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CT angiography examination-from head to feet

Conference Paper · March 2013

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Computed tomography angiography examination- from head
to feet

Poster No.: C-0292

Congress: ECR 2013
Type: Educational Exhibit
Authors: 1 1 2 1
M. Jukovi# , P. Avramov , V. A. vucaj-cirilovic ; Novi Sad/RS,
2
Novi Sad, Se/RS
Keywords: Arteries / Aorta, Head and neck, Extremities, CT-Angiography,
Computer Applications-General, Computer Applications-Virtual
imaging, Contrast agent-intravenous, Education and training
DOI: 10.1594/ecr2013/C-0292

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Learning objectives

To emphasize the importance and utility of computed tomography angiography (CTA)

application in neurosurgery, vascular surgery, neurology and internal medicine, and to
instruct young radiologists about the essence of CTA through presentation of usual and
unusual series of cases.

Background

A conventional angiogram was considered as a gold standard for diagnosis of arterial

diseases.A development in computer technology provides a significant implementation
of different diagnostic tool and software packages which are used for better visualization
and evaluation of arteries. CTA becomes a powerful diagnostic modality for a detection
of different vascular abnormalities. As minimally invasive technique, which gives it an
advantage over conventional angiography, CTA gradually takes significant place in daily
radiological practice. There are numerous indications for practical application of CTA.

Clinical conditions such as intracranial hemorrhage caused by rupture of aneurysm

or arteriovenous malformation, ischemic brain strokes, pulmonary thromboembolia
and dissection of thoracic or abdominal aorta, coronary stenosis, visceral stenosis/
occlusion and peripheral vascular diseases can be diagnosed using CTA. Also, computed
tomography has a role in focal trauma, but it is limited due to artifacts from metal implants,
dental implants or shrapnel. The patient's radiation exposure to CTA modality is the
one negative fact. Effective radiation dose delivered during the CTA exam depends on
particular part of the body. A mean estimated effective dose for CT brain angiography is
3.2-7.6 mSv, but effective dose for cardiac CTA is 4.4-5.8mSv. The average patient dose
for peripheral CTA examination is 7.47 mSv. CTA examination in our department (Clinical
Centre of Vojodina- Radiology Centre, Novi Sad) was performed with 16-slice and 64-
slice CT scanners, mostly in patients with carotid, visceral and peripheral steno-occlusive
diseases, also with intracranial and abdominal aneurysm. CT angiography includes
topogram, precontrast and contrast medium injection scan. A topogram is useful in
evaluation of position of calcified artery or stent position. A precontrast scanning is useful
in evaluation of mural haematoma or hemorrhage, calcifications or for determination of
place to set the cursor for bolus tracking. Patients get intravenous nonionic water-soluble
iodine contrast in dose of 1.2 ml per 1 kg body weight (usually Iodixanol 320 mgl/mL
or Iohexol 350 mgl/mL) and saline for contrast medium injection scan. Monophase or
biphasic contrast injection was used during the CT angiography. The biphasic injection
of contrast media is mostly used for CTA of lower extremities. Before an examination all
information about CTA procedure was given to patients and they sign written permission
for CTA exam. A serum creatinine is obtained before the injection of contrast medium
in all patients who at risk for contrast induced nephrotoxicity (CIN). Indication for a

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serum cretonne measurements before intravascular administration of iodinated contrast
medium are age above 60 years, history of diabetes mellitus, and history of medicament
treated arterial hypertension, and renal diseases (cancer, dialysis, single kidney, kidney
transplant or renal surgery). In special cases when CTA examination must be done
in patients who underwent hemodyalisis, patients require premedication and hydration.
There were not data about adverse acute or delayed reactions to contrast media in
our patients after the CTA procedure. Technical parameters for CT angiography of all
parts of the body including brain, neck, thorax, cardiac, abdominal aorta, upper and
lower extremities on 16-slice and 64-slice were used according to Siemens protocols
(http://www.ctisus.com/). A successful CT angiography depends on several technical
items including scanning parameters, precise application of intravenous contrast material
and its delivery through the vessel, and correct timing of data acquisition. There are
1000-5000 images as a result of CTA reconstruction of data sets after one examination.
Post processing procedures that include three-dimensional reconstructions (3D-CTA)
such as MPR, MIP and VRT are very important parts of CTA modality. These volume
rendering techniques have applications in many medical fields such as oncology, internal
medicine, forensic medicine, and orthopedics and for planning surgery.

