CASE 11099 Published on 21.08.2013
0

Double drain

Section

Chest imaging

Case Type

Anatomy and Functional Imaging

Authors

O'Connor S, Hanson J, Cristiu O, Mulroy M

Our Lady of Lourdes Hospital;
Drogheda D Co. Louth, Ireland;
Email:maryjohnny@eircom.net
Connected authors
John Hanson IRELAND
Patient

73 years, male

Categories
Area of Interest Cardiovascular system, Lung ; Imaging Technique CT
Download as PDF Print Show related cases Notify admin
Clinical History
This 73-year-old male patient presented with a sudden history of slurred speech and left sided weakness. A chest X-ray was performed on admission showing a right basal mass lesion, required cross sectional characterisation.
Imaging Findings
The patient had a chest radiograph on admission, which showed a right basal rounded mass lesion (Figure 1). This required CT for characterisation. On CT, the right basal lesion was sharply demarcated and heavily calcified, likely an incidental granuloma (Fig. 2). The CT also showed absence of the left brachiocephalic vein crossing the midline to form the superior vena cava with the right brachiocephalic vein (Fig. 3-5).
There was a left-sided vena cava draining into the coronary sinus (Fig. 4, 5).
Discussion
A persistent left superior vena cava (PLSVC) is the most frequent thoracic venous anomaly, with a prevalence of 0.3-0.5% in the general population increasing to 10-12.9% in patients with congenital heart defects [1, 2, 3]. It occurs when the left anterior cardinal vein fails to occlude during early embryological development. The majority of cases are discovered as an incidental finding during routine investigations or procedures and patients are usually asymptomatic. In 80-90% of cases, a PLSVC will drain via a dilated coronary sinus into the right atrium (Figures 3-5). However, a small number of PLSVC can drain directly into the left atrium causing an anatomical right-to-left shunt, which may become symptomatic [1, 3].
It is for this reason that there should be an awareness of the potential incidental finding of a PLSVC such as during pacemaker insertion [4, 5, 6], central venous catheter placement [7, 8, 9] and benign calcification, which would warrant further evaluation. Consequently, knowledge of this embryological variant is particularly important for these and other cardiac procedures including surgery.
Differential Diagnosis List
Left-sided superior vena cava
Collateral venous anatomy
Aneurysm of sinus of Valsalva
Surgical bypass
Final Diagnosis
Left-sided superior vena cava
Case information
URL: https://www.eurorad.org/case/11099
DOI: 10.1594/EURORAD/CASE.11099
ISSN: 1563-4086
Figure 1

CXR

CXR
CXR on admission, showing a right basal density (black arrow).
Figure 2

Coronal reconstruction of CT thorax

Coronal reconstruction of CT thorax
Coronal reconstruction of CT thorax showing a calcified lesion in the right base, likely a granuloma.
Figure 3

Coronal reconstruction of CT

Coronal reconstruction of CT
Coronal reformat of CT thorax, showing an incidental finding of bilateral SVC. The white arrows are depicting the left sided SVC.
Coronal reconstruction of CT
Coronal reformat of CT thorax, the arrows are highlighting the left sided SVC draining into the coronary sinus
Figure 4

Sagittal reconstruction of CT

Sagittal reconstruction of CT
Sagittal reconstruction of CT thorax. White arrows highlighting the left SVC course through the thorax to drain into the coronary sinus.
Figure 5

Axial CT Thorax

Axial CT Thorax
Axial CT thorax, showing both SVC, short white arrow right and long white arrow, left.
Axial CT Thorax
Axial CT thorax, showing the left SVC draining into the coronary sinus, white arrow.