RADIOLOGICAL APPROACH TO

TAKAYASU ARTERITIS

Dr. Muhammad Bin ZulfiqarPGR IV SIMS / SHL

PATIENT:Sabeen a 20 year old unmarried female

resident of jallo mor Lahore. Presented with: Joint pains► 3 weeks Shortness of breath► 5 days Palpitations► 01 day

Past H/O weakness of right side of body 1 year back.

PULSES ON RIGHT SIDE (ARTRIES): Carotid Brachial all palpable with Radial normal Rate, Femoral Rhythm and

Posterior tibial Volume.

Dorsalis pedis

PULSES CONT. ON LEFT SIDE (ARTRIES):

Carotid all these NOT Brachial palpable Radial Dorsalis Pedis

Femoral palpable with good Posterior tibial volume

Left PulsesRight pulses

BLOOD PRESSURE Upper limb:

right side: 130/90 mmHg left side : NOT recordable

Lower limb:

right side: 140/90 mmHg left side : 140/90 mmHg

CLINICAL INTERPRETATION After detailed history and examination it

is evident that we are dealing with a case of VASCULITIS based on following features

Constitutional features likeFeverWeight lossJoint pains

Asymmetrical peripheral pulses

Radiological Modalities:

Conventional: Radiograph chest. Abdominal ultrasound.Specific: Color Doppler ultrasound Ct Angiography MRI MRA Conventional Angiography

Abdominal ultrasound : Shows a difference in the sizes of both kidneys. Right kidney is smaller as compared to left kidney

with impaired CMD .For which doppler ultrasound was done.

Rest of the abdominal scan is unremarkable.

Doppler Imaging

Renal Artery Color Doppler :

Right kidney is smaller as compared to left and shows high resistive flow with reversal of diastolic flow.

Right kidney shows high resistant flow with RI=0.89 (normal value is less than 0.7) Left kidney shows high resistant flow with RI=0.80 (normal value is less than 0.7).

Renal Artery Color Doppler :

Carotid Doppler

Gray scale Doppler image shows intimomedial thickening of right n left CCA measures 1.5mm (normal value 0.8-0.9 mm) .

Carotid doppler of R-ICA shows normal flow and velocities with biphasic spectral pattern.

CT brain with I/V contrast shows a hypodense leison in left high parietal region suggestive of infarct.

CT ANGIOGRAPHY

Raw Data CT Angio axial images reveal diffuse smooth mural thickening of right brachiocephalic trunk, Left CCA, Left subclavian artery and aortic arch with subtle mural enhancement.

Right Side Negative Axial image shows smooth diffuse thickening of Ascending and descending thoracic aorta.

On left side smooth diffuse thickening of abdominal aorta seen.

We see there that right kidney is smaller with poor contrast extraction compared to left and is by two markedly narrowed renal arteries.

CT Aortic Angiogram

MIP reconstructed coronal images shows smooth thickening of wall of brachiocephalic trunk and left CCA starting from its origin

MIP reconstructed color coded heat scale coronal images shows smooth thickening of wall of brachiocephalic trunk and left CCA starting from its origin

MIP reconstructed color coded heat scale images shows diffuse smooth thickening of wall of descending thoracic aorta, wall thickness varies from 2-3mm

Axial MIP images show narrow right renal artery compared to left.

MIP reconstructed coronal images shows smooth wall thickening of abdominal aorta upto the origin of renal arteries. Right renal artery shows narrow lumen , becomes unopacified (stenosed) at distal end.

Our Diagnosis Fever Joint pains Weight loss Ischemic fits High ESR Asymmetrical peripheral pulses & Ultrasound, Doppler and CT findings are

suggestive of acute takayasu arteritis type V.

New angiographic classification of Takayasu arteritis according to vessels involved .

Nastri MV, Baptista LP, Baroni RH, Blasbalg R, de Avila LF, Leite CC, et al. Gadolinium-enhanced three-dimensional MR angiography of Takayasu arteritis. Radiographics 2004;24:773–86.

Takayasu Arteritis Also known as pulseless disease, occlusive

thromboaortopathy and Martorell syndrome Takayasu arteritis is a chronic progressive

inflammatory and obliterative disease of large vessels with a predilection for the aorta and its major branches.

The process may also involve the coronary and pulmonary arteries.

Eight time more common in females.

Nastri MV, Baptista LP, Baroni RH, Blasbalg R, de Avila LF, Leite CC, et al. Gadolinium-enhanced three-dimensional MR angiography of Takayasu arteritis. Radiographics 2004;24:773–86.

