Magnetic resonance imaging diagnosis of Takayasu arteritis

Overview of imaging in adult- and childhood-onset Takayasu arteritis

Takayasu Arteritis is an idiopathic large vessel vasculitis, that affects young adults and children and can lead to ischemia and end-organ damage. Vascular imaging is crucial for diagnosis, assessment of disease extent and management of the disease. In this article, we critically review evidence for the clinical use of the different imaging modalities conventional angiography, magnetic resonance imaging, computed tomography, Doppler ultrasound and ¹⁸fluorodeoxyglucose positron emission tomography. We thereby focus on their clinical applicability, challenges and specific use in children.

Role of imaging in the diagnosis of large and medium-sized vessel vasculitis

In large-vessel vasculitis, imaging studies are useful to document temporal artery involvement and crucial to show large-vessel involvement. Color Doppler sonography, magnetic resonance, and computed tomography show early vasculitic lesions. Angiography delineates later vascular complications well. Color Doppler sonography, magnetic resonance angiography, and computed tomography angiography can also be used to show vascular luminal changes. Positron emission tomography is very sensitive in detecting large-vessel inflammation. Imaging procedures can also be used to monitor the course of large-vessel vasculitis. In medium-vessel vasculitis, imaging studies can be used to show both vascular changes and internal organ changes.

Delayed contrast-enhanced MRI of the coronary artery wall in takayasu arteritis

BACKGROUND

Takayasu arteritis (TA) is a rare form of chronic inflammatory granulomatous arteritis of the aorta and its major branches. Late gadolinium enhancement (LGE) with magnetic resonance imaging (MRI) has demonstrated its value for the detection of vessel wall alterations in TA. The aim of this study was to assess LGE of the coronary artery wall in patients with TA compared to patients with stable CAD.

METHODS

We enrolled 9 patients (8 female, average age 46±13 years) with proven TA. In the CAD group 9 patients participated (8 male, average age 65±10 years). Studies were performed on a commercial 3T whole-body MR imaging system (Achieva; Philips, Best, The Netherlands) using a 3D inversion prepared navigator gated spoiled gradient-echo sequence, which was repeated 34-45 minutes after low-dose gadolinium administration.

RESULTS

No coronary vessel wall enhancement was observed prior to contrast in either group. Post contrast, coronary LGE on IR scans was detected in 28 of 50 segments (56%) seen on T2-Prep scans in TA and in 25 of 57 segments (44%) in CAD patients. LGE quantitative assessment of coronary artery vessel wall CNR post contrast revealed no significant differences between the two groups (CNR in TA: 6.0±2.4 and 7.3±2.5 in CAD; p = 0.474).

CONCLUSION

Our findings suggest that LGE of the coronary artery wall seems to be common in patients with TA and similarly pronounced as in CAD patients. The observed coronary LGE seems to be rather unspecific, and differentiation between coronary vessel wall fibrosis and inflammation still remains unclear.

Takayasu arteritis in children and adolescents

Takayasu arteritis is a devastating vasculitis of the aorta and its major branches. The clinical manifestations in paediatric patients are less specific than in adults: in children the disease presents with fever, arthralgias and hypertension. Intramural inflammation results in narrowing of the blood vessel lumen and therefore hypoperfusion of the parenchyma. Conventional angiography is the gold standard diagnostic procedure. Corticosteroids, cyclophosphamide, MTX and biological therapies such as TNF-α blocking agents are treatment options.

Thoracic aorta evaluation in patients with Takayasu's arteritis by transesophageal echocardiography

BACKGROUND

There is no detailed description of thoracic aorta abnormalities assessed by transesophageal echocardiography (TEE) in patients with Takayasu's arteritis (TA). We aimed to evaluate these features in a series of patients in the chronic stage of TA.

METHODS

Fourteen patients (13 women, mean age 30 years) with inactive chronic TA were studied by TEE, and compared with 14 matched patients without aortic disease defined by TEE, who served as control subjects. In each segment of the thoracic aorta (ascending, arch, proximal, and distal descending aorta), we analyzed: (1) wall thickness; (2) diastolic diameters; and (3) systolic expansion index as a percentage of aortic expansibility.

