55 yo male with 6 mo progressive shortness of breath. Quit smoking 13 mo ago.120 pack years.
The frontal projection demonstrates relics of previous pulmonary
disease including plate-like atelectasis in the right upper and lower lung
zones, and also in the left lower lung zones. There is a superimposed
density on the right side which does not appear to represent the right diaphragm since
this margin is visualized. The right hemidiaphragmatic mass is noted
posteriorly, but not seen anteriorly, suggesting that the density noted
anteriorly on the lateral projection and also overlying the right
hemidiaphragmatic margin on the frontal projection probably represents
anterior eventration of the right hemidiaphragm.
1. THERE IS THE SUGGESTION OF ANTERIOR EVENTRATION OF THE RIGHT HEMIDIAPHRAGM.
MRI: Sagittal gradient echo T2-weighted images, demonstrate fatty mass adjacent to the heart with direct connection to the abdominal omentum.
CT: Axial imaging demonstrates a fatty mass adjacent to the right border with multiple linear densities consistent with vessels.
Cardiophrenic Angle Masses
Epicardial lymph nodes
Foramen of Morgagni hernias are herniations of abdominal contents through the anterior medial diaphragmatic foramen of Morgagni. This is herniation through the sternalcostal trigone due to failed fusion of the sternal and costal fibrotendinous elements of the diaphragm. This typically results in a Cardiophrenic angle mass most commonly seen on the right side. These herniations most commonly contain omentum but may also contain liver or colon. When they contain only omentum they'll have the appearance of lipoma on CT and omental vessels will be visible within the fat. These asymptomatic hernias are associated with obesity and are covered by both peritoneum and parietal pleura.
Congenital diaphragmatic hernias (CDH) include hiatal, posterolateral (Bochdalek), and anteromedial (Morgagni) varieties. The Morgagni hernia is the rarest form of CDH, accounting for only 2-3%. Yet it is the most common cardiophrenic angle mass in children (1). The defect arises during embryogenesis between the third to the seventh week of development during the formation of the septum transversum, the structure that normally divides the the pleural and peritoneal cavities (1). CDH is commonly associated with other congenital anomalies.
With CDH there is the risk of pulmonary hypoplasia due to restriction of lung development by the encroachment of abdominal organs into the thorax. In pulmonary hypoplasia, there is a decrease in the number of alveoli and also a reduction in the number of airway generations. Pulmonary hypoplasia is almost always secondary to another congenital abnormality such as CDH or renal agenesis. There is no specific treatment for hypoplasia, only supportive measures such as mechanical ventilation and supplemental oxygen. Surgical correction of the anatomical defect in CDH is undertaken to improve ventilation. Outcomes can vary widely and are mostly dependent upon the degree of lung hypoplasia. Morgagni hernias are typically asymptomatic and are usually found incidentally on routine chest radiographs (2).
With respect to Morgagni hernias specifically, they can be surgically repaired using either the abdominal or transthoracic approach. The abdominal approach is used in cases where the diagnosis has been made preoperatively, thus eliminating the need for exploratory thoracotomy. Traditionally, these hernias have been repaired by laparotomy. However, with advances in endoscopic surgery, repairs may be performed laparoscopically or by video-assisted thoracic surgery (VATS) (2).
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