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A Time-Bomb Twirl

Nafisah Idris, Mohd Boniami Yazid, Mohammad Zikri Ahmad, Mohd Hashairi Fauzi, Shaik Farid Abdull Wahab, Woon Wee Chong, Khai Yen Lim

AIM

To demonstrate the use of bedside ultrasound to identify potentially dangerous vascular malformations as important differentials for hypoechoic lesions.

METHODS

A 70 year old moderately obese man was diagnosed with acute pulmonary oedema secondary to hypertensive emergency in Emergency Department.

Patient appeared congested with biventricular heart failure, confirmed by bedside cardiac and lung ultrasounds. During ultrasonography of the L4 region, an incidental finding of a hypoechoic lesion 6x7cm at the left upper quadrant, overshadowing the spleen and anterior to kidney, with acoustic enhancement.

There was a swirling movement within the lesion that intrigued further details.

DISCUSSION

Echocardiographic evaluation plays an important role in the hemodynamic insufficiency.

Especially in patients with TAVI, it is necessary to distinguish between the cardiac tamponade caused by the rupture of aortic root and Suicidal Left Ventricle; a pathological condition due to an afterload decreasing.

In this case, it was difficult to distinguish that because it developed slowly. According to the ICU-bedside TTE and the CAG findings, finally, we could make the diagnosis and preferable patient management.

RESULTS

Further scan with pulse wave Doppler detected continuous in-and-out flow within the lesion, in consistent with feeding arteries and draining veins respectively.

This continuous in-and-out flow formed such swirling movement in its center, making it to look distinctively different with a simple hypoechoic collection.

This finding is suggestive of vascular malformations like aneurysm or arteriovenous malformation (AVM). A CT scan was planned in our patient to confirm the diagnosis, however, patient succumb to death after few days being warded before CT scan was performed.

The cause of death was attributed to his severe pulmonary oedema.

In this case, patient’s worsening condition could be multifactorial i.e., not only biventricular heart failure, but another possibility was leaking from the huge vascular-like lesion. This is unknown as no post mortem was done.

Any suspected vascular malformation detected from ultrasonography warrant further detailed imaging as it may progress from stable, contained and asymptomatic form to symptomatic stages i.e leakage.

If it were to be an AVM, its location within intraabdominal cavity, which is not the usual site of AVM, may allow it to be expansible without a significant compression effect.

CONCLUSIONS

A hypoechoic collection in a well-defined structure need to be further elucidated to see the nature of the lesion.

Catching any vascular malformation at its early stage is important for close follow up, keeping in mind of its possible progression to become more expansive and later destructive stages. *No potential conflict of interest was reported by the authors

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