Medical Imaging Analysis Report

I. Imaging Findings

Based on the provided enhanced chest CT images, the following observations are noted:

1. In the superior mediastinum, post-surgical changes are observed, possibly with localized fibrosis, suggesting deformation of mediastinal structures due to previous surgery or an inflammatory process.
2. The right brachiocephalic vein (innominate vein) appears compressed, and there is significant collateral formation, including enlargement of the paravertebral venous plexus.
3. An enhanced signal is visible at the posterior sections of the vertebral bodies (the basivertebral vein channel located centrally in the posterior part of the vertebral body), consistent with basivertebral vein enlargement. On non-contrast CT, dilation of the basivertebral channel can sometimes be observed.
4. No obvious signs of an invasive or lytic destructive lesion are identified, and the enhancement pattern aligns with the venous pathway.
5. No new mass lesions are clearly observed in either lung fields or chest wall soft tissues. Direct signs of mediastinitis are not apparent, but fibrotic remnants are evident.

II. Potential Diagnoses

Considering the clinical history (previous chest surgery/infection, possibly resulting in mediastinal fibrosis and compression of the brachiocephalic vein) and the imaging findings, the following diagnoses or differential diagnoses should be considered:

1. Vertebral Basivertebral Vein Enlargement: Compression of the SVC or right brachiocephalic vein may lead to recurrent high pressure and significant dilation of the paravertebral venous plexus and basivertebral veins. On enhanced CT, these may appear as “bright areas” easily mistaken for metastatic lesions within the vertebral body.
2. Bone Metastases: In patients with a malignancy history, local vertebral enhancement may raise the suspicion of metastatic lesions. However, in this case, typical destructive changes or abnormal signals are absent, and no distinct lesion is seen on non-contrast scans, which does not match common metastatic patterns.
3. Other Benign Hemangiomas or Vascular Malformations: Vertebral hemangiomas are common benign vertebral lesions, generally showing “vertical striations” or a “reticulated” pattern on routine CT. This case lacks those typical features and appears to have some connection to venous channels, which is suggestive of a venous plexus enlargement due to elevated venous pressure.

III. Most Likely Final Diagnosis

Based on the patient’s clinical history (past surgical mediastinal infection/fibrosis and prior chest surgery) and current imaging (compression of the brachiocephalic vein and notable enlargement of the basivertebral vein in the vertebral bodies), the most likely diagnosis is:

“Benign vascular changes (basivertebral vein enlargement) due to brachiocephalic vein compression caused by mediastinal fibrosis, resulting in collateral formation in the paravertebral venous plexus.”

IV. Treatment Plan and Rehabilitation

1. Treatment Strategy:
   • Conservative Observation: If the patient presents with no obvious symptoms or only mild discomfort, and maintains stable hemodynamics, dynamic observation with regular imaging follow-ups is recommended.
   • Medication and Supportive Care: Once confirmed that venous outflow obstruction is causing venous distension, anticoagulants may be considered (particularly if a thrombotic risk exists). Collaboration with cardiology or pulmonology may be required if there is concomitant cardiac or pulmonary dysfunction or any indication of pulmonary hypertension.
   • Intervention/Surgery: If severe compression of the SVC or brachiocephalic vein leads to marked clinical symptoms (e.g., facial swelling, arm swelling, obstructed venous return), an evaluation for vascular reconstruction, stenting, or decompressive surgery could be considered. However, if changes are asymptomatic or mildly symptomatic, invasive interventions may not be immediately necessary.
2. Rehabilitation and Exercise Prescription:

   For a 72-year-old patient, a gradual approach is recommended, focusing on safety and maintaining basic cardiopulmonary function:

   • Exercise Options: Low-impact exercises (e.g., walking, stationary cycling, simple Tai Chi, or water aerobics) to decrease excessive stress on the chest and spine.
   • Initial Frequency and Intensity: Start with 3–4 sessions per week, each lasting 15–20 minutes at moderate to low intensity (RPE < 11–12).
   • Progressive Approach: Depending on the patient’s tolerance, extend the duration to 30 minutes over 2–4 weeks. As tolerated, intensity or frequency (4–5 times per week) can be increased, but monitor heart rate, blood pressure, and perceived exertion levels.
   • Special Precautions: If chest discomfort, severe shortness of breath, or noticeable neck or facial swelling occurs, cease exercise immediately and seek medical advice.
   • Strength and Flexibility: Use simple resistance bands or light dumbbells to strengthen the back and scapular muscles, promoting spinal stability. Movements should be gentle to avoid excessive chest strain. Include stretching exercises after each session to maintain muscle flexibility.

Disclaimer: This report is based on limited available information and is provided for medical reference only. It should not substitute for in-person consultation or individualized advice from a qualified physician. If you have any questions or if your condition changes, please seek medical attention promptly.