cases_vascular.pptx Radiology Reporting Sample

Radiology Reporting Sample

1. Vascular Cases 1-25

2. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 Case directory

3. Case 1

4. Replaced RHA Case findings: right hepatic artery arises from SMA Replaced artery: vessel supplying an entire lobe arises aberrantly Accessory artery: portion of a hepatic lobe is supplied by a vessel of normal origin, but an additional vessel of aberrant origin also supplies a portion of the lobe Replaced RHA: arise from SMA (MC 1 st branch from SMA) Replaced LHA: arise from left gastric artery Case directory

5. Case 2

6. Non-occlusive mesenteric ischemia (NOMI) Case findings: Vasoconstriction of the SMA and its branches Etiology: Intense mesenteric vasoconstriction in response to a period of mesenteric hypoperfusion Low flow syndrome of mesenteric circulation followed by vasoconstriction High mortality rate

7. Non-occlusive mesenteric ischemia (NOMI) Angiography: Constriction of SMA branches Patch filling of peripheral arcades Diminished bowel blush Poor visualization of the SMV Treatment: papaverine infusion into SMA If spasm is detected at angiography, a test dose of 30-60 mg of papaverine (or other vasodilator) in the SMA in an attempt to assess reversibility 🡪 if response is seen, a 24-hour infusion of papaverine into the SMA

8. Acute NOMI SMA injection: SMA is patent Diffuse narrowing of the SMA branches Reflux of contrast into the aorta with the injection

9. Acute NOMI

10. SMA branches

11. IMA branches

12. Mesenteric collaterals Case directory

13. Case 3 Arterial phase

14. Venous phase

15. Angiodysplasia Case findings: Vascular tuft or tangle of vessels with early intense filling of draining vein that then slowly empties Early venous phase displays an early draining vein (arrows) Telangiectasia : dilations of normal, preexisting structures and NOT true AVM Cause of chronic intermittent GIB , rarely acute GIB MC elderly, cecum or proximal ascending colon, multiple

16. Angiodysplasia Angiography: Arterial phase: densely opacified tuft or tangle of vessels Late arterial phase or early venous phase: early-filling vein that slowly empties Extravasation of contrast into the colon Treatment: Colonic resection curative Intraarterial administration of vasopressin or embolization DDX: Bleeding diverticulum (MC source of GIB in right colon) Congenital AVM Carcinoma Case directory

17. Case 4

18. Leriche syndrome Case findings: Occlusion of infrarenal abdominal aorta Collateral filling of IMA via the middle colic artery and an arc of Riolan Early collateral reconstitution of deep iliac circumflex arteries from intercostals and lumbar arteries Clinical triad: Buttock and thigh claudication Absent femoral pulses Impotence Etiology: Thrombosis superimposed on chronic atherosclerotic stenosis Occlusion of congenitally small aortic bifurcation Treatment: surgical bypass graft (e.g., aortobifemoral) Case directory

19. Case 5 Percutaneous transhepatic cholangiography

20. Sclerosing cholangitis Case findings: PTC: intra and extrahepatic biliary tree including CBD, beaded or pruned tree appearance Chronic inflammation and progressive fibrosis of intra and extrahepatic biliary system Associated with: Autoimmune diseases: IBD (UC, Crohn’s), RPF, mediastinal fibrosis, pancreatitis, Riedel's thyroiditis

21. Sclerosing cholangitis DDX: Cholangiocarcinoma (diffuse) PBC Infectious cholangitis (bacterial, viral, parasitic) Complication : cholangiocarcinoma, acute cholecystitis, biliary cirrhosis with portal hypertension Treatment : liver transplant, or palliation (percutaneous biliary drainage or hepaticojejunostomy Case directory

22. Case 6

23. Caroli’s disease Case findings: Dilated intra- and extrahepatic biliary tree Walls of the biliary tract are irregular in appearance 🡪 as opposed to smoothly marginated (consistent with an inflammatory process) DDX: Oriental cholangiohepatitis Severe cholangitis

