Well, good evening and welcome to the final instalment of our diagnostic imaging series. The webinar tonight will be focusing on thoracic emergencies. I'm delighted you're able to join us this evening and you've pulled yourself away from that little football match that's taking place over in Russia.
This will give us a good indication er of our community of. The interest in football or not, but I am I can assure you that joining us tonight, you won't be let down. Mike has done many, many webinars with us, and I'm delighted he's, with us again tonight.
So, before I, talk about Mike, I just want to do a little bit of housekeeping. For those of you joined us previously, obviously I'm sure you know the routine by now, but if you haven't joined us before, I'll just go through some of the information that we give to you. I would encourage all of you to think of questions throughout the presentation.
There is an option to put type questions, which is at the bottom of the screen in the Q&A box. So as you're going through, if there's any questions popping your mind, please do type them down. And at the end of the webinar, we will then be asking Mike some questions, based on that.
So please do engage with us. Also through throughout Mike's presentation this evening, there's going to be 6 poll questions. They'll be relating to, obviously, what Mike is showing you on the slides.
Please do engage with us and, answer them. You're not going to get wrapped over the knuckles if you get it wrong. It just helps with the engagement of the presentation and, helps Mike understand, who's getting involved with the, with, with the webinar and what sort of level of knowledge you got.
So please do. What will happen, the poll question will pop up, we'll read out it and then just select the correct, the answer that you think it is, and we'll give you about 30 seconds to do that. We're also joined this evening by my colleague Peter.
Peter is on hand to answer any of your technical queries. So if you've got any issues with the vision or sound, etc. Either you can pop it in the chat box, which once again is at the bottom of the screen next to the Q&A box, or you can send an email to office at the webinar vets.com, and we will answer your emails then as well.
So. Our speaker tonight, I would say, it's one of those where our speaker needs no introduction. Professor Mike Kurti, graduated from Liverpool University and is currently Professor of Small Animal Medicine at the University of Cambridge and a fellow of Saint Edmund's College, Cambridge.
He's dean of the Cambridge Veterinary School and is in charge of the small small animal medicine and diagnostic imaging services at the Queen's Veterinary School Hospital. He has a wealth of experience and he's been awarded numerous awards and accolades throughout the years. So all it leaves me to do is hand over to Mike.
Over to you, Mike. Thank you very much for that kind introduction and welcome everyone to this final in the series, diagnostic imaging series on thoracic emergencies. So let's move into our cases.
The first case is a, domestic short-haired cat of unknown age, but female. Now this was a stray cat that was found lapsed and shocked. She was unable to stand.
She had severe dyspnea, for which a pneumothorax was diagnosed. A thoracic drain was inserted, but there was continuous leakage through the drain. And so I want you to look at the radiographs and decide whether you can understand why the leakage is continuing.
So this is the dorsoventral radiographer from this cat. And I'll let you look at that for a few moments. This is the lateral radiograph from the cat, and obviously you can see the chest strainer in place in both cases, as well as the fact that the cat's anaesthetized from the endotracheal tube on the lateral view.
So this is the dorsoventral. The question that you're gonna be asked is, which radiological sign is most clinically relevant? Is it the pneumothorax, the pneumo mediastinum?
The pulmonary haemorrhage and contusion, a ruptured diaphragm, or a fractured spine. And of course, it may not have some of those lesions. So there's the lateral view again.
And the poll question has just popped up, so, place your bets. Thanks Mike. As I said, you know, there's nowhere, you don't get penalised for getting it wrong.
It is just to see what your thoughts are. So, just select A, B, C, D. And and we'll just give you a few more seconds to complete that.
Come on, don't be shy. I can see how many have voted, so there's a couple more of you that haven't voted yet. So once again, which radiological sign is most clinically relevant?
OK. So we'll just leave it there. OK.
Ah. A couple of people there didn't, respond, Mike, but, we had 25% said pneumothorax, 25% said pneumo pneumoedstinum. We had 25% say pulmonary haemorrhage and contusion.
And guess what? We had 25% say ruptured diaphragm. OK, well, .
There is a slight pneumothorax. There is a pneumoed sternum. There is pulmonary haemorrhage and contusion, but there is no.
Ruptured diaphragm. So let's look at the films and see whether we can make a better decision on this. So we have a chest strain coming in on the right hand side of the thorax.
