aneurysmal disease

Development
Aneurysmal disease – non
atherosclerotic
Dysplastic
Development
Contents
Annual RSNA meeting, Chicago, 2007
• Supraaortic vessels
Dysplastic
• Aorta and thoracic vessels
Inflammatory
• Visceral and retroperitoneal
Inflammatory
• Peripheral
Prof. Dr. Stefan O. Schoenberg
Professor and Chairman of Radiology
Traumatic
Department of Clinical Radiology and Nuclear Medicine
University Hospital Mannheim,
Medical Faculty Mannheim – University of Heidelberg, Germany
Definition of aneurysm
• Dilatation of all three layers of the artery1
• Most common definition is a 50% increase
over the normal diameter
Flow-related
Development
Traumatic
http://www.ma.uni-heidelberg.de/inst/ikr/RSNA2007/aneurysmaldisease
Flow-related
Development
• hereditary
• flow-related
Intracerebral aneurysm
Dysplastic
Dysplastic
Inflammatory
Inflammatory
Traumatic
Traumatic
• Arterial diameter dependent on age,
gender and body habitus
1Baxter
BT. Cardiovascular Pathology 2005; 14: 185–188
Flow-related
Development
• hereditary
• flow-related
By autopsy: MCA bifurc (25%) = aCom (25%) > pCom (18%)
By DSA (symptomatic): pCom (38%) > aCom (36%) > MCA (21%)
By risk of bleeding: aCom (70% bleed) > pCom
Flow-related
Better visibility of small aneurysms
@ 3Tesla
Development
• hereditary
• flow-related
Dysplastic
Dysplastic
Inflammatory
Inflammatory
Rupture:
• 28,000 cases / year
• 40-60 years of age
Traumatic
• Rupture size 5-15 mm
• No true critical size of rupture
• aCom 70%
Flow-related
Traumatic
1.5T
Courtesy of John Huston III MD, Mayo Clinic
3.0T
Flow-related
Development
• hereditary
• flow-related
CE MRA for partially thrombosed
aneurysms
1.5T
3.0T
Development
• hereditary
• flow-related
Elliptic-centric CE-MRA:
aneurysm of ACA
Dysplastic
Dysplastic
Inflammatory
Inflammatory
Traumatic
Traumatic
CE 3.0T
Flow-related
Courtesy of John Huston III MD, Mayo Clinic
Comparative value of different sequences
Flow-related
Development
• hereditary
• flow-related
CE MRA: masked aneurysm in the
cavernous sinus
A – TOF @ 1.5T without
contrast agent:
coronal 15mm thin MIP Dysplastic
B – CE-MRA @ 1.5T:
coronal 15mm thin MIP
C – TOF @ 1.5T with
contrast agent:
↑ signal of peripheral
vessels,
but also ↑ background
Improvements by Time-resolved MRA
Development
• hereditary
• flow-related
Dysplastic
Inflammatory
Inflammatory
Traumatic
Traumatic
1.5T
Flow-related
Development
• hereditary
• flow-related
3.0T
CE 3.0T
Courtesy of John Huston III, Mayo Clinic
Improvements by time-resolved MRA
Flow-related
Development
• hereditary
• flow-related
Dysplastic
Dysplastic
Inflammatory
Inflammatory
Traumatic
Traumatic
Flow-related
Flow-related
Temporal resolution: 1.5 seconds
CE MRA: value after coiling > TOF
TOF 3.0T
Development
• hereditary
• flow-related
Natural progression of aneurysms
over years
Development
• hereditary
• flow-related
Dysplastic
Dysplastic
Inflammatory
Inflammatory
Traumatic
Traumatic
CE 3.0T
Courtesy of John Huston III MD, Mayo Clinic
Aneurysm vs. tumor
Flow-related
Development
• hereditary
• flow-related
Dysplastic
Courtesy of John Huston III MD, Mayo Clinic
Increased Incidence
• Anomalous vessels
Flow-related
Development
• hereditary
• flow-related
Dysplastic
• Aortic coarctation
• Polycystic kidney disease
Inflammatory
• Fibromuscular dysplasia
Inflammatory
• Connective tissue disorder (Marfan, EhlersDanlos)
Traumatic
• High flow states (vascular malformations,
fistulae)
25% of all aneurysms, in 43% cavernous segment of ICA, combination of
Flow-related
subacute and chronic hemorrhage, flow void, calcification)
Extracranial segments
35 y o male, Incidental aneurysm, no previous trauma
Development
• extracranial
carotids
Traumatic
Flow-related
Inflammatory aneurysm
Development
Dysplastic
Dysplastic
Inflammatory
Inflammatory
• bacterial
(mycotic)
Traumatic
Traumatic
Flow-related
S/P staphylococcus aureus sepsis: increasing incidence
(19 30% > salmonella infections (38% 10%))
Flow-related
Inflammatory aneurysm
most common causes: bacteremia (20% of all cases), surgery