24. Caroli’s disease Choledochal cyst variant (Type V) Cystic dilatation of intrahepatic ducts is classic, but extrahepatic biliary tree may be involved Associated with: cirrhosis and portal hypertension, or congenital hepatic fibrosis Caroli's disease MC involves entire intrahepatic biliary tree 🡪 hepatic resection is not practical

25. Choledochal cyst Type 1: MC, fusiform dilatation of CBD Type 2: diverticulum of CBD Type 3: dilatation of intraduodenal portion of CBD ( choledochocele ) Type IV: Type IV-a: intrahepatic and extrahepatic ductal dilatation Type IV-b: extrahepatic ductal dilatation Type V: Caroli’s disease (MC intrahepatic ductal dilatation) Case directory

26. Case 7 Early arterial injection Delayed images

27. Left vertebral artery Bidirectional flow : reversed or retrograde flow away from intracranial circulation throughout diastole

28. Left brachial artery Parvus tardus waveform: Diminished peak systolic velocity Long systolic acceleration time Consistent with steno-occlusive disease proximal to the point of interrogation

29. Right brachial artery (normal) Normal triphasic Doppler waveform of extremity arteries without proximal disease Note higher peak systolic velocity and sharp systolic upstroke of short systolic acceleration time

30. Subclavian steal Case findings: Early aortogram reveal patency of the brachiocephalic artery and LCCA, occlusion of the LSA at its origin Delayed imaging shows retrograde flow in the left vertebral artery 🡪 supplying flow to the LSA and LUE Etiology: MC atherosclerosis , congenital web/absence, dissecting aneurysm, embolism, inflammatory arteritis ( Takayasu's ) Clinical: vertebral basilar insufficiency 🡪 drop attacks Treatment Occlusion of subclavian artery: carotid-to-subclavian bypass Proximal subclavian stenosis: intravascular stent Case directory

31. Case 8

32. AML Case findings: selective injection of the right kidney reveals two abnormal areas: Aneurysm in midpole Hypervascular exophytic mass extending off lower pole Angiography: Hypervascular masses with large tortuous feeding arteries arranged circumferentially Feeding vessels often distorted and branch vessels may contain aneurysms AV shunting does NOT commonly occur

33. AML DDX: RCC Complication: hemorrhage (> 4 cm) Treatment: surgical resection, percutaneous embolization

34. AML Early and late images show a large right AML with a bizarre arterial pattern and several aneurysms Case directory

35. Case 9

36. Median arcuate ligament syndrome (celiac artery compression syndrome) Case findings: Inspiratory: proximal celiac artery displays subtle, superior compression, and the proximal SMA is patent Expiratory : smooth, superior eccentric narrowing of the celiac artery Intestinal angina : caused by insufficient blood flow to GI tract MC visceral arterial compression syndrome Worsens with expiration (celiac axis moves superiorly and becomes entrapped beneath the ligament of the diaphragm creating a stenosis) Extrinsic compression of the celiac artery by median crus of diaphragm , and/or celiac neural plexuses and connective tissues

37. Median arcuate ligament syndrome (celiac artery compression syndrome) Treatment: Enlarge diaphragmatic hiatus, resect celiac ganglion NO response to angioplasty 🡪 because of external compression Stenting contraindicated 🡪 from device fatigue due to external compression DDX: Chronic mesenteric ischemia from atherosclerotic disease Chronic mesenteric ischemia from median arcuate ligament syndrome Acute mesenteric ischemia from embolus Case directory

38. Case 10

39. Fibromuscular dysplasia 2 nd MC cause of renovascular hypertension (1 st is atherosclerotic RAS) Angiography: MC affects mid and distal of main renal arteries String of beads appearance DDX: Atherosclerosis (MC ostial lesions) Congenital webs Treatment: Percutaneous transluminal angioplasty (PTA 5-year patency 90%) Case directory