We have a little bit of subcutaneous emphysema, probably associated with the insertion of that chest strain, since there's nothing on the other side and it doesn't extend up into the neck area. What you can see in the lung is that there are some areas of the lung that has increased capacity in a rather sort of wispy, cloudy way, more on the left hand side than on the right-hand side, which could suggest That the cat was actually hit from the right hand side because it's the deflation and then reinflation that causes most of the pulmonary haemorrhage and contusion, which is on the opposite side to the impact very often. There are some areas that are just sort of suspicious.
There might be something here, a sort of a little gas lucency, and there might be here a gas lucy, possibly a gas lucency over there as well. On the lateral, now probably, many of you thought that there might be a pneumothorax here. In fact, the heart is being lifted off the sternum by gas within the mediastinum.
And you can say that because actually you can see the dorsal lung lobes coming right up to the top of the chest, and it's not until here that they curl over. And so these are fully expanded on this side. That means that this isn't free air because these would deflate and the everything would sink into the middle of the, chest.
What perhaps none of you saw was that there is a little fracture to the spine here on the thoracic vertebral body, a little caudal aspect of the the vertebral body. Now, if you look at the CT, then it just gives you a little bit more information because the CT obviously doesn't have the superimposition that you have with a standard radiograph. It's a cross sectional image with no overlapping tissue, whereas, of course, a radiograph is a two dimensional representation of a three dimensional image in a shadowgram.
And moving from the cranial aspect of the chest to the caudal aspect of the chest, you can see the subcutaneous. Emphysema on the right hand side here. We can see the lungs are pretty fully expanded on both sides here, but there is air within the pneumo within the mediastinum here.
So there is undoubtedly a pneumoedtinum. If we move a little bit more cordially, we can see the chest strain up here, a little bit of free gas. So there is a small amount of pneumothorax, but you'd expect that with the tube in place.
But really quite a marked amount of pulmonary haemorrhage and contusion here, mostly on the right hand side, a little bit also, on the left. And then when we move a little bit more cordially, we can see that there's a little bit of free gas, but we can also see that there's a, a pulmonary bulla on the dorsal aspect of the right caudal lung lobe. And this bulla is probably caused dramatically through pressure into the lung.
And below it we can see again some pulmonary haemorrhage and contusion, quite a lot at this caudal aspect here. So the diaphragm is intact and what you can see on this case is subcutaneous emphysema, pneumo mediastinum, a small and you gain a very small amount of pneumothorax. Pulmonary contusion and haemorrhage, a pulmonary bullar, which is evident only really on the CT, and a fractured thoracic vertebral body, and here you can see the slight displacement of that fracture of the thoracic vertebral body taken on a slice from the CT reconstructed.
The cat, made a full recovery, did gain use of its hind legs, but of course the major complications would have been the pulmonary, the pulmonary contusion and haemorrhage and the fractured spine. The pneumothorax sealed, and, and this often happens if you keep the lung lobes fully inflated by constantly draining or by continuous drainage of the air, then they will seal and then the chest strain can be removed. So the second case tonight is a shih-tzu, a 7 year old female called Molly, and Molly was presented with sudden onset dyspnea.
Now, in a very dysic animal, you position them in the way that they are most comfortable, and for most animals, this will be in the dorsoventral positions. The animal just lies on the table and you take the best radiograph that you can, and this is the radiograph that we got from Molly. So I want you to look at that for a few moments, and then we'll ask you again, which is the radiological sign that is most clinically relevant.
Is it a pulmonary emphysema, a pneumothorax, a tension pneumothorax, or fractured ribs? So have a look at that radiograph, decide what you think is going on in this radiograph and what you might do next. And then answer the question.
OK, so once again, if you just place your vote, please. A B C O D. As Mike says, which radiological site is most clinically relevant?
Oh, seems like we're gonna have a clear win on this one, mate. OK. OK.
So we'll end it there. OK, so no one has said pulmonary emphysema. 1, 17% have said pneumothorax, 83% have said tension pneumothorax, and no one has said fractured ribs.
OK, so the real distinction here is this is a tension pneumothorax and this is life threatening, so we need to do something very quickly. The quickest thing would just be to put a needle into the thorax and because of the pressure, within the, plural space, the air would come out and equilibrate with, atmospheric pressure which would allow the animal to breathe better whilst you've got a chest strain in place. But if you leave it, then the pressure within the plural space will continue to collapse the lung lobes here right down to almost nothing, and the animal will have severe difficulty in breathing.
So identifying this as a tension pneumothorax with lots of air, building up very rapidly compared with the pneumothorax, is, is quite an important aspect. So chest strain was put in place, and, the lungs were reinflated, but what was quite noticeable was that, if you stopped, draining the chest, then the pneumothorax just recurred. And so we needed to know why this was recurring.