RESULTS

Increased circumferential wall thickness (71% of 55 aortic segments studied) and dilated segments (37%) were observed in patients with TA, with significant higher values than control subjects (P < .05). A global impairment of the elastic properties of the thoracic aorta of patients with TA was noted in 85% of the analyzed segments, expressed by a significant reduction of the systolic expansion index (3.9 +/- 3.8%) as compared with control subjects (14 +/- 5.7%; P < .005).

CONCLUSIONS

TA as assessed by TEE is characterized by a remodeling process of the thoracic aorta with a marked and global decrease of aortic distensibility and concentric wall thickening. These features may be useful for noninvasive diagnosis of the chronic stage of TA by TEE.

Hypertension and Elevated ESR as Diagnostic Features of Takayasu Arteritis in Children

Takayasu arteritis (TA) is an inflammatory disease of the aorta and its branches. Delay in diagnosis is a common problem for adults and children. Although early manifestations are nonspecific (i.e., malaise, fever, anorexia, weight loss, myalgia, arthralgia/arthritis, elevated acute phase reactants), the clinical features that lead to diagnosis often appear suddenly and are related to vascular involvement. Hypertension, which is rare in children, and elevated ESR are found in most patients with TA. The authors hypothesized that these features, then, could be used as way to raise the clinical suspicion of TA. A total of 190 young patients with TA were retrospectively analyzed from local records and the literature to find the signs and symptoms associated with the disease that could be used to educate caregivers about when to suspect TA and to provide a screening tool for the disease. Hypertension and elevated ESR are found in most patients with TA. For this local study group, the sensitivity of this combination was 67%. Including the literature sources for which patient-specific information was available, the overall sensitivity was 65%. Thus, the combination of hypertension and elevated ESR in pediatric patients should merit further screening for TA, particularly in those with systemic complaints. Physical examination should focus on pulse abnormalities. Further evaluation should involve extensive imaging of the vascular system.

Exertional dyspnea as initial manifestation of Takayasu's arteritis--a case report and literature review

BACKGROUND

Takayasu's arteritis is a chronic systemic inflammatory disease that usually affects the aorta, its primary branches and occasionally the pulmonary and coronary arteries. Female gender in reproductive age and Asian origin are known factors associated with higher disease prevalence. The clinical manifestations vary considerably and are typically caused by limb or organ ischemia illness and fever. The estimated incidence rate in the western world is 2.6 cases per million persons per year. Occasionally, exertional dyspnea can be the sole primary clinical manifestation of Takayasu's arteritis.

CASE PRESENTATION

We report the case of a 57-year-old woman who was referred to our institution with increasing exertional dyspnea caused by pulmonary artery involvement in Takayasu's arteritis. In a review of the literature we discuss demographic data, clinical and radiographic findings and available therapeutic options.

CONCLUSIONS

Dyspnea due to pulmonary artery involvement can be the initial symptom of Takayasu's arteritis. Simple clinical tests, including a complete pulse-status and blood pressure measuring at both arms can lead to the right diagnosis and should always be done beyond the auscultation of the heart and lungs in patients with dyspnea.

Magnetic resonance imaging of thoracic aortic aneurysm and dissection

MRI is an extremely useful technique for the evaluation of the thoracic aorta. It provides a comprehensive evaluation of all the important structures within the chest and allows for high-resolution imaging of both the aortic lumen and the wall itself. As such, it is a sensitive method for delineating the extent of disease, branch-vessel involvement, and superimposed complications. Technical advances, such as stepped-table MRA and bolus-timing strategies, continue to improve overall image quality. In addition, the recent development of blood-pool contrast agents may further impact the diagnostic yield. Given these facts, MRI is likely to remain a mainstay in this patient population for years to come.

