Age / Sex : 62 / F

Chief complaint: Acute chest pain

What is your impression? (Diagnosis and etiology)

Two weeks later, you can see the final diagnosis with a brief discussion of this case.

(Please submit only one answer)

Pulmonary embolism after vertebroplasty

Discussion

Findings:

1)     Chest PA-1

-       There was no remarkable finding in the lung before the procedure. However after the procedure, High density linear streaky lesion is opacified in right upper lung field (white arrowed)

2)     Chest CT-1

-       Chest CT also revealed high density materials in RUL subsegmental pulmonary artery.

1)     MR-1

-       T1, T2 and T1 contrast enhancement study showed acute benign compression fracture at superior endplate of L2 vertebral body.

2)     L-spine AP & Lat

-       She underwent percutaneous vertebroplasty at outside hospital. On the L-spine AP and Lateral view, there is tubular high density structure at right anterior aspect of vertebral body (white arrowed) from L2, suggesting cement leakage causing cement embolism in the right lung. On the MR images, there was fracture line at superior aspect of L2 vertebral body. However, cement insertion was done at body to lower aspect, suggesting improper needle placement during the procedure.

Discussion:

 [Pulmonary cement embolism]

•        Definition: Leakage of Polymethyl methacrylate(PMMA) cement into perivertebral veins

•       Incidence: 4.6-26%

•       Etiology

–      Improper needle placement

–      Inadequate intraprocedural monitoring of cement injection

–      Low viscosity cement

–      Too large volume of cement injected

–      Underlying neoplasm with deficient vertebral cortex

•       Symptoms: asymptomatic (m/c), dyspnea/tachypnea, tachycardia, cyanosis, chest pain, coughing, hemoptysis, pulmonary infarction, cardiac arrest

•       Image findings: the appearance of high-density opacities in a tubular branching pattern corresponding to pulmonary arterial distribution is suggestive

–      Plain image

•       Multiple high-density opacities with a tubular and branching shape

•       FB in cardiac chambers or scattered throughout the lungs

–      CT

•       Multiple high-density opacities with a tubular and branching shape

•       Extruded cement within perivertebral veins, cardiac chanbers or pulmonary arteries

•       Better detected on noncontrast or portal venous phased study

•       Treatment: anticoagulation, surgery

References:

Diagnostic imaging : spine, 2^nd edition ; pp.VII-1 (22-25).

Radiology 2009;251:250–259

Eur Spine J (2009) 18:1257–1265