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Of the Pediatric Mediastinum
MRI of the Pediatric Mediastinum Dianna M. E. Bardo, MD Director of Body MR & Co-Director of the 3D Innovation Lab Disclosures Consultant & Speakers Bureau – honoraria Koninklijke Philips Healthcare N V Author – royalties Thieme Publishing Springer Publishing Mediastinum - Anatomy Superior Mediastinum thoracic inlet to thoracic plane thoracic plane to diaphragm Inferior Mediastinum lateral – pleural surface anterior – sternum posterior – vertebral bodies Mediastinum - Anatomy Anterior T4 Mediastinum pericardium to sternum Middle Mediastinum pericardial sac Posterior Mediastinum vertebral bodies to pericardium lateral – pleural surface superior – thoracic inlet inferior - diaphragm Mediastinum – MR Challenges Motion Cardiac ECG – gating/triggering Breathing Respiratory navigation Artifacts Intubation – LMA Surgical / Interventional materials Mediastinum – MR Sequences ECG gated/triggered sequences SSFP – black blood SE – IR – GRE Non- ECG gated/triggered sequences mDIXON (W, F, IP, OP), eTHRIVE, turbo SE, STIR, DWI Respiratory – triggered, radially acquired T2W MultiVane, BLADE, PROPELLER Mediastinum – MR Sequences MRA / MRV REACT – non Gd enhanced Gd enhanced sequences THRIVE, mDIXON, mDIXON XD Mediastinum – Contents Superior Mediastinum PVT Left BATTLE: Phrenic nerve Vagus nerve Structures at the level of the sternal angle Thoracic duct Left recurrent laryngeal nerve (not the right) CLAPTRAP Brachiocephalic veins Cardiac plexus Aortic arch (and its 3 branches) Ligamentum arteriosum Thymus Aortic arch (inner concavity) Trachea Pulmonary -
Vessels and Circulation
CARDIOVASCULAR SYSTEM OUTLINE 23.1 Anatomy of Blood Vessels 684 23.1a Blood Vessel Tunics 684 23.1b Arteries 685 23.1c Capillaries 688 23 23.1d Veins 689 23.2 Blood Pressure 691 23.3 Systemic Circulation 692 Vessels and 23.3a General Arterial Flow Out of the Heart 693 23.3b General Venous Return to the Heart 693 23.3c Blood Flow Through the Head and Neck 693 23.3d Blood Flow Through the Thoracic and Abdominal Walls 697 23.3e Blood Flow Through the Thoracic Organs 700 Circulation 23.3f Blood Flow Through the Gastrointestinal Tract 701 23.3g Blood Flow Through the Posterior Abdominal Organs, Pelvis, and Perineum 705 23.3h Blood Flow Through the Upper Limb 705 23.3i Blood Flow Through the Lower Limb 709 23.4 Pulmonary Circulation 712 23.5 Review of Heart, Systemic, and Pulmonary Circulation 714 23.6 Aging and the Cardiovascular System 715 23.7 Blood Vessel Development 716 23.7a Artery Development 716 23.7b Vein Development 717 23.7c Comparison of Fetal and Postnatal Circulation 718 MODULE 9: CARDIOVASCULAR SYSTEM mck78097_ch23_683-723.indd 683 2/14/11 4:31 PM 684 Chapter Twenty-Three Vessels and Circulation lood vessels are analogous to highways—they are an efficient larger as they merge and come closer to the heart. The site where B mode of transport for oxygen, carbon dioxide, nutrients, hor- two or more arteries (or two or more veins) converge to supply the mones, and waste products to and from body tissues. The heart is same body region is called an anastomosis (ă-nas ′tō -mō′ sis; pl., the mechanical pump that propels the blood through the vessels. -
Thoracic Aorta
GUIDELINES AND STANDARDS Multimodality Imaging of Diseases of the Thoracic Aorta in Adults: From the American Society of Echocardiography and the European Association of Cardiovascular Imaging Endorsed by the Society of Cardiovascular Computed Tomography and Society for Cardiovascular Magnetic Resonance Steven A. Goldstein, MD, Co-Chair, Arturo Evangelista, MD, FESC, Co-Chair, Suhny Abbara, MD, Andrew Arai, MD, Federico M. Asch, MD, FASE, Luigi P. Badano, MD, PhD, FESC, Michael A. Bolen, MD, Heidi M. Connolly, MD, Hug Cuellar-Calabria, MD, Martin Czerny, MD, Richard B. Devereux, MD, Raimund A. Erbel, MD, FASE, FESC, Rossella Fattori, MD, Eric M. Isselbacher, MD, Joseph M. Lindsay, MD, Marti McCulloch, MBA, RDCS, FASE, Hector I. Michelena, MD, FASE, Christoph