EURORAD ESR

Case 14274

Hypovolemic shock with subtle imaging signs: systemic capillary leak syndrome

Author(s)
Tonolini Massimo, MD.

"Luigi Sacco" University Hospital, Radiology Department; Via G.B. Grassi 74 20157 Milan, Italy; Email:mtonolini@sirm.org
 
Patient
male, 49 year(s)
 
 
  • Figure 1
    Chest X-rays
     

    Semisupine antero-posterior chest radiograph failed to detect active pleuropulmonary changes and significant hilar, cardiac and mediastinal abnormalities.

     
    Area of Interest: Lung; Imaging Technique: Plain radiographic studies; Procedure: Diagnostic procedure; Special Focus: Haemodynamics / Flow dynamics;

    During resuscitation manoeuvers, repeated antero-posterior chest radiograph documented airway intubation, positioning of nasogastric tube (arrow) and of double central venous line (thick arrows).

     
    Area of Interest: Lung; Imaging Technique: Plain radiographic studies; Procedure: Diagnostic procedure; Special Focus: Haemodynamics / Flow dynamics;
     
     
  • Figure 2
    Contrast-enhanced body multidetector CT - thoracic findings
     

    Chest scans (a...c in craniocaudal order) excluded active pulmonary changes, pleural and pericardial effusions, interstitial and alveolar oedema, and acute airway aortic and mediastinal abnormalities.

     
    Area of Interest: Lung; Imaging Technique: CT; Procedure: Diagnostic procedure; Special Focus: Haemodynamics / Flow dynamics;

    Chest scans (a...c in craniocaudal order) excluded active pulmonary changes, pleural and pericardial effusions, interstitial and alveolar oedema, and acute airway aortic and mediastinal abnormalities.

     
    Area of Interest: Lung; Imaging Technique: CT; Procedure: Diagnostic procedure; Special Focus: Haemodynamics / Flow dynamics;

    Chest scans (a...c in craniocaudal order) excluded active pulmonary changes, pleural and pericardial effusions, interstitial and alveolar oedema, and acute airway aortic and mediastinal abnormalities.

     
    Area of Interest: Lung; Imaging Technique: CT; Procedure: Diagnostic procedure; Special Focus: Haemodynamics / Flow dynamics;

    No significant abnormalities of the thoracic aorta and mediastinum were present. No signs of pulmonary thromboembolism were noted, the main pulmonary arteries had caliber at lower normal limits.

     
    Area of Interest: Pulmonary vessels; Imaging Technique: CT; Procedure: Diagnostic procedure; Special Focus: Haemodynamics / Flow dynamics;
     
     
  • Figure 3
    Contrast-enhanced body multidetector CT - retroperitoneal findings
     

    Portal venous phase images showed marked, bilateral symmetric and homogeneous enhancement (average 320 Hounsfield units compared to 35 HU precontrast attenuation) of the renal parenchyma.

     
    Area of Interest: Kidney; Imaging Technique: CT; Procedure: Diagnostic procedure; Special Focus: Haemodynamics / Flow dynamics;

    Portal venous phase images showed marked, bilateral symmetric and homogeneous enhancement (average 320 Hounsfield units compared to 35 HU precontrast attenuation) of the renal parenchyma.

     
    Area of Interest: Kidney; Imaging Technique: CT; Procedure: Diagnostic procedure; Special Focus: Haemodynamics / Flow dynamics;

    The thin, normal-shaped adrenal glands (arrowheads) also showed subtle pronounced contrast enhancement. Note poor inhomogeneous splenic enhancement.

     
    Area of Interest: Kidney; Imaging Technique: CT; Procedure: Diagnostic procedure; Special Focus: Haemodynamics / Flow dynamics;

    The thin, normal-shaped adrenal glands (arrowheads) also showed subtle pronounced contrast enhancement. Note gastric overdistension with abundant fluid, slit-like inferior vena cava (IVC).

     
    Area of Interest: Kidney; Imaging Technique: CT; Procedure: Diagnostic procedure; Special Focus: Haemodynamics / Flow dynamics;

    Sagittal reformatted image confirmed slit-like retrohepatic and infrahepatic IVC (arrows) with sub-centimeter anteroposterior diameter.