Diagnostic techniques in assessing vessels of the gastrointestinal tract

Vascular disorders of the gastrointestinal tract include a variety of different underlying diseases, thus requiring different and, in many cases, more than one imaging procedure. Only a knowledge of the newest developments in vascular imaging techniques with all the possibilities and limits will ensure a time- and cost-effective, accurate and reliable diagnosis. In many acute cases and also as a screening procedure, ultrasound in combination with colour Doppler and duplex sonography, plays an important role in setting the right course for further imaging techniques, and can provide the correct diagnosis in many cases.Depending on the most prominent symptoms and the expected disease, the right choice of technique saves valuable time. Computed tomography (CT) and magnetic resonance imaging (MRI) are cross-sectional imaging techniques that not only demonstrate lesion vascularization, but also provide information about neighbouring structures and complications in an understandable and demonstrable way. The use of angiography as an invasive tool should be limited to cases where a high temporal and spatial resolution is necessary to make the diagnosis or where therapeutic interventions are also likely to be performed within the same setting. For the diagnosis of gastrointestinal vascular diseases, often no generally valid recommendation can be given, since the impact of all imaging techniques will depend on the examiner's experience, the technical equipment and on their 24-h availability in a hospital. This chapter tries to give some information about the inherent limits and indications of the different imaging techniques, as well as the newest study results concerning the most frequent vascular diseases of the gastrointestinal tract.

Magnetic resonance imaging of large vessel vasculitis

Conventional x-ray angiography has traditionally played a prominent role in the radiologic evaluation of large vessel vasculitis. Recently, noninvasive magnetic resonance (MR) methods have received much attention for their potential to complement and possibly supplant conventional angiography. In particular, promising advances have been made in the areas of MR angiography and physiologic imaging. MR provides high resolution anatomic information, including lumen configuration and vascular wall thickness, and physiologic data, such as measurements of the degree of wall enhancement and the presence of edema. Moreover, imaging data are obtained noninvasively in a multitude of obliquities. Owing to these features, MR occupies a unique role in the evaluation of large vessel vasculitis.

Takayasu arteritis: diagnosis with breath-hold contrast-enhanced three-dimensional MR angiography

The purpose of the study was to determine the diagnostic accuracy of breath-hold contrast-enhanced three-dimensional (3D) magnetic resonance (MR) angiography in Takayasu arteritis. Thirty patients suspected of having Takayasu arteritis were examined with MR angiography and conventional angiography. Takayasu arteritis was diagnosed in 20 of these patients. MR angiography was performed using a 1.5-T system after bolus injection of 0.1 mmol/kg of gadodiamide. MR angiography clearly depicted various vascular lesions in the aorta and its major branches in all 20 patients with Takayasu arteritis. It also depicted pulmonary artery lesions in 10 (50%) of the 20 patients. MR angiography accurately depicted 323 (98%) of 330 arteries, but 7 (2%) stenotic arteries were overestimated as occluded. The sensitivity and specificity of MR angiography for the diagnosis of Takayasu arteritis were both 100%. Breath-hold contrast-enhanced 3D MR angiography clearly depicts various vascular lesions in both the systemic and pulmonary arteries in Takayasu arteritis, thus allowing a definitive diagnosis of Takayasu arteritis.

Takayasu arteritis: diagnosis with MR imaging and MR angiography in acute and chronic active stages

Early diagnosis and treatment of Takayasu arteritis is important in prevention of serious complications. Spin-echo magnetic resonance imaging (MRI) can depict early wall thickening of the aorta and cine MRI can evaluate aortic valve function. Significant enhancement in and around the aorta and carotid arteries is observed on postcontrast MR images in acute phase Takayasu arteritis. In the chronic phase, contrast enhancement in the aortic wall stronger than in the myocardium suggests activity of the disease. Breath-hold contrast-enhanced three-dimensional MR angiography is very effective in noninvasive evaluation of luminal change of aortitis. Contrast-enhanced MRI and MR angiography have an important role in early diagnosis, activity determination, and follow-up of Takayasu arteritis. MRI and MR angiography can be utilized for initial diagnosis of Takayasu arteritis and replace catheterization angiography. J. Magn. Reson. Imaging 1999;10:751-757.