Ectopic pregnancy occurs when implantation of the blastocyst takes place in a site other than the endometrium of the uterine cavity. Uncommon implantation sites of ectopic pregnancy include the cervix, interstitial segment of the fallopian tube, scar from a prior cesarean delivery, uterine myometrium, ovary, and peritoneal cavity. Heterotopic and twin ectopic pregnancies are other rare manifestations. Ultrasonography (US) plays a central role in diagnosis of uncommon ectopic pregnancies. US features of an interstitial ectopic pregnancy include an echogenic interstitial line and abnormal bulging of the myometrial contour. A gestational sac that is located below the internal os of the cervix and that contains an embryo with a fetal heartbeat is indicative of a cervical ectopic pregnancy. In a cesarean scar ectopic pregnancy, the gestational sac is implanted in the anterior lower uterine segment at the site of the cesarean scar, with thinning of the myometrium seen anterior to the gestational sac. An intramural gestational sac implants in the uterine myometrium, separate from the uterine cavity and fallopian tubes. In an ovarian ectopic pregnancy, a gestational sac with a thick hyperechoic circumferential rim is located in or on the ovarian parenchyma. An intraperitoneal gestational sac is present in an abdominal ectopic pregnancy. Intra- and extrauterine gestational sacs are seen in a heterotopic pregnancy. Two adnexal heartbeats suggest a live twin ectopic pregnancy. Recognition of the specific US features will help radiologists diagnose these uncommon types of ectopic pregnancy.
Vertebral artery dissection (VAD) is increasingly identified as a cause of ischemic stroke in young adults. Patients most commonly present with neck pain, headache, visual disturbance, or focal extremity weakness. We present a case of spontaneous VAD in a patient whose only symptoms at presentation were neck pain and headache. A 42-year-old male presented to the emergency department with one week of left neck pain and headache. Computed tomography (CT) neck with contrast was initially ordered for neck pain. CT neck revealed an incidental anterior communicating artery (ACOM) aneurysm. Digital subtraction angiography (DSA) performed for ACOM aneurysm coiling demonstrated a left VAD, which was the attributable etiology to the patient's presentation. Subsequent magnetic resonance angiogram (MRA) neck confirmed this finding. Follow-up brain MRI revealed a small acute left occipital lobe infarct secondary to thromboembolism from the VAD. The patient underwent endovascular coiling of the ACOM aneurysm and received aspirin for the VAD, obtaining resolution of his symptoms. VAD involves an intimal tear of the vasa vasorum leading to narrowing of the vessel lumen that can result in thromboembolic complications. Risk factors for development of VAD include neck manipulations, trauma, or abnormal posturing. DSA remains the gold standard imaging exam for diagnosis of VAD. However, recognition of VAD on more common non-invasive modalities, such as computed tomography angiogram or MRA, remains critical for establishing the correct diagnosis. Although the clinical presentation of VAD is highly variable, dissection should be considered in a young patient with craniocervical pain, even in the absence of neurological symptoms. Early diagnosis and treatment of VAD can lower the risk of long-term neurologic sequelae.
a diagnostic challenge to the clinician with disastrous consequences, if not treated in a timely fashion. MDCT plays a key role in detecting IMA injuries, directing rapid surgical or endovascular therapy. Background: Internal mammary arteries (IMA) are 1.9-2.6 mm vessels with average flow of 120 to 240 ml/minute. The structure of the IMA explains a reduced tendency for spasm and development of atherosclerosis, which makes it ideal for coronary revascularization and flap reconstructions. The course of this artery adjacent to the sternum makes it susceptible to both blunt and penetrating injury, as well as iatrogenic injury. Laceration, arteriovenous fistula and pseudoaneurysm of the internal mammary artery are a rare but known sequelae of cardiothoracic surgery and blunt chest trauma. Intrathoracic bleeding of this vessel can lead to life-threatening events such as cardiac tamponade, which may be obscured in conventional angiography, and detectable by MDCT. Clinical Findings/Procedure Details: Introduction-IMA anatomy and collateral circulation in special cases (aortic coartation, interrupted aorta)-Surgical techniques involving the IMA: indirect myocardial revascularization and flap reconstructions Case review:-Transection of the IMA following CABG-LIMA-PA fistula-Transection of the IMA from the placement of an ICD lead-Rupture of IMA during CT-guided pulmonary biopsy-IMA transection due to Crash,stab wound, and gunshot-Spontaneous internal mammary artery tear-Central catheter placed in the IMA Review of complications related to IMA injury:-Left phrenic nerve injury-Coronary steal syndrome Conclusions:-The course of the internal mammary artery adjacent to the sternum makes it susceptible to blunt, penetrating and iatrogenic injury.-Internal mammary artery injury can cause anterior mediastinal hemorrhage and cardiac compromise even after minor trauma.-MDCT is a valuable non-invasive tool to detect early recognition of active internal mammary artery bleeding within the chest resulting in direct rapid surgical or endovascular therapy.
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