Search
CTisus CT Scanning CTisus CT Scanning CTisus CT Scanning CTisus CT Scanning CTisus CT Scanning CTisus CT Scanning CTisus CT Scanning Ask the Fish

Everything you need to know about Computed Tomography (CT) & CT Scanning

Vascular: Vasculitis Imaging Pearls - Educational Tools | CT Scanning | CT Imaging | CT Scan Protocols - CTisus
Imaging Pearls ❯ Vascular ❯ Vasculitis

-- OR --

  • "Kawasaki’s disease (KD) is a vasculitis that predominantly affects children and can lead to the development of coronary artery aneurysms. These aneurysms can subsequently thrombose and occlude, which may lead to chest pain and other signs and symptoms of acute coronary syndrome in young patients. Coronary CT angiography, including 3D visualization techniques, is a common modality used in the follow-up of KD patients."
    Evaluation of Kawasaki’s disease-associated coronary artery aneurysms with 3D CT cinematic rendering
    Rowe SP, Zimmerman SL, Johnson PT, Fishman EK
    Emergency Radiology (2018) 25:449–453
  • "The most important potential complication of KD is inflammatory damage to the coronary arteries, which classically leads to the formation of coronary artery aneurysms. These aneurysms will often undergo vascular remodeling and partial
    thrombosis in order to produce a psuedonormal vascular lumen. However, progressive thrombosis and other stenotic processes such as fibrosis can, over time, precipitate cardiac ischemia that can lead to emergency room presentations for chest pain or other signs of acute coronary syndrome and necessitate invasive and/or surgical interventions."
    Evaluation of Kawasaki’s disease-associated coronary artery aneurysms with 3D CT cinematic rendering
    Rowe SP, Zimmerman SL, Johnson PT, Fishman EK
    Emergency Radiology (2018) 25:449–453
  • CR differs from traditional VR in making use of a global lighting model that more realistically takes into account the interactions of propagating photons with the component materials of the imaged volume. As a result, this method enhances surface detail and creates lifelike shadowing effects in order to generate truly photorealistic visualizations from standard CT acquisition volumetric data."
    Evaluation of Kawasaki’s disease-associated coronary artery aneurysms with 3D CT cinematic rendering
    Rowe SP, Zimmerman SL, Johnson PT, Fishman EK
    Emergency Radiology (2018) 25:449–453
  • " While the advantages of this new technique are still under investigation, potential applications include improved visualization of complex anatomic structures that obviates the need for expensive 3D printing, better display of soft tissue texture that may improve detection and characterization of subtle lesions, improved pre-operative planning, and better trainee and patient engagement."
    Evaluation of Kawasaki’s disease-associated coronary artery aneurysms with 3D CT cinematic rendering
    Rowe SP, Zimmerman SL, Johnson PT, Fishman EK
    Emergency Radiology (2018) 25:449–453
  • In this case series, we have demonstrated the ability of CR visualizations to effectively convey key anatomic information related to coronary artery aneurysms in patients with history of KD. While the role of imaging in following patients with KD has been previously investigated, this is the first reported experience with the novel CR visualization methodology, and these examples demonstrate the potential of this technique for evaluating such complex vascular pathologic states.
    Evaluation of Kawasaki’s disease-associated coronary artery aneurysms with 3D CT cinematic rendering
    Rowe SP, Zimmerman SL, Johnson PT, Fishman EK
    Emergency Radiology (2018) 25:449–453
  • "As with other 3D visualization methods, CR would be expected to provide a global overview of the disease process that is not easily appreciated on 2D axial or multi-planar reformatted images. In particular, this may help to identify relatively distal, small caliber sites of aneurysmal enlargement, which stand out with high contrast on the 3D images but can be subtle when only 2D images are viewed."
    Evaluation of Kawasaki’s disease-associated coronary artery aneurysms with 3D CT cinematic rendering
    Rowe SP, Zimmerman SL, Johnson PT, Fishman EK
    Emergency Radiology (2018) 25:449–453
  • “Vasculitis represents a range of different diseases that result in inflammation and necrosis of the blood vessels, with different types of vasculitis showing involvement of different types of vasculature. In the past, vasculitis has been divided into 3 categories depending on the caliber of vessels involved: large vessel vasculitis, which involves the aorta and its major branches (eg, Takayasu arteritis, giant cell arteritis); medium vessel arteritis (eg, polyarteritis nodosa [PAN], Kawasaki disease); and small vessel vasculitis (eg, lupus vasculitis, Henoch-Schönlein purpura [HSP], Wegner granulomatosis, Behcet disease).”


