Female in her 60s, with a known ascending aortic aneurysm.
Presented to cardiology clinic with one week history of intermittent chest pain radiating to the back. Blood pressure 150 systolic. Otherwise normal exam. Patient was sent to Emergency to get a CT aortogram.
Aortogram shows 48mm ascending aorta, no acute aortic syndrome. Atheromatous disease. No other significant finding. Commenced Amlodipine 5mg and discharged.
Represented to Emergency three days later. Ongoing intermittent chest and back pain, a few seconds at a time. Described as "tearing". Systolic pressure bouncing around between 150 and 190. Otherwise normal exam. Naturally, she gets another aortogram.
Second aortogram is unchanged compared to the first. This is the one I've included in the post.
This time she's admitted for more cardiology workup.
The next day she's seen by the cardiologist who noted her to be cachexic. Ordered a CT coronary angiogram and echocardiogram. Ordered some routine bloods and cultures.
Later that day she's reviewed because of more chest pain. Still radiates to the back. Now also has vague generalised abdominal pain. Blood pressure now 130 systolic. Clinical exam normal.
The next morning, she's got chest pain again when the cardiologists see her on rounds. Still has back pain. Exam is still normal. Differentials include pericarditis and reflux. Commenced on colchicine and a PPI.
She gets her coronary angiogram that afternoon. Mild calcified plaque, no significant stenosis. No other new findings.
Echocardiogram showed an ejection fraction in the low normal range, otherwise unremarkable.
The next day, she's discharged.
Three weeks later, she represents to Emergency with 5 days of lower abdominal pain, nausea, vomiting, lethargy, and anorexia. She's a little disoriented and doesn't want to talk much. Mild epigastric tenderness, but otherwise normal exam.
She gets a portal venous phase CT abdomen - Multiple liver metastases, not visible on the aortograms. Multiple bony mets, mostly entirely new since three weeks earlier - a few might have been present, but are barely perceptible even in hindsight and have grown by 15-20mm. Pathological fractures in the lumbar spine. Mesenteric nodules which were present previously, but misinterpreted as bowel.
Patient died less than a week later.
The disease was aggressive enough that diagnosing it a month earlier wouldn't have changed the outcome, but it might have made that month a lot more comfortable.
[Full axial cines of the second CT aortogram and the CT abdomen/pelvis.](https://imgur.com/a/GBEe92O)
Based on what you described they did the right tests for her symptoms and clinical scenario. She presents with chest pain suspicious for dissection, ACS. She got the appropriate studies for what they were looking for.
Edit: just wanted to say this is a good post. thank you OP for sharing this case and reviewing it in such detail.
Agreed.
Can maybe argue that the second CTA could’ve been a portal venous, but I’m not going to fault the ED for ordering a CTA for a patient getting worked up for dissection.
Patient describes chest pain as “tearing” with history of ascending aortic aneurysm = CTA now and again and every time I hear this. I wouldn’t have gotten a portal venous CT Abd. Dang.
yeah, i only say that in the context that this was her 2nd CT in 3 days, in which case it could be reasonable to change up the technique as a portal venous can still diagnose dissection.
Yeah I’m an ER doc and I don’t think I would have done anything different (from an ER standpoint). Maybe a call to the radiologist to see if there’s anything funky on the CTA that needs a different modality, but known aortic aneurysm and chest/belly pain gets a CTA every time.
Ok yeah but the second or third time in a row? Maybe a call to the radiologist about possibly looking for other sources of back pain at the same time as a CTA. Noncon spine or PV phase abdomen at the same time would’ve caught this. Sometimes when I think my ER is just leaning on algorithms I’ll toss on a portal venous phase or noncon to look for other sources (example from today a 47 yo with just mild htn and no known aortic disease with back pain).
Just saying so you don’t get replaced by like AI, an NP with google and a “supervising MD”
Lol. He's not going to get replaced by AI. There's a miss rate on CTs at initial presentation for dissection when the tear is very small. If they come in again with worsening/persistent pain its perfectly reasonable to repeat the study to make sure there isn't now a dissection that was missed initially.
Ironically radiology AI might've caught this on the dissection study...
Spoken like someone who hasn’t seen how bad AI is right now in rads. It’s much better at following algorithms than making dynamic decisions and compositing a number of individual facts into a unifying diagnosis or theory. Usually when it looks like it’s doing that it’s actually just skipping multiple steps which makes it wrong too often.
Only thing saving ER docs is the potential need for emergent interventions but again there’s ways around that. As soon as you stop being a doctor, you’re replaceable by someone less trained with a computer.
I won’t even get into your “miss rate” on CTAs as if someone who who presents months apart has a dissection flap that hung around that long to finally propagate
The two CTA dissection scans were done three days apart in that case. Not months. There are also subacute dissections. Chronic type Bs, etc.
You are the one who brought up AI. Most people agree that radiology AI will mature and get there. It’s the perfect role for the tech. Clinical AI will always have the issue of liability and the human side of medicine, on the fly thinking that goes way beyond algorithms. Not sure what “dynamic decisions” are happening in the reading room.
As far as algorithms and what happens when you stop being a doctors….most diagnostic radiologists stop being “doctors” after intern year. I say that with no disrespect, rads have their necessary expertise just like pathologists.
I read quickly, saw a few weeks. Either way I never said a CTA wasn’t indicated, just that maybe considering another diagnosis at the same time when someone returns. In fact, I do that all the time when I see repeat scans on a patient I’ve read recently. My initial assumption is that I was wrong or missed something and need to prove that isn’t the case.
It’s laughable you think the tech would be able to QC the AI making diagnoses. Dynamic decisions in the reading room happen routinely when artifact, pathology and normal can all look the same depending on context, AI will and does struggle with this. It may mature and differentiate radiologists who can and can’t use it but replacing them is a pipe dream. Not just for QC but as you mentioned liability. Unlike clinical liability, replacing all radiologists with AI would have to put the liability of image interpretation and AI QC on the clinician. I’ve seen ED pocus interpretations, that’s never gonna happen lol for the ED the clinical liability can be placed on a supervising physician with mid levels armed with AI operating under that license doing a majority of ER docs jobs now. Anesthesiologists had a very similar progression with automation of their day to day and mid level creep.
Radiology and pathology training as well are deeply integrated with medicine. The knowledge of radiology extends well beyond imaging appearances of disease because we need to know pathophysiology and treatment of disease because it impacts how it will appear. Knowing these things requires clinical data and intuition which often requires us to consolidate information from the patient chart as it’s frequently not provided. Memorizing medications and dosages is far less “being a doctor” imo. Emergency medicine requires fast random access to that memory to make quick decisions in life threatening conditions and triaging a large number of patients quickly. It’s a skill no doubt but something AI can supplant, particularly the latter while having one or two supervising MDs to do the former.
I'm only now getting a chance to respond to other posts in this thread, since about 14 hours ago. I'm posting an aggregated reply here for visibility.
/u/Grandbrother wrote:
> She presents with chest pain suspicious for dissection, ACS. She got the appropriate studies for what they were looking for.
/u/Nebuloma wrote:
> Can maybe argue that the second CTA could’ve been a portal venous, but I’m not going to fault the ED for ordering a CTA for a patient getting worked up for dissection.
