from coronavirus infection (COVID-19).&#x0D; AIM: This study aims to find the differences in the patterns of myocardial injury between patients who had COVID-19 and those from the pre-pandemic period, as determined by contrast-enhanced cardiac magnetic resonance imaging.&#x0D; MATERIALS AND METHODS: The study encompassed a retrospective analysis of 47 patients who underwent contrast-enhanced cardiac magnetic resonance imaging to rule out acute myocarditis. Group 1 comprised 34 patients with a confirmed history of COVID-19 through PCR testing (nasal and/or throat swabs), while Group 2 comprised 13 individuals who underwent contrast-enhanced cardiac magnetic resonance imaging in 2017 prior to the onset of the COVID-19 pandemic. All patients enrolled in the study had clinical manifestation of cardiac injury without signs of coronary artery disease as an underlying cause of condition.&#x0D; RESULTS: The mean time from the onset of heart symptoms to the administration of contrast-enhanced cardiac magnetic resonance imaging was 166 days. In group 1, a decrease in exercise tolerance was observed in 77% of patients, and 14 (42%), 30 (88%), and 28 (85%) of patients complained of chest pain, shortness of breath, and heart palpitations, respectively. In group 2, four patients (30%) had dyspnea, nine patients (69%) complained of chest pain, and six patients (46%) had heart palpitations and/or feeling of arrhythmia. Myocardial injury in group 1 was more generalized. The third of them had displayed preserved increased pulmonary vascularity and pleural effusion. Within group 1, men had significantly lower left ventricular ejection fraction, lower values of global longitudinal deformation, and higher values of left atrial function compared with the corresponding parameters in women. Differences in women were found only in the number of the affected segments in the left ventricular myocardium.&#x0D; CONCLUSION: SARS-CoV-2 virus caused extended myocardial injury, affecting a significant number of myocardial segments. Men had more frequent postinflammatory complications, characterized by abnormal function of the left ventricle and left atrium. Obtained results require continuous efforts for further assessment of long-term consequences of previous COVID-19 to the cardiovascular system. In this regard, contrast-enhanced cardiac magnetic resonance imaging may represent a sensitive imaging tool for the assessment of cardiac injury severity.

Step by Step: Radiologic Features of Pulmonary Vascular Disease Made Simple

“Pulmonary vascular disease” is a broad term that includes any condition that affects the blood vessels within the lungs. Most of these pathologies have similar radiologic findings, thus clinical and histopathologic complements are essential tools for an appropriate diagnosis. This article provides methodologic radiology guidelines to approach the diagnosis of the most frequent pathologies that involve pulmonary vascularity.

Chest radiological features and their association with clinical manifestations in COVID-19 positive neonates and young infants

We report the Radiological findings in relation to the clinical features of coronavirus disease (COVID-19) in 37 symptomatic neonates and young infants (&lt;2 months of age) who presented with a sepsis-like picture and proved to be infected with COVID-19. Patients and methods: We reviewed, recorded, and analyzed the clinical findings in relation to the imaging features of coronavirus disease (COVID-19) in 37 symptomatic neonates and young infants (&lt;2 months of age) who presented with sepsis-like picture (fever, hypotonia, hypoactivity, cough, and poor feeding) and proved to be infected with COVID19 (PCR) between January 1, 2020, and June 1, 2020. Results: Our symptomatic newborns with COVID-19 infection had increased pulmonary vascularity in 6.2%, slightly accentuated central lung vascularity in 12.5%, and prominent hilar shadows with increased linear lung shadowing in the perihilar and precardiac in 34%. Increased linear lung shadowing with a tiny beaded-like appearance more distributed peripherally and at lower lobes occurred in 28%. Superadded peri-bronchial cuffing and perivascular haziness and lace-like fine linear appearance of interstitium occurred in 9.3%. Ground glass fine opacities (GGO) scattered in two or more lobes of both lungs appeared in 15.6%. Only 6.2% of symptomatic newborns showed superadded consolidations in both lungs, mainly peripherally oriented. Correlation with clinical severity of the disease (requirement of oxygen and assisted ventilation) proved that the appearance of GGO without consolidations was associated with moderate clinical severity, while the appearance of consolidations was associated with marked disease severity. Conclusions: These findings brought more attention and understanding of the radiological manifestations and their association with the clinical severity in COVID19 positive newborns and young infants.