Now on this lateral radiograph, you can see that the lung lobes are slightly better expanded. One lung lobe here, still away from the thoracic spine, away from the, diaphragmatic recess has got air free, and the other one has got a little bit more air, so it's a little bit further collapsed around here. Little bit of air and fluid ventrally but otherwise quite good, but now we're starting to see what looks like, a soft tissue opacity within the cranial lung lobes.
This is a right lateral and so this could be on the left hand side because without seeing the left lateral, this was the clearest image of that soft tissue mass. So that was a worry and it was a worry because this was continuously leaking air into the plural space and we were having difficulty getting the lungs up. So again, we decided to do a CT.
And this is what the CT shows us. So this is a transverse section through the cranial part of the thorax, probably about this sort of level across here. You can see that there's a little bit of air in the pleural space on the right hand side, but most of the air is present on the left hand side.
So that'll be the side where the lung lobe was more collapsed. And that there's more opacity within the left lung field compared with the right lung field. But when we go to the cranial lung lobe, then we can see that there is a soft tissue mass here with a bulla which has a fairly thickened wall.
And if we reconstruct that in the other plane, looking down through this side here, we'll see that we can identify this lung lobe, which has got the same shape as we saw on the radiograph with air around it. We can now see the bulla with a soft tissue mass in the centre of it. And we took a fine needle aspirate of that soft tissue mass to find out exactly what it was, and it is a pulmonary carcinoma.
And that pulmonary carcinoma had no secondaries, and so it was removed, at least the lung lobe, on the left hand side, cranial and middle lung lobe was removed and the dog did very well after that. The next case I'd like to present is a Maine Coon, 2 year old male called Butch Cassidy. And Butch Cassidy had some trauma, which had caused a fracture of the right femoral neck, and the right femoral head and neck was removed at surgery two weeks prior to his presentation at the stage that we saw him.
The owners had noticed a swelling around the neck and chest about one day ago, and this swelling around the neck and chest then rapidly spread all over the body to the hind legs. So on clinical examination, Butch Cassidy was now fairly dull and depressed. He had massive subcutaneous emphysema over the neck and the back legs.
You could feel the crinkling of the air within the subcutaneous space. His breathing was more audible, but there was no coughing. The swelling, had spread down, the swelling had spread down his back, and to his legs.
There was no pain over his hips, and he was able to bear weight. So the previous surgery, had not caused any problem. So now we'll look at the radiographs and you can see this is the right lateral radiograph including most of the chest and the neck.
This is the dorsoventral radiograph of the same animal at the same time. And then we took an oblique view, which we will discuss a little bit more later. So have a look at those radiographs.
And the question that we're going to pose is. Would you Drain this cat's chest, would you insert a chest drain? OK, I've launched the poll question.
So what we're looking for is a simple yes or no. Would you insert a chest string? OK, cool, and everyone's voted.
Thank you very much for voting so quickly. And it's a unanimous, no, no, 100% of people would not insert a chest strain like. Excellent, that's very good.
You're all correct, because this has got no evidence of a pneumothorax. The lung extends right out to the thoracic wall, right to the diaphragm, the heart's in the normal place. There is, though, a pneumoedstinum, and those that had looked at this in a little bit more detail, would see this air shadow coming up along the line of the aorta, around the heart and then into the cranial mediastinum.
So this air that is around the neck and around the body is also tracking down the mediastinum, and from the mediastinum, it doesn't usually get into the plural space because the pressure gradient doesn't really allow that. So a pneumo media stinum does not required. Drainage, but a pneumothorax would, and there's no evidence here of a pneumothorax.
And again, we can see that on this, lateral view, the lung parenchyma extends right out to the, extent of the thoracic, volume. So the heart is here, you can see lung vessels moving out right to the edge of the thoracic, wall. But you can see a pneumo mediastinum because you can now identify vessels within the cranium mediastinum that you wouldn't normally be able to identify, because they would just be soft tissue opacities within this area.
But you can see the the left subclavian and brachocephalic trunk, and you can also see the cranial vena cava coming in, as well as the air around the aorta coming back there. So maybe some of you wanted to know where this air might have come from, and one of our worries was that for so much subcutaneous air, And no evidence of a puncture wound anywhere on the body or or any sort of skin wounds on the cranial aspect of the body where this subcutaneous emphysema occurred. We wanted to know whether there was any damage to the trachea.
