BRANT: Chapter 12 - PULMONARY VASCULAR DISEASE

Question 1

Most common mechanism that results to pulmonary edema

Answer 1

Increased capillary hydrostatic pressure
(Hydrostatic pulmonary edema)

Question 2

Thickening of the following structures results to what radiologic finding/s:
a. Axial interstitium
b. Peribronchovascular interstitium
c. Central connective tissue septa
d. Peripheral interlobular septa
e. Interlobar fissures

Answer 2

a. Loss of definition on the intrapulmonary vascular shadows
b. Peribronchial cuffing and tram tracking
c. Kerley A lines
b. Kerley B lines
e. Subpleural edema

Question 3

Most common form of pulmonary edema which is usually caused by an elevation in the pulmonary venous pressure (pulmonary venous hypertension [PVH])

Answer 3

Hydrostatic pulmonary edema (normal capillary permeability)

Question 4

Give the PCWP with the following findings:
a. Normal chest
b. Alveolar following with radiographic findings of bilateral airspace opacities in the perihilar and lower lung zones
c. Interstitial edema: loss of vascular definition, peribronchial cuffing and Kerley lines
d. Constriction of lower lobe vessels and enlargement of upper lobe vessels

Answer 4

a. 8 to 12 mm Hg
b. >25 mm Hg
c. 19 to 25 mm Hg
d. 12 to 18 mm Hg

Cephalization first before interstitial edema and then alveolar edema

Question 5

Unilateral pulmonary edema may develop in the lung that is reexpanded by the rapid evacuation of a large pleural fluid collection or pneumothorax. This is known as ____

Answer 5

Reexpansion pulmonary edema

Question 6

The following are causes of unilateral pulmonary edema, except:
a. Position
b. Central pulmonary embolism
c. Bronchogenic carcinoma
d. Fibrosing mediastinitis
e. All of the above can cause unilateral pulmonary edema

Answer 6

e. All of the above can cause unilateral pulmonary edema

Question 7

In severe mitral regurgitation, which lobe is the resulting alveolar pulmonary edema most expected?

Answer 7

Right upper lobe

Alveolar pulmonary edema localized to the right upper lung may be seen in patients with severe mitral regurgitation, likely as a result of preferential regurgitant flow of blood into the right upper lobe pulmonary vein across the superiorly and posteriorly oriented mitral valve.

Question 8

Edema associated with ALI or ARDS is called

Answer 8

Lung injury or increased capillary permeability edema

Question 9

The following are causes of pulmonary venous hypertension and pulmonary edema:
a. Systemic overload
b. Mitral regurgitation
c. Mitral valve stenosis
d. All of the above

Answer 9

d. All of the above

Question 10

The following are etiiologies of increased permeability pulmonary edema, except:
a. Aspiration of fluid
b. Narcotics
c. Fat embolism
d. All of the above

Answer 10

d. All of the above

Question 11

Stage of ARDS:

Within 12 to 24 hours following the initial insult, damage to capillary endothelium produces engorged capillaries and proteinaceous interstitial edema.

Answer 11

Stage 1: Exudative ARDS

Question 12

Stage of ARDS:

Within the first week, the injury to type 1 pneumocytes leads to the flooding of alveoli with edema fluid and proteinaceous and cellular debris, which form hyaline membranes lining the distal airways and alveoli.

Answer 12

Stage 2 or proliferative ARDS

Question 13

Stage of ARDS:

Occurring 10 to 14 days following the initial insult, type 2 pneumocytes proliferate in an attempt to reline the denuded alveolar surfaces, and fibroblastic tissue proliferates within the airspaces. This fibroblastic tissue may resolve and leave minimal scarring or, particularly in those with severe disease and long-standing oxygen requirements, result in extensive interstitial fibrosis.

Answer 13

Stage 3 or fibrotic ARDS

Question 14

Widened vascular pedical on PA view

Answer 14

> 53 mm

Vascular pedicle represents the mediastinal width at the level of the SVC and left subclavian artery

Question 15

The following can sometimes distinguish capillary permeability edema from hydrostatic edema:
a. Nondependent or peripheral distribution of edema
b. Absence of other signs such as interlobular septal thickening and subpleural edema
c. Lack of short-term change
d. All of the above

Answer 15

d. All of the above

Question 16

Pulmonary edema following head trauma, seizure, or increased intracranial pressure. It is a complex phenomenon that appears to involve both hydrostatic and increased permeability mechanisms.

Answer 16

Neurogenic pulmonary edeama

Massive sympathetic discharge from the brain in these conditions produces systemic vasoconstriction and increased venous return, with resultant increase in LV diastolic pressure and hydrostatic pulmonary edema.

Question 17

This develops in certain individuals after rapid ascent to altitudes above 3,500 m. Edema typically develops within 48 to 72 hours of ascent and appears to reflect a varied individual response to hypoxemia, in which scattered areas of pulmonary arterial spasm result in transient pulmonary arterial hypertension (PAH).

Answer 17

High-altitude pulmonary edema

Question 18

A severe and often fatal form of pulmonary edema may develop in a pregnant woman when amniotic fluid gains access to the systemic circulation during labor.

Answer 18

Amniotic fluid embolism

Embolic obstruction of the pulmonary vasculature by mucin and fetal squames within the amniotic fluid leads to sudden PAH and cor pulmonale with decreased cardiac output and pulmonary edema.

Question 19

The embolization of marrow fat to the lung is a common complication occurring 24 to 72 hours after the fracture of a long bone such as the femur.

Answer 19

Fat embolism

Within the lung, the fat is hydrolyzed to its component fatty acids, causing increased pulmonary capillary permeability and hemorrhagic pulmonary edema.

