The emerging role of multidetector row CT angiography in the diagnosis of cervical arterial dissection: preliminary study

Introduction Cervical artery dissection is an important cause of ischemic stroke, particularly in young patients. The diagnosis can be made with invasive catheter angiography or non-invasive imaging, either with MRI in conjunction with MR angiography (MRA) or CT angiography (CTA). Both modalities have been shown to have a high specificity and sensitivity. New developments such as multi-slice CTA (MSCTA) are emerging as an alternative methods for imaging the cervical and intracranial arteries. However, the contribution of modern MSCTA to carotid artery dissection has not been reported.Methods We present a retrospective series of seven patients in whom both MSCTA and cervical axial T1 MRI and MRA were performed in the acute to subacute setting of internal carotid artery dissection.Results Carotid artery dissection was identified in all seven patients by MSCTA. The combination of MRI and MRA identified dissection in five of the seven patients. Additionally, a pseudoaneurysm was identified by MSCTA that was missed by MRI and MRA.Conclusion Our findings confirm that MSCTA is a complementary technique in comparison to cervical axial T1 MRI and cervical MRA for diagnosing carotid artery dissection, and at times may provide additional information that can impact patient management.     

Intracranial arterial dissection

We review the angiographic and CT findings, precipitating factors and clinical features in nine patients with ten intracranial arterial dissections. The internal carotid artery was involved in five cases, the vertebral artery in four and the posterior inferior cerebellar artery in one. Angiography revealed irregular stenosis in four cases, irregular stenosis and a pseudoaneurysm in two, irregular stenosis and irregular dilatation in one, arterial occlusion in two and a pseudoaneurysm in one. CT demonstrated an infarct in four cases, a dense middle cerebral artery in two and subarachnoid haemorrhage in one. A possible precipitating factor was identified in five cases. Six patients recovered well, while three had persisting neurological deficits. Received: 30 August 1997 Accepted: 31 October 1997     

颈部搏动性肿块的影像学诊断

目的探讨颈部搏动性肿块的影象学诊断价值,并着重分析其血管造影征象。材料与方法经病理和临床证实的颈部搏动性肿块患32例,其中颈动脉体瘤9例．动静脉瘘7例、颈动脉瘤5例．颈部假性动脉瘤3例．颈动脉迂曲症7例和巨大蔓状血管瘤1例。所有患均行选择性颈动脉造影,20例行血流超声检查．4例行CT检查、1例行MR检查、结果32例患中术前血管造影正确诊断31例,其中21例与病理结果相符,仅有1例假性动脉瘤误诊为真性动脉瘤;所有病变均显示其大小．起源和与周围大血管的关系。2例假性动脉瘤和5例颈动脉迂曲症彩超术前误诊为真性颈动脉瘤。结论选择性颈动脉造影足一种安全可靠的低创伤性影像学检查方法,结合其他影像学技术如彩超．CT、MR等口,准确做出定位和定性诊断。     

21例假性动脉瘤的治疗策略

目的 探讨假性动脉瘤的部位、类型和发生原因,选择不同的治疗方法.方法 对21例假性动脉瘤患者(四肢动脉11例、脾动脉3例、肾动脉2例、髂总动脉2例、髂内动脉1例、胆囊动脉1例、阴茎动脉1例)选择不同的治疗方法,9例肢体动脉近大关节处假性动脉瘤采用球囊临时阻断血流下瘤体切除、血管吻合术或直接切开修补术,4例主干型假性动脉瘤采用覆膜支架腔内隔绝术,其中2例发生于髂内动脉开口处的髂总动脉主干型假性动脉瘤采用分支动脉栓塞和覆膜支架腔内隔绝术,6例终末型假性动脉瘤采用明胶海绵结合不锈钢圈栓塞术.结果 21例假性动脉瘤采用不同的方法治疗后瘤腔全部消失,11例肢体动脉假性动脉瘤患者术后远端血管搏动正常,未出现神经损伤,2例脾动脉主干近端、2例髂总动脉主干假性动脉瘤覆膜支架隔绝术后无内漏、远端血流通畅,6例终末型假性动脉瘤患者栓塞后瘤腔消失,出血停止,未出现脏器缺血坏死,其中1例髂内动脉二级分支多发假性动脉瘤患者,栓塞后1周因骨盆复合伤并发重度感染死亡.结论 根据假性动脉瘤的部化、类型和产生原因,选择不同的治疗方法,在尽量小的创伤下使各部位假性动脉瘤得到有效的治疗.     