40. Case 11 Post thrombolysis image Prior to thrombolysis, there is left common iliac vein stenosis

41. Superimposed IVDSA and ascending venogram

42. May-Thurner syndrome (iliac vein compression) Case findings: Band-like lucency is seen crossing the left common iliac vein (post-thrombolysis) Superimposed IVDSA and ascending venogram show the right common iliac artery compresses the vein Ileofemoral DVT: MC on the left MC women in 2 nd to 4 th decades

43. May-Thurner syndrome (iliac vein compression) Etiology: compression of left common iliac vein by crossing right common iliac artery Differentiated from bland DVT of the LE by the presence of fibrous spur or adhesions in the left common iliac vein 🡪 represents an inflammatory response to chronic compression of the vein and adjacent arterial pulsations Treatment: thrombolysis (remove acute thrombus) followed by iliac vein stent placement Post-thrombotic syndrome : major long-term complication of DVT Case directory

44. Case 12

45. Bronchial artery hypertrophy Findings: hypertrophied and tortuous bronchial arteries Etiology: MC worldwide TB , bronchiectasis , CF, bronchogenic carcinoma, Aspergillosis Treatment: Embolize with polyvinyl alcohol ( PVA ) particles, or Gelfoam Coils are NOT used since they cause proximal occlusion 🡪 precluding repeat embolization should hemoptysis recur Embolization 85-90% effective with a 15% recurrence rate If recurrence, repeat embolization is usually effective

46. Bronchial artery embolization Presents with massive hemoptysis Need to identify spinal arteries (spinal artery of Adamkiewicz) that arise from the bronchial and intercostal arteries Artery of Adamkiewicz : feeds anterior spinal cord, arise between T8 and L2, MC left Also interrogate anastomosis with bronchial arteries: intercostals, inferior phrenic, internal mammary, branches of the subclavian artery Angiography: Need to perform selective injection of LIMA post-treatment 🡪 this vessel common source of collateral supply to lungs Hypertrophied and tortuous bronchial arteries Pulmonary AV shunting

47. Bronchial artery hypertrophy

48. Bronchial artery hypertrophy Subselective cannulation shows a large bronchial artery with areas of increased vascularity

49. Bronchial artery hypertrophy DSA shows significant increased vascularity likely representing inflammation in the area causing the hemoptysis

50. Bronchial artery hypertrophy Spinal artery of Adamkewicz : Small artery extending to the midline Has a sharp, hairpin turn Travels down the center of the anterior aspect of the spinal canal (arrow) Case directory

51. Case 13 Arms neutral Arms abducted

52. Thoracic outlet syndrome Case findings: Neutral position shows no abnormalities Arms in abduction shows impingement on bilateral subclavian arteries resulting in significant bilateral subclavian artery stenoses Etiology: cervical rib , hypertrophied muscles, scalene minimus muscle, clavicle fracture Complication: distal embolization of thrombus Treatment: surgical thoracic outlet decompression

53. Upper extremity arteries Case directory

54. Case 14 DSV of proximal RUE and central veins

55. Paget-Schroetter syndrome (primary subclavian-axillary vein thrombosis) Case findings: DSV of proximal RUE and central veins 🡪 shows occlusion of the subclavian vein , intraluminal filling-defect within the axillary vein , and numerous collateral vessels reconstituting the innominate vein

56. Paget-Schroetter syndrome (primary subclavian-axillary vein thrombosis) Etiology: Primary subclavian-axillary vein thrombosis Secondary 🡪 MC catheters Treatment: Thrombolysis followed by thoracic outlet decompression Anticoagulation Stenting NOT an option 🡪 stent fracture from mechanical compression Case directory

57. Case 15 Percutaneous transhepatic cholangiography (PTC)

58. Cholangiocarcinoma (Klatskin tumor) Case findings: PTC: dilated left and right ducts with obstruction at the hilum CT: mass at confluence of hepatic ducts, causing obstruction Klatskin tumor: hilar cholangiocarcinoma 🡪 located at the bifurcation of main biliary ducts 2 nd MC primary hepatic tumor (after HCC) Slow growing, MC adenocarcinoma