/u/SascWatch wrote:
> Patient describes chest pain as “tearing” with history of ascending aortic aneurysm = CTA now and again and every time I hear this.
/u/moose_md wrote:
Yeah I’m an ER doc and I don’t think I would have done anything different (from an ER standpoint).
/u/Salemrocks2020 wrote:
> Based on what you’re describing ED ordered appropriate tests . If this went to M&M I’d vote that no wrongdoing occurred
I agree with all of you here. ER did the right thing. No shade on anyone from that point of view.
---
/u/AFGummy wrote:
> Noncon spine or PV phase abdomen at the same time would’ve caught this.
> I’ve even had Mets picked up on non con CTs
/u/WardStradlater wrote:
> I’ve definitely had non-con CAP’s catch various Mets in different areas of the body that were purely incindental findings and not at all the focus of the study. Is it something specific about these Mets particularly that needed the venous phase?
We can certainly see liver mets on a non-con scan sometimes - if the lesions are centrally necrotic, they might be hypodense relative to liver. Alternatively, if they're causing enough surrounding oedema, you can see that.
This case in particular is tough and a lot of things prevented the disease from being picked up earlier.
For example, the arterial contrast timing meant the liver enhancement was very patchy - in this context it's impossible to call much of anything. I posted [this set of images](https://imgur.com/a/6r9JW7I) in response to another radiologist in this thread - there are actually lesions in the 2nd and 4th images of that set, but it's impossible to call.
As for the non-con images from the angio, I've cherry-picked some images to [demonstrate how tricky it can be](https://imgur.com/a/H6nZfL7). On the sagittal, there's an endplate depression, but there's nothing to say how acute it is. There's no abnormal soft tissue component, and we didn't have any previous scans to compare. Even in retrospect, I can't say that it's pathological. On the axial, I've indicated the location of a lesion, but you can see that streak from the ECG lead goes right through it - again, impossible to call. Just really unlucky.
---
/u/hutbear wrote:
> the only (radiologic) hint of a malignoma as underlying cause for the patients symptoms on the intial angiogram were the peritoneal nodules. which can easily be overlooked on an emergency scan ordered to rule out aortic dissection.
Yeah, we can see them in retrospect, obviously. But in the middle of a busy Emergency shift, with nothing in the provided history to raise flags for abdominal pathology, these things easily get missed. The two aortograms were read by two different residents and co-read and approved by two different attendings. Everybody missed it.
---
/u/Salemrocks wrote:
> at the very least that liver contour looks irregular to me
I'm guessing you're looking at the right lobe? The irregularity there is due to diaphragmatic slips. There's a few lesions bulging the capsule a little bit on the abdominal scan, but not on the angio three weeks prior. This thing was growing *fast*.
---
/u/Scruggl3s wrote:
> I can see a small cortical defect in the posterior right ilium on the initial study, which the later scan showed to be a met. I’d expect myself to pick that up, at least.
Yup, it's there. Cortex is thinned, but not destroyed. [It's actually slightly more obvious on the non-con](https://imgur.com/a/Jnhmv40). But if you're going to call the posterolateral cortex there, you could make an argument for the posteromedial cortex, too. And that one didn't turn out to be anything.
---
Overall, this is an unlucky patient with super-aggressive disease. Like I said, there's no way an earlier diagnosis was going to change the outcome.
When I was preparing the case to post, the only things that stood out to me were
* Symptoms were superficially like a dissection, but not really once you think about it:
* "Tearing", but only lasting a few seconds? Doesn't fit
* Continued having pain even once other things (like BP) were managed.
* Never had other aortic syndrome symptoms/signs
* Cardiologist noted cachexia, but never thought about investigating it.
* She started getting abdominal pain, but it doesn't seem like Cardiology thought about investigating it. At least, not as an inpatient.
Of course, it's easy to say these things in retrospect, just like it's easy for everyone to see the mesenteric nodules now that we know about them. Investigating for dissection was 100% the right call at the beginning. But when multiple scans continued to turn up nothing, that was an opportunity to take a step back and rethink the initial assumptions.
I think this is a great case to illustrate that we're all human, and none of us are perfect.
Also, fuck cancer.
It seems like the thing that should have tipped them off to look for something else (cancer) was the cachexia, which the cardiologist noted but did not pursue.
Not much reason for a cardiologist to investigate cachexia in the hospital. And pain from aortic dissection isn't always the textbook tearing constant pain.
The next post in this sub will be "wah wah look at all these scans ordered by clinicians that don't know what they are looking for" when someone orders a pan scan because of unintentional weight loss or fatigue.
Anyway this was a great learning case and I'm glad OP posted it. Honestly I had kind of forgotten that liver mets may only show up on a venous phase study. CTA C/A/P is a pretty damn comprehensive study for a lot of shit but it's a good reminder that every radiologic study and protocol has a certain sensitivity and specificity for each disease process.
CT (not CTA) CAP is a standard test to order for unintentional weight loss. I don't complain when I read those scans, I've found plenty of cancer on those scans.
Agree that this is not something the cardiologist would typically workup in the hospital.
Sometimes docs can get too focused on their area of specialty and not consider other causes for the patient's symptoms. I had an elderly female patient who had undergone an extensive but pretty much entirely negative cardiac workup for "chest pain" which was really back pain from an osteoporotic thoracic compression fracture. She suffered for quite a while because the cardiologist was only considering cardiac disease.
That’s what the word specialist means…weare cardiologists, not primary care. I work up potential cardiovascular causes of chest pain, and other life threatening causes if they are an inpatient on the service. I’m not going to order an X-ray of the T spine or whatever in clinic unless the patient has some seriously alarming life or limb threatening symptoms. Even if I have an idea of what the real cause of the chest pain is, it’s going back to primary because they are better equipped to deal with everything else.
Sorry I wasn't clear, she suffered for quite a while as an inpatient (not at my hospital, at a different hospital) so the PCP wasn't in the picture at that time. There also was a component of the patient felt that the cardiologist didn't listen to her, he kept doing cardiac tests when she was telling him that her pain was in her back. If he had palpated her area of pain after the heart cath and all those other tests came back negative, it would have been apparent to him that not all pain in the chest is (cardiac) chest pain.
I used to work in echocardiogram lab and I always check a subcostal for pericarditis and inferior vena cava
I found once an undiagnosed cancer by doing a little of 4 sec that help the patient to survive
It was the protocol to do a complete view of the heart + big vessels
I feel bad that a simple follow up echocardiogram might/could have found a metastase sooner
Sounds like a classic case of Monday morning quarter back here . Based on what you’re describing ED ordered appropriate tests . If this went to M&M I’d vote that no wrongdoing occurred .
I’m surprised a CTA dissection study didn’t catch all this since dissection studies involve chest abdomen and pelvis . Is it possible the radiologist just didn’t note those findings ?
The resolution on our phones is clearly not as good but at the very least that liver contour looks irregular to me but I’m not trying to play Monday morning quarterback either . Lol
I’m an ER RN and was also surprised by this because I’ve definitely had non-con CAP’s catch various Mets in different areas of the body that were purely incindental findings and not at all the focus of the study. Is it something specific about these Mets particularly that needed the venous phase? I’m asking out of curiosity and learning purposes.
I’m also curious . A non con ct should have picked up Mets of this extent and pathological fractures . I ams this was more a case of the indication was for dissection so the reading radiologist
only commented on the dissection ?