    Computed Tomography Angiography of the Small Bowel and Mesentery 
Raman SP, Fishman EK
Radiol Clin N Am 54 (2016) 87–100
  • “Although most visceral artery dissections merely reflect the extension of an aortic dissection into a branch vessel, isolated visceral artery dissections are still thought to be rare (despite their increasing diagnosis), and almost always reflect an underlying intrinsic weakness of the vessel wall caused by such entities as fibromuscular dysplasia (FMD), cystic medial necrosis, collagen vascular disease, vasculitis, Marfan, or Ehlers-Danlos. The most commonly involved vessel is the SMA, although any visceral artery can theoretically be involved. In most cases, isolated visceral artery dissections occur close to the vessel ostium, possibly as a result of shear stresses to the vessels in this location.”


    Computed Tomography Angiography of the Small Bowel and Mesentery 
Raman SP, Fishman EK
Radiol Clin N Am 54 (2016) 87–100
  • “Classically diagnosed in elderly patients who have abdominal pain after meals with signs of anorexia and chronic weight loss, chronic mesenteric ischemia is much less common than acute mesenteric ischemia.Most cases are attributable to atherosclerotic narrowing of the origin of the major mesenteric arteries, and symptoms typically result only in patients who have a significant stenosis in at least 2 of the 3 major mesenteric arteries (celiac, SMA, and IMA). However, given that atherosclerotic disease is widespread in the elderly population, the diagnosis of this entity requires not only correlation with appropriate clinical symptoms but also visualization of collateral pathways (eg, celiac-SMA collaterals via the pancreaticoduodenal arcade and SMA-IMA collaterals via the arc of Riolan and marginal artery of Drummond). Although these collateral pathways can compensate for significant stenoses over long periods of time, symptoms usually develop when blood flow via these collaterals is no longer sufficient to supply the bowel.”


    Computed Tomography Angiography of the Small Bowel and Mesentery 
Raman SP, Fishman EK
Radiol Clin N Am 54 (2016) 87–100
  • “Classically diagnosed in elderly patients who have abdominal pain after meals with signs of anorexia and chronic weight loss, chronic mesenteric ischemia is much less common than acute mesenteric ischemia.Most cases are attributable to atherosclerotic narrowing of the origin of the major mesenteric arteries, and symptoms typically result only in patients who have a significant stenosis in at least 2 of the 3 major mesenteric arteries (celiac, SMA, and IMA).”


    Computed Tomography Angiography of the Small Bowel and Mesentery 
Raman SP, Fishman EK
Radiol Clin N Am 54 (2016) 87–100
  • Vasculitis of the Abdominal Aorta: Facts
    • Giant cell arteritis (GCA) and Takayasu arteritis (TA) are the most common large vessel vasculitides to have imaging findings on CTA. Both are systemic large vessel granulomatous inflammatory processes.
    • Both diseases are idiopathic inflammatory disorders with various postulated environmental, autoimmune, and genetic causes.
    • GCA typically affects older individuals of northern European heritage, whereas TA is classically associated with younger females of Asian heritage.
    • Clinical manifestations of disease include abnormal or absent pulses as well as symptoms related to occlusion or narrowing of large vessels (eg, mesenteric ischemic symptoms if the splanchnic vasculature is involved or renal failure if the renal arteries are involved).

    Computed Tomographic Angiography of the Abdominal Aorta Hansen NJ Radiol Clin N Am 54 (2016) 35–54
  • Vasculitis of the Abdominal Aorta: Facts
    • Giant cell arteritis (GCA) and Takayasu arteritis (TA) are the most common large vessel vasculitides to have imaging findings on CTA. Both are systemic large vessel granulomatous inflammatory processes.
    • Both diseases are idiopathic inflammatory disorders with various postulated environmental, autoimmune, and genetic causes.

    Computed Tomographic Angiography of the Abdominal Aorta Hansen NJ Radiol Clin N Am 54 (2016) 35–54
  • Vasculitis of the Abdominal Aorta: Facts
    • GCA typically affects older individuals of northern European heritage, whereas TA is classically associated with younger females of Asian heritage.
    • Clinical manifestations of disease include abnormal or absent pulses as well as symptoms related to occlusion or narrowing of large vessels (eg, mesenteric ischemic symptoms if the splanchnic vasculature is involved or renal failure if the renal arteries are involved).

    Computed Tomographic Angiography of the Abdominal Aorta Hansen NJ Radiol Clin N Am 54 (2016) 35–54
  • “Lower extremity CTA is performed for a number of clinical indications, including peripheral artery disease, trauma, assessment of variant anatomy and congenital malformations, vasculitis, and surgical planning.”


