Massive pulmonary embolism

Case contributed by Yaïr Glick
Diagnosis certain


Cough and feeling of "lack of air" for several days.

Patient Data

Age: 50 years
Gender: Male

Scout view:

Enlarged right pulmonary artery (Fleischner sign) with abrupt tapering (knuckle sign), suggesting thromboembolism.

Massive emboli in the main pulmonary arteries, in all of the lobar arteries, and many segmental arteries. Emboli fill most of the left lower lobe (LLL) arteries.

Pulmonary infarct with ground glass appearance at the base of the right upper lobe (RUL). Similar infarcts in the LLL. Small opaque subpleural infarcts at the lung bases.

Contrast material reflux into the inferior vena cava (IVC) and hepatic arteries.

The main pulmonary arteries and thoracic aorta are of normal caliber. The cardiac chambers are normal size.

Status post sleeve gastrectomy. Small hiatal hernia.

Old burst fractures in T10-L1 vertebrae, consisting of notching of the superior endplate in T10-T12 and a biconcave L1 vertebra. Known trauma from almost 20 years prior.

Large "holes" in scapulae (see 3D render) - developmental variant.


Chest x-ray taken 2.5 months earlier showing non-enlarged pulmonary arteries, compared to the CTPA scout view.

Subsegmental atelectasis at the lung bases.

Case Discussion

Shortness of breath, palpitations, and a cough for the past week. Usually healthy, except for obesity, for which he had underwent bariatric surgery. No known hypercoagulability. Syncope two days before reception and on the day of reception. At the ER, appeared ill, moderate tachypnea, desaturation of 90% in room air, diaphoretic. Temperature normal. EKG: atrial flutter, 116 beats per minute. Deep negative T waves on lead III and V1-V6. Bedside cardiac POCUS: mildly hypokinetic right ventricle.

CTPA showed bilateral massive pulmonary embolism, with resultant pulmonary infarcts.

A large portion of the emboli were retrieved and the patient recovered uneventfully.

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