Superior Vena Cava Obstruction Evaluation With MDCT

Sheth, Sheila; Ebert, Mark; Fishman, Elliot K.

doi:10.2214/ajr.09.2894

Cited by 80 publications

(47 citation statements)

References 14 publications

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“…Chest collateral veins usually occur in superior vena cava obstruction and then develop through four classic pathways: azygos and hemiazygos, internal thoracic and laterothoracic, superficial thoracoabdominal, and vertebral venous plexus (posterior way) [1,2]. These patients usually present with a symptomatic superior vena cava syndrome [3].…”

Section: Discussionmentioning

confidence: 99%

Transient high density vertebral bone lesions

et al. 2013

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DiagnosisBone marrow enhancement by retrograde contrast filling through collateral veins due to a left brachiocephalic vein thrombosis. DiscussionThe contrast-enhanced CT examination revealed sclerotic-like lesions associated with consecutive anterior and posterior elements from the fourth cervical vertebra to the fifth thoracic vertebra, without any lytic components, which could at first be considered as bony metastases (Fig. 1a-b). CT scan also highlighted significant collateral venous circulation secondary to a brachiocephalic left venous thrombosis. A PET-CT performed at the same time was negative. A non-contrast CT scan performed 10 days later did not reveal the initially noted bone lesions (Fig. 2a-b) and suggested diagnosis of intraosseous venous contrast media. The 1-year non-contrast CT follow-up did not show any progression of the disease.Given the lack of corresponding findings on the unenhanced CT, in the setting of central venous obstruction and collateral pathway formation, the high-attenuation lesions seen on the enhanced CT examination can be explained by the presence of intraosseous venous collaterals. In fact, the left brachiocephalic vein obstruction was responsible for the development of an extensive collateral venous pathway (Fig. 2c-d) involving the mediastinum, anterior jugular veins, anterior, and basivertebral venous plexi. The venous pressure in the dilated capillaries allowed marrow enhancement through the anastomosis capillary sites: basivertebral veins bed (between the anterior external plexus and the posterior internal plexi) and pedicular sites (between the intervertebral veins and the vertebral plexi) (Fig. 3a-b). Our patient remained asymptomatic despite the huge collateral venous substitution. The rate of injection of contrast and the time of image acquisition following contrast injection might be factors influencing the appearance of these findings.

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Section: Discussionmentioning

confidence: 99%

Transient high density vertebral bone lesions

et al. 2013

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“…Four classic collateral pathways involving the azygos and hemiazygos, internal mammary and lateral thoracic, superficial thoraco-abdominal and vertebral venous plexuses have been described and proven by venography [2][3][4]. In practice, several collateral pathways may be involved together and the specific pattern in a given patient will depend on the cause, exact location and duration of venous obstruction, along with individual variations in venous anatomy.…”

Section: Discussionmentioning

confidence: 99%

Vanishing bone metastases — a pitfall in the interpretation of contrast enhanced CT in patients with superior vena cava obstruction

Thomas

Oliver²,

Sudarshan³

2011

BJR

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ABSTRACT. We describe a previously unreported case of vertebral marrow enhancement owing to collateral circulation in a patient with superior vena cava obstruction. Failure to recognise this phenomenon led to the misdiagnosis of sclerotic bone metastases. We describe a patient with superior vena cava (SVC) obstruction who had retrograde filling of the thoracic and vertebral venous collateral systems, which caused enhancement of the thoracic vertebrae and was mistaken for metastatic infiltration.Several other venous collateral imaging patterns have been reported in patients with SVC obstruction, but we are not aware of any previous description of the above phenomenon, which we believe to be of general interest to radiologists. Case reportA 60-year-old male smoker presented with weight loss and clinical features suggestive of SVC obstruction. A chest radiograph showed a superior mediastinal mass and a contrast enhanced CT (CECT) of the chest and abdomen was performed using the following parameters: 64 slice Lightspeed VCT (GE Medical Systems, Milwaukee, WI), 0.625 mm source image thickness, 100 ml iodinated contrast (Ultravist 300, Schering, Berlin, Germany), via iv cannula in left antecubital fossa injected by pump at 3 ml s 21 with a 26 s delay. CT confirmed a large anterior mediastinal mass. This occluded the left brachiocephalic vein and the SVC, proximal to the azygocaval junction. Contrast filled an extensive collateral circulation involving the mediastinum, left chest wall and vertebral venous plexus, passing into the distal SVC via the azygos vein.High attenuation was observed within the vertebral bodies and left posterior elements of several upper thoracic vertebrae. This was ascribed to metastatic disease (Figure 1a,b).Following biopsy diagnosis of squamous cell carcinoma, a CT positron emission tomography (PET) staging study was performed. The non-contrast enhanced CT study showed that the upper thoracic vertebrae were normal (Figure 2). On re-examination of the initial CECT, it was noted that much of the vertebral abnormality was centred around the opacified basivertebral and the anterior vertebral body veins and it was realised that retrograde opacification of the capillary spaces within the vertebrae had been mistaken for sclerotic metastatic disease (Figure 3). DiscussionSVC obstruction is due to malignancy in 80% of cases, but is also a recognised complication of iatrogenic or noniatrogenic trauma and fibrosing mediastinitis owing to granulomatous infection, autoimmune disease or drugs [1].When SVC obstruction develops, blood is diverted via venous collaterals. Four classic collateral pathways involving the azygos and hemiazygos, internal mammary and lateral thoracic, superficial thoraco-abdominal and vertebral venous plexuses have been described and proven by venography [2][3][4]. In practice, several collateral pathways may be involved together and the specific pattern in a given patient will depend on the cause, exact location and duration of venous obstruction, along with individual variations ...

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“…In a SVC syndrome, this finding has been reported to have a sensitivity and specificity on CT of 96% and 92%, respectively [17]. The azygous and hemiazygous venous systems become brightly opacified and develop retrograde flow towards the inferior vena when the SVC is obstructed below the azygous arch which corresponds to the area of anastomosis of the SLSVB [15,16,18]. Furthermore, a chronic occlusion of the SLSVB would manifest like a chronic central vein occlusion with an enlarged, welldeveloped bypassing azygous system [15,19].…”

Section: Cardiac Imagingmentioning

confidence: 97%

“…These findings can be equally appreciated on venography and cardiac MRI [15]. An important finding of a significant SVC syndrome, and therefore SVC obstruction, is the presence of dilated tortuous azygous and hemiazygous systems [16][17][18]. In a SVC syndrome, this finding has been reported to have a sensitivity and specificity on CT of 96% and 92%, respectively [17].…”

Section: Cardiac Imagingmentioning

confidence: 98%