Hospital: HOSPITAL PUERTA DE HIERRO MAJADAHONDA.
Ciudad:
Nº:
Aut@r o Autores: J. Martínez González, J. El-Khatib Núñez, C. Cortés León, L. Gómez-Pimpollo García, M. Collado Torres, I. Gordo Molina.,
Presentación:
A 51 y.o man with no previous known diseases was brought after two syncope of seconds of duration. He referred thoracic pain the previous 24 hours that calmed with conventional analgesia. He was tachypneic, showed mucocutaneous pallor and complained of transfixive chest pain. Blood pressure was 80/40 mmHg, heart rate 90 bpm, electrocardiogram and laboratory normal. Thoracoabdominal computerized tomography (CT) was performed to rule out acute aortic pathology. Hyperdense pericardial effusion associated to ascending aortic dilatation with a focal wall vessel irregularity was demonstrated. Also, substantial delay in vascular opacification after contrast material injection, reflux of contrast material in inferior vena cava, contrast pooling in the dependent liver parenchyma and abdominal veins, absence of visceral enhancement, central pulmonary “ground glass” opacities and peripancreatic edema were observed. Findings suggested aortic rupture and cardiac tamponade with secondary cardiogenic shock. During the venous post-contrast phase CT acquisition monitors warned and cardiopulmonary resuscitation was needed. Patient underwent emergent thoracothomy and ascending aorta aneurysm rupture was repaired.
Discusión:
Cardiac tamponade results from accumulation of fluid in the pericardial cavity. Intrapericardial pressure increases leading to insufficient cardiac compliance in diastole, with subsequent cardiac inflow limitation. Stroke volume and blood pressure decrease, causing diminished cardiac ouput and cardiogenic shock. Severity of the shock depends directly on the velocity of accumulation of fluid in the pericardial cavity. In this case, the aortic rupture caused an extremely rapid hemopericardium and thus cardiogenic arrest in the exploration table. Echocardiography is the initial imaging tool for depicting pericardial effusion. When an extracardiac cause is suspected a chest CT must be performed to assess mediastinal vessels integrity and repercussion of the organs. Hemopericardium is seen as dense pericardial effusion in pre-contrast CT. Dilated ascending aorta with a focal irregularity (also called “bleb”) in the angiographic phase suggest aortic rupture secondary to vessel wall injury. Hemodynamic impairment due to pump failure in cardiogenic shock drives to blood stasis. This causes gravity-dependent contrast material pooling and layering in the veins. As the organs blood supply is limited, they don’t enhance after contrast. Systemic hemodynamic alteration causes generalized edema seen as opacities in the lungs or abdominal fat stranding.
Conclusión:
Cardiac tamponade results from accumulation of fluid in the pericardial cavity. Intrapericardial pressure increases leading to insufficient cardiac compliance in diastole, with subsequent cardiac inflow limitation. Stroke volume and blood pressure decrease, causing diminished cardiac ouput and cardiogenic shock. Severity of the shock depends directly on the velocity of accumulation of fluid in the pericardial cavity. In this case, the aortic rupture caused an extremely rapid hemopericardium and thus cardiogenic arrest in the exploration table. Echocardiography is the initial imaging tool for depicting pericardial effusion. When an extracardiac cause is suspected a chest CT must be performed to assess mediastinal vessels integrity and repercussion of the organs. Hemopericardium is seen as dense pericardial effusion in pre-contrast CT. Dilated ascending aorta with a focal irregularity (also called “bleb”) in the angiographic phase suggest aortic rupture secondary to vessel wall injury. Hemodynamic impairment due to pump failure in cardiogenic shock drives to blood stasis. This causes gravity-dependent contrast material pooling and layering in the veins. As the organs blood supply is limited, they don’t enhance after contrast. Systemic hemodynamic alteration causes generalized edema seen as opacities in the lungs or abdominal fat stranding.
Bibliografía:
– Restrepo CS et al. “Imaging Findings in Cardiac Tamponade with Emphasis on CT”. Radiographics Nov 2017 – Manisha J et al. “Case series: CT scan in cardiac arrest and imminent cardiogenic shock”. Indian J Radiol Imaging. 2010 May – Roth C et al. “Depen