A. Nienaber, MD, FESC, Jae K. Oh, MD, FASE, Mauro Pepi, MD, FESC, Allen J. Taylor, MD, Jonathan W. Weinsaft, MD, Jose Luis Zamorano, MD, FESC, FASE, Contributing Editors: Harry Dietz, MD, Kim Eagle, MD, John Elefteriades, MD, Guillaume Jondeau, MD, PhD, FESC, Herve Rousseau, MD, PhD, and Marc Schepens, MD, Washington, District of Columbia; Barcelona and Madrid, Spain; Dallas and Houston, Texas; Bethesda and Baltimore, Maryland; Padua, Pesaro, and Milan, Italy; Cleveland, Ohio; Rochester, Minnesota; Zurich, Switzerland; New York, New York; Essen and Rostock, Germany; Boston, Massachusetts; Ann Arbor, Michigan; New Haven, Connecticut; Paris and Toulouse, France; and Brugge, Belgium (J Am Soc Echocardiogr 2015;28:119-82.) TABLE OF CONTENTS Preamble 121 B. How to Measure the Aorta 124 I. Anatomy and Physiology of the Aorta 121 1. Interface, Definitions, and Timing of Aortic Measure- A. The Normal Aorta and Reference Values 121 ments 124 1. -
Blood Vessels
BLOOD VESSELS Blood vessels are how blood travels through the body. Whole blood is a fluid made up of red blood cells (erythrocytes), white blood cells (leukocytes), platelets (thrombocytes), and plasma. It supplies the body with oxygen. SUPERIOR AORTA (AORTIC ARCH) VEINS & VENA CAVA ARTERIES There are two basic types of blood vessels: veins and arteries. Veins carry blood back to the heart and arteries carry blood from the heart out to the rest of the body. Factoid! The smallest blood vessel is five micrometers wide. To put into perspective how small that is, a strand of hair is 17 micrometers wide! 2 BASIC (ARTERY) BLOOD VESSEL TUNICA EXTERNA TUNICA MEDIA (ELASTIC MEMBRANE) STRUCTURE TUNICA MEDIA (SMOOTH MUSCLE) Blood vessels have walls composed of TUNICA INTIMA three layers. (SUBENDOTHELIAL LAYER) The tunica externa is the outermost layer, primarily composed of stretchy collagen fibers. It also contains nerves. The tunica media is the middle layer. It contains smooth muscle and elastic fiber. TUNICA INTIMA (ELASTIC The tunica intima is the innermost layer. MEMBRANE) It contains endothelial cells, which TUNICA INTIMA manage substances passing in and out (ENDOTHELIUM) of the bloodstream. 3 VEINS Blood carries CO2 and waste into venules (super tiny veins). The venules empty into larger veins and these eventually empty into the heart. The walls of veins are not as thick as those of arteries. Some veins have flaps of tissue called valves in order to prevent backflow. Factoid! Valves are found mainly in veins of the limbs where gravity and blood pressure VALVE combine to make venous return more 4 difficult. -
The Descending Thoracic Aorta Morphological Characteristics
ARS Medica Tomitana - 2016; 3(22): 186 - 191 10.1515/arsm-2016-0031 Malik S., Bordei P., Rusali A., Iliescu D. M. The descending thoracic aorta morphological characteristics Faculty of Medicine, “Ovidius” University, Constanta ABSTRACT Introduction Our study was conducted by consulting angioCT sites made on a CT GE LightSpeed VCT64 Slice CT and a CT GE LightSpeed 16 Slice CT, following the path and relationships of the descending thoracic aorta against the vertebral column, outside diameters thereof at the Descending thoracic aorta extends from the thoracic vertebrae T4, T7, T12 and posterior intercostal aortic arch (which it continues) and aortic hiatus of arteries characteristics. The origin of of the descending the diaphragm at level of T12 vertebra [1,2,3,4,5] thoracic aorta we found most commonly on the left corresponding to the front of T10 [6], level that flank of the lower edge of the vertebral body T4, but continues with the abdominal descending aorta. She I have encountered cases where it had come above the enters the posterior mediastinum at the T4 vertebra and lower edge of T4 on level of intervertebral disc T4-T5 or describes a trajectory which is vertically downward as even at the upper edge of T5 vertebral body. At thoracic a whole, being slightly inferior oblique and to the right, vertebra T4, on a total of 30 cases, the descending thoracic aorta present a diameter of 20.0 to 32.6 mm, then, first at a distance of 2-3 cm midline, progressive values that correspond to male gender and to females approach to become median and prevertebral at the diameter ranging from 25.5 to 27, 4 mm. -