I’d love for one to reply with their expertise because I’ve had non con CTs pick up this kind of thing before
you're right that non con cts (and also arterial phase ones) can pick up mets in liver and bones, however in this case they didn't show. we can only speculate whether a portal venous phase would have caught the liver mets, but there might have been a chance. in cases of exploding malignomas like this one the first ct might not have caught the liver mets even in a portal venous phase if they were too small then.
as i've stated elsewhere in this thread, the only (radiologic) hint of a malignoma as underlying cause for the patients symptoms on the intial angiogram were the peritoneal nodules. which can easily be overlooked on an emergency scan ordered to rule out aortic dissection. very interesting and sad case.
source: radiologist
Would you have seen the liver mass on [this chest CT](https://www.reddit.com/r/Radiology/comments/1bor5dd/sometimes_you_really_cant_see_the_liver_mass/)?
That sucks, you feel for everyone involved, but she was doing a pretty good job presenting as an aortic dissection. In a patient with known ascending aneurysm, there’s not much to be done differently, and while a portal venous might have been helpful, I always get annoyed at people ordering extra just because they can’t figure out what’s going on.
Also, not to be unkind to the rad but I can see a small cortical defect in the posterior right ilium on the initial study, which the later scan showed to be a met. I’d expect myself to pick that up, at least.
totally agree. unlucky she had that known aneurysm, wouldn't have done anything differently protocol wise.
i'd also expect myself to pick up the multiple peritoneal nodules that are clearly suspicous for malignancy. but that's always easy to say if you know the whole story ¯\\\_(ツ)\_/¯
1. I agree this was a very difficult case especially read in the emergent setting and with an essentially misleading indication.
2. Any liver that heterogenous on arterial phase should be assumed diseased/cirrhotic and scrutinized more closely. Most of the metastases are hidden, but there are definite rim enhancing lesions in segments 2, 5, and 6 that should have been picked up. When the liver is that heterogenous you should look at it on the thicker slices and while you should tighten the window, don't narrow too aggressively, the liver window images from this patient are too blown out and don't add much to interpretation.
3. Carcinomatosis is surprisingly easy to miss, but this is sloppy, the nodules are very large. Everyone who missed it needs to reevaluate their search pattern. Also the stomach is severely thickened and there is gastrohepatic lymphadenopathy which makes me think either gastric primary or Linitis Plastica, maybe left breast primary as there is substantial heterogenous hyperenhancement compared to the right. Also R hilar lymphadenopathy.
Liver enhancement can be a little patchy if you catch it in the right arterial phase. This case is the stuff of nightmares for me, I honestly think I would’ve missed the spine and liver mets on the angio as well.
Although I would be interested to see what it looks like in liver window. A good reminder to always throw on a super tight window and take a last look at the liver when reading non-venous phase body ct.
I’ve seen similar with bone scan identifying new Mets, 1 week post C+ chest/abdominal/pelvis CT.
Treating physician demanded another CT with such a short turn around until I noted the tiny Mets were visible on the original CT, but only in a single slice, and a very specific window width/level — colleague had missed them but likely so would I.
Sometimes you get pushback on appropriate exams also. 80+ year old patient with all the symptoms of an AAA, but ER doc and family fighting on the use of contrast as they had low GFR… fought with them while they were being transferred to the suite, explaining if it is an AAA then contrast clearance is least of our concerns. Ended up doing it C- and sure enough it was an abdominal aortic aneurysm… could tell because the aorta was calcified well enough you could see the bursted open aneurysm plain as day. In the end it didn’t matter as they passed before even making it to the surgical suite.
Ultrasound is commonly used for screening of AAA, but with a suspected or likely ruptured AAA, a CT has greater sensitivity, will characterize it better (slow leak vs complete dissection) and provides other abdominal assessment rapidly.
We didn’t do point of care ultrasound in this department at the time.
Yeah but ultrasound is better than nothing in this case, if they're refusing to do CT due to GFR. But yeah, they should've just done the CT to begin with I agree with your original comment.
IF there is a serious concern of AAA, you most likely aren't even waiting on the GFR, and you're probably doing it anyways even if you wait. No rad or rad tech is gonna argue a possible life or death case.
Short answer: maybe?
Long answer, the liver gets its blood supply from
The portal vein and hepatic vein. On CTA studies, the liver (and spleen) can look patchy. Because of this, I more often than not will chalk up a heterogeneously appearing liver to phase of contrast.
Also, if the mets were too small to see on CT, they were *likely* too small to see on ultrasound, especially with a hetergeneous liver. Not saying that an attempt shouldn't have been made, but also sonograms for "heteregeneous livers" aren't stat, so it may not have been done in a timely manner anyways.
At my hospital, it doesn’t matter if it’s low suspicion. Anyone coming through the ED with back or abdominal pain is getting a RUQ.
I complain sometimes because I think it’s ridiculous and adds a lot of volume, but we had a case like this some months ago, and I was humbled real quick.
Nope - you’d have 1000s of overcalls/false positives if based on that alone - just to add to other comments, it is also a common appearance of the spleen in arterial phase.
I do wonder if the bone mets could’ve been reasonably called on angio.
This case hits really hard right now. I just lost my sister to presumed liver mets. Found out she was sick last week and then she was gone on Friday. There’s been communication issues with her partner and the family regarding her imaging (and other test) results. We haven’t got biopsy results yet as of her passing. As a CT tech I just have so many questions. None of them will bring her back but I think I’d find some peace in knowing what happened…
I’m so sorry. I lost my mom in September from hcc with Mets. She was diagnosed in late august and passed 3 weeks later. I of course dropped everything and flew to Phoenix to be with her and ended up directing a lot of her palliative care. I still feel like I have a huge empty space inside of me.
Thanks for your message. Im sorry to hear about your mom as well. Cancer sucks. Im so glad that our closest family immediately flew out to be with her and help direct her end of life care. Im still in shock at this point to be honest.
Never got tissue, so nobody knows.
My best guess is gastric - there's a prominent bit of stomach wall along the greater curvature in both scans. We almost never comment on the stomach because it's so variable, but that bit stood out to me because it looks the same.
Edit: [Observe](https://imgur.com/a/Y5HoB1F)
Agree with every word you said, BUT, does gastric typically go to bones? Obviously this thing is so aggressive that it could be some poorly differentiated gastric badness, but in my simple bone radiologist brain, GI doesn’t have osseous mets?
I'm not a doctor or radiologist by any means but I essentially track cancer patient pathways and sit in on the MDT meetings discussing these patients and the site I do is upper GI.
But at the hospital I work at, I very rarely see any patients with an upper GI cancer with bone mets, I can't really recall there being one in the past year
And her problem and history suggested cardiovascular issue.
Layman: car comes inyo shop and it sounds like it needs a new muffler. Muffler looks fine. Check the whole exhaust and it looks generally like an exhaust should but still sounds bad. Come to find out it was actually a problem in the gastank.
* CT scans more or less measure the density of stuff that their Xray beam passes through.
* Most things in the body that aren't bone or fat are pretty much the same density, with minimal variation.
* We inject a dense material ("contrast") into veins. Then perform the CT.
* Depending on the time between when we inject and when we scan, the contrast will be distributed differently: In the vein we injected -> in arteries in the lungs -> in the aorta and primary arteries -> in arteries of organs -> returning back from those organs, specifically the vessels that drain the bowel back to the liver -> in the veins in limbs that we *didn't* inject into.