Imaging findings OR Procedure details

The utility of CTA examination in many situations are presented and illustrated with
detailed descriptions of usual and unusual individual conditions.

CEREBRAL ARTERIES

CT angiography is widely used for evaluation of cerebral arteries especially in

neurosurgical and neurological conditions such as subarachnoidal hemorrhage (SAH)
and hemorrhagic or ischemic stroke. The CTA modality provides information about
diameter, location, number of aneurysms and also about presence of intraluminal
thrombus. Sensitivity of CT angiography for detection of intracranial malformation is
between 81-90% and specificity is 93%. CTA is also powerful to detect stenosis and
occlusion of arteries. The common cause of intracranial hemorrhage is the rupture
of intracranial aneurysms or arteriovenous malformation. The intracranial aneurysm
is detected in 3-6% of general population, with female predominance, but some of
them were detected only at autopsy. A small aneurysm is defined as aneurysm with
diameter below 10 mm, large aneurysms have diameter between 10-25 mm, but giant
aneurysms have diameter above 25 mm. The most frequently aneurysms are located
at the bifurcation of arteries, usually in the anterior circulation in about 80-85%, while
the 15-20% aneurysms are located in the posterior circulation, mostly arise from the
basilar artery bifurcation. There are numerous risk factors for aneurysm formation
such as genetic factors (dominant polycystic kidney disease, Marfan's syndrome,

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Neurofibromatosis I) or environmental factors (cigarette smoking, alcohol consumption,
arterial hypertension, oral contraceptives). The treatment of aneurysms is the domain
of neurosurgery (surgical clipping) but endovascular treatment (coil embolisation) of
aneurysms is designed for interventional radiologists.

Vertebrobasilar artery aneurysms occur in 15% of all intracranial aneurysms.

The symptoms of vertebrobasilar dolichoectasia and aneurysm in patients
include subarachoidal hemorrhage, ischemic stroke, cranial nerves compression or
hydrocephalus. The aneurysms of basilar artery are not common (occur in less than 1%)
and their surgical treatment are very difficult with unpredictable outcome.

The brain arteriovenous malformations (AVMs) are a group of brain vascular lesions.
AVMs are congenital abnormal vascular connections between the arterial feeder which
supply the brain tissue and veins that drain the brain. AVM occur with two forms: nidal
and fistulous. This lesion is usually connected with high possibility for occurrence of
intracranial hemorrhage or decrease of cerebral perfusion leading to neurological deficit.
There are several treatment modalities for AVM: endovascular treatment, surgery or
radiotherapy intervention.

The brain ischemic stroke is the urgent condition in medicine. It is major cause of
disability in adult people. The early signs of ischemic brain stroke are confirmed by non
contrast CT scan and additional modalities are CT angiography and CT perfusion that
have a significant role in decision about thrombolysis. CTA could show the occlusion
site and collateral flow and help in the characterization of plaque on carotid arteries
or endocranial vessels. A modern treatment approach to patients with cerebrovascular
ischemic infarction is the brain tissue reperfusion with implementation of fibrinolytic
therapy.

Images for this section: Fig.1- 11

THORACIC AORTA, PULMONARY AND CORONARY ARTERIES

CT angiography has irreplaceable role in diagnostic of pulmonary embolism. It is the

most practical routine imaging diagnostic test for pulmonary thrombosis in daily medicine
associated with D-dimer analysis. The effective dose of CTA for patients with suspected
pulmonary embolism is about 5-7mSv, but dose reduction was achieved by decreasing of
kV which is recommended for children and low to normal weight patients. A poor quality of
CTA method could be if there are several factors such as patient's overweight or motion
and weak contrast filling of pulmonary arteries. Furthermore, CTA is a fast, inexpensive
and available diagnostic method and has a key role in diagnosis of many emergency

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conditions such as thoracoabdominal aneurysms and dissection and also in diagnosis of
heart anomaly and coronary artery stenosis.