Now you can see the trachea here. But then, around about this area, we kind of lose it. We can see some soft tissue stripes here.
So this looks like the soft palate. This looks like gas around a muscle belly going down the neck, and then we've got gas around. The neck here as well.
And we knew that we had gas around the neck from the dorsoventral view and also from this oblique view. But this oblique view is to show us really that the trachea, the ventral border of the trachea, is intact. And that's important because one of our worries was that this might have a ruptured trachea and the two ends might have completely dislodged from each other, but the ventral border, the ventral wall of the trachea is certainly intact.
So because the subcutaneous emphysema was was quite severe, we decided that we should explore the trachea. We actually did some endoscopy first and we showed that there was this little tear in the dorsal ligament of the trachea. The trachea's been rolled over to show this tear within the trachea at this point.
So this is where the air was coming from. This is now the dorsal tracheal wall showing you the area that's been of the dorsal ligament that's been lost, two little holes, and this will have occurred because usually a cuffed endotracheal tube has just been blown up too hard for too long, causing ischemic necrosis. Of the dorsal ligament.
So something just to be aware about that can occur, but that would cause this massive, subcutaneous emphysema. So it had a ruptured trachea or tracheal membrane, subcutaneous emphysema, pneumo mediastinum, and there was a surgical repair of the tracheal defect. The next case was a very acute emergency, a 10 week old female pug called Sharky, and Sharky was presented with rapidly progressive dysnea.
The dysne was, noted, at the veterinary surgery and, and the animal was transported to us, as quickly as possible, given oxygen on the way because, Thay was already cyanotic and had a rapidly falling, SPO2 despite, oxygen therapy. So now have a look at these radiographs and see what you can think. So there's a dorsoventral radiograph there.
Dorsoventral radiograph or vent dorsoventral radiograph rather of the neck, and we didn't take a ventro dorsal because this is a dysneic animal. We never lie dysneic animals on their back without knowing exactly what's going on, in the chest because fluid could be redistributed and collapse the expanded lung lobe causing an acute exacerbation of the clinical signs. And then we have the right lateral thorax here.
And the left lateral thorax here. So have a look at those again, Dorsoventral. Cervical area.
Right lateral. And left lateral. And the question is, what are your thoughts?
Is this a pneumothorax? Has there been trauma? Is there a congenital lobar emphysema?
A pneumo mediastinum or a pulmonary bulla. OK. Just a couple more of you left to vote.
So if you just wanna have a quick think and then put down what your thoughts are, that'd be great. Go left vote. OK.
And we'll end the polling there. So, 17% have said the pneumothorax, 17% have said trauma. No one has said congenital lobe or emphysema.
23% of said pneumoeddenum and 33% have said pulmonary bula bula sorry. So yep, neck and neck between the last two. OK, OK, well, actually this is congenital lobar emphysema.
And it's quite an important, it's, although it's not common, it's quite an important distinction to make, because if you put a needle into this, a dog's chest or a drain, then you would burst the emphysematous bulla and have a massive pneumothorax. Now, why is it not a pneumothorax? Well, let's have a look at the radiographs.
Oops, sorry. So here we are on the dorsoventral. Well, first of all on the dorsoventral, perhaps some of you noticed there were a series of fractured ribs along here.
Now, this is an unusual sight for flat fractured ribs because of course they're well protected by the scapula. And it would be unusual for trauma to cause these fractured ribs. So these fractured ribs are much more likely to be associated with the severity of the dysnea that this animal was showing.
Just the excursion of the ribs can actually break the ribs, and we see that not uncommonly in cats with bronchial feline bronchial disease or bronchi or feline asthma. What you can see is that there's this loop coming out of the thoracic inlet. And this loop is connected to the chest, as we'll see in the next radiograph.
But what you can see down here is that there's lung tissue in this area here, because you can see the vessels extending right out. To the edge of the thorax. There's a small area here where you can't see any evidence of, of lung tissue and that's because actually this is the caudal lung lobe that's compressed.
The mediastinum is shifted over to the left hand side by this enlargement on the right hand side. The mediastinums pushed right the way over here with the caudal vena cava, normally on the right side here, push right over to the left side, the mediastinal flexure over here. This will be the caudal lung lobe, the cranial lung lobe, and the middle lung lobe.
And, and these are, are quite compressed by this over-enlargement of the right hand side. Now, congenital lobar emphysema tends to affect the right middle lung lobe. And what happens is that the cartilage within the, bronchus to the right middle lung lobe collapses.