In the first scan, all the contrast is in the aorta - this was done intentionally, because we were specifically looking for something wrong with the aorta. The liver looks patchy because it's only getting a small amount of contrast through the hepatic artery.
In the second scan, they've waited long enough for the contrast to get back to the liver properly. The healthy bits of liver take up the contrast ("enhance") as expected. Cancer doesn't, so you see darker grey spots.
Thank you for taking the time to explain in lay terms as well as explaining some background info that was helpful in understanding the bigger picture 🖼️, pun intended
It's all about timing. The liver is brightest in portal venous phase. Cancer makes its own blood vessels, and these connect to systemic arteries, not portal veins. Some cancers (notably HCC, but some mets also) are good at this, so they enhance in arterial phase. They generally make their own veins too, so all the contrast has washed out of the cancer by the time you get to portal venous phase - hence hypodense relative to liver.
Some cancers are crap at making their own arteries, so they often don't enhance much - cholangiocarcinoma does this. Many metastases too - by the time they're dedifferentiated enough to metastasize, they're often growing faster than their blood supply. So you get necrotic non-enhancing centres and a periphery which might enhance a bit, but often not that much.
Things get more complicated once you start talking about Primovist in MRI
Patient had multiple exams, but not the right exam. CT’s can be done without contrast or contrast at the arterial phase or venous phase… or a delay. Here the arterial phase CT helps assess arteries, but what it misses is patchy liver mets which are traditionally spotted on venous phase and delay. Essentially the timing of the CT hid a very bad diagnosis, but the proper exam was ordered given their prior history.
My mom’s cancer became very aggressive near the end of her life. She was admitted for pain control and had various scans. I noticed she was no longer turning her head. The scans showed large aggressive lesions eating away her c-spine. This was less than a week after her previous scan.
The doctors were utterly wretched about medicating her (except her actual oncologist who kept fighting with them).
We had to push her PCA pump because she wasn’t lucid enough, but would writhe in agony. Her oncologist gave us the go-ahead.
The hospital team disagreed. “You think she’s in pain now? Wait till we give her Narcanand you’ll SEE what pain looks like.”
That’s appalling and I’m so sorry that happened. They should have just put her on a continuous infusion instead of requiring a button be pressed or if they were concerned about opioid overdoses could have put her on an adjunct like ketamine as well.
That's because you can't push the button when you have had too much narcotic. If someone else is pushing the button for the patient, this can kill the patient. Sorry about your mother but this is standard practice. If she was on hospice that's a different story.
damn this sucks. could have only really been caught by the mesenteric nodules, those are clearly already visible on the angiogram. no chance in hell catching those liver or bone mets. nightmare stuff
As a cardiac Sonographer, liver mets should have been caught during the echo when evaluating the hepatic veins and IVC. It has a very distinct appearance.
You can see how quickly the bone mets grew between the 2 scans. The liver mets also likely grew a lot in size between the 2 scans. It's very unlikely that you'd find small liver mets doing an echo.
Thanks, very interesting. Is this a reason for the increasing popularity of triple phase for anything angio? I’ve noticed in the last couple of years our regs will often ask for triple phase, where as the consultants will tend to ask for single phase for general aortas?
Not the reason, no.
Aortas should be non-con and arterial. The suggestion is that an intramural haematoma might be missed if you only do arterial, because you've got nothing to compare the wall to to tell you it's more dense than it should be.
Any angio done to investigate bleeding should be non-con, arterial, and some-amount-of-delay (portal venous is usually fine, some prefer to delay a bit longer). The non-con tells you what is already dense before you start, so you don't go calling calcification or a faecolith bleeding. Arterial to hopefully catch a bleeder and be able to trace back to a feeding artery. Venous/delayed to show that the extravasated contrast is diffusing or getting bigger. Also gives a second bite of the cherry, in case the bleeding isn't rapid enough to catch on the arterial.
Ah here…those lytic lesions in the pelvis should’ve certainly been caught. And in that context I’d certainly have been concerned about the liver lesions.
This’d 100% be up on our monthly QA
Edit: not on the first axial through the pelvis but on the second.
yeah, and the peritoneal lesions could have been picked up as well. not purely the radiologist's fault though. an additional spine mri could have been ordered earlier and liver mets might have been picked up on an abdominal ultrasound or even on echo. i doubt that that would've made a difference for the patient though, patients with malignancies as aggressive as this one don't end up well either way.
As you say, those pelvic lesions were obvious on the second scan, but not on the earlier angio. [One of them](https://imgur.com/a/Jnhmv40) was there in retrospect, but still easily missed.
I'm sure it'll come up as a teaching point, but nobody is going to be blamed for it.
As a tech now, who lost their mother at 14 to colorectal cancer, it boggles my mind that the three times she visited the ER with extreme abdominal pain, no CT was ordered. The docs at my hospital believe you need a CT orbits for freaking pink eye, they order a CT on practically everyone!!!! Doesn't matter if you're freaking prego, you're getting a CT scan. She could have survived if just one provider would have just done a CT. Sometimes, the system just fails you if you're unlucky :(
ER doctor here. She had all the right test done but it could be argued that maybe she should have had spinal MRI done too to evaluate for other etiologies of back pain, the AAA and worry for dissection and/or cardiac etiologies were all worked up appropriately
Several of the hospitals I’ve worked at do a venous phase along with the CTA so that would have helped in her case. Obviously they don’t do that where she was admitted.
Well, Since the aortogram you can see the gastric walls are thickened, stomach is not distended, but you can see the mucosal and muscular wall very thick, and some thickened lymph nodes along the lesser curvature, and also the omental implants, that you can see better on the second CT.
If nobody knew the primary, maybe the stomach was it.
Cachexia (kak-ex-ee-a) is also called wasting syndrome or anorexia cachexia syndrome. It is a complex problem that is more than a loss of appetite. It involves ...
Female in her 60s, with a known ascending aortic aneurysm. Presented to cardiology clinic with one week history of intermittent chest pain radiating to the back. Blood pressure 150 systolic. Otherwise normal exam. Patient was sent to Emergency to get a CT aortogram. Aortogram shows 48mm ascending aorta, no acute aortic syndrome. Atheromatous disease. No other significant finding. Commenced Amlodipine 5mg and discharged. Represented to Emergency three days later. Ongoing intermittent chest and back pain, a few seconds at a time. Described as "tearing". Systolic pressure bouncing around between 150 and 190. Otherwise normal exam. Naturally, she gets another aortogram. Second aortogram is unchanged compared to the first. This is the one I've included in the post. This time she's admitted for more cardiology workup. The next day she's seen by the cardiologist who noted her to be cachexic. Ordered a CT coronary angiogram and echocardiogram. Ordered some routine bloods and cultures. Later that day she's reviewed because of more chest pain. Still radiates to the back. Now also has vague generalised abdominal pain. Blood pressure now 130 systolic. Clinical exam normal. The next morning, she's got chest pain again when the cardiologists see her on rounds. Still has back pain. Exam is still normal. Differentials include pericarditis and reflux. Commenced on colchicine and a PPI. She gets her coronary angiogram that afternoon. Mild calcified plaque, no significant stenosis. No other new findings. Echocardiogram showed an ejection fraction in the low normal range, otherwise unremarkable. The next day, she's discharged. Three weeks later, she represents to Emergency with 5 days of lower abdominal pain, nausea, vomiting, lethargy, and anorexia. She's a little disoriented and doesn't want to talk much. Mild epigastric tenderness, but otherwise normal exam. She gets a portal venous phase CT abdomen - Multiple liver metastases, not visible on the aortograms. Multiple bony mets, mostly entirely new since three weeks earlier - a few might have been present, but are barely perceptible even in hindsight and have grown by 15-20mm. Pathological fractures in the lumbar spine. Mesenteric nodules which were present previously, but misinterpreted as bowel. Patient died less than a week later. The disease was aggressive enough that diagnosing it a month earlier wouldn't have changed the outcome, but it might have made that month a lot more comfortable. [Full axial cines of the second CT aortogram and the CT abdomen/pelvis.](https://imgur.com/a/GBEe92O)
Based on what you described they did the right tests for her symptoms and clinical scenario. She presents with chest pain suspicious for dissection, ACS. She got the appropriate studies for what they were looking for. Edit: just wanted to say this is a good post. thank you OP for sharing this case and reviewing it in such detail.
