Caceres’ Corner: Case No. 39 (Update: Solution)

Dear Friends,

Since we had very few answers in the previous case (too easy or too difficult?), Muppet is reverting to plain films and straightforward questions. The following are pre-employment radiographs of a 43-year-old female. She was told that she had enlargement of the ascending aorta. What would be your diagnosis?

1. Marfan’s
2. Aortic coarctation
3. Aortic valvular disease.
4. None of the above


43-year-old female, PA chest

43-year-old female, lateral chest

Click here for the answer to case #39

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    Oct 2012
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    DISCUSSION 35 Comments

    35 Responses to : Caceres’ Corner: Case No. 39 (Update: Solution)

    1. Burak says:

      There is knotching of the ribs,that suggesting an aortic coartation.however 40year old age can be considered a late diagnosis,and patient should have symptoms.

    2. mariam says:

      i think non of above suggestions…..another diagnose
      😀 😀 😀

    3. abdulameer says:

      ascending aortic aneurysm

    4. Maria S. says:

      pseudocoarctation?

    5. Lonci says:

      It’s Marfan’s syndrome, causing ascending aortic aneurism.

    6. Xose says:

      Ascending aortic aneurism. The woman seems to be tall and thin. Pectus excavatum. No scoliosis.
      I cannot see the rib-knotching.
      Aortic valvular disease should be sympthomatic.
      On balance, it might be Marfan’s… or a thin woman with aortic aneurism.

    7. RadLex says:

      There is dilatation of the aortic root and the ascending aorta is aneurysmal. There is some narrowing at the junction of the aortic arch and the descending aorta suggestive of post-ductal coarcation of the aorta, possibly with a congenitally bicuspid aortic valve.

      Differential diagnosis includes pseudocoarctation, aortic stenosis with post-stenotic dilatation, Ehlers-Danlos syndrome, Marfan’s syndrome and homocystinuria.

    8. ABED says:

      coarctation aortique

    9. Burak says:

      Pseudocoartation the final answer should be thebdiagnosis

    10. Gabriela says:

      The most likely diagnosis is the aortic valvular disease, because:
      – the enlargement of the ascending aorta in a supravalvular location seen on the lateral chest X-Ray
      – the convex middle mediastinal arch on the right, from the ascending aorta that pushes a little the SVC at this level, on the PA chest x-Ray;
      -the left inferior mediasinal arch is convex suggesting a hipertrophy of the left ventricle
      – I cannot see any skeletal abnormalities
      – the patient breathed in strongly and we can see the diaphragms are flattened and ribbs are horizontally ;
      – I can see the aortic knob so there is no aortic coarctation
      – the pulmonary vessels are clearly seen on both sides with a normal pattern.
      – I cannot see any calcifications of the aortic valve and the patient is middle aged so maybe the aortic valve stenosis is rheumatic

    11. Angelis Barlampas says:

      Findings
      dilatation of the aortic root
      the ascending aorta is aneurysmal
      There is narrowing at the junction of the aortic arch and the descending aorta suggestive of coarcation of the aorta
      I cannot see rib-knotching.
      The most suitable diagnosis could be aortic coarcation

    12. Özkan says:

      TheRe is diffuse dilatation of the asendan aorta,and may be the root of the aorta,.the patient is female and Middle aged,suggesting that an Marfan syndrome.

    13. Genchi Bari Italia says:

      Nel radiogramma AP, si nota dilatazione del 1 arco di sx(arco aortico);non ci sono anomalie costali e-o vertebrali. In LL si conferma la dilatazione dell’arco aortico ma sopratutto dell’aorta ascendente alla radice;vi è un restringimento(?) nel tratto istmico dell’aorta.La patologia piu’ probabile( la paziente è asintomatica) è una vavola aortica bicuspide, che nel suo decorso naturale può complicarsi con dilatazione della base aortica e con eventuale dissezione cronica.Non mi spiego però il restringimento post-istmico(pseudo-coartazione?).

    14. Artur says:

      Ascending aorta anuerysm – no ribs notching and asymptomatic – I’d think about Marfan syndrome, and I’d check eyes, skins etc.

    15. Jose Caceres says:

      So far, nobody has mentioned the correct diagnosis. Muppet very concerned!

    16. Kelvin says:

      The most striking feature on the PA radiograph is the abnormal aorto-pulmonary window…the aorta on the PA view appears normal, but the pulmonary trunk does not show the normal appearance (on the PA view).

      Moving on the lateral view. The relatively well defined structure projecting in the anterior mediastinum is too anterior to be the ascending aorta…in my opinion this is more likely to represent a distended pulmonary trunk. This might be idiopathic and asymmptomatic in young(ish) females…I cannot see any CXR signs of pulmonary hypertension. Other considerations would be post-stenotic dilatation in RVOT stenoses, left to right shunts and anomalous pulmonary venous return – however you would expect some symptoms in these conditions at the given age.

      So my final diagnosis is idiopathic asymmptomatic dilatation of the pulmonary trunk.

      Now all this is coming from a guy who’s interest is hepatobiliary radiology…so please bear with me if it’s all nonsense! 🙂

    17. Artur says:

      It could be Ehlers-Danlos syndrome – but patient is asymptomatic and I wouldn’t make diagnosis based on single Xray.
      There is a big list on differential diagnosis of widening of aorta.
      Maybe some clues?more informations about patient?

    18. Genchi Bari Italia says:

      Quello che è strano è che in AP, non c’è evidenza della cosiddetta dilatazione dell’aorta ascendente: questa ipotesi deriva dalla visione in LL.E se foose una immagine di sovrapposizione ? Chiaramente la TC risolve il caso: caro professore voi come avete fatto la diagnosi?

      • Kelvin says:

        Quella sarebbe una altra possibilità – detto questo sei d’accordo con me a proposito della finestra aorto-polmonare?

        • Genchi Bari Italia says:

          SI, in LL non si riesce a vedere lo spazio chiaro della finestra aorta-polmonare

          • Genchi Bari Italia says:

            Una dilatazione idiopatica del tronco della polmonare, potrebbe essere diagnosticata con una ecocardiografia ed RM.Dilatazione idiopatica tronco polmonare:BJR (2002)75,532-535.

      • Jose Caceres says:

        You thinking goes in the right direction. I saw the films after the patient was told she had an abnormal ascending aorta. I thought the chest was normal.
        MRI confirmed that no abnormality was present. Will explain on Tuesday.

    19. burak says:

      Patent PDA ?

    20. Dr J says:

      Noe of the above

    21. Irene says:

      straight back syndrome?

    22. Genchi Bari Italia says:

      Grazie professore: sei Stellare come il tuo Real !!!!!Bellissima lezione!!!!!

    23. Genchi Bari Italia says:

      Anche se non ho centrato la….porta!!!!

    24. Dr J says:

      Excelente caso.Gracias por la enseñanza recibida.

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