Stent-coil treatment of a distal internal carotid artery dissecting pseudoaneurysm on a redundant loop by use of a flexible, dedicated nitinol intracranial stent

Treatment of dissecting pseudoaneurysms of the distal cervical internal carotid artery with preservation of the parent artery by using stents or coils has become routine. Tortuosity remains a significant obstacle to successful endovascular treatment in some cases. We report the use of a stent-coil technique to treat a nonhealing dissecting pseudoaneurysm and associated stenosis with anatomic preservation of a redundant loop involving the stented arterial segment. This was accomplished by using a Neuroform dedicated intracranial stent.     

Pseudoaneurysm and renal arteriovenous fistula after nephrectomy: two cases treated by transcatheter coil embolization

Pseudoaneurysms and arteriovenous fistulas of renal arteries are rare clinical lesions. Invasive renal procedures may lead to pseudoaneurysm or arteriovenous fistulas (AVFs). We report two pseudoaneurysms and arteriovenous fistula cases that were treated by transcatheter embolization with metallic coils. The first case is left main renal artery pseudoaneurysm after nephrectomy in a patient with a solid renal tumor. The second case is right main renal artery AVF with giant pseudoaneurysm after both gunshot injury and nephrectomy. On the basis of color Doppler sonography and computed tomography (CT) findings, cases were diagnosed as pseudoaneurysm after nefrectomy. Contrast-enhanced CT scans showed a hyperdense area within the hematoma consistent with pseudoaneurysm. Endovascular treatment with coil embolization succeeds to total occlusion in renal artery pseudoaneurysm. Delayed hemorrhage related to postnephrectomy may be life-threatening conditions because of diagnostic difficulties. AVF and pseudoaneurysm can be treated safely and successfully by transcatheter arterial embolization.     

Acute pseudoaneurysm of the femoral artery after repeated trauma in full-contact karate practice

Traumatic pseudoaneurysms of the deep femoral artery are only encountered infrequently in sports medical literature. We present the case of a male who, after practising full-contact karate, experienced pain and oedema in the right thigh. The ultrasound results and the arteriography showed the presence of a pseudoaneurysm in a branch of the deep femoral artery. Traumatic pseudoaneurysms of the deep femoral artery are normally secondary to endovascular interventions or to mycotic infections in injecting drug users. The majority appear asymptomatically as a pulsatile mass, although on occasions clinical signs of compression (pain, neurological or venous symptoms) may occur or, if the aneurysm bursts, hypovolemic shock.     

Carotid and vertebral artery trauma: clinical and angiographic features.

Injury to the carotid or vertebral artery is an important clinical entity that requires angiography for definitive diagnosis and evaluation. The common carotid artery may be injured by penetrating trauma while the internal carotid artery is usually damaged by either trivial or blunt trauma. With trivial trauma extracranial internal carotid artery dissection should be considered if there is unilateral headache, Horner's syndrome or delayed transient ischaemic attack, and intracranial dissection if a profound neurological defect occurs immediately following trauma. Injury to the internal carotid artery following blunt trauma includes dissection of the extracranial internal carotid artery, carotid-cavernous fistula and pseudoaneurysm formation. These should be considered in a patient with delayed neurological deficit, mandibular or skull fracture, a constellation of orbital signs or diffuse subarachnoid haemorrhage, respectively. Vertebral artery injury is less frequent. Dissection typically follows abrupt cervical rotation and occurs at C1-2, whereas penetrating trauma may involve either the proximal or distal vertebral artery and occlusion, arteriovenous fistula or pseudoaneurysm may be found. Endovascular techniques may be used in either the carotid or vertebral artery to close fistulae or occlude an extensively damaged vessel.     

Bare Stent Implantation in Iatrogenic Dissecting Pseudoaneurysm of the Superior Mesenteric Artery

Iatrogenic arterial dissection leading to the development of dissecting pseudoaneurysms of the superior mesenteric artery (SMA) is a rare complication of angiography. Surgical and endovascular treatment options exist for this important condition. We report a case of bare stent implantation in dissecting pseudoaneurysm of the SMA that developed after angiography in a patient with acute mesenteric ischemia. Although it is rarely published, iatrogenic arterial dissection causing pseudoaneurysm can occur after diagnostic and interventional angiography. Bare stent implantation in dissecting pseudoaneurysm of the SMA could be an advantageous endovascular treatment option in selected cases due its to potential preservation of important side branches of the SMA.     

Massive epistaxis related to petrous carotid artery pseudoaneurysm after radiation therapy: emergency treatment with covered stent in two cases

Two patients had acute left carotid rupture from radiation therapy-induced pseudoaneurysms, resulting in hemodynamic collapse. Because the patients were semicomatose and in shock, an immediate salvage procedure was needed. Location of the pseudoaneurysm at the skull base made surgical treatment less possible. Endovascular therapy was the treatment of choice. Preserving patency of the carotid artery was a desirable option. The successful use of a covered stent in the emergency treatment of massive epistaxis due to active bleeding from pseudoaneurysm in the petrous internal carotid artery (ICA) is described.     