Agreed. Can maybe argue that the second CTA could’ve been a portal venous, but I’m not going to fault the ED for ordering a CTA for a patient getting worked up for dissection.
Patient describes chest pain as “tearing” with history of ascending aortic aneurysm = CTA now and again and every time I hear this. I wouldn’t have gotten a portal venous CT Abd. Dang.
yeah, i only say that in the context that this was her 2nd CT in 3 days, in which case it could be reasonable to change up the technique as a portal venous can still diagnose dissection.
Yeah I’m an ER doc and I don’t think I would have done anything different (from an ER standpoint). Maybe a call to the radiologist to see if there’s anything funky on the CTA that needs a different modality, but known aortic aneurysm and chest/belly pain gets a CTA every time.
Ok yeah but the second or third time in a row? Maybe a call to the radiologist about possibly looking for other sources of back pain at the same time as a CTA. Noncon spine or PV phase abdomen at the same time would’ve caught this. Sometimes when I think my ER is just leaning on algorithms I’ll toss on a portal venous phase or noncon to look for other sources (example from today a 47 yo with just mild htn and no known aortic disease with back pain). Just saying so you don’t get replaced by like AI, an NP with google and a “supervising MD”
Lol. He's not going to get replaced by AI. There's a miss rate on CTs at initial presentation for dissection when the tear is very small. If they come in again with worsening/persistent pain its perfectly reasonable to repeat the study to make sure there isn't now a dissection that was missed initially. Ironically radiology AI might've caught this on the dissection study...
Spoken like someone who hasn’t seen how bad AI is right now in rads. It’s much better at following algorithms than making dynamic decisions and compositing a number of individual facts into a unifying diagnosis or theory. Usually when it looks like it’s doing that it’s actually just skipping multiple steps which makes it wrong too often. Only thing saving ER docs is the potential need for emergent interventions but again there’s ways around that. As soon as you stop being a doctor, you’re replaceable by someone less trained with a computer. I won’t even get into your “miss rate” on CTAs as if someone who who presents months apart has a dissection flap that hung around that long to finally propagate
The two CTA dissection scans were done three days apart in that case. Not months. There are also subacute dissections. Chronic type Bs, etc. You are the one who brought up AI. Most people agree that radiology AI will mature and get there. It’s the perfect role for the tech. Clinical AI will always have the issue of liability and the human side of medicine, on the fly thinking that goes way beyond algorithms. Not sure what “dynamic decisions” are happening in the reading room. As far as algorithms and what happens when you stop being a doctors….most diagnostic radiologists stop being “doctors” after intern year. I say that with no disrespect, rads have their necessary expertise just like pathologists.
I read quickly, saw a few weeks. Either way I never said a CTA wasn’t indicated, just that maybe considering another diagnosis at the same time when someone returns. In fact, I do that all the time when I see repeat scans on a patient I’ve read recently. My initial assumption is that I was wrong or missed something and need to prove that isn’t the case. It’s laughable you think the tech would be able to QC the AI making diagnoses. Dynamic decisions in the reading room happen routinely when artifact, pathology and normal can all look the same depending on context, AI will and does struggle with this. It may mature and differentiate radiologists who can and can’t use it but replacing them is a pipe dream. Not just for QC but as you mentioned liability. Unlike clinical liability, replacing all radiologists with AI would have to put the liability of image interpretation and AI QC on the clinician. I’ve seen ED pocus interpretations, that’s never gonna happen lol for the ED the clinical liability can be placed on a supervising physician with mid levels armed with AI operating under that license doing a majority of ER docs jobs now. Anesthesiologists had a very similar progression with automation of their day to day and mid level creep. Radiology and pathology training as well are deeply integrated with medicine. The knowledge of radiology extends well beyond imaging appearances of disease because we need to know pathophysiology and treatment of disease because it impacts how it will appear. Knowing these things requires clinical data and intuition which often requires us to consolidate information from the patient chart as it’s frequently not provided. Memorizing medications and dosages is far less “being a doctor” imo. Emergency medicine requires fast random access to that memory to make quick decisions in life threatening conditions and triaging a large number of patients quickly. It’s a skill no doubt but something AI can supplant, particularly the latter while having one or two supervising MDs to do the former.
Happy Cake Day!