     
    Area of Interest: Veins / Vena cava; Imaging Technique: CT; Procedure: Diagnostic procedure; Special Focus: Haemodynamics / Flow dynamics;

    The extremely thin retrohepatic IVC (arrow) was surrounded by subtle hypoattenuating oedematous halo.

     
    Area of Interest: Veins / Vena cava; Imaging Technique: CT; Procedure: Diagnostic procedure; Special Focus: Haemodynamics / Flow dynamics;

    Similarly to the slit-like IVC (arrow), the renal veins also appeared collapsed.

     
    Area of Interest: Veins / Vena cava; Imaging Technique: CT; Procedure: Diagnostic procedure; Special Focus: Haemodynamics / Flow dynamics;
     
     
  • Figure 4
    Contrast-enhanced body multidetector CT - colonic findings
     

    Most of the collapsed colon showed diffuse, moderate circumferential mural thickening (thin arrows) with mucosal enhancement and mural hypoattenuation suggesting submucosal oedema.

     
    Area of Interest: Colon; Imaging Technique: CT; Procedure: Diagnostic procedure; Special Focus: Haemodynamics / Flow dynamics;

    Most of the collapsed colon showed diffuse, moderate circumferential mural thickening (thin arrows) with mucosal enhancement and mural hypoattenuation suggesting submucosal oedema.

     
    Area of Interest: Colon; Imaging Technique: CT; Procedure: Diagnostic procedure; Special Focus: Haemodynamics / Flow dynamics;

    Diffuse, moderate circumferential mural thickening (thin arrows) with mucosal enhancement and mural hypoattenuation suggesting submucosal oedema. Note gastric overdistension with abundant fluid, poor inhomogeneous...

     
    Area of Interest: Colon; Imaging Technique: CT; Procedure: Diagnostic procedure; Special Focus: Haemodynamics / Flow dynamics;

    Diffuse, moderate circumferential mural thickening (thin arrows) with mucosal enhancement and mural hypoattenuation suggesting submucosal oedema. Note marked nephrogram, slit-like inferior vena cava (arrow).

     
    Area of Interest: Colon; Imaging Technique: CT; Procedure: Diagnostic procedure; Special Focus: Haemodynamics / Flow dynamics;
     
     
  • Figure 5
    Unenhanced MRI of the calves
     

    Coronal (a,b) and axial (c) T2-weighted images showed hyperintense oedematous muscle swelling of both calves, particularly severe on the right side and mostly affecting the gastrocnemius and soleus muscles.

     
    Area of Interest: Musculoskeletal soft tissue; Imaging Technique: MR; Procedure: Diagnostic procedure; Special Focus: Oedema;

    Coronal (a,b) and axial (c) T2-weighted images showed hyperintense oedematous muscle swelling of both calves, particularly severe on the right side and mostly affecting the gastrocnemius and soleus muscles.

     
    Area of Interest: Musculoskeletal soft tissue; Imaging Technique: MR; Procedure: Diagnostic procedure; Special Focus: Oedema;

    Coronal (a,b) and axial (c) T2-weighted images showed hyperintense oedematous muscle swelling of both calves, particularly severe on the right side and mostly affecting the gastrocnemius and soleus muscles.

     
    Area of Interest: Musculoskeletal soft tissue; Imaging Technique: MR; Procedure: Diagnostic procedure; Special Focus: Oedema;

    Axial fat-suppressed T2-weighted images (d,e) better showed intramuscular oedematous changes, with associated fluid-like epimysial, perimysial and fascial effusions, causing swelling particularly severe in the right...

     
    Area of Interest: Musculoskeletal soft tissue; Imaging Technique: MR; Procedure: Diagnostic procedure; Special Focus: Oedema;

    Axial fat-suppressed T2-weighted images (d,e) better showed intramuscular oedematous changes, with associated fluid-like epimysial, perimysial and fascial effusions, causing swelling particularly severe in the right...

