Omission error - pulmonary ateriovenous malformation

Case contributed by Liz Silverstone
Diagnosis certain



Patient Data

Age: 50 years
Gender: Female

Small rounded soft-tissue attenuation opacities in the right mid zone periphery.

External CT for comparison


Solitary lobulated vascular lesion with large feeding and draining vessels. It is supplied from a single segmental artery and is therefore classified as a simple pulmonary AVM.

Case Discussion

Right to left shunting through a pulmonary AVM provides a route for paradoxical emboli to enter systemic arteries potentially causing distant infarction. This can be prevented by transcatheter embolization. She had no evidence of HHT or other associated conditions.

Omission errors: The nodular opacities were missed by many readers on serial chest radiographs. Radiographs offer a perceptual challenge due to superimposition of everything between the anode and the detector. An initial careful geographical search will avoid most errors of omission. Macular vision covers only a small area and must be moved over the entire image in a comprehensive pattern. For efficiency, examine all structures in each area of sharply focused vision and then move on. Optimize window settings and magnification and apply edge-enhancement for lung and bone.

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