Surgical Indications. a Critical Point of View
Surgical indications in ascending aorta aneurysms: What do we know? Jean-Luc MONIN, MD, PhD. Institut Mutualiste Montsouris, Paris, FRANCE Disclosures related to this talk : www.imm.fr NONE 2 Clinical case www.imm.fr • A 40 year-old woman • Height: 172 cm/ Weight: 70 kg • Ascending aortic aneurysm • She wants to become pregnant (3-year old kid) • No Marfan syndrome or bicuspid AV • Younger sister: sudden unexplained death (at 18 years old) • 2012 (MRI): Valsalva: 42 mm, tubular: 43 mm • 2013 (MRI): Valsalva: 40 mm, tubular: 45 mm 3 www.imm.fr www.imm.fr www.imm.fr www.imm.fr www.imm.fr www.imm.fr What would we advise to this woman www.imm.fr ? A. Pregnancy is temporarily contra indicated, MRI or cardiac CT is needed B. No contra indication for pregnancy, TTE or MRI at 1 year 10 Thoracic aortic aneurysm www.imm.fr Thoracic Aortic Aneurysm: An indolent but virulent process www.imm.fr Ascending Aorta 1 mm/ year 45 mm 60 mm 3 mm/ year 34% Rate of aortic dilatation is EXPONENTIAL • Expansion rate ≈ 2.1 mm/ year for an initial diameter of 35-40 mm (%) rupture dissection/ of risk Lifetime Aortic diameter (cm) • Expansion rate ≈ 5.6 mm/ year for aneurysms ≥ 60 mm Coady et al. J Thorac Cardiovasc Surg. 1997;113: 476 Mechanical properties of human ascending aorta : >6 cm is the limit www.imm.fr Exponential relationship between wall stress and aneurysm size in ascending aortic aneurysms. • Pink columns : SBP =100 mm Hg • Purple columns : SBP = 200 mm Hg • Range of maximum tensile strength of the human aorta : 800 to 1,000 kPa Koullias et al. -
Aorta and Supra-Aortic Trunks 4
Aorta and Supra-aortic Trunks 4 Amelia Sparano, Gennaro Barbato L. Romano, M. Silva, S. Fulciniti, A. Pinto (eds.) MDCT Anatomy – Body 23 © Springer-Verlag Italia 2011 24 A. Sparano, G. Barbato Anonymous trunk Ascending aorta Descending thoracic aorta a Pulmonary trunk Aortic root Left ventricle b Anonymous trunk Left subclavian Aortic arch artery c Fig. 4.1 a The thoracic aorta arises from the left cardiac ventricle through the semilunar valve, at the level of the lower border of the third left costal cartilage. b The ascending aorta passes upwards towards the right until it reaches the level of the lower border of the right second costal cartilage. From above downwards, it is related anteriorly with the right ventricle and posteriorly with the left atrium and right pulmonary artery. c The aortic arch describes a curve that is concave forwards; it passes behind to the left, remaining in front of the trachea on its left side. The supra-aortic trunks arise from the aortic arch 4 Aorta and Supra-aortic Trunks 25 Aorta Aortopulmonary window a Esophagus Descending aorta b Liver dome Descending aorta c Fig. 4.2 a The aortic arch begins at the level of the second costal cartilage and runs behind the tra- chea until it reaches the fourth thoracic vertebra (TIV). b The descending thoracic aorta is contin- uous with the aortic arch. c It runs from the body of TIV to TXII, where it is continuous with the abdominal aorta. The descending aorta gives rise to visceral (bronchial, pericardial, esophageal, and mediastinal) and parietal (intercostal, subcostal, superior phrenic) branches 26 A. -
Aorta and the Vasculature of the Thorax
