CTICasesSpontaneous Pneumothorax with Contralateral Pulmonary Vein Compression
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Imaging findings
Chest radiograph and CT show a massive right-sided pneumothorax causing severe lung atelectasis and mediastinal shift, with giant subpleural apical bullae in both lungs. Prior to chest tube placement, there are ill-defined, confluent opacities in the contralateral left upper lobe. After chest tube placement, the right lung re-expands but shows extensive ipsilateral re-expansion pulmonary edema, while the left lung opacities persist. CT also shows subcutaneous emphysema, pneumomediastinum, extrapleural air, and air tracking into the spinal canal (pneumorrhachis).
Key takeaways
Spontaneous pneumothorax typically occurs due to the rupture of apical subpleural bullae or blebs. In cases of tension pneumothorax with severe mediastinal shift, mechanical compression or rotation of the contralateral pulmonary veins can lead to venous congestion and edema in the contralateral lung prior to decompression. Following chest tube insertion, rapid lung re-expansion can trigger ipsilateral re-expansion pulmonary edema. Additionally, air can dissect from the pleural space into the extrapleural space, chest wall, mediastinum, and even the spinal canal (pneumorrhachis).
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