Sharma Criteria for DiagnosisMajor Criteria Left mid-subclavian artery lesion

Right mid-subclavian artery lesionCharacteristic signs and symptoms of at least one month duration (1)

Minor Criteria High erythrocyte sedimentation Carotid artery tendernessHypertensionAortic regurgitation or annuloaortic ectasisPulmonary artery lesionLeft mid-common carotid lesionDistal brachiocephalic trunk lesionDescending thoracic aorta lesionAbdominal aorta lesionCoronary artery lesion

Presence of two major, or one major and two minor criteria, or four minor criteria suggests a high probability of Takayasu arteritis.(1) limb claudication, pulse lessness or pulse differences in limbs, an unobtainable or significant blood pressure.

F P Zhu, S Luo, Z J Wang et al. Takayasu arteritis: imaging spectrum at multidetector CT Angiography. The British Journal of Radiology, 85 (2012), e1282–e1292

CT Angio Features Acute

Mural thickening andcontrast enhancement.

ChronicCalcifications in the wall (usually transmural) Occlusion and StenosisEctasis and AneurysmCollateral Vessels

F P Zhu, S Luo, Z J Wang et al. Takayasu arteritis: imaging spectrum at multidetector CT Angiography. The British Journal of Radiology, 85 (2012), e1282–e1292

Role of MR ImagingCommon Findings in Takayasu Arteritis and Best MR Imaging Techniques

Findings Best MR Imaging Techniques

Abnormalities of large arteries(stenosis and dilatation)

3D MR angiography

Thickening of the vascular wall T1- and T2-weighted multiplanar imaging and 3D MR angiography

Enhancement of the vascular wall Unenhanced and contrast-enhanced T1-weighted multiplanar imaging

Edema of the vascular wall Fat-suppressed T2-weighted multiplanar imaging

Marcio V. Nastri et al. Gadolinium-enhanced Three-dimensionalMR Angiography of Takayasu Arteritis. RadioGraphics 2004; 24:773–786

Advantages: MR imaging in particular allows better

soft-tissue differentiation and Show other signs of inflammation,

including mural edema and increased mural vascularity.

lack of iodinated contrast material or ionizing radiation.

Marcio V. Nastri et al. Gadolinium-enhanced Three-dimensionalMR Angiography of Takayasu Arteritis. RadioGraphics 2004; 24:773–786

Role of Conventional Angiography Angiography is invasive, A substantial radiation dose, May require a large amount of iodinated contrast

material, and can be difficult to perform in patients with long-segment stenoses or heavy arterial calcification.

Angiography does not depict wall architecture changes and cannot differentiate vascular narrowing due to acute mural inflammation from stenoses due to chronic transmural fibrosis.

Ischemic complications. Angiography is useful in guiding interventional

procedures such as angioplasty or stent placement.

Gotway et al. Imaging Findings in Takayasu’s Arteritis. AJR:184, June 2005

Differentials: Atherosclerosis, Giant cell arteritis and Polyarteritis nodosa. Fibromuscular Dysplasia.

F P Zhu, S Luo, Z J Wang et al. Takayasu arteritis: imaging spectrum at multidetector CT Angiography. The British Journal of Radiology, 85 (2012), e1282–e1292

Atherosclerotic plaques are more common in patients aged 45 years and above, and not usually associated with long segment luminal stenosis.

Calcification in ascending aorta can be observed in some TA patients, but it is rare in atherosclerosis.

Giant cell arteritis shares similar pathogenesis and imaging features with TA; however, giant cell arteritis commonly affects patients older than 50 years. In giant cell arteritis, branches of the external and

internal carotid arteries are most frequently diseased. Polyarteritis nodosa frequently occurs in adults who are 30–50 years

old, affecting males more than females, and it also more commonly affects patients with hepatitis B. Gastrointestinal and renal arteries are the primary sites diseased. Multiple small aneurysm formation in the involved artery is the characteristic manifestation on CTA images

F P Zhu, S Luo, Z J Wang et al. Takayasu arteritis: imaging spectrum at multidetector CT Angiography. The British Journal of Radiology, 85 (2012), e1282–e1292

Take Home Message Clinical data CTA and MRA are excellent tools to

detect Acute disease.

Gotway et al. Imaging Findings in Takayasu’s Arteritis. AJR:184, June 2005Marcio V. Nastri et al. Gadolinium-enhanced Three-dimensional MR Angiography of Takayasu Arteritis. RadioGraphics 2004; 24:773–786F P Zhu, S Luo, Z J Wang et al. Takayasu arteritis: imaging spectrum at multidetector CT Angiography. The British Journal of Radiology, 85 (2012), e1282–e1292

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