Question 20

25/M, CKD, with hemoptysis. Diagnosis

Answer 20

Goodpasture syndrome

Goodpasture syndrome is an autoimmune disease characterized by damage to the alveolar and renal glomerular basement membranes by a cytotoxic antibody. The antibody is directed primarily against renal glomerular basement membrane and cross reacts with alveolar basement membrane to produce the renal injury and pulmonary hemorrhage characteristic of this disorder

CT scans demonstrate ground-glass and airspace opacities without interlobular septal thickening acutely. Within several days, the airspace opacities resolve, giving rise to reticular opacities in the same distribution owing to resorption of blood products into the pulmonary interstitium. This results in the so-called CRAZY PAVING PATTERN

DDX: Idiopathic Pulmonary Hemorrhage: children, F=M, normal renal function

Question 21

T/F: The most common radiographic findings in PE without infarction are cardiac enlargement, or more precisely right heart enlargement

Answer 21

False

Peripheral airspace opacities and linear atelectasis.

Question 22

Signs of pulmonary embolism:
a. Localized peripheral oligemia with or without distended proximal vessel
b. Pleura-based, homogenenous, wedge-shaped opacity without air bronchograms, typically found in the posterior or lateral costophrenic sulcus of the lung
c. Enlarged pulmonary artery
d. Abrupt tapering or cutoff of a pulmonary artery
e. Enlarged right descending pulmonary artery
f. Dilated right descending pulmonary artery with sudden cut-off

Answer 22

a. Westermark sign
b. Hampton hump
c. Fleischner sign
d. Knuckle sign
e. Palla sign
f. Chang sign

Question 23

Sign and diagnosis.

Answer 23

Hampton hump of PE

Question 24

T/F: In embolism without infarction, the airspace opacities should resolve completely within 7 to 10 days, whereas infarcts resolve over the course of several weeks or months and usually leave a residual linear parenchymal scar and/or localized pleural thickening.

Answer 24

True

Question 25

First imaging study in pregnant women with a normal chest radiograph suspected to have pulmonary embolism

Answer 25

V/Q scanning

Because the radiation dose to the breast is less with V/Q scanning than with CT angiography

Question 26

T/F: Contiguous or overlapping 1- to 2-mm scans through the entire thorax during injection of 80 to 120 mL of 300 to 350 mg I(iodine)/mL nonionic contrast injected through an 18-gauge or larger IV catheter at 10 mL/s allow routine dense opacification of second- and third-order subsegmental pulmonary arteries.

Answer 26

False

Contiguous or overlapping 1- to 2-mm scans through the entire thorax during injection of 80 to 120 mL of 300 to 350 mg I(iodine)/mL nonionic contrast injected through an 18-gauge or larger IV catheter at 5 mL/s allow routine dense opacification of second- and third-order subsegmental pulmonary arteries.

Question 27

Chronic vs Acute thrombus in PE:
a. Intraluminal filling defect or nonopacified vessels with a convex filling toward the proximal lumen
b. Filling defect is adherent to the vessel wall rather than in the center of the lumen or when a web is present

Answer 27

a. Acute
b. Chronic

Question 28

Acute or Chronic PE

Answer 28

Acute

Question 29

Acute or Chronic PE

Answer 29

Chronic

Question 30

It was traditionally considered to be the gold standard in the diagnosis of PE, but has been almost entirely supplanted by CTA.

Answer 30

Pulmonary angiography

PE is diagnosed on pulmonary angiography when an intraluminal filling defect or the trailing end of an occluding thrombus is outlined by contrast. Secondary signs, including a prolonged arterial phase, diminished peripheral perfusion, and delay in the venous phase, are nonspecific and are not used to diagnose PE.

Question 31

Most common source of PE

Answer 31

DVT in the LE

Question 32

PAH is defined as a systolic pressure in the pulmonary artery exceeding ____ either measured directly by right heart catheterization or as estimated by echocardiography.

Answer 32

30 mm Hg

Question 33

A useful measurement for enlargement of the central pulmonary arteries, usually indicating PAH in the absence of a left-to-right shunt, is a transverse diameter of the proximal interlobar pulmonary artery on posteroanterior chest radiograph that exceeds ____.

Answer 33

16 mm

Question 34

In patients younger than 50 years, a ratio of the diameter of the main pulmonary artery (measured at the level of the main right pulmonary artery) to the transverse diameter of the ascending aorta at the same level greater than 1 strongly correlates with a mean pulmonary artery pressure greater than ____

Answer 34

20 mm Hg

Question 35

Because the aorta normally enlarges with advancing age, in patients older than 50 years, a maximum transverse measurement of the main pulmonary artery greater than ____ correlates better

Answer 35

29 mm

Question 36

Most common causes of PAH. Give 2

Answer 36

Parenchymal lung disease and obesity hypoventilation syndrome

Parenchymal lung disease, particularly emphysema and diffuse interstitial fibrosis, are common causes of PAH.

Question 37

The following comprise the three diseases that comprise idiopathic or primary pulmonary hypertension, except:
a. Plexogenic pulmonary arteriopathy
b. Recurrent microscopic PE
c. Pulmonary venoocclusive disease
d. All of the above

Answer 37

d. All of the above

Question 38

It is characterized by the proliferation of capillaries throughout the pulmonary interstitium, resulting in venular obstruction.

Answer 38

Pulmonary capillary hemangiomatosis (PCH)

Question 39

The combination of pulmonary edema with a normal heart size, absent findings for PVH, normal PCWP, and the insidious onset of dyspnea should suggest this diagnosis rather than left heart failure, mitral valve disease, or large vessel pulmonary venous occlusion.

Answer 39

PVOD/PCH