     
    Area of Interest: Musculoskeletal soft tissue; Imaging Technique: MR; Procedure: Diagnostic procedure; Special Focus: Oedema;
     
     
Semisupine antero-posterior chest radiograph failed to detect active pleuropulmonary changes and significant hilar, cardiac and mediastinal abnormalities.
 
During resuscitation manoeuvers, repeated antero-posterior chest radiograph documented airway intubation, positioning of nasogastric tube (arrow) and of double central venous line (thick arrows).
 
Chest scans (a...c in craniocaudal order) excluded active pulmonary changes, pleural and pericardial effusions, interstitial and alveolar oedema, and acute airway aortic and mediastinal abnormalities.
 
Chest scans (a...c in craniocaudal order) excluded active pulmonary changes, pleural and pericardial effusions, interstitial and alveolar oedema, and acute airway aortic and mediastinal abnormalities.
 
Chest scans (a...c in craniocaudal order) excluded active pulmonary changes, pleural and pericardial effusions, interstitial and alveolar oedema, and acute airway aortic and mediastinal abnormalities.
 
No significant abnormalities of the thoracic aorta and mediastinum were present. No signs of pulmonary thromboembolism were noted, the main pulmonary arteries had caliber at lower normal limits.
 
Portal venous phase images showed marked, bilateral symmetric and homogeneous enhancement (average 320 Hounsfield units compared to 35 HU precontrast attenuation) of the renal parenchyma.
 
Portal venous phase images showed marked, bilateral symmetric and homogeneous enhancement (average 320 Hounsfield units compared to 35 HU precontrast attenuation) of the renal parenchyma.
 
The thin, normal-shaped adrenal glands (arrowheads) also showed subtle pronounced contrast enhancement. Note poor inhomogeneous splenic enhancement.
 
The thin, normal-shaped adrenal glands (arrowheads) also showed subtle pronounced contrast enhancement. Note gastric overdistension with abundant fluid, slit-like inferior vena cava (IVC).
 
Sagittal reformatted image confirmed slit-like retrohepatic and infrahepatic IVC (arrows) with sub-centimeter anteroposterior diameter.
 
The extremely thin retrohepatic IVC (arrow) was surrounded by subtle hypoattenuating oedematous halo.
 
Similarly to the slit-like IVC (arrow), the renal veins also appeared collapsed.
 
Most of the collapsed colon showed diffuse, moderate circumferential mural thickening (thin arrows) with mucosal enhancement and mural hypoattenuation suggesting submucosal oedema.
 
Most of the collapsed colon showed diffuse, moderate circumferential mural thickening (thin arrows) with mucosal enhancement and mural hypoattenuation suggesting submucosal oedema.
 
Diffuse, moderate circumferential mural thickening (thin arrows) with mucosal enhancement and mural hypoattenuation suggesting submucosal oedema. Note gastric overdistension with abundant fluid, poor inhomogeneous splenic enhancement.
 
Diffuse, moderate circumferential mural thickening (thin arrows) with mucosal enhancement and mural hypoattenuation suggesting submucosal oedema. Note marked nephrogram, slit-like inferior vena cava (arrow).
 
Coronal (a,b) and axial (c) T2-weighted images showed hyperintense oedematous muscle swelling of both calves, particularly severe on the right side and mostly affecting the gastrocnemius and soleus muscles.
 
Coronal (a,b) and axial (c) T2-weighted images showed hyperintense oedematous muscle swelling of both calves, particularly severe on the right side and mostly affecting the gastrocnemius and soleus muscles.
 
Coronal (a,b) and axial (c) T2-weighted images showed hyperintense oedematous muscle swelling of both calves, particularly severe on the right side and mostly affecting the gastrocnemius and soleus muscles.
 
Axial fat-suppressed T2-weighted images (d,e) better showed intramuscular oedematous changes, with associated fluid-like epimysial, perimysial and fascial effusions, causing swelling particularly severe in the right calf.
 
Axial fat-suppressed T2-weighted images (d,e) better showed intramuscular oedematous changes, with associated fluid-like epimysial, perimysial and fascial effusions, causing swelling particularly severe in the right calf.
 
 
 
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