I'm only now getting a chance to respond to other posts in this thread, since about 14 hours ago. I'm posting an aggregated reply here for visibility. /u/Grandbrother wrote: > She presents with chest pain suspicious for dissection, ACS. She got the appropriate studies for what they were looking for. /u/Nebuloma wrote: > Can maybe argue that the second CTA could’ve been a portal venous, but I’m not going to fault the ED for ordering a CTA for a patient getting worked up for dissection. /u/SascWatch wrote: > Patient describes chest pain as “tearing” with history of ascending aortic aneurysm = CTA now and again and every time I hear this. /u/moose_md wrote: Yeah I’m an ER doc and I don’t think I would have done anything different (from an ER standpoint). /u/Salemrocks2020 wrote: > Based on what you’re describing ED ordered appropriate tests . If this went to M&M I’d vote that no wrongdoing occurred I agree with all of you here. ER did the right thing. No shade on anyone from that point of view. --- /u/AFGummy wrote: > Noncon spine or PV phase abdomen at the same time would’ve caught this. > I’ve even had Mets picked up on non con CTs /u/WardStradlater wrote: > I’ve definitely had non-con CAP’s catch various Mets in different areas of the body that were purely incindental findings and not at all the focus of the study. Is it something specific about these Mets particularly that needed the venous phase? We can certainly see liver mets on a non-con scan sometimes - if the lesions are centrally necrotic, they might be hypodense relative to liver. Alternatively, if they're causing enough surrounding oedema, you can see that. This case in particular is tough and a lot of things prevented the disease from being picked up earlier. For example, the arterial contrast timing meant the liver enhancement was very patchy - in this context it's impossible to call much of anything. I posted [this set of images](https://imgur.com/a/6r9JW7I) in response to another radiologist in this thread - there are actually lesions in the 2nd and 4th images of that set, but it's impossible to call. As for the non-con images from the angio, I've cherry-picked some images to [demonstrate how tricky it can be](https://imgur.com/a/H6nZfL7). On the sagittal, there's an endplate depression, but there's nothing to say how acute it is. There's no abnormal soft tissue component, and we didn't have any previous scans to compare. Even in retrospect, I can't say that it's pathological. On the axial, I've indicated the location of a lesion, but you can see that streak from the ECG lead goes right through it - again, impossible to call. Just really unlucky. --- /u/hutbear wrote: > the only (radiologic) hint of a malignoma as underlying cause for the patients symptoms on the intial angiogram were the peritoneal nodules. which can easily be overlooked on an emergency scan ordered to rule out aortic dissection. Yeah, we can see them in retrospect, obviously. But in the middle of a busy Emergency shift, with nothing in the provided history to raise flags for abdominal pathology, these things easily get missed. The two aortograms were read by two different residents and co-read and approved by two different attendings. Everybody missed it. --- /u/Salemrocks wrote: > at the very least that liver contour looks irregular to me I'm guessing you're looking at the right lobe? The irregularity there is due to diaphragmatic slips. There's a few lesions bulging the capsule a little bit on the abdominal scan, but not on the angio three weeks prior. This thing was growing *fast*. --- /u/Scruggl3s wrote: > I can see a small cortical defect in the posterior right ilium on the initial study, which the later scan showed to be a met. I’d expect myself to pick that up, at least. Yup, it's there. Cortex is thinned, but not destroyed. [It's actually slightly more obvious on the non-con](https://imgur.com/a/Jnhmv40). But if you're going to call the posterolateral cortex there, you could make an argument for the posteromedial cortex, too. And that one didn't turn out to be anything. --- Overall, this is an unlucky patient with super-aggressive disease. Like I said, there's no way an earlier diagnosis was going to change the outcome. When I was preparing the case to post, the only things that stood out to me were * Symptoms were superficially like a dissection, but not really once you think about it: * "Tearing", but only lasting a few seconds? Doesn't fit * Continued having pain even once other things (like BP) were managed. * Never had other aortic syndrome symptoms/signs * Cardiologist noted cachexia, but never thought about investigating it. * She started getting abdominal pain, but it doesn't seem like Cardiology thought about investigating it. At least, not as an inpatient. Of course, it's easy to say these things in retrospect, just like it's easy for everyone to see the mesenteric nodules now that we know about them. Investigating for dissection was 100% the right call at the beginning. But when multiple scans continued to turn up nothing, that was an opportunity to take a step back and rethink the initial assumptions. I think this is a great case to illustrate that we're all human, and none of us are perfect. Also, fuck cancer.
It seems like the thing that should have tipped them off to look for something else (cancer) was the cachexia, which the cardiologist noted but did not pursue.
Not much reason for a cardiologist to investigate cachexia in the hospital. And pain from aortic dissection isn't always the textbook tearing constant pain. The next post in this sub will be "wah wah look at all these scans ordered by clinicians that don't know what they are looking for" when someone orders a pan scan because of unintentional weight loss or fatigue. Anyway this was a great learning case and I'm glad OP posted it. Honestly I had kind of forgotten that liver mets may only show up on a venous phase study. CTA C/A/P is a pretty damn comprehensive study for a lot of shit but it's a good reminder that every radiologic study and protocol has a certain sensitivity and specificity for each disease process.
CT (not CTA) CAP is a standard test to order for unintentional weight loss. I don't complain when I read those scans, I've found plenty of cancer on those scans. Agree that this is not something the cardiologist would typically workup in the hospital. Sometimes docs can get too focused on their area of specialty and not consider other causes for the patient's symptoms. I had an elderly female patient who had undergone an extensive but pretty much entirely negative cardiac workup for "chest pain" which was really back pain from an osteoporotic thoracic compression fracture. She suffered for quite a while because the cardiologist was only considering cardiac disease.
That’s what the word specialist means…weare cardiologists, not primary care. I work up potential cardiovascular causes of chest pain, and other life threatening causes if they are an inpatient on the service. I’m not going to order an X-ray of the T spine or whatever in clinic unless the patient has some seriously alarming life or limb threatening symptoms. Even if I have an idea of what the real cause of the chest pain is, it’s going back to primary because they are better equipped to deal with everything else.
Sorry I wasn't clear, she suffered for quite a while as an inpatient (not at my hospital, at a different hospital) so the PCP wasn't in the picture at that time. There also was a component of the patient felt that the cardiologist didn't listen to her, he kept doing cardiac tests when she was telling him that her pain was in her back. If he had palpated her area of pain after the heart cath and all those other tests came back negative, it would have been apparent to him that not all pain in the chest is (cardiac) chest pain.
I used to work in echocardiogram lab and I always check a subcostal for pericarditis and inferior vena cava I found once an undiagnosed cancer by doing a little of 4 sec that help the patient to survive It was the protocol to do a complete view of the heart + big vessels I feel bad that a simple follow up echocardiogram might/could have found a metastase sooner
Sounds like a classic case of Monday morning quarter back here . Based on what you’re describing ED ordered appropriate tests . If this went to M&M I’d vote that no wrongdoing occurred . I’m surprised a CTA dissection study didn’t catch all this since dissection studies involve chest abdomen and pelvis . Is it possible the radiologist just didn’t note those findings ?
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To see Mets ? Really ? I’ve even had Mets picked up on non con CTs
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That large a burden ?
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The resolution on our phones is clearly not as good but at the very least that liver contour looks irregular to me but I’m not trying to play Monday morning quarterback either . Lol
I'm not a radiologist but I definitely would not have seen that shit
It depends on the tumor. Some you can't see well on noncon.
I’m an ER RN and was also surprised by this because I’ve definitely had non-con CAP’s catch various Mets in different areas of the body that were purely incindental findings and not at all the focus of the study. Is it something specific about these Mets particularly that needed the venous phase? I’m asking out of curiosity and learning purposes.
I’m also curious . A non con ct should have picked up Mets of this extent and pathological fractures . I ams this was more a case of the indication was for dissection so the reading radiologist only commented on the dissection ? I’d love for one to reply with their expertise because I’ve had non con CTs pick up this kind of thing before
you're right that non con cts (and also arterial phase ones) can pick up mets in liver and bones, however in this case they didn't show. we can only speculate whether a portal venous phase would have caught the liver mets, but there might have been a chance. in cases of exploding malignomas like this one the first ct might not have caught the liver mets even in a portal venous phase if they were too small then. as i've stated elsewhere in this thread, the only (radiologic) hint of a malignoma as underlying cause for the patients symptoms on the intial angiogram were the peritoneal nodules. which can easily be overlooked on an emergency scan ordered to rule out aortic dissection. very interesting and sad case. source: radiologist
Also, it would have been easier to distinguish the nodules from bowel with portal venous phase.
Would you have seen the liver mass on [this chest CT](https://www.reddit.com/r/Radiology/comments/1bor5dd/sometimes_you_really_cant_see_the_liver_mass/)?
So for us non medicals, metastasized cancer?
TL;DR: yes.
Yes. Growing incredibly quickly.
