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Montreal Chest Institute, Royal Victoria Hospital, Montreal, Quebec H2X 2P4, Canada
I read with great interest the On the AJR Viewbox article by R. C. Gilkeson, John R. Haaga, and Leslie M. Ciancibello, "Anomalous Unilateral Single Pulmonary Vein: Multidetector CT Findings" [1].
This entity was first described by Kozuka and Nosaki [2] in 1968 as a single pulmonary vein that collected all pulmonary veins draining the ipsilateral lung and entered alone on that side into the left atrium. A somewhat different but closely related entity is the meandering vein described by Goodman et al. in [3] 1972. It may differ in the course of the pulmonary vein, and it may or may not be the only pulmonary venous drainage of the ipsilateral lung.
A colleague and I described the unique but related entity of anomalous bilateral single pulmonary vein. Our article [4] described a case with one single pulmonary vein for both lungs (bilateral). We imaged the vein with clear anatomic visualization without using a multidetector CT scanner, but we emphasized in our article that helical CT would be needed to obtain three-dimensional reconstruction.
When we published the case in the journal of the Canadian Association of Radiologists in 1998 [4], we found in the literature 22 cases of anomalous single pulmonary vein that obviously escaped the present authors' attention. However, no other case of anomalous bilateral single pulmonary vein was found. We believe it likely that our case was, to that date, the only case in the literature to illustrate a meandering single pulmonary vein that collected all lobar veins of both lungs and drained into the left atrium in a peculiar vertical course resembling the scimitar syndrome. (Hence we may also name it pseudoscimitar syndrome.) Our findings also included hypogenetic right lung (similar to scimitar syndrome).
It is commendable that the authors have published their case to improve the understanding of this rare pulmonary anomalous vascular anatomy that is so neglected in the radiology literature (or so rarely detected). Although multidetector CT is not a requirement to identify this entity, helical CT is necessary, because volume analysis is a prerequisite for clear anatomic understanding.
References
University Hospitals of Cleveland, Case Western Reserve University School of Medicine, Cleveland, OH 44106
We appreciate Dr. Hidvegi's letter, and we regret that we did not find the important reference by Hidvegi and Lapin [1] before our On the AJR Viewbox case discussion [2]. Their case report was particularly impressive, and it serves again as a reminder of the wide variety of pulmonary venous anomalies we may see in practice. It is clearly important to distinguish a scimitar from a pseudoscimitar syndrome, because scimitar syndrome constitutes a left-to-right shunt, whereas the case illustrated by Hidvegi and Lapin is an example of normal physiologic drainage to the left atrium.
We agree that multidetector CT is not crucial to the diagnosis, although we suspect that our ability to diagnose these unusual anomalies will increase with greater access to the three-dimensional capabilities that multidetector CT provides. As we gain sophistication of technique, our confidence in differentiating these unusual but benign congenital variants from potentially dangerous arteriovenous malformations will also improve.
References
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