Pulmonary embolism (PE) is common disease in developed countries and the third
cause of death after myocardial infarction and brain stroke. In 70-80% embolus originates
from deep veins of legs and about 10-15% from pelvic vessels. During the CTA exam the
main, lobar, segmental and sub segmental arteries are evaluated in patient suspected
on pulmonary thrombus for both lungs. There are two forms of PE: acute and chronic.
The filling contrast defect in the lumen of artery is the CTA sign of PE. The specific
sign in arteries ("polo mint" or "railway track") could be detected in acute forms of PE.
The pulmonary artery with diameter over 33 mm and pericardial effusion are the signs
of chronic PE. Other, but nonspecific signs of PE could be pleural effusion, mosaic
attenuation of lung parenchyma or lung infarction. The special attention should be given
to the right ventricle.

Aortic aneurysm is defined as dilatation whose diameter is at least 1.5 times larger
than normal diameter. A various pathogen factors are associated with descending
thoracic and thoracoabdominal aortic aneurysms such as atherosclerosis, degeneration
of vascular smooth muscle cells, chronic inflammation, connective tissue disorders and
infections. The important mechanism of aortic aneurysm formation is the group of factors
that include genetics and mechanical stress such as destruction and remodeling of
aortic wall, turbulent blood flow, inflammation and angiogenesis. Patients with aortic
aneurysm usually have co morbidities -pulmonary or heart diseases which could take
into the consideration in evaluation of operative risk and patient's clinical outcome. A
both type of aneurysm, descedenting thoracic aortic aneurysm and thoracoabdominal
aortic aneurysm are classified into IV category and repaired by surgery. Endovascular
aneurysm repair (EVAR) is relatively new technique which uses stent-graft for repairing
abdominal or thoracic (TEVAR) aneurysm before its rupture. One of the complications
after this method is the appearance of the endoleaks which are categorized in five types.

Coronary artery disease (CAD) is widespread all over the world with the high morbidity
and serious complications-cerebrovascular accidents, myocardial infarction or death.
A good management of CAD and early diagnosis for patients and clinicians provide
reduction of morbidity and mortality. The special focus is on patients with coronary
anomaly, although the prevalence of that condition in general population is less than
1%. Today the CTA application offers some benefits in early diagnosis of diseases in
children. A cardiac catheterization is common method for diagnosis of coronary artery
lesions, but invasive, with a complication rate about 1-2%. Technological improvement
has contributed to better testing, less invasive and rapid diagnostic method like coronary
CT angiography. Agatston score is widely in use for detection of calcium deposits in
coronary arteries which could be measured on non contrast cardiac CT scan before
the administration of intravenous contrast. A measurement is based on the CT number

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(Hounsfield units) and the area of calcium deposits. ECG gated, or retrospective scanning
is technique we use in our department for coronary CTA on Siemens Cardiac Sensation
64-slice scanner. Several indications for this technique are: patients with small or mild risk
for coronary stenosis, evaluation of anomaly of coronary artery or heart tumor lesions,
dilemmas after catheterization, stent or bypass evaluation, preoperative evaluation of
coronary arteries.

Images for this section: Fig.12-20

ABDOMINAL AORTA AND VISCERAL ARTERIES

Mycotic abdominal aneurysm of the aorta is rare condition but lead to fatal outcome
because of the rupture and consequently sepsis in patients. Used together, clinical
analysis and imaging diagnostic give a final diagnosis. In study of Finseth and Abbott the
pathogenesis and mechanism of infective focus formation for mycotic aneurysm could be
primary, secondary and cryptogenic. On CT scan one sign of mycotic aneurysm is low
attenuation of perianeurysmal collection with rim contrast enhancement.

In literature, there is data about small percent of aneurysms of visceral arteries in about
0.2% of general population. According to its frequency, aneurysms of lienal artery are
on the third place, after abdominal aortic aneurysm and iliac arteries. Some of them are
recognized only post mortem. If it is a symptomatic, patients usually complain of long
term pain in abdomen. A rupture of visceral aneurysm occurs in about 25% and surgical
treatment is essential. Also, the mesenteric ischemia is urgent condition which is very
important for clinicians and radiologist. Because of possibility of fatal outcome for patients
it needs a rapid diagnosis and therapy. Its presentation could be acute or chronic and
there are numerous factors that contribute to mesenteric ischemia development such as
mixed, lipid or calcified plaque formation, embolus from abdominal or visceral aneurysm
or from heart, atherosclerosis, vasculitis or fibromuscular dysplasia.