Aorta and the Vasculature of the Thorax Ali Fırat Esmer, MD Ankara University Faculty of Medicine Department of Anatomy THE AORTA After originating from left ventricle, it ascends for a short distance, arches backward and to the left side, descends within the thorax on the left side of the vertebral column It is divided for purposes of The aorta is the main arterial trunk description into: that delivers oxygenated blood from Ascending aorta the left ventricle of the heart to the Arch of the aorta and tissues of the body. Descending aorta (thoracic and abdominal aorta) Ascending Aorta The ascending aorta begins at the base of the left ventricle runs upward and forward at the level of the sternal angle, where it becomes continuous with the arch of the aorta it possesses three bulges, the sinuses of the aorta Branches Right coronary artery Left coronary artery ARCH OF THE AORTA The aortic arch is a continuation of the ascending aorta and begins at the level of the second sternocostal joint. • It arches superiorly, posteriorly and to the left before moving inferiorly. • The aortic arch ends at the level of the T4 vertebra / at level of sternal angle. Branches; Brachiocephalic artery (Innominate artery) Left common carotid artery Left subclavian artery It begins when the ascending aorta emerges from the pericardial sac and courses upward, backward, and to the left as it passes through the superior mediastinum, ending on the left side at vertebral level TIV/V. Extending as high as the midlevel of the manubrium of the sternum, the arch is initially anterior and finally lateral to the trachea. -
Aneurysm of the Ascending Aorta Presenting with Pulmonary Stenosis
Thorax: first published as 10.1136/thx.21.3.236 on 1 May 1966. Downloaded from Thorax (1966), 21, 236. Aneurysm of the ascending aorta presenting with pulmonary stenosis M. H. YACOUB, M. V. BRAIMBRIDGE,1 AND R. G. GOLD From the Brornpton Hospital, London S.W.3 The symptoms and signs of aneurysms of the The chest radiograph (Fig. 1) showed old bilateral thoracic aorta are due mainly to compression of apical tuberculosis, and both lungs were emphyse- surrounding mediastinal structures and depend on matous. The emphysema was most marked in the left the size and location of the aneurysm. Compres- upper lobe with bullae present. A hemispherical mass, sion of the trachea, bronchi, oesophagus, recurrent 9 by 6 cm., lay to the left and in front of the ascend- ing aorta. Its border was slightly irregular. and laryngeal nerve, bone, and superior vena cava is showed flecks of linear calcification laterally and common, but pressure on the pulmonary artery has superiorly. The heart size was within normal limits. not been described in spite of its intimate relation At right heart catheterization difficulty was experi- to the ascending aorta. enced in passing the catheter into the pulmonary The object of this paper is to describe a case artery. The right ventricular systolic pressure was presenting in this way and to discuss the particular 44 mm. Hg and the pulmonary artery systolic pres- surgical problems involved in the excision of such sure was 18 mm. Hg. the systolic gradient being 24 an aneurysm. mm. Hg, with a single change in pressure fromarterial to ventricular configuration in the vicinity of the pulmonary valve. -
Aortic Disease
Aortic Disease The Aorta Center in Cleveland Clinic’s Heart & Vascular Institute is organized to optimize the Cleveland Clinic’s Acute care of patients and to facilitate collaboration across disciplines with a focus on conditions that Aortic Treatment affect all segments of the aorta. This multidisciplinary effort has resulted in the busiest aorta center in the US, leading the way in quality, innovation, and research. Center provides rapid transport, treatment, and follow-up for patients with aortic dissection Aortic Surgery and impending aneurysm Volume and Type rupture. In 2016, 5634 2012 – 2016 patients were transported by Cleveland Clinic’s Critical Volume 2016 Totals Care Transport team. More 1500 Open ascending/ than 20% of the patients arch repair (N = 709) transported were treated in Open descending/ the Sydell and Arnold Miller thoracoabdominal repair (N = 34) 1000 Family Heart & Vascular Endovascular descending/ Institute, and many had thoracoabdominal repair (N = 265) acute aortic syndromes. 