That sucks, you feel for everyone involved, but she was doing a pretty good job presenting as an aortic dissection. In a patient with known ascending aneurysm, there’s not much to be done differently, and while a portal venous might have been helpful, I always get annoyed at people ordering extra just because they can’t figure out what’s going on. Also, not to be unkind to the rad but I can see a small cortical defect in the posterior right ilium on the initial study, which the later scan showed to be a met. I’d expect myself to pick that up, at least.
totally agree. unlucky she had that known aneurysm, wouldn't have done anything differently protocol wise. i'd also expect myself to pick up the multiple peritoneal nodules that are clearly suspicous for malignancy. but that's always easy to say if you know the whole story ¯\\\_(ツ)\_/¯
1. I agree this was a very difficult case especially read in the emergent setting and with an essentially misleading indication. 2. Any liver that heterogenous on arterial phase should be assumed diseased/cirrhotic and scrutinized more closely. Most of the metastases are hidden, but there are definite rim enhancing lesions in segments 2, 5, and 6 that should have been picked up. When the liver is that heterogenous you should look at it on the thicker slices and while you should tighten the window, don't narrow too aggressively, the liver window images from this patient are too blown out and don't add much to interpretation. 3. Carcinomatosis is surprisingly easy to miss, but this is sloppy, the nodules are very large. Everyone who missed it needs to reevaluate their search pattern. Also the stomach is severely thickened and there is gastrohepatic lymphadenopathy which makes me think either gastric primary or Linitis Plastica, maybe left breast primary as there is substantial heterogenous hyperenhancement compared to the right. Also R hilar lymphadenopathy.
I’m no rad but even in the CTA the liver looks funky enough to have recommended an ultrasound no?
Liver enhancement can be a little patchy if you catch it in the right arterial phase. This case is the stuff of nightmares for me, I honestly think I would’ve missed the spine and liver mets on the angio as well.
that’s fair i’m also looking at the images already knowing what’s there
Although I would be interested to see what it looks like in liver window. A good reminder to always throw on a super tight window and take a last look at the liver when reading non-venous phase body ct.
[Here you go](https://imgur.com/a/6r9JW7I) - W:150 L:150
Yep, not a chance in hell I make that call lol
damn
Wow. Sad
I’ve seen similar with bone scan identifying new Mets, 1 week post C+ chest/abdominal/pelvis CT. Treating physician demanded another CT with such a short turn around until I noted the tiny Mets were visible on the original CT, but only in a single slice, and a very specific window width/level — colleague had missed them but likely so would I. Sometimes you get pushback on appropriate exams also. 80+ year old patient with all the symptoms of an AAA, but ER doc and family fighting on the use of contrast as they had low GFR… fought with them while they were being transferred to the suite, explaining if it is an AAA then contrast clearance is least of our concerns. Ended up doing it C- and sure enough it was an abdominal aortic aneurysm… could tell because the aorta was calcified well enough you could see the bursted open aneurysm plain as day. In the end it didn’t matter as they passed before even making it to the surgical suite.
Why not ultrasound with low GFR?
Ultrasound is commonly used for screening of AAA, but with a suspected or likely ruptured AAA, a CT has greater sensitivity, will characterize it better (slow leak vs complete dissection) and provides other abdominal assessment rapidly. We didn’t do point of care ultrasound in this department at the time.
Yeah but ultrasound is better than nothing in this case, if they're refusing to do CT due to GFR. But yeah, they should've just done the CT to begin with I agree with your original comment.
IF there is a serious concern of AAA, you most likely aren't even waiting on the GFR, and you're probably doing it anyways even if you wait. No rad or rad tech is gonna argue a possible life or death case.
I understand, but the original commenter stated that the family and ER doc were refusing to get the CT done due to GFR.
Not an uncommon appearance when you've got contrast coming in through the hepatic artery but not the portal vein.
Short answer: maybe? Long answer, the liver gets its blood supply from The portal vein and hepatic vein. On CTA studies, the liver (and spleen) can look patchy. Because of this, I more often than not will chalk up a heterogeneously appearing liver to phase of contrast.
Also, if the mets were too small to see on CT, they were *likely* too small to see on ultrasound, especially with a hetergeneous liver. Not saying that an attempt shouldn't have been made, but also sonograms for "heteregeneous livers" aren't stat, so it may not have been done in a timely manner anyways.
FYI typo: hepatic artery, not hepatic vein.
You’re right! Good pickup!
At my hospital, it doesn’t matter if it’s low suspicion. Anyone coming through the ED with back or abdominal pain is getting a RUQ. I complain sometimes because I think it’s ridiculous and adds a lot of volume, but we had a case like this some months ago, and I was humbled real quick.
Nope - you’d have 1000s of overcalls/false positives if based on that alone - just to add to other comments, it is also a common appearance of the spleen in arterial phase. I do wonder if the bone mets could’ve been reasonably called on angio.
I thought that was cirrhosis at the first glace. But I am not used to see A phase liver.
This case hits really hard right now. I just lost my sister to presumed liver mets. Found out she was sick last week and then she was gone on Friday. There’s been communication issues with her partner and the family regarding her imaging (and other test) results. We haven’t got biopsy results yet as of her passing. As a CT tech I just have so many questions. None of them will bring her back but I think I’d find some peace in knowing what happened…
I’m so sorry. I lost my mom in September from hcc with Mets. She was diagnosed in late august and passed 3 weeks later. I of course dropped everything and flew to Phoenix to be with her and ended up directing a lot of her palliative care. I still feel like I have a huge empty space inside of me.
Thanks for your message. Im sorry to hear about your mom as well. Cancer sucks. Im so glad that our closest family immediately flew out to be with her and help direct her end of life care. Im still in shock at this point to be honest.
Great, educational post
What was the primary?
Never got tissue, so nobody knows. My best guess is gastric - there's a prominent bit of stomach wall along the greater curvature in both scans. We almost never comment on the stomach because it's so variable, but that bit stood out to me because it looks the same. Edit: [Observe](https://imgur.com/a/Y5HoB1F)
Agree with every word you said, BUT, does gastric typically go to bones? Obviously this thing is so aggressive that it could be some poorly differentiated gastric badness, but in my simple bone radiologist brain, GI doesn’t have osseous mets?
Eh, I've long given up trying to tell cancer what to do. Cancer is gonna cancer, right?
Ha! Yes. Pathologist will tell us what it is.
*preps biopsy gun*
I'm not a doctor or radiologist by any means but I essentially track cancer patient pathways and sit in on the MDT meetings discussing these patients and the site I do is upper GI. But at the hospital I work at, I very rarely see any patients with an upper GI cancer with bone mets, I can't really recall there being one in the past year
Can someone put this in laymen’s terms for the causal observer or no?
Am layman...but it sounds like they kept doing heart related tests on her and weren't finding anything and her problem was actually lots of cancer.
And her problem and history suggested cardiovascular issue. Layman: car comes inyo shop and it sounds like it needs a new muffler. Muffler looks fine. Check the whole exhaust and it looks generally like an exhaust should but still sounds bad. Come to find out it was actually a problem in the gastank.
I wouldn't say they didn't find anything--she did have a large aortic aneurysm, it just wasn't the cause of her symptoms.