    Computed Tomography Angiography of the Lower Extremities 
Cook TS
Radiol Clin N Am 54 (2016) 115–130
  • “Acute thromboembolic disease may occur as a result of embolism originating in the heart or in a more proximal diseased segment of vessel, or thrombosis of a vessel, bypass graft, or lower extremity aneurysm. Patients present with symptoms of acute limb ischemia that can progress over hours to days, and include pain, paresthesias, pallor, pulselessness, and paralysis.The goal of treatment is reperfusion of the affected limb, which is usually achieved with a combination of anticoagulation and either surgery or endovascular intervention; in rare cases, anticoagulation alone is used.”


    Computed Tomography Angiography of the Lower Extremities 
Cook TS
Radiol Clin N Am 54 (2016) 115–130
  • CT Angiography of the Upper Extremities: Applications
    - Atherocsclerotic disease
    - Thromboembolic disease
    - Aortic dissection
    - Vasculitis
    - Small artery vasculitis
    - Fibromuscular dysplasia
    - Extrinsic compression syndrome
    - Connective tissue disorders
    - Preprocedural planning and postprocedural evaluation
  • “ Takayasu arteritis, giant cell arteritis and thromboangitis obliterans (Buerger disease) are the most common types of vasculitides that affect upper extremity vessels.”
    CT Angiography of the Upper Extremity Arterial System: Part 2-Clinical Applications Beyond Trauma Patients
    Bozlar U et al.
    AJR 2013; 201:753-763
  • “Segmental arterial mediolysis (SAM) is a rare vasculopathy of unknown etiology characterized by disruptioSegmental arterial mediolysis (SAM) is a rare vasculopathy of unknown etiology characterized by disruption of the arterial medial layer, with resultant susceptibility to vessel dissection, hemorrhage, and ischemia. n of the arterial medial layer, with resultant susceptibility to vessel dissection, hemorrhage, and ischemia.”
    Clinical diagnosis of segmental arterial mediolysis: Differentiation from vasculitis and other mimics
    Baker-LePain JC et al
    Arthritis Care Res 2010, 62: 1655–1660. 
  • “ Although the abdominal visceral arteries are most frequently affected in SAM , any vessel may be involved, including the retroperitoneal , intracranial , and coronary arteries. The histopathologic changes begin with vacuolar degeneration of smooth muscle cells in the arterial media, followed by fibrin deposition at the medial–adventitial junction . This in turn predisposes to dissecting aneurysms.”
    Clinical diagnosis of segmental arterial mediolysis: Differentiation from vasculitis and other mimics
    Baker-LePain JC et al
    Arthritis Care Res 2010, 62: 1655–1660. 
  • “ The angiographic appearance of SAM is variable, ranging from arterial dilation to aneurysm formation (single or multiple) to stenoses or occlusion, frequently with dissection . Correspondingly, symptoms arise both from stenoses and occlusions (e.g., postprandial pain from intestinal ischemia) and from dissections and aneurysms (e.g., sudden and catastrophic intraperitoneal bleeding).”
    Clinical diagnosis of segmental arterial mediolysis: Differentiation from vasculitis and other mimics
    Baker-LePain JC et al
    Arthritis Care Res 2010, 62: 1655–1660. 
  • “The differential diagnosis of SAM includes atherosclerosis, fibromuscular dysplasia (FMD), infection (e.g., mycotic aneurysm and endocarditis), connective tissue diseases (e.g., Behçet's disease and polyarteritis nodosa [PAN]), neurofibromatosis, and inherited defects in vessel wall structural proteins (e.g., type IV Ehlers-Danlos syndrome and Marfan's syndrome). ”
    Clinical diagnosis of segmental arterial mediolysis: Differentiation from vasculitis and other mimics
    Baker-LePain JC et al
    Arthritis Care Res 2010, 62: 1655–1660. 
  • “In summary, SAM is a rare but important cause of unexplained vascular lesions in patients in whom other inflammatory, infectious, or heritable diseases have been ruled out. The diagnosis should be considered when a patient presents with unexplained acute-onset abdominal pain with or without intraabdominal bleeding. SAM should also be kept in mind when aneurysms, stenoses, and occlusions are identified in medium-sized and large vessels, especially when these lesions are limited to a single anatomic location.”
    Clinical diagnosis of segmental arterial mediolysis: Differentiation from vasculitis and other mimics
    Baker-LePain JC et al
    Arthritis Care Res 2010, 62: 1655–1660. 
  • “ The discrimination of SAM from systemic inflammatory vasculitides is particularly important, since corticosteroids and immunosuppressive agents, which are crucial in the treatment of the inflammatory vasculitides, have no proven benefit in SAM. Without any evidence of an inflammatory etiology, the use of immunosuppressive regimens in SAM exposes the patient to undue risks, including infection and poor wound healing, and could possibly worsen the prognosis. Treatment of SAM involves embolization, surgical bypass, or resection of the injured arteries.”
    Clinical diagnosis of segmental arterial mediolysis: Differentiation from vasculitis and other mimics
    Baker-LePain JC et al
    Arthritis Care Res 2010, 62: 1655–1660.
  • Differential Diagnosis
    - SLE
    - Churg Strauss Syndrome
    - Vasculitis from drug abuse
    - Microscopic polyangitis
  • CTA Findings in PAN
    - Multiple aneurysms of varying sizes
    - Smooth narrowing of vessels; stenosis and occlusions of larger vessels
    - Thickening of wall of medium sized vessels
    - Aneurysms may be associated with hemorrhage
    - Bowel wall thickening often with associated strictures or perforation
  • Polyarteritis Nodosa: Facts
    - Most common in 5th-7th decade of life
    - More common in males (2-1)
    - Survival at 5 yrs less than 15% in fulminant disease
    - 50% of patients with abdominal involvement develop acute surgical abdomen with mortality of 12.5%
  • Polyarteritis Nodosa: Clinical Presentation
    Subacute presentation with weight loss, FUO, malaise
    Acute presentation could include;