59. Cholangiocarcinoma (Klatskin tumor) Findings Large mass, hypoattenuating, with irregular margins CT: delayed enhancement with increasing attenuation (differentiate between HCC which has arterial enhancement) DDX : Liver metastasis HCC Portal adenopathy PSC Risk factors : choledochal cyst, UC, Caroli’s disease, Clonorchis sinensis infection, PSC Case directory

60. Case 16 Early renal arteriography Late renal arteriography

61. Polyarteritis nodosum Case findings: Multiple micro aneurysms involving the segmental and subsegmental branches of the right kidney DDX: Polyarteritis nodosum Diffuse multiple septic emboli , SLE Necrotizing angiitis (methamphetamine) 🡪 speed kidney

62. Polyarteritis nodosum Celiac arteriography reveals multiple micro aneurysms involving the hepatic arteries and GDA

63. Renal artery aneurysms Renal artery aneurysms from congenital etiologies Selective left renal arteriography reveals an aneurysm in the proximal portion of a midpole branch vessel

64. Methamphetamine abuse necrotizing angiitis (speed kidney) Renal arteriography reveals multiple micro and macro aneurysms involving the segmental and subsegmental branches of the right kidney

65. Methamphetamine abuse necrotizing angiitis (speed kidney) Celiac arteriography Multiple micro aneurysms involving the GDA, proper hepatic artery and left hepatic artery branches

66. Methamphetamine abuse necrotizing angiitis (speed kidney) Superior mesenteric arteriography Replaced RHA arising from the SMA Multiple areas of micro aneurysms involving the hepatic vasculature and the superior mesenteric vasculature Case directory

67. Case 17

68. Chronic mesenteric ischemia Lateral abdominal aortogram shows occlusion of the celiac and IMA Severe stenosis of the proximal SMA is present (arrow)

69. Chronic mesenteric ischemia Clinical: postprandial pain 🡪 intestinal angina, weight loss Angiography: tight origin of the celiac artery and SMA Angiographic findings and above clinical findings 🡪 pathognomonic LC than acute mesenteric ischemia Etiology: MC atherosclerosis (of mesenteric artery ostia) Treatment: aorto-mesenteric bypass Case directory

70. Case 18

71. Renal artery stenosis Case finding: ostial renal artery stenosis secondary to atherosclerosis Etiology: MC atherosclerosis , FMD , NF Treatment: Aorto-renal bypass FMD: PTA (5-year patency 80-90%) 🡪 non-ostial lesions Atherosclerosis: endovascular stent placement 🡪 ostial lesions

72. Renal artery stenosis Diagnosis: Renal artery stenosis secondary to NF1 LAO view shows the proximal stenosis in the left renal artery

73. Renal artery stenosis, NF1 NF1 : stenosis due to direct effect of fibrous proliferation of the intima or the media Angiography: smooth stenotic segment (usually at orifice) with a tubular segment of dilatation distal to the stenosis, MC bilateral Appearance differs from FMD where stenosis non-ostial Treatment: angioplasty can be successful, in general endovascular management has had poor results NB: hypertension in a child with NF could also be secondary to a pheochromocytoma (NF2) DDX (RAS in a child ): FMD, NF1, Takayasu’s arteritis Case directory

74. Case 19

75. Pulmonary AVM Case finding: single artery connects to a draining pulmonary vein via an aneurysmal sac PAVM: dilated vascular channels that consist of a direct connection of a pulmonary artery to a pulmonary vein 🡪 R-L shunt Complication: stroke, TIA, brain abscess Associated with HHT (OWR) Treatment: Transcatheter embolotherapy 🡪 eliminate arterial inflow (use coils or detachable balloon ) In contrast non-pulmonary (peripheral) AVM 🡪 where the goal is to eliminate the nidus Case directory