Unique Pulmonary Hypertension in Young Children: A Case Series Study.

Pediatric pulmonary hypertension (PH) has a similar clinical presentation to the adult disease but is associated with several additional disorders and challenges that require a specific approach for their fulminant course. With improved care for premature infants, various forms of pulmonary vascular disease have been found in children that did not previously exist. Pediatric PH can begin in utero, resulting in pulmonary vascularity growth abnormalities that may persist into adulthood. Here, we retrospectively reviewed several unique pediatric PH cases from 2000 to 2020 at Kaohsiung Medical University Hospital, Taiwan, a tertiary teaching hospital. Their comorbidities varied and included surfactant dysfunction, bronchopulmonary dysplasia, premature closure of the ductus arteriosus, high levels of renin and aldosterone, and Swyer–James–Macleod syndrome. Their clinical profiles, radiological characteristics, echocardiography, pulmonary angiogram, and therapeutic regimens were recorded. Further, because the underlying causes of pediatric PH were complex and markedly different according to age, adult PH classification may not be applicable to pediatric PH in all settings. We also classified these cases using different systems, including the Panama classification and the Sixth World Symposium on PH, and compared their advantages and disadvantages.

Computed tomography evaluation of pediatric pulmonary hypertension.

Although rare in the pediatric population, pulmonary hypertension is a significant cause of morbidity and mortality in affected individuals. In addition to evaluating potential causes and severity of parenchymal lung diseases, non-contrast high-resolution CT of the chest can aid in the diagnosis of heritable and acquired causes. In addition to evaluating parenchymal lung disease, CT angiography can help to confirm findings of pulmonary hypertension using criteria similar to echocardiography, and provide detailed assessment of the pulmonary vascularity in specific causes.

Densité pulmonaire et quantification vasculaire tomodensitométrique dans l’hypertension pulmonaire associée aux pneumopathies interstitielles diffuses fibrosantes

The main objective of this work was to investigate a possible link between lung density, small pulmonary vessels, and pulmonary hypertension (PH) in patients with progressive fibrosing interstitial lung disease (PF-ILD). The study focused on patients with PF-ILD, all of whom underwent right cardiac catheterization and chest computed tomography prior to lung transplantation. Computed tomography scans were analyzed quantitatively for density and pulmonary vascularity. The relationship between computed tomography features and PH was investigated. Fifty-one patients with usual interstitial pneumonia (UIP) damage on lung explant were included. mPAP was positively correlated with lung mass (r=0.36, P=0.03) and lung volume (r=0.43, P=0.007). Patients with severe PH had more voxels lower than -856 Hounsfield Units (HU) (+16%, P=0.02), fewer voxels greater than -700 HU (-20%, P=0.03), and a higher lung volume (+1.57L, P=0.007) compared to patients without PH. No correlation was found between vascularization and HTP. Patients with PF-ILD and severe PH have lower lung density than patients with moderate or without PH.

Magnetic Resonance Imaging Assessment of Pulmonary Vascularity in Infants with Congenital Diaphragmatic Hernia: A Novel Tool for Direct Assessment of Severity of Pulmonary Hypertension and Hypoplasia

To assess the feasibility of magnetic resonance imaging (MRI) for postnatal assessment of pulmonary vascularity in infants with congenital diaphragmatic hernia (CDH). Infants with prenatally diagnosed CDH (n=24) received postnatal pulmonary MRI. Infants with nonpulmonary birth defects served as controls (n=5). Semiautomatic segmentation was performed to obtain total vascular volume using time of flight images to assess vascularity. Average vascular density (vascular volume/lung volume) in control infants was 0.23±0.06mm3/mm3 compared with 0.18±0.06mm3/mm3 in infants with CDH is (P=.09). When stratified further based on CDH severity, the difference between control infants and moderate CDH group was statistically significant. (0.23mm3/mm3 vs 0.15mm3/mm3, P=.01). Ipsilateral vascular density on MRI in infants with CDH significantly correlated with the prenatal pulmonary hypertensive index (P=.0004, Spearman R=+0.87) and with number of days on mechanical ventilation (P=.04, Spearman R=-0.44), total days on inhaled nitric oxide (P=.02, Spearman R=-0.47), use of epoprostenol for acute pulmonary hypertension (PH) (0.14mm3/mm3 vs 0.20mm3/mm3, P=.005), and use of sildenafil for chronic PH (0.15mm3/mm3 vs 0.19mm3/mm3, P=.03). Our results suggest that postnatal pulmonary vascularity assessed by MRI strongly correlates with prenatal and postnatal markers of PH severity and that pulmonary vascularity may serve as a direct measure of pulmonary vascular hypoplasia in infants with CDH.