And so what happens on inspiration, there's a small amount of air that goes into the lung, and then on expiration, when the surrounding pressure is increased, the bronchus collapse and the air is trapped within that lung lobe. So this is a large lung lobe that has pushed the mediastinum to the left, compressed the other, lobes and started to collapse them. And of course being emphysematist, it doesn't have good exchange capacity.
In fact, it's so large that it's ballooning out of the thoracic inlet, and you occasionally see that in very dysneic animals, where the lung will start to just come out of the thoracic inlet. There's no real diaphragm to hold it in, if the lung lobe overexpands at that point. Now the left and right lateral views are not particularly easy to to interpret, but what you can be sure of is that the the lung lobe extends well up here into the thoracic area, and what is around it has that lung parentchimal.
Opacity that we saw before with vessels extending right out towards the periphery. So this is still lung tissue, but it's not normal lung tissue. It's quite, over distended and, and overexpanded.
And we can see that also on the left side, which of course should show the right lung lobes. So the right lung lobe is here, and this is the overexpanded right middle lung lobe extending right the way across the whole of the right hemithorax. So this is a a a a a a congenital lobar emphysema and this is a small video of of how the surgeon made their incision.
Unfortunately I've cut out the sound because there were some expletives there, but that is the right middle lung lobe, and you can see the collapsed lung lobes behind them on the left hand side and the caudal lung field. That is the whole of the. Left or the right middle, lung lobe that's grossly over distended and overexpanded by the congenital lobe or emphysema.
Once it's removed, of course, the other lung lobes can, fully expand and fill the space and will respire much more effectively, because they've got the right sort of, flow of air and gas into them. The next case I want to talk about is a 10 year old Weimaran, a male dog called Blue, who was presented after an episode of collapse. There was a history of coughing, lethargy and exercise intolerance, and dysnea was noted on clinical examination.
So because of the collapse, the first thing that we wanted to do with this dog was to echo the heart to see whether there was any heart abnormality. And hopefully, all of you can see that the left atrium, the left ventricle are grossly dilated. If you compare the diameter of the left atrium with the aorta, it's 2.3 times the diameter of the aorta, where it should be 1 to 1 or 1 to 1.5.
So gross distention of the left atrium. And then when we look at the contractility with an MO going through the left ventricle, we can see that there's really very poor contractility, a very dilated left ventricular lumen. So this has all the hallmarks of dilated cardiomyopathy.
The rate is regular, so it hasn't gone into atrial fibrillation at the moment, but, it's, definitely, got dilated cardiomyopathy. And here's a little movie of the echo and see if you can see anything on that echo that you find is abnormal. Just try and play it again.
It's quite a short little video. Maybe some of you have just started to notice that there's something over here. And that's something over here can be defined as something in the right atrium.
And that's a right atrial mass. Now, it could be a clot, it could be a tumour, but it's certainly there. So this dog has These changes, and I think these changes, you would say, are compatible with dilated cardiomyopathy, enlarged left atrium, increased opacity within the perihia region and perhaps ventrally as well, but certainly in the perihilar region, quite marked distension of the pulmonary veins, much larger than the pulmonary arteries, and so this looks like a dog that's in congestive heart failure.
With pulmonary edoema. And that also is seen here. We could have done a faster T scan.
This is, would show you if you put the probe against the wall, that you saw these bee lines going into the lung where you can see the fluid within the lung and the reverberation that occurs around it. That's quite diagnostic of pulmonary edoema if you've got used to looking at fast scans then. That would give you that definition.
So at this stage, you'd think the dog was in congestive heart failure, and so the dog was treated for congestive heart failure, and this is one day later. And I want you to have a look at these radiographs in some details. So this is the right lateral radiograph.
This is the dorsoventral radiograph. And the question I want you to ask is, is this just resolving pulmonary edoema? Simple yes or no.
OK. So as Mike says it's just a simple yes or no. Is this just resolving pulmonary edoema?
Just give me 10 more seconds to answer this question. Mm OK. We'll end it there.
We have 33% have said yes, and 67% have said no. Excellent. So the majority have it.
If we now look at these radiographs again, we've certainly cleared much of the pulmonary edoema. The lungs are much clearer, but hopefully now what you can see are these nodules within the lung. Quite a large one here, about 1 centimetre in diameter.
There's no end on vessel, whereas this is an end on vessel. This is the right pulmonary arteries. It comes across underneath the trachea.
But there's no vessel this size there, there are no vessels this size in those areas because you can see the vessels behind them are much smaller. There's another one here. So there are multiple nodules within the lung.