Images for this section: Fig.21-27

PERIPHERAL CIRCULATION (upper and lower extremities)

Arterial steno-occlusive diseases of upper and lower extremities could be

local or systemic. Multiple pathogen factors are responsible for its genesis such
as atherosclerosis, fibromuscular dysplasia, radiation therapy, hypercoaguability,
connective-tissue diseases, arteritis, cigarette smoking or trauma. The most frequent
symptom of upper limb arterial occlusion is digital gangrene and the most affected is the
brachial artery.

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In lower extremities, steno occlusive diseases are common on the femoral, popliteal
and infrapopliteal arteries. Not so rare, the popliteal artery occlusion is associated with
femur or knee dislocations. Treatments for steno-occlusive disease in lower limbs include
thrombolytic infusion, percutaneous transluminal angioplasty (PTA), the stent positioning
or bypass graft. The stenosis severity determines whether to apply PTA or surgery. CTA
examination with the usage of 3D reconstructions in post processing gives excellent
information about arterial patency, localization of calcified or mixed plaque and stenosis
or occlusion that have big influence on vascular planning and surgery. Bypass graft and
a stent position are monitored after vascular intervention by CTA. Moreover, incidental
findings and nonvascular lesions could be found during the CTA.

A normal diameter of popliteal artery is 0.7-1 cm. The sign of growing popliteal artery
aneurysm is usually pulsatile mass in the popliteal fossa. This aneurysm is common and
very often associated with femoral artery aneurysm. Popliteal aneurysm could be true
and false and symptoms could be acute and chronic. Thromboembolism or aneurysm
rupture is acute condition, but ischemia of lower limbs with claudicating is connected
with chronic state in patients. In about 45% of patients, aneurysms of popliteal artery are
asymptomatic.

Images for this section: Fig 28-31

Images for this section:

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Fig. 1: Aneurysm of basilar artery

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Fig. 2: Fusiform aneurysm of the left vertebral and basilar artery

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Fig. 3: Aneurysm of pericalosal artery

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Fig. 4: Fusiform aneurysm of the left internal carotid artery

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Fig. 5: Small aneurysm of the left cerebral media artery (M2)

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Fig. 6: Arteriovenous malformation_ blood supply ACM sin., ACA dex et AComP, vein
drainage- superior sagital sinus et sinus transfersus sin.

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Fig. 7: AV malformation in the left temporal lobe

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Fig. 8: AV malformation in the right temporal lobe

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Fig. 9: Hemorrhage caused by AV malformation

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Fig. 10: Significant stenosis (calcified plaque) of the common carotid and internal carotid
artery

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Fig. 11: Occlusion of the right cerebral media artery

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Fig. 12: Pulmonary thromboembolia in segmental branches of the right pulmonary artery

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Fig. 13: Thromboembolus in both pulmonary arteries

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Fig. 14: Pulmonary tromboembolia in the branches of the right pulmonary artery

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Fig. 15: Calcifications in the left coronary artery

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Fig. 16: Normal lumen of the right coronary artery

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Fig. 17: Rupture of the thoracoabdominal aneurysm

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Fig. 18: Aneurysm with dissection of the thoracic aorta

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Fig. 19: Dissection of the thoracic aorta with aneurysm of abdominal aorta (VRT)

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Fig. 20: Thoracic aneurysm with abdominal aneurysm dissection

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Fig. 21: Mycotic abdominal aneurysm

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Fig. 22: Rupture of abdominal aneurysm with hematoma on the left side

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Fig. 23: Thrombosis of abdominal aorta aneurysm

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Fig. 24: Lienal artery aneurysm

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Fig. 25: Occlusion of superior mesenteric artery

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Fig. 26: Liver and spleen necrosis as consequences of air in portal system and visceral
artery occlusion

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Fig. 27: After EVAR procedure_ without endoleak

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Fig. 28: Brachial artery occlusion

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Fig. 29: Occlusion of P1 segment of popliteal artery

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Fig. 30: Bilateral popliteal artery aneurysm

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Fig. 31: Aneurysm of the right common iliac artery

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Conclusion

Many qualities of CTA provide its great potential to replace conventional angiography.
CTA is very useful in prompt diagnosis of different types of vascular pathology or injury-
from head to feet. Moreover, it can be powerful method in treatment planning for patients.

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