500 Open abdominal repair (N = 102) Call 877.379.CODE (2633) Endovascular abdominal to expedite the transfer of repair (N = 90) 0 patients with acute aortic 2012 2013 2014 2015 2016 Endovascular ascending aorta syndromes. N = 1194 1219 1230 1185 1228 repair (N = 28) In-Hospital Mortality (N = 1228) 2016 Percent 30 Elective Expected Emergency 20 10 0 0 Ascending/Arch Descending TAAA AAA Open/Endovascular AAA = abdominal aortic aneurysm, TAAA = thoracoabdominal aortic aneurysm Source: Data from the Vizient Clinical Data Base/Resource ManagerTM used by permission of Vizient. All rights reserved. Sydell and Arnold Miller Family Heart & Vascular Institute 41 Aortic Disease Redefining When to Operate Ascending Aorta and Aortic Arch Open Surgery Volume 2012 – 2016 Volume 800 600 400 200 0 2012 2013 2014 2015 2016 N =6728 76 762720 709 In 2016, Cleveland Clinic surgeons performed 709 open procedures to repair the ascending aorta and aortic arch. -
Icd-9-Cm (2010)
ICD-9-CM (2010) PROCEDURE CODE LONG DESCRIPTION SHORT DESCRIPTION 0001 Therapeutic ultrasound of vessels of head and neck Ther ult head & neck ves 0002 Therapeutic ultrasound of heart Ther ultrasound of heart 0003 Therapeutic ultrasound of peripheral vascular vessels Ther ult peripheral ves 0009 Other therapeutic ultrasound Other therapeutic ultsnd 0010 Implantation of chemotherapeutic agent Implant chemothera agent 0011 Infusion of drotrecogin alfa (activated) Infus drotrecogin alfa 0012 Administration of inhaled nitric oxide Adm inhal nitric oxide 0013 Injection or infusion of nesiritide Inject/infus nesiritide 0014 Injection or infusion of oxazolidinone class of antibiotics Injection oxazolidinone 0015 High-dose infusion interleukin-2 [IL-2] High-dose infusion IL-2 0016 Pressurized treatment of venous bypass graft [conduit] with pharmaceutical substance Pressurized treat graft 0017 Infusion of vasopressor agent Infusion of vasopressor 0018 Infusion of immunosuppressive antibody therapy Infus immunosup antibody 0019 Disruption of blood brain barrier via infusion [BBBD] BBBD via infusion 0021 Intravascular imaging of extracranial cerebral vessels IVUS extracran cereb ves 0022 Intravascular imaging of intrathoracic vessels IVUS intrathoracic ves 0023 Intravascular imaging of peripheral vessels IVUS peripheral vessels 0024 Intravascular imaging of coronary vessels IVUS coronary vessels 0025 Intravascular imaging of renal vessels IVUS renal vessels 0028 Intravascular imaging, other specified vessel(s) Intravascul imaging NEC 0029 Intravascular -
Pericardial Tamponade Caused by a Perforating Atherosclerotic Ulcer of the Ascending Aorta
Netherlands Journal of Critical Care Copyright © 2010, Nederlandse Vereniging voor Intensive Care. All Rights Reserved. Received May 2010; accepted August 2010 CASEREPORT Pericardialtamponadecausedbyaperforating atheroscleroticulceroftheascendingaorta EMvanDriel1,PKlein2,EdeJonge1,MSArbous1 1DepartmentofIntensiveCare,LeidenUniversityMedicalCenter,Leiden,TheNetherlands 2DepartmentofCardio-Thoracicsurgery,LeidenUniversityMedicalCenter,Leiden,TheNetherlands Abstract-We present the case of a patient with pericardial tamponade caused by a rare complication of atherosclerosis. An eighty- year-old male suffered a witnessed cardiac arrest due to pulseless electrical activity (PEA). Transthoracic echocardiography showed a pericardial effusion of 1.5 to 2 cm. Emergency subcostal pericardiocentesis drained approximately 15 ml of sanquinolent fluid. sub- sequent CT scan of the thorax showed a penetrating atherosclerotic ulcer (PAU) of the proximal ascending aorta with signs of active bleeding into the pericardium and right pleural cavity. The patient was diagnosed with a pericardial tamponade and haematothorax due to a perforated PAU of the ascending aorta, resulting in PEA. Although a PAU of the descending aorta and distal aortic arch can be treated by endovascular repair (EVAR), open thoracic surgery remains the treatment of choice for lesions located in the ascending aorta or proximal mid-aortic arch. Keywords- Cardiac tamponade, penetrating atherosclerotic ulcer, CT scan, endovascular repair, surgical repair, atherosclerotic disease. Introduction