Saddle pulmonary embolism with resultant right ventricular strain

Case contributed by Dr Balint Botz

Presentation

Cough, dyspnea, elevated D-dimer.

Patient Data

Age: 70 years
Gender: Female

Marked cardiomegaly even considering the supine position and AP projection, with prominent perihilar vessels suggestive of congestion.

The chest x-ray did not reveal any important differentials (e.g. pneumonia), thus CT pulmonary angiography (CTPA) was requested to rule out pulmonary embolism

At our center all CTPAs are sent out with two main smooth kernel reconstructions. On the standard mediastinal window reconstruction pulmonary arteries are really bright, which facilites assessment of gross vessel patency, but it also increases CT blooming artifacts which can obscure e.g. small mural non-occlusive thrombi. Also note the marked streak artifact caused by dense contrast retained in the superior vena cava. The broader angiographic window is better at depicting wall irregularities and smaller thrombi. 

Findings: 

  • saddle embolus of the main pulmonary trunk, with bilateral extensions into multiple segmental branches. 
  • moderately enlarged right ventricle. 
  • small pericardial effusion 
  • mild bibasal subsegmental partial atelectasis

Case Discussion

Classic saddle pulmonary embolus with resultant right heart strain. Optimizing the window while viewing CTPAs (or any CT angiographic study) in general is crucial. 

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