Presentation
Non specific cough
Patient Data
Note the opacified left superior intercostal vein (LSICV) which causes the aortic nipple appearance seen on chest X-rays.
The LSICV drains into the accessory hemiazygos vein on the left which in turn drains into the azygous system after crossing the midline.
Case Discussion
Opacification and more importantly dilation of azygous and accessory systems usually indicates venous obstruction, but in this case there was none.
Occasionally, if the contrast density in the left superior intercostal vein is similar to the aorta, its curvilinear course near the arch can mimic a dissection flap, or "pseudo dissection".