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Radiological Reasoning: Pulmonary Embolism—Thinking Beyond the Clots

Pierre D. Maldjian1, Ather Anis2 and Muhamed Saric2

1 Department of Radiology, University Hospital, UMDNJ-NJ Medical School, 150 Bergen St., UH C-320, Newark, NJ 07103-2406.
2 Department of Medicine, Division of Cardiology, University Hospital, UMDNJ-NJ Medical School, Newark, NJ.


Figure 1
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  		Fig. 1A —60-year-old woman who developed acute dyspnea and hypoxia 2 days after left pneumonectomy. Images are from CT pulmonary angiography. CT images at level of right interlobar artery (A), at level of cardiac chambers (B), through upper abdomen (C), and at level of superior pole of left kidney (D).

 

Figure 2
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  		Fig. 1B —60-year-old woman who developed acute dyspnea and hypoxia 2 days after left pneumonectomy. Images are from CT pulmonary angiography. CT images at level of right interlobar artery (A), at level of cardiac chambers (B), through upper abdomen (C), and at level of superior pole of left kidney (D).

 

Figure 3
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  		Fig. 1C —60-year-old woman who developed acute dyspnea and hypoxia 2 days after left pneumonectomy. Images are from CT pulmonary angiography. CT images at level of right interlobar artery (A), at level of cardiac chambers (B), through upper abdomen (C), and at level of superior pole of left kidney (D).

 

Figure 4
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  		Fig. 1D —60-year-old woman who developed acute dyspnea and hypoxia 2 days after left pneumonectomy. Images are from CT pulmonary angiography. CT images at level of right interlobar artery (A), at level of cardiac chambers (B), through upper abdomen (C), and at level of superior pole of left kidney (D).

 

Figure 5
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  		Fig. 2A —Images from transesophageal echocardiography performed 6 days after CT study show atrial septal aneurysm oscillating throughout cardiac cycle and right-to-left shunt at atrial level after administration of agitated saline. RA = right atrium, LA = left atrium, AV = aortic valve, arrow = atrial septum. Image in diastole shows bulging of atrial septum toward right atrium.

 

Figure 6
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  		Fig. 2B —Images from transesophageal echocardiography performed 6 days after CT study show atrial septal aneurysm oscillating throughout cardiac cycle and right-to-left shunt at atrial level after administration of agitated saline. RA = right atrium, LA = left atrium, AV = aortic valve, arrow = atrial septum. Image in systole shows atrial septum bulging into left atrium.

 

Figure 7
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  		Fig. 2C —Images from transesophageal echocardiography performed 6 days after CT study show atrial septal aneurysm oscillating throughout cardiac cycle and right-to-left shunt at atrial level after administration of agitated saline. RA = right atrium, LA = left atrium, AV = aortic valve, arrow = atrial septum. Image after administration of saline containing microbubbles shows increased echogenicity in right atrium representing bolus and speckled echoes in left atrium from passage of microbubbles through patent foramen ovale.

 

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