CIP Case of the Month

Chronic Pulmonary Embolism by Ana Claudia Ferreira Rosa, MD.CIP case of month

Since its introduction in 2005, the ACR Case in Point (CIP) daily case challenge has been embraced by members and participating radiologists. Recently, CIP Editor-in-Chief Kitt Shaffer, MD, PhD, FACR, decided to highlight a "Case of the Month," which is chosen based on a survey of CIP readers, who give each case an overall rating.


The ACR Bulletin interviewed April 2012 Case of the Month corresponding author Ana Claudia Ferreira Rosa, MD, third-year radiology resident at the University of Minnesota in Minneapolis, about her team's submission, "Chronic Pulmonary Embolism," and the benefits of online education.

Q: Why did you choose to submit "Chronic Pulmonary Embolism" to CIP?

A: It's crucial to recognize chronic pulmonary embolism (PE) for proper management to reduce patient mortality and morbidity. This was also an excellent teaching case, as it demonstrated the majority of the radiographic findings in chronic PE. We thought our case would be a valuable addition.

Q: What is unique or interesting about this particular case?

A: In most chronic cases of PE, there are radiographic findings such as eccentric filling defects and vascular webs. However, in this case, the majority of findings are demonstrated in the images, including mosaic perfusion, right heart strain, and an enlarged main pulmonary artery.

Q: Explain your thought process as you interpreted the patient's images and made recommendations to the referring clinician.

A: In interpreting the images, the diagnosis of chronic PE quickly became apparent based on the multitude of image findings consistent with the diagnosis. After we determined right heart strain and pulmonary artery hypertension were present, our thought process centered on notifying the ordering provider of the critical diagnosis; the findings portend a poor prognosis.

Q: What do you hope ACR members or radiologists take away from this case?

A: We hope those reviewing the case master the interpretation of chronic PE to facilitate prompt diagnosis and management. In addition, a chest CT is often obtained to identify a cause of pulmonary hypertension. Given that the management of pulmonary hypertension is specific to the cause (i.e., venodilators in idiopathic, anticoagulation/surgery in chronic PE, and the paradoxical life-threatening reaction to venodilator therapy in pulmonary veno-occlusive disease), it is critical that radiologists are aware of the imaging phenotypes associated with the various causes for pulmonary hypertension.

Q: Was there a pericardial effusion on the presented case?

A: There was indeed a small pericardial effusion. Its presence indicates a poor prognosis.

Q: Many of the recognized CIP submissions have been thoracic cases. Why do you think this topic is so popular?

A: One reason may be that the diseases of the chest tend to have high morbidity and mortality and require clinical as well as radiologic findings to make the diagnosis. That makes for some of the most challenging cases and the broadest differentials in radiology.

Q: What is the appeal of online learning opportunities, such as CIP, over print tools?

A: Online learning opportunities are essential to residents and offer easy access to classic cases, which are important in learning to recognize and diagnose promptly. Online cases also provide easy references when a case is encountered in practice. Residents like to compare the case being read with similar cases and learn more about a particular diagnosis. Online availability, a digital format, and flexibility are key aspects of 21st-century education.

Q: Are you a regular reader of CIP?

A: I have been a regular reader of CIP since I began my radiology residency last year. I try to participate in the cases every day, and I have learned a lot.

Q: Why should radiologists take advantage of CIP?

A: It serves as an excellent learning tool, review source, and reference guide. Case in Point provides quick, easy access to review radiology cases, which can be useful to everyone — from the first-year resident to a senior radiologist. Since cases are often published soon after the patient encounter, CIP can provide the most current knowledge on many topics.

By Alyssa Martino
Alyssa Martino (This email address is being protected from spambots. You need JavaScript enabled to view it.) is a freelance writer.

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