CT Pulmonary Vessels and MRI Ventilation in Chronic Obstructive Pulmonary Disease: Relationship with worsening FEV1 in the TINCan cohort study

The relationships between computed tomography (CT) pulmonary vascularity and MRI ventilation is not well-understood in chronic obstructive pulmonary disease (COPD) patients. Our objective was to evaluate CT pulmonary vascular and MRI ventilation measurements in ex-smokers and to investigate their associations and how such measurements change over time. Ninety ex-smokers (n = 41 without COPD 71 ± 10 years and n = 49 COPD 71 ± 8 years) provided written informed-consent to an ethics-board approved protocol and underwent imaging and pulmonary-function-tests twice, 31 ± 7 months apart. 3He MRI was acquired to generate ventilation-defect-percent (VDP). CT measurements of the relative area-of-the-lung with attenuation <-950 Hounsfield units (RA950), pulmonary vascular total-blood-volume (TBV) and percent of vessels with radius < one voxel (PV1) were evaluated. At baseline, there were significant differences in RA950 (p = 0.0001), VDP (p = 0.0001), total-blood-volume (p = 0.0001) and PV1 (p = 0.01) between ex-smokers and COPD participants as well as for VDP (p = 0.0001) in COPD participants with and without emphysema. The annual FEV1 change (-40 ± 93 mL/year) was not different among participant subgroups (p = 0.87), but the annual RA950 (p = 0.01) and PV1 (p = 0.007) changes were significantly different in participants with an accelerated annual FEV1 decline as compared to participants with a diminished annual FEV1 decline. There were significant but weak relationships for PV1 with FEV1%pred (p = 0.02), FEV1/FVC (p = 0.001), and log RA950 (p = 0.0001), but not VDP (p=0.20). The mean change in PV1 was also weakly but significantly related to the change in RA950 (p = 0.02). CT pulmonary vascular measurements were significantly different in ex-smokers and participants with COPD and related to RA950 but not VDP worsening over 2.5 years.

Radiation dose reduction and improvement of image quality in digital chest radiography by new spatial noise reduction algorithm.

PurposeTo evaluate the image quality of low-dose chest digital radiographic images obtained with a new spatial noise reduction algorithm, compared to a conventional de-noising technique.Materials and methodsIn 69 patients, the dose reduction protocol was divided into A, B, and C test groups– 60% (n = 22), 50% (n = 23), and 40% (n = 24) of the baseline dose. In each patient, baseline dose radiographs were obtained with conventional image processing while low-dose images were acquired with new image processing. A set of baseline and low-dose radiographic images per patient was evaluated and scored on a 5-point scale over seven anatomical landmarks (radiolucency of unobscured lung, pulmonary vascularity, trachea, edge of rib, heart border, intervertebral disc space, and pulmonary vessels in the retrocardiac area) and three representative abnormal findings (nodule, consolidation, and interstitial marking) by two thoracic radiologists. A comparison of paired baseline and low-dose images was statistically analyzed using a non-inferiority test based on the paired t-test or the Wilcoxon signed-rank test.ResultsIn A, B, and C test groups, the mean dose reduction rate of the baseline radiation dose was 63.4%, 53.9%, and 47.8%, respectively. In all test groups, the upper limit of the 95% confidence interval was less than the non-inferiority margin of 0.5 every seven anatomical landmarks and three representative abnormal findings, which suggested that the image quality of the low-dose image was not inferior to that of the baseline dose image even if the maximum average dose reduction rate was reduced to 47.8% of the baseline dose.ConclusionIn our study, an image processing technique integrating a new noise reduction algorithm achieved dose reductions of approximately half without compromising image quality for abnormal lung findings and anatomical landmarks seen on chest radiographs. This feature-preserving, noise reduction algorithm adopted in the proposed engine enables a lower radiation dose boundary for the sake of patient’s and radiography technologist’s radiation safety in routine clinical practice, in compliance with regulatory guidelines.