(20%), soft tissue infections of the head / neck (9%),
endocarditis (8%), and dental procedures / infections (8%)
Inflammatory aneurysm
Mycotic aneurysm of left internal carotid artery, partially thrombosed,
soft tissue inflammation
FMD of the carotid artery
Development
Inflammatory aneurysm
Development
Dysplastic
Dysplastic
Inflammatory
• bacterial
(mycotic)
Inflammatory
• bacterial
(mycotic)
Traumatic
Traumatic
Flow-related
Flow-related
Development
Inflammatory aneurysm
Development
Dysplastic
Dysplastic
Inflammatory
• bacterial
(mycotic)
Inflammatory
• bacterial
(mycotic)
Traumatic
Traumatic
Flow-related
Flow-related
Development
Dysplastic
Contents
• Supraaortic vessels
Development
Dysplastic
• FMD
• Aorta and thoracic vessels
Inflammatory
• Visceral and retroperitoneal
Inflammatory
• Peripheral
Traumatic
Michaely HM, Schoenberg SO et al. Radiologe 2004; 39: 698-705
Flow-related
• Multifocal involvement
http://www.ma.uni-heidelberg.de/inst/ikr/RSNA2007/aneurysmaldisease
Traumatic
Flow-related
Marfan`s syndrome
Development
Cystic media necrosis: Erdheim-Gsell
Dysplastic
Development
Dysplastic
• Marfan`s
• Ehlers-D.
8 y o child with funnel chest, 2 non-dissected giant aortic
aneurysms of the ascending (funnel-like) and descending
(saccular) aorta w compression of the supraaortic vessels
Cystic fibrosis
Aneurym of dilated bronchial artery
Invasive aspergillosis
Inflammatory
Inflammatory
Traumatic
Traumatic
Flow-related
Flow-related
Development
Development
Dysplastic
Dysplastic
Inflammatory
Inflammatory
Traumatic
Traumatic
Flow-related
Flow-related
Development
Invasive aspergillosis
Development
Dysplastic
Dysplastic
Inflammatory
Inflammatory
• fungal
25 y o male with long-term IVDA
Cystic fibrosis
• fungal
Traumatic
Traumatic
Flow-related
Flow-related
Invasive aspergillosis
Development
Multifocal inflammatory aneurysms
Dysplastic
Dysplastic
Inflammatory
Inflammatory
• fungal
• fungal
• bacterial
(mycotic)
Traumatic
25 y o male with long-term IVDA
Multifocal inflammatory aneurysms
Development
Flow-related
Traumatic
58 y o male with ideopathic pulmonary fibrosis
and long-term steroid therapy
Development
Rate of progression
Flow-related
Development
10/2005
Before and after stent treatment
Dysplastic
Dysplastic
Inflammatory
• fungal
• bacterial
(mycotic)
Inflammatory
• fungal
• bacterial
(mycotic)
2 weeks earlier
08/2005
Traumatic
Abdominal aorta = most common site of salmonella aneurysm Flow-related
Treatment
Traumatic
Bilateral subclavian artery aneurysms
Development
Contents
Flow-related
Development
Before and after stent treatment
Dysplastic
• Supraaortic vessels
Dysplastic
• Aorta
Inflammatory
• fungal
• bacterial
(mycotic)
Traumatic
Stent implantation: only bridging to reduce acute risk of rupture,
definitive therapy by surgical repair
Flow-related
• Visceral and retroperitoneal
Inflammatory
• Peripheral
• Multifocal involvement
http://www.ma.uni-heidelberg.de/inst/ikr/RSNA2007/aneurysmaldisease
Traumatic
Flow-related
Development
Splenic artery aneurysm
MRA vs. DSA
Diffuse
ectasia
Dysplastic
Development
Dysplastic
• FMD
• diff ectasia
Inflammatory
Inflammatory
Traumatic
Traumatic
Flow-related
Progression over time
11/2004
01/2005
Pseudoaneurysm after biliary stent
Development
48 y o women with autoimmune hepatitis
PAN of the liver
Dysplastic
Inflammatory
Inflammatory
06/2005
Traumatic
Traumatic
Flow-related
Flow-related
Development
Aneurysm of the gastroduodenal artery
due to pancreatitis
Dysplastic
Inflammatory
After 1st coil embolization
Traumatic
Development
Dysplastic
Inflammatory
Successful coil embolization
S/P hemihepatectomy (hydatid disease), recurrent CDB stricture
Development
Dysplastic
After coil embolization
Re-bleeding 4 weeks later
Flow-related
After 2nd coil embolization
Traumatic
• iatrogenic
• iatrogenic
Flow-related
Flow-related
Fibromuscular dysplasia
Development
Higher resolution: FMD @ 3 Tesla
Dysplastic
FMD + aneurysm in 37% of cases:
requires high spatial resolution for CE-MRA (<1mm3)
FMD + aneurysm @ 3 Tesla
Development
Dysplastic
• spontan.