76. Case 20

77. Takayasu’s arteritis Case findings: Tight stenoses of the BCA extending to the carotid-subclavian artery bifurcation Tapered stenosis of the left CCA Granulomatous vasculitis MC women < 50 year old, elevated ESR

78. Takayasu’s arteritis Angiography: MC affect aorta and large branch vessels (MC LSA) Smooth concentric narrowing Classically there is sparing of the distal abdominal aorta above the bifurcation Pulmonary artery disease is common but frequently asymptomatic DDX: Giant cell arteritis (differentiate by age, > 50 year old) Radiation-induced arteritis Treatment: PTA (disease should be inactive at the time of intervention as measured by ESR)

79. Takayasu’s arteritis Involvement of the subclavian artery 🡪 with smooth concentric narrowing Case directory

80. Case 21

81. Giant cell arteritis Case findings: long segment smooth stenosis of axillary artery MC large vessel involvement is subclavian/axillary arteries, followed by superficial and deep femoral arteries DDX: Takayasu's arteritis: angiographically indistinguishable, discriminate by age Radiation arteritis Treatment: steroids Case directory

82. Case 22

83. Male varicocele Case findings: Distal injection of the left gonadal vein showed collateral veins, with a varicocele (tangle of vessels) Varicocele : Dilatation of the pampiniform plexus (MC left) Infection of left renal vein with reflux into left gonadal vein Clinical: male infertility, scrotal pain Treatment: Surgical ligation Embolotherapy (coils, sclerosing agent)

84. Male varicocele Injection in left renal vein showed reflux into the left testicular (gonadal) vein (arrows) Case directory

85. Case 23 Hepatic vein injection (hepatic venography)

86. Budd-Chiari syndrome Case finding: Spider-web appearance of intrahepatic collateral veins Hepatic venography is the gold standard for diagnosis Clinical: severe ascites, HSM, hepatic encephalopathy, portal hypertension, hepatic failure Etiology : MC worldwide intrinsic webs, polycythemia vera, PNH, hepatic veno-occlusive disease Treatment: PTA, stent if stenosis recurs, TIPS

87. Budd-Chiari syndrome Findings: CT or MRI: fan-shaped central area of increased attenuation in the liver with IV contrast, enlarged caudate lobe, ascites, cirrhosis Tc99m sulfur colloid scan: hot caudate lobe sign 🡪 decreased activity in the right and left hepatic lobes and increased uptake in the caudate lobe which is usually less affected due to its separate venous drainage into the IVC DDX: hepatic veno-occlusive disease BCS is clinically indistinguishable Endemic in Jamaica due to consumption of the toxic bush tea Also seen after radiation, chemotherapy and bone marrow transplant

88. Budd-Chiari syndrome Injection at the junction of the hepatic vein and IVC shows a focal stenosis of the hepatic vein (arrow)

89. Budd-Chiari syndrome Wedged hepatic injection shows a complex spider-web network of tortuous hepatic venous collateral vessels without filling of the portal vein Case directory

90. Case 24

91. Thoracic aortic aneurysm (tertiary syphilis) Case findings: Saccular aneurysm of ascending aorta Valves of the aorta and sinotubular ridge are not involved Normal descending aorta MC saccular (2/3) and LC fusiform MC ascending aorta

92. Thoracic aortic aneurysm DDX: Atherosclerosis Pseudoaneurysm from trauma Bacterial infection, (tertiary) syphilis Takayasu's arteritis, giant cell arteritis Connective tissues disease: Ehlers-Danlos syndrome Marfan's syndrome Case directory

93. Case 25

94. Splenic artery pseudoaneurysm Etiology: pancreatitis , pancreatic carcinoma DDX: Congenital aneurysm Mycotic aneurysm Treatment: Basic tenant for embolization of pseudoaneurysms is to occlude both proximal and distal to its origin Proximal embolization alone would allow perfusion to the pseudoaneurysm through collateral pathways Case directory