You could see a few, on, on this one. There's, there's one here, for example. A few more, one over there, maybe, but certainly on the lateral, there's quite a lot of evidence of pulmonary metastasis.
So what we have is a dog with dilated cardiomyopathy, with pulmonary edoema, but it does have a right atrial mass and it does have pulmonary metastasis. And a right atrial mass with pulmonary metastasis will be most likely to be a hemangiosarcoma. In this case, It's not associated with pericardial fusion, but, certainly associated with the secondary metastasis within the the lung.
The next case I'd like to present is a 13 year old domestic long-haired cat called Ollie, and Ollie was presented with quite a long history, so there was a history of dyspnea, weight loss, and lethargy, and this was first noticed to be a problem approximately a year previously. When he came in from the garden, made a rather distressing noise, and then collapsed. He was taken to the vet and he fully recovered from that.
But over the past few months prior to referral, he was gradually losing weight. He'd become much less active. His breathing had been increasingly laboured, and especially, laboured over the last 4 weeks.
On clinical examination, he was fairly thin with a body condition score of 3 out of 9. Otherwise he was quite bright and alert. He had a heart rate of 240 beats per minute, with a gallop rhythm.
He had harsh, inspiratory noise over the entire thorax. Respiratory rate was 52 breaths per minute, with a marked abdominal component and moderately, increased effort. So again, we took the dorsoventral radiograph first, and if you have a look at that radiograph.
For a few moments. Again, because the animals mildly dissonate, we just position the cat in the most comfortable position, so this is in a sternal recumbency. Hopefully we can all appreciate that there's some free fluid.
Around the lungs. Here's a lung lobe, a lung fissure, a caudal lung lobe rather rounded on this side, more fluid on the right than on the left, but of course the mediastinum won't be intact, so it can move from one side to the other. Fluid around here, pushing the lung away from the thorax, a little bit of fluid up here, pushing the left cranial lung lobe a little bit more caudally.
But when you look at the lung lobes, they don't look normal either, because you can see these little nodular passages within the lungs spread throughout the whole lung field. And so, obviously, in a 13 year old cat, you're worried that this could be a manifestation of metastasis. So the first thing that we did was to improve the dyspnea.
We confirmed that the free pleural fluid was there, and then we took the free pleural fluid away. And here you can see with ultrasound, there's free pleural fluid, a little bit of pericardial fluid. Perhaps you can already appreciate that actually, the atria, is quite large, on this particular view.
But we took the pleural fluid, and we had that examined. It was a modified transitate containing lymphocytes. Non-degenerative neutrophils, reactive macrophages, and some eosinophils.
No bacteria or other infectious agents were seen, and no overtly nearoplastic cells were seen. And part of the reason for doing this fluid was to see whether or not this was neoplasia. So having failed to appreciate whether this was neoplastic, we then re-raiographed the animal and then did a fine needle aspirate of its lungs.
So this is the radiograph taken after 165 mL of fluid was taken off. And again, you can see that there's quite a marked pattern within the lungs. Perhaps now it looks a little bit more like an interstitial, either, .
A soap bubble appearance, maybe these are peribronchial infiltrates. It doesn't look quite so nodular now. There might be a few solid nodules, but a lot of them have air-filled holes in the centre, so this now doesn't look quite so neoplastic as the first picture that I showed you.
On the lateral view, there are still some odd opacities that could be quite solid, but there are more of them that have a peribronchial infiltrate and thickening of the bronchial walls, both in the cross section here, as well as in longitudinal section there. A little bit of fluid left between the lung lobes. Here is a fissure and ventrally around the ventral aspect of the heart and a little bit dorsally as well.
So a fine needle aspirate was done of the lungs, but after a little bit more work was done on the ultrasound examination of the heart. And here we could see the right atrium that we saw before, which is quite markedly distended, but not as big as the left atrium, which you can see here. So this cap has bi atrial enlargement.
Quite a small lumen apparently to the left side, which you can see here in cross section. So here's the right ventricular wall, here's the left ventricular wall and the septum here with the lumen of the left ventricle very compressed down here with a very thickened wall. Very large left atrium, the, aortic to left atrial ratio being 2.5, so 2.5 times the diameter of the, of the aorta.
So the fine needle aspirate of the lung was suggestive of chronic inflammation or possibly some haemorrhage. No neoplastic cells were seen, no bacteria or other infectious agents were seen. And so we considered that this animal had.