    - Renal insufficiency or hemorrhage
    - Abdominal pain including ischemia, infarction, or perforation
    - Palpable purpura or ulcerations
  • Polyarteritis Nodosa (PAN): Facts
    - Systemic vasculitis causing necrotizing inflammation of small and medium sized vessels, resulting in microaneurysms, occlusions and strictures
    - Kidney is most commonly involved (70-80% of cases)
    - GI tract involved in up to 50% of cases
    - Muscle, skin and CNS are often involved
  • Secondary Vasculitides
    - Sarcoidosis
    - Retroperitoneal fibrosis
    - Inflammatory aneurysm
  • Thromboangitis obliterans: Facts
    - Usually involves young males
    - Strong association with smoking
    - Usually involves the extremities
    - Can lead to superficial thrombophlebitis, raynauds phenomenon, and gangrene
  • Behcets disease: facts
    - Chronic inflammatory vascular disease characterized by recurrent oral and genital aphthous ulcers
    - Arteries of all sizes can be involved and lead to dissection, aneurysm or thrombosis
    - Large vessels involved in up to 25% of cases
  • Small Vessel Vasculitis
    - Wegeners granulomatosis
    - Churg-Strauss syndrome
    - Behcets disease
    - Thromboangitis obliterans
    - Cerebral vasculitis
  • Small Vessel Vasculitis
    - Wegeners granulomatosis
    - Churg-Strauss syndrome
    - both are ANCA associated small vessel vasculities (ANCA-antineutrophilic cytoplasmic antibody)
  • Kawasaki’s Disease: Facts
    - Patients usually younger than age 5 years
    - Involves medium sized vessels
    - Key area of involvement is the coronary arteries where up to 25% of patients may develop aneurysms
  • Medium Sized Vessels
    - Kawasaki’s disease
  • Takayasu’s Arteritis: Facts
    - Usually involves aorta and its main branches
    - Usually in woman
    - More common in Asia
    - May also involve pulmonary arteries and coronary arteries
    - Stenosis often occurs proximately and skip lesions do occur
  • Giant Cell Arteritis: Facts
    - Immune mediated disease characterized by granulomatous infiltration of medium and large arteries
    - Most common presentation Is headache
    - More common in woman usually in the 50’s
    - Vessel wall thickening of 1.5 mm or greater and usually symmetric
  • Large Vessel Vasculitides
    - Giant Cell Arteritis
    - Takayasu’s Arteritis
  • "Large and medium sized vessels are affected by many primary and secondary inflammatory disorders or mimicking conditions, often preventing similar imaging characteristics. Knowledge of distinctive imaging features such as location, length, and degree of vessel wall enhancement as well as the particular clinical settings will help the clinician in appropriately narrowing down the differential diagnosis." Imaging of Primary and Secondary Inflammatory Disease Involving Large and Medium Sized Vessels and Their Potential mimics: A Multitechnique Approach
    Spira D et al.
    AJR 2010;194:848-858
© 1999-2018 Elliot K. Fishman, MD, FACR. All rights reserved.