Answer for BIR CoW 02 Jun 2024
Left ventricle pseudoaneurysm with systemic embolic phenomenon
Findings
Given the history of seizures, MRI Brain was done. Multiple cortical and sub-cortical FLAIR hyperintense lesions were visualized in multiple arterial territories with few showing diffusion restriction. These findings were most likely suggestive of recent and chronic embolic infarcts. The patient also had an additional history of right testicular pain. Ultrasound scrotum images showed altered echotexture of the right testis with a large area showing absent vascularity, suggestive of chronic infarct of about 60 to 70 percent of testicular parenchyma. A routine Chest x-ray showed an incidental finding of an ill-defined radio-dense mass in the left lower zone with peripheral curvilinear calcifications. The left mediastinal border appeared indistinct. Contrast-enhanced CT thorax showed an abnormal contrast containing cavity in mediastinum communicating with the left ventricle through a neck /orifice measuring around 1 cm. The neck to lumen ratio was about 0.17 suggesting a pseudoaneurysm. A large hyperdense thrombus partially occupied it. Reflux of arterial contrast into the Inferior vena cava was noted as a sign of right heart failure. Left-sided superior vena cava was noted which appeared compressed by the pseudoaneurysm. Transthoracic Echocardiography showed aliasing and a typical bidirectional flow at the neck of the pseudoaneurysm. Additionally, there was moderate Mitral regurgitation and severe tricuspid regurgitation. Diagnosis of partially thrombosed left ventricle pseudoaneurysm was given.
Discussion
Left ventricular free wall rupture is rare and fatal. Pseudoaneurysm is formed when the pericardium, thrombotic material, or scar tissue contains a ventricular rupture, whereas true ventricular aneurysm contains all three layers (epicardium, myocardium, pericardium). Myocardial infarction is the most common cause. Other causes include trauma, sarcoidosis, and Chagas disease. Pseudoaneurysm has a risk of rupture even after years of formation and can lead to sudden death. Other complications include functional mitral regurgitation, aneurysmal thrombosis leading to systemic embolism, heart failure, and ventricular arrhythmia. Patients may present with recurrent chest pain, dizziness, and breathlessness. About 3 percent of patients are asymptomatic. Our patient presented with embolic episodes and symptoms of heart failure. Differential diagnoses include true ventricular aneurysm and ventricular diverticula. Echocardiography is very useful in differentiating diverticula from aneurysm. Ventricular diverticula contract with the unaffected cardiac wall. True aneurysms are hypokinetic or akinetic. Pseudoaneurysms show paradoxical ballooning outwards during contraction with an increase in ventricular pressure. CT helps differentiate a true ventricular aneurysm from a pseudoaneurysm. This can be done by calculating the ratio between the maximum internal diameter of the orifice and, the maximum parallel internal diameter of the aneurysm. A ratio of less than 0.5 implies a narrow neck seen in pseudoaneurysm. A Ratio of more than 0.5 is suggestive of true aneurysm. Active surgical management with primary closure is a highly recommended first-choice treatment. Conservative treatment can be considered in asymptomatic patients with aneurysms of size less than 3 cm or in patients with high surgical risk.
Findings
Given the history of seizures, MRI Brain was done. Multiple cortical and sub-cortical FLAIR hyperintense lesions were visualized in multiple arterial territories with few showing diffusion restriction. These findings were most likely suggestive of recent and chronic embolic infarcts. The patient also had an additional history of right testicular pain. Ultrasound scrotum images showed altered echotexture of the right testis with a large area showing absent vascularity, suggestive of chronic infarct of about 60 to 70 percent of testicular parenchyma. A routine Chest x-ray showed an incidental finding of an ill-defined radio-dense mass in the left lower zone with peripheral curvilinear calcifications. The left mediastinal border appeared indistinct. Contrast-enhanced CT thorax showed an abnormal contrast containing cavity in mediastinum communicating with the left ventricle through a neck /orifice measuring around 1 cm. The neck to lumen ratio was about 0.17 suggesting a pseudoaneurysm. A large hyperdense thrombus partially occupied it. Reflux of arterial contrast into the Inferior vena cava was noted as a sign of right heart failure. Left-sided superior vena cava was noted which appeared compressed by the pseudoaneurysm. Transthoracic Echocardiography showed aliasing and a typical bidirectional flow at the neck of the pseudoaneurysm. Additionally, there was moderate Mitral regurgitation and severe tricuspid regurgitation. Diagnosis of partially thrombosed left ventricle pseudoaneurysm was given.
Discussion
Left ventricular free wall rupture is rare and fatal. Pseudoaneurysm is formed when the pericardium, thrombotic material, or scar tissue contains a ventricular rupture, whereas true ventricular aneurysm contains all three layers (epicardium, myocardium, pericardium). Myocardial infarction is the most common cause. Other causes include trauma, sarcoidosis, and Chagas disease. Pseudoaneurysm has a risk of rupture even after years of formation and can lead to sudden death. Other complications include functional mitral regurgitation, aneurysmal thrombosis leading to systemic embolism, heart failure, and ventricular arrhythmia. Patients may present with recurrent chest pain, dizziness, and breathlessness. About 3 percent of patients are asymptomatic. Our patient presented with embolic episodes and symptoms of heart failure. Differential diagnoses include true ventricular aneurysm and ventricular diverticula. Echocardiography is very useful in differentiating diverticula from aneurysm. Ventricular diverticula contract with the unaffected cardiac wall. True aneurysms are hypokinetic or akinetic. Pseudoaneurysms show paradoxical ballooning outwards during contraction with an increase in ventricular pressure. CT helps differentiate a true ventricular aneurysm from a pseudoaneurysm. This can be done by calculating the ratio between the maximum internal diameter of the orifice and, the maximum parallel internal diameter of the aneurysm. A ratio of less than 0.5 implies a narrow neck seen in pseudoaneurysm. A Ratio of more than 0.5 is suggestive of true aneurysm. Active surgical management with primary closure is a highly recommended first-choice treatment. Conservative treatment can be considered in asymptomatic patients with aneurysms of size less than 3 cm or in patients with high surgical risk.
Note:
We do not discourage differential diagnosis. But all the differentials must satisfy the findings noted in the case.
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Did you Know?
The order in which the names appear in this winner's list is based on the time of submission. The first person to send the correct answer gets his/her name on top of the list!
We do not discourage differential diagnosis. But all the differentials must satisfy the findings noted in the case.
If you feel you have answered rightly but cannot find your name in the above list, please call 09551942599.
Did you Know?
The order in which the names appear in this winner's list is based on the time of submission. The first person to send the correct answer gets his/her name on top of the list!