Radiological evaluation of takayasu arteritis Dr. muhammad Bin Zulfiqar Services Institute of Medical Sciences Services Hospital Lahore In this presentation we will discuss the role of imaging in TA.

1. Dr. Muhammad Bin Zulfiqar
PGR IV SIMS / SHL

2. 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.

3. PULSES
 ON RIGHT SIDE (ARTRIES):
Carotid
Brachial all palpable with
Radial normal Rate,
Femoral Rhythm and
Posterior tibial Volume.
Dorsalis pedis

4. PULSES CONT.
 ON LEFT SIDE (ARTRIES):
Carotid all these NOT
Brachial palpable
Radial
Dorsalis Pedis
Femoral palpable with good
Posterior tibial volume

5. Left PulsesRight pulses

6. 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

7. 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 like
 Fever
 Weight loss
 Joint pains
 Asymmetrical peripheral pulses

8. Radiological Modalities:
Conventional:
 Radiograph chest.
 Abdominal ultrasound.
Specific:
 Color Doppler ultrasound
 Ct Angiography
 MRI
 MRA
 Conventional Angiography

9. 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.

10. Doppler Imaging

11. Renal Artery Color Doppler :
 Right kidney is smaller as compared to left and
shows high resistive flow with reversal of diastolic
flow.

12. 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 :

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

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

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

16. CT ANGIOGRAPHY

17.  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.

18.  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.

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

20. CT Aortic Angiogram
 MIP reconstructed coronal images shows smooth thickening of wall of
brachiocephalic trunk and left CCA starting from its origin

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

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

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

24.  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.

26. 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.

27.  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.

28. 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.

29. Sharma Criteria for Diagnosis
Major Criteria Left mid-subclavian artery lesion
Right mid-subclavian artery lesion
Characteristic signs and symptoms of at least one
month duration (1)
Minor Criteria High erythrocyte sedimentation
Carotid artery tenderness
Hypertension
Aortic regurgitation or annuloaortic ectasis
Pulmonary artery lesion
Left mid-common carotid lesion
Distal brachiocephalic trunk lesion
Descending thoracic aorta lesion
Abdominal aorta lesion
Coronary 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

30. CT Angio Features
 Acute
 Mural thickening and
 contrast enhancement.
 Chronic
 Calcifications in the wall (usually transmural)
 Occlusion and Stenosis
 Ectasis and Aneurysm
 Collateral 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

31. Role of MR Imaging
Common 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-dimensional
MR Angiography of Takayasu Arteritis. RadioGraphics 2004; 24:773–786

32. 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-dimensional
MR Angiography of Takayasu Arteritis. RadioGraphics 2004; 24:773–786

33. 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

34. 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

35.  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

36. 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 2005
Marcio V. Nastri et al. Gadolinium-enhanced Three-dimensional MR Angiography of Takayasu Arteritis.
RadioGraphics 2004; 24:773–786
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

37. THANK YOU