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Gas in the Left Atrium and Ventricle: The CT Diagnosis of a Catastrophic Atrioesophageal Fistula After Atrial Fibrillation Ablation

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  Clinical Hook A 60-year-old man with coronary artery disease, ischemic cardiomyopathy, an implanted cardioverter-defibrillator, and atrial fibrillation presented with chest pain and bilateral arm numbness. During his initial presentation, he suddenly collapsed and lost consciousness. CT angiography of the chest, abdomen, and pelvis was obtained because acute aortic dissection was an important clinical consideration. The striking finding was not aortic dissection. There was gas within the left-sided cardiac chambers . At first glance, intracardiac gas can be interpreted as an iatrogenic phenomenon, particularly in a patient with previous vascular instrumentation. But in this case, the distribution of gas was the diagnostic clue. Careful review demonstrated gas in the left atrium and a communication between the left atrium and the adjacent esophagus. His family subsequently reported that he had undergone radiofrequency ablation for atrial fibrillation approximately six weeks earlie...
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Bilateral Adrenal Hemorrhage on CT: Imaging Diagnosis, Adrenal Insufficiency, and Emergency Management

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1. Clinical Hook A 39-year-old woman presented with acute generalized abdominal pain and vomiting. Her previous history included abdominal hernia surgery and a prior episode of intestinal obstruction, making an intra-abdominal surgical or gastrointestinal process an understandable initial consideration. The CT examination, however, revealed something considerably more consequential: both adrenal glands were enlarged and heterogeneous, with abnormal changes in the surrounding fat . That observation changes the clinical question. The important question is no longer simply: What is causing this patient's abdominal pain? It becomes: Could bilateral adrenal injury be causing or contributing to acute adrenal insufficiency? This distinction matters because unilateral adrenal hemorrhage is often clinically silent or self-limited, whereas extensive bilateral adrenal injury can destroy sufficient cortical tissue to produce primary adrenal insufficiency and, in severe cases, adrenal crisis. T...
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