Presentation
Request for CXR reads as follows: "Pleuritic chest pain, dyspnea, spinal op yesterday ?PE. Osteoporosis, severe ??rib fracture"
Patient Data
There are linear hyperdense abnormalities around the right hilum, and also in both upper zones adjacent to the mediastinum.
CT pulmonary angiogram (CTPA) is requested by the clinical team to exclude a pulmonary embolus.
On the standard soft tissue windows (1st stack), the pulmonary arteries enhance normally with no filling defects. On re-windowing to vascular windows (2nd stack), linear high density abnormalities are seen in the right main pulmonary artery and its segmental branches. Further abnormalities in the left pulmonary artery segmental branches.
Review of previous imaging.
On review of the patient's previous imaging, it becomes apparent that the patient had undergone 4 level vertebroplasty the previous day. This explains the abnormalities seen on CXR and CTPA: cement embolism. In retrospect, on the CXR, the vertebroplasty cement can just be seen on the bottom of the radiograph.
Case Discussion
Following vertebroplasty, the reported incidence of cement embolism ranges widely, from 2.1% to 26% 1. Meticulous technique and high quality fluoroscopy are necessary to reduce the risks of cement leakage into the venous system or into surrounding soft tissues.
This case illustrates the importance of rewindowing angiographic studies to vascular windows, as the pulmonary artery cement could not be visualized on standard soft tissue windows.
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