Hypertrophic cardiomyopathy and also feline bronchial disease. So we treated the, hyper hypertrophic cardiomyopathy with a low-ish dose of rosemide and benazepril and spironolactone to clear the lungs. A little bit of aspirin every 3 days to reduce the possibility of clots appearing within the enlarged atria, then flying off into the aorta, causing aortic thrombosis.
And then we gave inhaled corticosteroids. Now the reason that we went straight for inhaled corticosteroids was that if you give corticosteroids to an animal which you know has congestive heart failure, then you will worsen the congestive heart failure because there'll be fluid loading of the the circulation, and that will be detrimental to your effects of the benazepril, the spironolactone, and the rosemide. So this cat was trained to use fluticasone, through an inhaler, one of these aeroca inhalers.
It took to it very well. It found it quite a relief to have the steroid on board that way. And the cat made a considerable amount of improvement.
This isn't the same cat, but we have some pictures of its lungs. Have cleared quite a lot, but this is just to show the a cat with hypertrophic cardiomyopathy, showing the the area of biattrial enlargement on the left hand right hand side, giving the Valentine shaped heart in the dorsoventral view and the . The, enlargement of the left atrium, sorry, I've lost my mouse for a moment, and don't seem to be able to get it back.
OK, well, the atria in the cat, of course, is just below the carina, so the swelling of the long body of the the heart that you can see in the . Here we are, in the lateral view. This is all left atrium, so you've got a sort of bulge here, that's all left atrium and the dog, it comes up between the bronchi, but in the cat it's all beneath the bronchi, and here you can see the Valentine shaped part of a cat with hypertrophic cardiomyopathy.
The final case tonight is an eight year old boxer male called Polo. Polo had a history of coughing for several weeks, but more recently he become off his food and he was losing weight with occasional vomiting. On clinical examination, he was rather subdued.
He had a poor poor body condition score of 3 out of 9. His mucous membranes were pink with the capillary refill time was prolonged. His heart rate was 130 beats per minute, and he had very weak femoral pulses.
He had a low grade systolic murmur over the heart base where he did it 1 out of 6. And his cardiac sounds sounded muffled and were more audible on the right than the left. He also had jugular pulses and he had an abdominal fluid wave that was detected suggesting that he was in some degree of right-sided compromise.
So we've got a lateral radiograph of the thorax here. We have a dorsoventral radiograph of the thorax. I want you to look at those for a moment.
And what I want you to do is to jot down the radiological signs that you can identify in this dorsoventral view. And also in this lateral view. And when you've jotted down those signs, I want you to say whether they're 2345 or 6 radiological signs that you've seen.
OK. So do you need to go back and have another look at the other slide or can they work it out from the slide that you're on my? I think if they could have another quick look at this slide that they saw the dorsoventral one OK, but if they can see this one again, that would be good.
No problem. So just give me another 10 seconds. So how many radiological signs can you identify?
2345 or 6. OK, so I'll end the polling there. So, no one has said 2, 33% have said 3, 33% said 4, and then 17% have said 5 and 17% have said 60, very split vote there.
Well, 5 is probably the correct answer, but we'll go through the radiographs and show you. What signs you might have picked up. So on the lateral, I think the most striking feature is that the trachea is deviated dorsally and then comes down to the carina.
So something here must be pushing it up and you get the impression that you can see a soft tissue mass, perhaps, in this region here. Also, if you look at the cranial abdomen, it's got a loss of abdominal detail. You can see gas within the stomach, you can't see the stomach wall, you can't see the liver, you can't see the falciform ligaments.
So it looks as though there might be some fluid within the abdomen, and of course, we should have guessed that from the fact that there was a fluid wave palpable in the abdomen. On the dorsoventral view, we can perhaps make out that the heart has a very globular appearance. There's no particular.
Chamber enlargement, the left atrium isn't big, the right side of the heart isn't particularly big. It just looks globular in this view and on the lateral view, there was no evidence of any chamber enlargement either. So this would suggest the possibility of a pericardial fusion.
When you come to the cranial aspect, there's widening of the cranial mediastinum. Now, this is the area where we could see that soft tissue mass, previously, and the air-filled lung between the right cranial lung lobe and the left cranial lung lobe is very widened here. Also, the trachea is now pushed out towards the right hand side.
So, in my calculation, that is 5, the trachea was displaced dorsally on the lateral cranial to the carina. It was very globular in appearance, with no obvious individual chamber enlargement. There was a loss of serosal detail in the cranial abdomen, suggesting fluid.