Dispersion of coils after parent-artery occlusion of radiation-induced internal carotid artery pseudoaneurysm

We report a rare complication following parent-artery occlusion in a patient with radiation-induced carotid pseudoaneurysms. Both the right internal carotid artery pseudoaneurysm and the recurrent external carotid artery pseudoaneurysm were treated by parent-artery occlusion with coils. Although rebleeding was not observed after the second embolization, angiography and endoscopy at the 12-month follow-up showed dispersion and migration of coils into the pharynx and the external auditory canal due to progressive radiation necrosis.     

Eagle syndrome presenting with external carotid artery pseudoaneurysm

Eagle syndrome refers to a clinical syndrome caused by the abnormal elongation of the styloid process with calcification/ossification of the stylohyoid ligament. We present the first reported case of Eagle syndrome resulting in an external carotid artery (ECA) pseudoaneurysm. A patient presented to emergency room with an expanding, painful right-neck mass. CT angiography with three-dimensional volume rendering showed a bilobed 4.0-cm right ECA pseudoaneurysm and bilateral ossification of the stylohyoid ligaments with a sharpened edge of the right styloid process at the level of the carotid artery. Aneurysmectomy was performed, and a common carotid to internal carotid bypass with reversed saphenous vein restored arterial continuity. Local resection of the styloid process with a rotational sternocleidomastoid flap was performed. The pathology report was consistent with a diagnosis of a pseudoaneurysm. A six-month clinical follow-up confirmed the complete resolution of symptoms with no neurological deficits.     

Pseudoaneurysm of internal mammary artery caused by pulmonary actinomycosis

Although internal mammary artery pseudoaneurysms are a rare vascular abnormality, they are sometimes seen after sternotomy, diagnostic and therapeutic vascular access or penetrating chest trauma. To our knowledge, internal mammary artery pseudoaneurysm caused by pulmonary actinomycosis has not been reported previously. We report a case of pseudoaneurysm of the left internal mammary artery caused by pulmonary actinomycosis. A 50-year-old woman initially presented with clinical and radiological features of pneumonia, for which she was treated empirically with antibiotics. Later, she developed haemoptysis along with pain and swelling in the left upper chest wall. Multidetector CT (MDCT) with CT angiography showed a cavitating mass in the left upper lobe of the lung that infiltrated into the chest wall and a pseudoaneurysm of the left internal mammary artery. Imaging suggested that the lung mass resulted from pulmonary actinomycosis, which was confirmed by the histopathology of a fine-needle aspiration specimen.     

头颈部动脉夹层多层螺旋CT成像

目的：探讨头颈部动脉夹层（CAD）多层CT血管成像（MSCTA）表现及其临床应用价值。方法：对经DSA证实的35例CAD患者的临床及MSCTA资料进行回顾性分析。结果：35例患者共累及38支血管,3例患者病变累及2支血管段。其中颈内动脉系统夹层22支（57．9％）,椎基底动脉系统16支（42．1％）。双腔征（27支）、珠线征（11支）、锥状闭塞（8支）、瘤样扩张（13支）、内膜瓣（2支）是CAD特征性MSCTA表现。以DSA结果为标准,MSCTA诊断头颈部动脉夹层的敏感度为97．4％,特异度为99．1％,阳性预测值为92．5％,阴性预测值为99．7％,符合率为99．0％。结论：MSC—TA对头颈部动脉夹层的诊断具有较高的敏感性和特异性,可以作为评价头颈部动脉夹层的首选无创性检查手段。     

颈动脉16层螺旋CT成像和应用

随着多层螺旋CT的不断发展,多层螺旋CT成像及血管造影已成为颈动脉疾病的主要检查方法,研究证明CTA在评价颈动脉的狭窄和闭塞上与DSA有高度的一致性,可常规用来评价颈动脉狭窄等病变.同时CTA还可用来评价颈部血管外伤,可以发现颈部血管部分或完全闭塞、假性动脉瘤、夹层、动静脉瘘等,以及颈部软组织、气道、颈髓椎管等部位的病变,可作为怀疑颈部血管外伤但暂无手术指征的无创性检查方法.     

Use of covered stent grafts in the extracranial carotid artery: report of three patients with follow-up between 8 and 42 months

Currently, most carotid artery pathologic abnormalities resulting in pseudoaneurysm formation or stenosis are repaired by surgical intervention. Because surgical intervention requires proximal and distal control of the artery, pseudoaneurysms near the skull base may be very difficult to repair and pose greater risk to the patient. As a result, endovascular techniques have evolved in an effort to reduce morbidity associated with surgical techniques. Parent vessel occlusion and coil placement are the most frequently used endovascular techniques for carotid artery repair of pseudoaneurysms. Intimal hyperplasia is generally treated with balloon angioplasty, often in conjunction with uncovered stent placement. Parent vessel occlusion may be impractical if the patient is unable to tolerate occlusion of that artery. We report our experience in treating three patients with carotid artery stent grafts.     