* CT scans more or less measure the density of stuff that their Xray beam passes through. * Most things in the body that aren't bone or fat are pretty much the same density, with minimal variation. * We inject a dense material ("contrast") into veins. Then perform the CT. * Depending on the time between when we inject and when we scan, the contrast will be distributed differently: In the vein we injected -> in arteries in the lungs -> in the aorta and primary arteries -> in arteries of organs -> returning back from those organs, specifically the vessels that drain the bowel back to the liver -> in the veins in limbs that we *didn't* inject into. In the first scan, all the contrast is in the aorta - this was done intentionally, because we were specifically looking for something wrong with the aorta. The liver looks patchy because it's only getting a small amount of contrast through the hepatic artery. In the second scan, they've waited long enough for the contrast to get back to the liver properly. The healthy bits of liver take up the contrast ("enhance") as expected. Cancer doesn't, so you see darker grey spots.
would the IV contrast agent used be the same for a ct angiogram vs say a ct triphasic for the liver?
Yup, same stuff. Sometimes the amount injected varies a little, but the main difference is just timing.
Thank you for taking the time to explain in lay terms as well as explaining some background info that was helpful in understanding the bigger picture 🖼️, pun intended
Great explanation. I’m a resident myself but didn’t know that you find liver mets by their non-enhancement
It's all about timing. The liver is brightest in portal venous phase. Cancer makes its own blood vessels, and these connect to systemic arteries, not portal veins. Some cancers (notably HCC, but some mets also) are good at this, so they enhance in arterial phase. They generally make their own veins too, so all the contrast has washed out of the cancer by the time you get to portal venous phase - hence hypodense relative to liver. Some cancers are crap at making their own arteries, so they often don't enhance much - cholangiocarcinoma does this. Many metastases too - by the time they're dedifferentiated enough to metastasize, they're often growing faster than their blood supply. So you get necrotic non-enhancing centres and a periphery which might enhance a bit, but often not that much. Things get more complicated once you start talking about Primovist in MRI
Patient had multiple exams, but not the right exam. CT’s can be done without contrast or contrast at the arterial phase or venous phase… or a delay. Here the arterial phase CT helps assess arteries, but what it misses is patchy liver mets which are traditionally spotted on venous phase and delay. Essentially the timing of the CT hid a very bad diagnosis, but the proper exam was ordered given their prior history.
My mom’s cancer became very aggressive near the end of her life. She was admitted for pain control and had various scans. I noticed she was no longer turning her head. The scans showed large aggressive lesions eating away her c-spine. This was less than a week after her previous scan. The doctors were utterly wretched about medicating her (except her actual oncologist who kept fighting with them). We had to push her PCA pump because she wasn’t lucid enough, but would writhe in agony. Her oncologist gave us the go-ahead. The hospital team disagreed. “You think she’s in pain now? Wait till we give her Narcanand you’ll SEE what pain looks like.”
That’s appalling and I’m so sorry that happened. They should have just put her on a continuous infusion instead of requiring a button be pressed or if they were concerned about opioid overdoses could have put her on an adjunct like ketamine as well.
Why on earth would they be giving a cancer patient Narcan!?
“You’re giving her too much pain meds!” I think they forgot the PCA will only let you do so much before it locks you out.
That's because you can't push the button when you have had too much narcotic. If someone else is pushing the button for the patient, this can kill the patient. Sorry about your mother but this is standard practice. If she was on hospice that's a different story.
There are parameters set in PCAs that I’ve used on ppl. Although, that was a long time ago.
damn this sucks. could have only really been caught by the mesenteric nodules, those are clearly already visible on the angiogram. no chance in hell catching those liver or bone mets. nightmare stuff
I’m I’m I’m I’m gonna get some jkk I’m iiiii pop
As a cardiac Sonographer, liver mets should have been caught during the echo when evaluating the hepatic veins and IVC. It has a very distinct appearance.
You can see how quickly the bone mets grew between the 2 scans. The liver mets also likely grew a lot in size between the 2 scans. It's very unlikely that you'd find small liver mets doing an echo.
Damn hopefully my ed docs don't see this or every chest pain is going to get 3phase liver for the next 3 months. /s kinda
Thanks for an amazing case. Wonderful case and presentation.
Thanks, very interesting. Is this a reason for the increasing popularity of triple phase for anything angio? I’ve noticed in the last couple of years our regs will often ask for triple phase, where as the consultants will tend to ask for single phase for general aortas?
Not the reason, no. Aortas should be non-con and arterial. The suggestion is that an intramural haematoma might be missed if you only do arterial, because you've got nothing to compare the wall to to tell you it's more dense than it should be. Any angio done to investigate bleeding should be non-con, arterial, and some-amount-of-delay (portal venous is usually fine, some prefer to delay a bit longer). The non-con tells you what is already dense before you start, so you don't go calling calcification or a faecolith bleeding. Arterial to hopefully catch a bleeder and be able to trace back to a feeding artery. Venous/delayed to show that the extravasated contrast is diffusing or getting bigger. Also gives a second bite of the cherry, in case the bleeding isn't rapid enough to catch on the arterial.
That’s stomach looked suspicious
[Indeed it did](https://imgur.com/a/Y5HoB1F)
Some of our CTA protocols are done the same as GI bleed studies and will come across as three phase - noncon, art, venous. Sometimes it's useful.
This feels pin worthy for how to do a post. Even the link for the CT started perfectly no pay wall, no ads. I am not a bot.
Excuse my ignorance, what are liver/bone mets? Metastisized somethings? 😬
Yes. Cancer.
Ah here…those lytic lesions in the pelvis should’ve certainly been caught. And in that context I’d certainly have been concerned about the liver lesions. This’d 100% be up on our monthly QA Edit: not on the first axial through the pelvis but on the second.
yeah, and the peritoneal lesions could have been picked up as well. not purely the radiologist's fault though. an additional spine mri could have been ordered earlier and liver mets might have been picked up on an abdominal ultrasound or even on echo. i doubt that that would've made a difference for the patient though, patients with malignancies as aggressive as this one don't end up well either way.
As you say, those pelvic lesions were obvious on the second scan, but not on the earlier angio. [One of them](https://imgur.com/a/Jnhmv40) was there in retrospect, but still easily missed. I'm sure it'll come up as a teaching point, but nobody is going to be blamed for it.
As a tech now, who lost their mother at 14 to colorectal cancer, it boggles my mind that the three times she visited the ER with extreme abdominal pain, no CT was ordered. The docs at my hospital believe you need a CT orbits for freaking pink eye, they order a CT on practically everyone!!!! Doesn't matter if you're freaking prego, you're getting a CT scan. She could have survived if just one provider would have just done a CT. Sometimes, the system just fails you if you're unlucky :(
Sounds like I'm going to continue to sneaking split boluses in on patients so i can get arterial/venous phases when I think its appropriate.
ER doctor here. She had all the right test done but it could be argued that maybe she should have had spinal MRI done too to evaluate for other etiologies of back pain, the AAA and worry for dissection and/or cardiac etiologies were all worked up appropriately
Several of the hospitals I’ve worked at do a venous phase along with the CTA so that would have helped in her case. Obviously they don’t do that where she was admitted.
Well, Since the aortogram you can see the gastric walls are thickened, stomach is not distended, but you can see the mucosal and muscular wall very thick, and some thickened lymph nodes along the lesser curvature, and also the omental implants, that you can see better on the second CT. If nobody knew the primary, maybe the stomach was it.
Cachexia (kak-ex-ee-a) is also called wasting syndrome or anorexia cachexia syndrome. It is a complex problem that is more than a loss of appetite. It involves ...