Lifesaving surgery for a ruptured invasive thymoma using the hemi-clamshell approach: a case report

BackgroundAmong anterior mediastinal tumors, a teratoma is known to rupture with growth, but there have been few previous reports about thymoma rupture. We here report a rare case of an invasive thymoma with intrapulmonary and intrathoracic rupture requiring emergency life-saving surgery. To our knowledge, this is the first such case in the literature.Case presentationA 56-year-old woman suddenly experienced right precordial pain and hemoptysis. Enhanced computed tomography revealed a large mediastinal tumor pressing against the pulmonary hilar vascularity, with extravasation of blood into the right lung. Tumor rupture into the lungs was suspected. Given the deterioration of her respiratory status and hemodynamics, thymomectomy with removal of the involved tissues was urgently performed using the hemi-clamshell approach and intrapericardial dissection, with veno-arterial extracorporeal membrane oxygenation on standby. She survived, and no recurrence has been noted for 2 years postoperatively.ConclusionsA large thymoma can suddenly rupture into the thorax, similar to the rupture of a teratoma. Additionally, in cases with hemoptysis, an appropriate procedure should be selected to reach both the pulmonary hilum and thorax for complete resection, as hemoptysis might suggest tumor invasion into the lungs.

Pulmonary Arterial Hypertension: A Review Article

Pulmonary arterial hypertension (PAH) is characterized by the mean pulmonary artery pressure of more than 25 mmHg and pulmonary artery wedge pressure of less than 15 mmHg evidenced by right-heart catheterization. In the classification of PAH, some subgroups are defined as primary or secondary PAH based on the underlying etiologies of the disease. Early episodes of PAH have been reported to occur at younger ages and in women in idiopathic or familial forms with the survival rate of 1-3 years. According to recent registries, the affected patients are older and have better survival rates. Some of the key elements in the pathophysiology of PAH include intima and media proliferation, vascular remodeling, and blood coagulation, which could increase the defiance of pulmonary vascularity, so that the cellular and molecular pathways would be able to induce PAH through specific mechanisms. Although no pathognomonic signs and symptoms have been reported in the literature, the most prominent manifestations of PAH are associated with disorders such as heart failure. Currently, PAH is known as a severe and occasionally life-threatening multifactorial clinical condition. Considering endothelial dysfunction, vasoconstriction, inflammatory reactions, and platelet aggregation as the main pathophysiological arms of the disease, specific treatment approaches have been proposed to inhibit these manifestations. These methods result in the effective treatment response, as well as the proper early and late outcomes of PAH. Due to the high incidence of cardiovascular diseases and the associated progressive life-threatening conditions, such as heart failure and PAH in the Iranian population, identification of the etiological, pathophysiological, diagnostic, and novel therapeutic approaches for PAH is essential to the proper management of this clinical condition.

Longitudinal changes in structural abnormalities using MDCT in COPD: do the CT measurements of airway wall thickness and small pulmonary vessels change in parallel with emphysematous progression?

BackgroundRecent advances in multidetector computed tomography (MDCT) facilitate acquiring important clinical information for managing patients with COPD. MDCT can detect the loss of lung tissue associated with emphysema as a low-attenuation area (LAA) and the thickness of airways as the wall area percentage (WA%). The percentage of small pulmonary vessels <5 mm2 (% cross-sectional area [CSA] <5) has been recently recognized as a parameter for expressing pulmonary perfusion. We aimed to analyze the longitudinal changes in structural abnormalities using these CT parameters and analyze the effect of exacerbation and smoking cessation on structural changes in COPD patients.MethodsWe performed pulmonary function tests (PFTs), an MDCT, and a COPD assessment test (CAT) in 58 patients with COPD at the time of their enrollment at the hospital and 2 years later. We analyzed the change in clinical parameters including CT indices and examined the effect of exacerbations and smoking cessation on the structural changes.ResultsThe CAT score and forced expiratory volume in 1 second (FEV1) did not significantly change during the follow-up period. The parameters of emphysematous changes significantly increased. On the other hand, the WA% at the distal airways significantly decreased or tended to decrease, and the %CSA <5 slightly but significantly increased over the same period, especially in ex-smokers. The parameters of emphysematous change were greater in patients with exacerbations and continued to progress even after smoking cessation. In contrast, the WA% and %CSA <5 did not change in proportion to emphysema progression.ConclusionThe WA% at the distal bronchi and the %CSA <5 did not change in parallel with parameters of LAA over the same period. We propose that airway disease and vascular remodeling may be reversible to some extent by smoking cessation and appropriate treatment. Optimal management may have a greater effect on pulmonary vascularity and airway disease than parenchymal deconstruction in the early stage of COPD.