• FMD
• spontan.
• FMD
Inflammatory
Inflammatory
Traumatic
Traumatic
0.9x0.8x0.9 mm,
16 s scan time
Flow-related
Courtesy of J. Paul Finn MD PhD, UCLA
Development
FMD + aneurysm
Dysplastic
Flow-related
Development
Dysplastic
• spontan.
• FMD
• spontan.
• FMD
Inflammatory
Inflammatory
(Courtesy of
Dr. J. Paul Finn,
UCLA)
Traumatic
CE-MRA, 0.9x0.8x0.9 mm, PAT acceleration 3, 16 s scan time Flow-related
Dissection + aneurysm: postinterventional
Development
Traumatic
Time-resolved imaging (TREAT) @ 3 Tesla
Panarteritis nodosa
Flow-related
Development
64 row MS-CT
Dysplastic
Dysplastic
Inflammatory
Inflammatory
• infectious
• vasculitis
Traumatic
• iatrogenic
M. Osler-Rendu
Traumatic
M. Osler-Rendu
23 y o female c HTN
4 months later
Flow-related
Kidney most frequently involved organ in PAN (85%)
Flow-related
Panarteritis nodosa
Development
Development
Dysplastic
Dysplastic
Inflammatory
Inflammatory
Traumatic
Traumatic
SSFSE
PAN of small vessels without involvement of glomeruli, transmural
fibrinoid inflammation
Subarachnoid hemorrhage in upper thoracic spine
Flow-related
Aneurysm of IVC
Aneurysm of renal vein
3D SPGRE + SPIO
53 y o female with liver cirrhosis and extensive
porto-caval venous collaterals
Development
Dysplastic
Contents
• Supraaortic vessels
Flow-related
Development
Dysplastic
• Aorta
Inflammatory
• Visceral and retroperitoneal
Inflammatory
• Peripheral
Traumatic
Flow-related
PAN of the hands
Development
DSA – late arterial phase
• Multifocal involvement
http://www.ma.uni-heidelberg.de/inst/ikr/RSNA2007/aneurysmaldisease
PAN of the hands
Traumatic
Flow-related
Development
DSA – venous phase
Dysplastic
Dysplastic
Inflammatory
• vasculitis
Inflammatory
• vasculitis
Traumatic
Traumatic
Flow-related
Flow-related
ANCA-negative Vasculitis
Development
Pseudoaneurysm of femoral artery
Development
DSA
Dysplastic
Dysplastic
Inflammatory
• vasculitis
Inflammatory
Traumatic
Traumatic
• iatrogenic
arterial
venous
Development
Entrapment
1. Progressive intimal hyperplasia
2. Partially thrombosed aneurysm
of popliteal artery 3. occlusion
Flow-related
Needle-DSA
Contents
• Supraaortic vessels
after puncture of R femoral artery
DD: synovial sarcoma
Flow-related
Development
Dysplastic
Dysplastic
Inflammatory
Inflammatory
Traumatic
• iatrogenic
• mechanical
Traumatic
Flow-related
Development
26 y o female with synovial
sarcoma of left knee
Kawasaki’s Disease
Flow-related
Development
Dysplastic
Dysplastic
Inflammatory
Inflammatory
• Aorta
• Visceral and retroperitoneal
• infectious
• vasculitis?
• Peripheral
• Multifocal involvement
Traumatic
Traumatic
Courtesy of Martin R Prince MD PhD
http://www.ma.uni-heidelberg.de/inst/ikr/RSNA2007/aneurysmaldisease
Flow-related
CE-MRA of 2 y o male with multifocal aneurysms
Flow-related
Whole-body MRA
Incidental small
aneurysm of the
ICA
Development
Dysplastic
Inflammatory
Inflammatory
Traumatic
Development
Acknowledgment
• Department of Radiology, University Hospital Mannheim, Germany:
Henrik Michaely MD, Maliha Sadick MD
• Department of Radiology, Ludwig-Maximilians-University of Munich,
Germany:
Johannes Rieger MD, Christof Weber MD, Dirk Clevert MD
• Department of Radiology, Mayo Clinic, Rochester, Minnesota:
John Huston III MD
Dysplastic
Inflammatory
• Department of Radiology, UCLA:
J Paul Finn MD
• Department of Radiology, Cornell University:
Martin R Prince MD PhD
Traumatic
• Department of Radiology, University of Michigan:
Frank Londy RT
http://www.ma.uni-heidelberg.de/inst/ikr/RSNA2007/aneurysmaldisease
Development
Dysplastic
Flow-related
• Department of Internal Medicine I, University Hospital Mannheim,
Germany : Kurt Huck MD
Fibromuscular dysplasia
Flow-related
DSA
Traumatic
Flow-related