Aortic branch artery pseudoaneurysms accompanying aortic dissection. Part I. Pseudoaneurysm anatomy

PURPOSE: Small areas of blood flow are sometimes seen within an otherwise thrombosed false lumen on computed tomography (CT) scans of intramural hematomas of the aorta. These are blood-filled spaces that, although they have no apparent communication with the true lumen, appear isodense with the aorta on contrast-enhanced CT scans. The purpose of this report is to describe angiographic and autopsy studies that establish the nature of this entity and describe the principal CT features distinguishing it from a penetrating ulcer. MATERIALS AND METHODS: Conventional angiographic and CT aorta findings in two cases with small collections of contrast material within an otherwise thrombosed false lumen of an aortic dissection are discussed. Also examined is another case with pathologic and histologic findings in addition to those of small collections of contrast material within an otherwise thrombosed false lumen of an aortic dissection, which illustrate the pathoanatomy of these lesions. RESULTS: Angiographic and necropsy evidence shows that some of these lesions represent branch artery pseudoaneurysms and, as such, are secondary to an intramural hematoma, not the primary cause of it. CONCLUSIONS: Difficulty in demonstrating communication between these collections of contrast material and the adjacent true lumen of the aorta on helical CT examinations and the characteristic location of these lesions along the nonpleural portion of the aortic circumference distinguish them from penetrating ulcers and should suggest the diagnosis of branch artery pseudoaneurysm. Demonstration of a branch artery originating from the contrast collection confirms the diagnosis. These branch artery pseudoaneurysms should be distinguished from penetrating atherosclerotic ulcers.     

Pseudoaneurysm of the internal carotid artery after shrapnel injury in World War II: demonstration by CT angiography with 3D MIP reconstruction

A case of pseudoaneurysm of the left internal carotid artery (ICA) after shrapnel injury is demonstrated by intra-arterial digital subtraction angiography (DSA) and computed tomography angiography (CTA) with subtraction technique. Although the pseudoaneurysm was well demonstrated by intra-arterial DSA, CTA was the only modality to demonstrate the three-dimensional shape of the perfused part of pseudoaneurysm and the aneurysmal neck, which affected the therapeutic strategy. The CTA technique is useful in the assessment of large pseudoaneurysms and for therapeutic planning. Received: 2 July 1998; Revision received: 5 November 1998; Accepted: 7 December 1998     

Postoperative evaluation of composite aortic grafts: comparison of angiography and CT

Postoperative angiography and computerised tomography were performed in 10 patients 8 to 57 months after surgical repair (nine composite, one distal graft) of aneurysms of the thoracic aorta (six dissecting, four true aneurysms). Angiography and angio-CT showed chronic dissection of the distal aorta in five of six patients with dissecting aneurysms and detected a pseudoaneurysm originating from the distal suture line in another patient. CT may serve as an initial procedure for postoperative examinations after surgery of aortic aneurysms to demonstrate the state of the false lumen and the formation of pseudoaneurysms. The coronary arteries and aortic valve function have to be evaluated by angiography.     

US, CT, and MR evaluation of accessory renal arteries and proximal renal arterial branches

RATIONALE AND OBJECTIVES: The purpose of this study was to compare color Doppler ultrasound (US), computed tomographic (CT) angiography, and magnetic resonance (MR) angiography for the evaluation of accessory renal arteries and proximal branches of the main renal artery. MATERIALS AND METHODS: Fifty-six subjects who had undergone conventional arteriography of the renal arteries participated in a prospective comparison of Doppler US (45 patients), CT angiography (52 patients), and nonenhanced MR angiography (28 patients). Conventional arteriography depicted 28 accessory renal arteries and 21 proximal branches of the main renal artery within 2 cm of the aorta. RESULTS: US depicted five of 24 accessory renal arteries seen at arteriography but no proximal arterial branches. CT angiography depicted 24 of 26 accessory renal arteries and 13 of 17 proximal arterial branches, as well as 15 additional accessory renal arteries not seen at conventional arteriography. MR demonstrated 11 of 15 accessory arteries, as well as four additional accessory arteries not seen at conventional arteriography. MR did not depict any of nine proximal arterial branches seen at conventional arteriography. CONCLUSION: When compared with US or nonenhanced MR angiography, CT is the preferred method for evaluation of accessory renal arteries and proximal branches of the renal artery.