Anomalous Left Coronary Artery from the Pulmonary Artery: Images Studies of Echocardiographic, Heart CT and Angiography

Anomalous origin of the left coronary artery from the pulmonary artery (ALCAPA) is a very rare but serious congenital coronary arterial anomaly. Congestive heart failure, myocardial ischemia &even sudden cardiac death may occur in early infancy. Early diagnosis is usually difficulty before the occurrence of clinical symptoms. Surgical correction is usually necessary as soon as possible to avoid the long-term sequel of myocardial ischemia & significant mitral regurgitation. A 3 months old female infant was sent to pediatric clinic due to shortness of breath for two days . Physical examination revealed mild subcostal retraction, a grade II/VI systolic murmur over left lower sternal boarder, hepatomegaly with 3 cm below right costal margin. The peripheral arterial pulsations were normal and without no cyanosis, Chest X-ray film showed moderate cardiomegaly (Figure 1) with normal pulmonary vascularity. She was referred to pediatric cardiologic clinic and echocardiography revealed a single right main coronary artery with diameter of 2.2mm (Figure 2) and moderate to severe mitral valve regurgitation (Figure 3) . The ejection fraction of left ventricle was 12.5%. Emergency heart CT showed only the single right coronary artery (Figure 4). Cardiac catheterization and angiography (Figure 5) confirmed the diagnosis of anomalous origin of left coronary artery from the main pulmonary artery (ALCAPA). Then she received the surgical total correction with re-implantation of the left coronary artery from main pulmonary artery to ascending aorta. Post-operative recovery was not unevenly. She was under anti-congestive therapy and follow up at pediatric cardiologic clinic regularly. The follow-up echocardiography revealed good anastomosis of left coronary artery with aorta, moderate mitral regurgitation and nearly normal left ventricular function with ejection fraction of 58.97 %. Although ALCAPA is a very rare congenital coronary artery anomaly, but it is usually presented with sudden onset of congestive heart failure, myocardial ischemia, even cardiac death in infancy when the high pulmonary arterial pressure dropped down as normal sequence. Echocardiography can usually identify only the right coronary artery from aorta, mitral regurgitation and dilatation of left ventricle and atrium. Other images studies such as heart CT and angiography are the accurate diagnostic tool. Post-operative follow up with echocardiography is necessary to assess the anastomosis of re-implanted left coronary artery, the severity of mitral regurgitation and ventricular function.

Vein of Galen Aneurysmal Malformation in a Neonate: A Case Report

Vein of Galen aneurysmal malformation (VGAM) is a rare congenital malformation, accounting for less than 1% of cerebrovascular abnormalities. The majority of reported cases have been associated with congestive heart failure (CHF) in the neonatal period. Herein, we present a case of VGAM, diagnosed at 37 weeks of gestation during the intrauterine life Case report: A full-term female newborn presented with severe CHF at two days of age. The patient's peripheral pulses were bounding in all four extremities. The first heart sound appeared to be normal, while the second had an accentuated pulmonic component. A systolic murmur (grade 3/6), best heard in the pulmonary area, was reported, and a cranial bruit was sought and found. The echocardiography showed evidence of right ventricular hypertrophy, while the chest X-ray indicated cardiomegaly with increased pulmonary vascularity. Moreover, echocardiography revealed dilation of the right heart chambers, a patent foramen ovale, severe tricuspid regurgitation, as well as a moderate-sized secundum atrial septal defect and a patent ductus arteriosus with right-to-left shunting. Transcranial ultrasound and contrast-enhanced CT scan of the brain detected a vein of Galen malformation. Magnetic resonance venography confirmed VGAM and identified the vessels feeding the aneurysm. Postnatal management included aggressive medical treatment of CHF. Transarterial embolization of the vessels feeding the aneurysm was suggested. However, the newborn succumbed to her disease on the following day. Conclusion: VGAM, which is a rare cause of cyanosis and heart failure in newborns, can be clinically diagnosed via proper strategies. However, extensive distribution of aneurysm usually precludes surgical management and endovascular treatment.

