Hola amigos, después de las vacaciones vengo con fuerzas renovadas y un nuevo caso. Os muestro dos imágenes de TAC en un varón de 32 años.
1. Lobectomía inferior derecha
2. Cisura accesoria inferior
3. Duplicación del diafragma
4. Nada de lo expuesto
Podéis dar vuestra opinión hasta el viernes, día en el que se publicará la solución.
Caso preparado por el Dr. Alberto Villanueva
Hallazgos: Se observa una estructura lineal (A, flechas) con un orificio central a través del cual pasan los vasos del lóbulo inferior derecho (B, flecha). Hay una discreta hipoplasia del pulmón derecho, con desviación homolateral del corazón. Se observa también un pulmón en herradura (A,B, asterisco). El aspecto radiológico es muy sugerente de duplicación diafragmática.
Diagnóstico final: Duplicación congénita del diafragma
El objetivo de esta presentación es familiarizar a los radiólogos con la semiología del diafragma accesorio congénito en el adulto y describir los hallazgos que permiten sospecharlo en la radiografía de tórax y confirmarlo con CT. Reconocerlo es importante porque evita una cirugía innecesaria.
El diafragma accesorio congénito es una fina capa fibromuscular que divide el hemitórax derecho en dos compartimentos comunicados a través de un orificio por donde pasan vasos y bronquios (Figura 1). No es un fenómeno aislado sino que se asocia al pulmón hipogenético (síndrome veno-lobar, síndrome de la cimitarra). A efectos prácticos, ocurre siempre en el lado derecho.
Figura 1
Se puede identificar en la radiografía de tórax si se piensa en él y es muy fácil de diagnosticar mediante TC si se conoce su semiología. Esto permite evitar la cirugía que se solía hacer en la mayoría de los casos encontrados hasta ahora. Es una malformación congénita asociada al pulmón hipogenético.
Los signos de sospecha en la radiografía PA de tórax son un borramiento central del hemidiafragma derecho, causado por la inserción del diafragma duplicado. En la placa lateral, se observa una línea oblicua que simula una cisura mayor (Figuras 2-3). Se asocian también signos de hipoplasia pulmonar derecha y dextrocardia secundaria.
Figura 2. Paciente con diafragma accesorio. A. En la proyección PA el diafragma accesorio produce borramiento de la cúpula diafragmática (A, flecha). Como el paciente tiene hipoplasia pulmonar el pulmón derecho es pequeño y el mediastino está desplazado a la derecha. En la proyección lateral se identifica como una línea oblicua gruesa paralela a la cisura mayor (B, flechas). Termina en el diafragma derecho que es más alto que el izquierdo debido a la hipoplasia del pulmón derecho.
Figura 3. Otro ejemplo de paciente con duplicación diafragmática congénita. En la proyección lateral, el diafragma accesorio se ve como una fina línea oblicua que nace en el diafragma derecho, más elevado (A, flechas). En la placa PA, el diafragma derecho está borrado (cabeza de flecha) en el área donde contacta con el diafragma accesorio. El pulmón derecho es menor que el izquierdo y el corazón está desplazado a la derecha debido a la hipoplasia pulmonar algo menos evidente en este paciente.
Los hallazgos CT son patognomónicos, visibles en la Figura 4, que resume los hallazgos. Se observa el diafragma duplicado como una línea oblicua (flechas), con un orificio central a través del cual pasan los vasos del lóbulo inferior derecho (flecha roja). En el borde del orificio, se observa un engrosamiento que simula una lágrima (flecha amarilla):
Figura 4
Figura 5. Cuatro pacientes diferentes con diafragma accesorio. En todos los casos, se puede observar un engrosamiento como una lágrima en el borde anterior o posterior (flechas).
Figura 6. Reconstrucciones sagital oblicua (A) y coronal (B) de TC que muestran el diafragma accesorio como una línea (flechas blancas). Los vasos y bronquios (flechas amarillas) pasan a través del orificio hacia el hilio. El orificio se sitúa en la porcion anterior e inferointerna del diafragma accesorio (C, flechas curvas).
Los consejos de Dr. Pepe:
1. Piensa en un diafragma accesorio cuando veas en la radiografía de tórax signos de hipoplasia pulmonar derecha más los siguientes hallazgos:
1. Borramiento 2. Línea oblicua
Los consejos de Dr. Pepe:
2. Diagnostica un diafragma accesorio en TC cuando veas:
1. La línea 2. El orificio 3. La lágrima
Pulmón en herradura. Habría que valorar drenaje venoso porque suele asociarse a síndrome de cimitarra.
A qué más se asocia?
I think this case has duplication of the diaphragm with meandering of the pulmonary vein of the right lower lobe.
Felicidades a los dos participantes, especialment a Nop, que mencionó el diagnóstico correcto.
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Hola amigos, después de las vacaciones vengo con fuerzas renovadas y un nuevo caso. Os muestro dos imágenes de TAC en un varón de 32 años.
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¡Qué interesante caso! Nunca había visto algo así. Muy útil la explicación de los hallazgos en las radiografías y el CT. ¡Gracias Dr. Pepe por compartir estos casos tan educativos!
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¡Qué interesante caso! Me encanta cómo Dr. Pepe explica las cosas de forma tan clara y concisa. Siempre aprendo algo nuevo con estos casos. ¡Gracias por compartir!
¡Qué interesante caso del Dr. Pepe! Siempre aprendiendo algo nuevo. Nunca había oído hablar de la duplicación del diafragma, ¡pero ahora ya sé qué buscar en las radiografías! Gracias por compartir.
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Me ha parecido muy esclarecedor el caso, especialmente la parte sobre cómo diferenciar esa línea oblicua de una cisura mayor en la placa lateral. Es fundamental tener presente esta entidad para evitar intervenciones quirúrgicas innecesarias, ya que a menudo se confunde con otras patologías. Muchas gracias por compartir los hallazgos radiológicos, son de gran ayuda para la práctica diaria.
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