CORE Case 4 Workshop

1. Petra Lewis MD Professor of Radiology and OBGYN Geisel School of Medicine at Dartmouth CORE Case 4 Workshop

2. Learning objectives • Be able to identify some of the most common radigraphic findings in emphysema and COPD • Know what the imaging alternatives are for patients with suspected aortic dissection • Understand how aortic dissection can look on CT scans • Know some methods for decreasing renal toxicity from contrast • Know the CXR findings in mild and more severe pulmonary edema • Know the imaging options for patients with suspected PEs • See examples of PE on CT and VQ scans • Understand the significance of VQ scan reports

3. COPD and emphysema

4. What are some of the CXR signs of COPD/emphysema

8. What might we see on a CT?

9. Patient 2 Patient 1

11. Aortic dissection

12. What patients are at risk for aortic dissection? How might they present?

13. What are our imaging options?

14. What do we look for on a contrast enhanced chest CT in patients at risk of aortic dissection

19. How do we classify aortic dissections? What is the significance of the classifications

20. How can we decrease renal toxicity from iodinated contrast? • Which patients are at risk?

21. Pulmonary edema

22. What are some of causes of pulmonary edema?

23. How might we distinguish between the causes?

24. When might the heart not be enlarged, yet the cause be cardiogenic?

25. What are some of the earliest CXR signs of pulmonary edema?

27. Interstitial Pulmonary Edema

28. What are the radiographic signs of severe pulmonary edema?

29. Why do we sometimes see effusions in patients with CHF but no pulmonary edema? Severity Time

34. Pulmonary emboli

35. What are our diagnostic options in patients with suspected PE? • What guides our choice?

36. Put the following CT scans in order of how soon after injection that we acquire them. Abdominal CT for R/O mets CTPA for PE CTA for dissection

37. What do we look for on a CTPA for PE? How good is this test?

38. Patient 1 Patient 2

39. Patient 2 Patient 1

41. What do you see here that might suggest that the patient is at cardiovascular risk from her PE?

42. How are VQ scans reported?

43. What do the probabilities mean?What is the risk of PE? • Normal = • Very low = • Low = • Intermediate = • High =

44. What do we look for on a VQ scan?

47. Appendix

48. Recognize the typical changes of emphysema and COPD on chest radiographs. • Recognize the classic findings of aortic dissection on CT scans. • Understand how aortic dissections are classified based on imaging • Have a basic concept of complications of aortic dissections and how dissections can be treated • Know the different imaging options used to diagnose pulmonary embolism. • Understand the basic principles of nuclear medicine V/Q scan imaging • Understand the significance of V/Q scan interpretations: normal, low, intermediate and high probability. • Know options to decrease renal toxicity from IV contrast in a patient with impaired renal function • Know when a D-dimer should be measured and the significance of a raised or normal value • Know the typical appearance of pulmonary emboli on CT pulmonary angiograms • Understand the use of IVC filters. • Recognize cardiomegaly on chest radiographic and provide a differential diagnosis. • Know the imaging findings of pulmonary edema. • Understand the difference between in the terms “CHF” and pulmonary edema. • Recognize Kerley B lines (and what they mean). • Know where the heart chambers are on a chest radiograph and how the chest radiographs will change with chamber enlargement. • Know the approximate positioning of heart valves on chest radiographs.