Illustrated Imaging Essay on Congenital Heart Diseases: Multimodality Approach Part III: Cyanotic Heart Diseases and Complex Congenital Anomalies.

From the stand point of radiographic analysis most of the complex cyanotic congenital heart diseases (CHD), can be divided into those associated with decreased or increased pulmonary vascularity. Combination of a specific cardiac configuration and status of lung vasculature in a clinical context allows plain film diagnosis to be predicted in some CHD. Correlation of the position of the cardiac apex in relation to the visceral situs is an important information that can be obtained from the plain film. This information helps in gathering information about the atrio-ventricular, ventricular arterial concordance or discordance. Categorization of the cyanotic heart disease based on vascularity is presented below. Thorough understanding of cardiac anatomy by different imaging methods is essential in understanding and interpreting complex cardiac disease. Basic anatomical details and background for interpretation are provided in the previous parts of this presentation.

Distinctive Mediastinal Appearance in Chest Radiograph of a Patient with Total Anomalous Pulmonary Venous Connection

Abstract Despite technological advancements, diagnosis of total anomalous pulmonary venous connection (TAPVC) can be challenging in neonates and infants, particularly in asymptomatic cases. We report a case of a 22-month-old boy who presented to the Emergency department with a history of intermittent fever and cough, initially diagnosed as pneumonia. The presence of an enlarged mediastinal mass was noted in a chest radiograph and was interpreted as a potential malignancy. However, the presence of a supracardiac type of TAPVC with significant right-sided cardiac dilation and a large unobstructed ascending vertical vein was confirmed by echocardiogram. Elective and uneventful surgical correction was performed with subsequent follow-up to confirm cardiac stability and normalization. This case presents the “snowman” or “figure-of-eight” appearance characteristic of TAPVC. Moreover, our patient’s chest radiograph is suggestive of a well-defined, smooth and linear vascular shadow with the presence of a normal lung parenchyma along with increased pulmonary vascularity indicating a left-sided vertical vein in keeping with the supracardiac type of TAPVC. Not commonly reported in previous literature, these unique radiographic findings may hold significant value for pediatricians and imaging specialists as a diagnostic tool for the supracardiac variant of this congenital pathology

13-week Pulmonary Sonoangiogram by 3D HDlive Flow

ABSTRACT Recent development of three-dimensional (3D)/four-dimensional (4D) sonography has revealed structural and functional early human development in utero and 3D/4D sonography moved prenatal diagnosis of fetal anomalies from the second to the first trimester of pregnancy. HDlive flow is a recent application of 3D ultrasound technology generating a 3D-view of the blood flow and providing a realistic rendering of fine vascular structure. Combination of HDlive silhouette and flow can be described as a ‘see-through fashion’, because of its comprehensive orientation and persuasive localization of inner structure as well as of fetal angiostructure inside the morphological structure. The picture of this month demonstrates normal intracorporeal angiostructure by 3D HDlive silhouette/flow imaging with bidirectional power Doppler at 13 weeks of gestation. The umbilical arteries, umbilical vein, ductus venosus, inferior vena cava, descending aorta as well as rich pulmonary vascularity are clearly demonstrated in a single 3D reconstructed image. This image indicates existence of rich pulmonary vascularity from even before lung maturation in the first trimester. Prenatal prediction of neonatal prognosis in cases with still remains a challenge but previous trials have been done after 20 weeks of gestation. Nowadays, many of pulmonary lesions, such as congenital diaphragmatic hernia (CDH) and congenital cystic adenomatoid malformation (CCAM), have been diagnosed in the first or early second trimesters. Recent advanced imaging technology of HDlive flow showing pulmonary vasculature from the first trimester in this article may have a great potential to investigate fetal lung development and maturity from early gestation and lead to scheduling of prenatal fetal treatment and proper management. How to cite this article Pooh RK. 13-week Pulmonary Sonoangiogram by 3D HDlive Flow. Donald School J Ultrasound Obstet Gynecol 2015;9(4):355-356.