There was widening of the cranial mediaestinum which could be fluid or mass, and the trachea was deviated to the right on the desoventral view. So this dog then went for ultrasound, and on ultrasound, it's quite an easy diagnosis to make. We've got a marked anechoic sac around the beating heart.
So he's right ventricle, left ventricle, and around that we've got fluid. So there's a large amount of fluid and the question. Then is, well, what could be the cause of this fluid?
Is it idiopathic? I we can't find any pathology, or is there either a mass within the right atrium, or is there a mass at the heart base? And what we can identify now looking at the right atrium is the true effect of cardiac tamponade.
So the cardiac tamponade, the pressure within the pericardium, collapses the right atrium here whilst it tries to fill, and that stops filling of the right atrium. That's why you get the dis distention of the great vessels and the the ascites that develops subsequent to the right sided congestion. And so this is cardiac tamponade that we can see this flapping in every time the animal goes into diastole when it should be filling up and then going through to the right ventricle.
So the right ventricle output is reduced and that obviously causes the failure. But looking around this, we can now see that there's a mass in this area. Now that's the right atrium.
A right atrial mass would either be in the lumen, or the distal tip of the right atrial appendage. Looking around, further, we can see that there is a mass in the right atrium, but the mass is extending through the wall of the right atrium and actually surrounds the aorta. So this looks much more like a heart base mass than a a right atrial mass associated with a, a, a hemangiosarcoma.
Here's the mass around the aorta. Here it is growing through the wall into the right atrium. So you think this probably doesn't have a very good prognosis, but actually, if you drain the fluid off, these are very slow growing tumours, these neuroendocrine.
Brain tumours and the animals can often go for about a year following withdrawal of the fluid. If we look in the abdomen, of course, we can find the free fluid, we can find hepatic congestion as well. This will be a modified trans.
To date, associated with congestive congestion of the right side. So pericardiocentesis is performed. This is the sort of fluid that you get out.
It always looks a bit like a port wine coloured blood, heavily blood stained serous sanguinous fluid, and that doesn't decide you whether it's a tumour or whether it's idiopathic. It's the same in in both types. 450 mLs was taken off this dog, and here's the ultrasound 4 weeks later, you can see that the right atrium is now fully expanded.
It doesn't show any evidence of cardiac tamponade, still Little bit of a mass in there, of course, but it's slow growing. There's no free pericardial fluid around the heart, apart from this little bit of area here. And this dog went on for about 9 months, never got another pericardial effusion.
But then succumbed to the the mass which just slowly grew over that period of time, and this is the postmortem from that dog showing the heart-based mass around the aorta. Here's the aorta around here, a a aortic body tumour as a neuroendocrine tumour. Well, that's all I have for you today, and we seem to have taken up the the hour.
I'm happy to answer any questions that you might have. I hope you've enjoyed the whole of this series, particularly this one, and those of you who didn't watch it because you were watching the football, hopefully you can watch it a little bit later. Thank you I've got the result.
Thank you very much for that, Mike. Yeah, as Mike says, this is the, final webinar in the instalment on our diagnostic imaging series, which there have been 5. All of them are recorded.
So if you, came to the series late, they are available on our website for you to go back to and watch in your own time. So please do. As Mike said, he's happy to take any questions.
So, if any of you there, do want to, pose a question, then please do. And we'll have a look at them now. Also, just to remind you that at the end of this webinar, in your browser, a survey will pop up.
Please do take time to complete the survey as it does help us in planning for future, webinars and also give some great feedback to the speaker as well. . Couple of comments, many thanks, Mike and other attendees.
Oh, that's from Alastair, and Alastair, I believe is in New Zealand. So, glad you could join us, Alistair. thank you.
It's been a great series and Michael is such an excellent speaker. Well, we already knew that, but it's always great to hear it again, isn't it, Mike? So thank you for that, Sarah.
I don't think we don't seem to be having any questions come through, but thank you very much for that feedback. It's always great to, Yeah, you, and it's great, Alistair, that you're, getting involved with our webinars because I know you're relatively new to the webinar but so thanks for that, Alastair. So if it leaves, no one has got any questions, what least we do is say thank you to my colleague Peter, who's been on, his, computer at his house tonight, monitoring everything, making sure everything goes smoothly.
And thank you to obviously, Mike as well for such a great series. And I'm sure Mike will be back doing webinars with the webinar ve very soon. And also thank you to yourselves for tearing yourself away for the football.
And you never know, you may get, without giving any sports to be a bit more of a football after this. So wishing you all a very pleasant evening and look forward to voting you on to our webinar soon. Thank you very much.
Thank you.