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CARDIOVASCULAR IMAGING

A.Gunawan Santoso

Dept. of Diagnostic Radiology

Diponegoro Univ./Dr.Kariadi General Hospital

12/31/2013 1

CARDIAC IMAGING
• Conventional X-Rays / Plain film • Utrasound - Color Doppler

• Angiography
• CT - CT Angio

• MR - MR Angio
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CARDIAC IMAGING

COLOR DOPPLER
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CARDIAC IMAGING
• CT : Axial slices

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CARDIAC IMAGING • CT : Cine 12/31/2013 5 .

Plain Film • Very minor role in Dx of cardiac conditions • Changes in cardiac contour : LATE • Heart size : assessed only in PA film • Lateral film : oesophagus filled w/ Barium 12/31/2013 6 .

CARDIAC IMAGING • CT : Longitudinal slices 4 slices 12/31/2013 7 .

Plain Film Technique : • Erect PA • Film Focal Distance : 2 m • Sufficient inspiration : R Hemidiaphragm below ant.end of 6th rib 12/31/2013 8 .

Plain Film PA projection 12/31/2013 9 .

Plain Film 12/31/2013 10 .

Plain Film PA VIEW 12/31/2013 11 .

Plain Film CTR • Cardiac size : Cardio-Thoracic Ratio • (a+b)/ x • Normally CTR < 50% 12/31/2013 12 .

mass. Raised diaphragm : ascites.Plain Film CTR • Not valid in : 1. insp. Obesity 12/31/2013 13 . Flat chest or depressed sternum 4. AP film or Portable film 2.< 3.

Plain Film Lateral projection 12/31/2013 14 .

Plain Film Lateral view 12/31/2013 15 .

Plain Film Lateral Film 12/31/2013 16 .

Small Cardiac Shadow • Wasting diseases • Malnutrition • Addison’s disease • Emphysema • Constrictive Pericarditis 12/31/2013 17 .

view : >2 cm behind IVC (Retrocardial clear space <<) 12/31/2013 18 .Specific chamber enlargement LEFT VENTRICLE • Rounding of LV contour • Apex : left & downwards • Lat.

Left Ventricle Enlargement 12/31/2013 19 .

Specific chamber enlargement LEFT ATRIUM • Prominent left atrial appendage • Double density : on right side • Lateral View : L main bronchus : lifting & narrowing Collapse at L lower lobe (later) Ba swallow : L atrial indentation 12/31/2013 20 .

Left Atrium Enlargement 12/31/2013 21 .

Specific chamber enlargement RIGHT VENTRICLE • Usually not visible on plain film • Enlargement to left • Apex points upwards • PA view : displace R.A to right • Retrosternal clear space << 12/31/2013 22 .

Right Ventricle Enlargement 12/31/2013 23 .

Specific chamber enlargement RIGHT ATRIUM • Enlargement to the right (>1/3 R-diaphragm) • Lat.view : increased cardiac shadow in upper & anterior part 12/31/2013 24 .

Left Atrium Enlargement 12/31/2013 25 .

CARDIAC IMAGING • New CT • 16 slices • Endovascular imaging 12/31/2013 26 .

Congenital Heart Disease • Abnormalities of Position • Abnormalities of Size • Left to Right shunt • Right to Left shunt • Transposition of Great Vessels 12/31/2013 27 .

Abnormalities of Position • Dextrocardia • Complete Situs inversus • Right-sided aortic arch • Left-sided SVC 12/31/2013 28 .

Eisenmenger’s syndrome) 12/31/2013 29 .Left to Right shunt • Main & branch Pulmonary artery enlargement • Constriction of peripheral pulm.artery • Reversal of shunt (cyanosis.

Left to Right shunt • Common to : Atrial Septal Defect (ASD) Ventricular Septal Defect (VSD) Patent Ductus Arteriosus (PDA) 12/31/2013 30 .

Atrial Septal Defect (ASD) • R. : + • R.V.A. : + • A :- 12/31/2013 31 .

: + • L.Ventricular Septal Defect (VSD) • R.V.A.V. : + • L. : + • A :N 12/31/2013 32 .

V. : + 12/31/2013 33 .Patent Ductus Arteriosus (PDA) • A :+ • L.A. : + • L.

Right to Left shunt • Fallot’s Tetralogy • Truncus Arteriosus • Eisenmenger’s complex 12/31/2013 34 .

VASCULAR IMAGING • Aorta • Artery • Capilary • Vein 12/31/2013 35 .

Pathology • Atherosclerosis : Occlusive .aneurysmal • Intimal hyperplasia (restenosis) • Inflamatory disease • Fibrodysplasia • Neoplasia 12/31/2013 36 .

Pathology
• Abnormal arteriovenous communication • Traumatic injury

• Embolic disease
• Physiologic disturbances

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ATHEROSCLEROSIS
• • Degenerative disease of large & medium sized blood vessels Fibrofatty plaque


• • •

Calcification
Surface erosion or ulceration Internal hemorrhage Surface thrombus
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ATHEROSCLEROSIS
Sign of Stenoses
• Focal narrowing of the lumen • Descriptive features : Length Severity Morphology Collateral vessel
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ATHEROSCLEROSIS
Aneurysm
• Luminal diameter -adjacent or standard

• Loss Normal vascular tapering • Descriptive features : Luminal diameter Location • Limitation : partially filled with thrombus
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fibrin precipitation • Narrowing of the lumen • Thrombus & vessel rupture • Pseudoaneuryms formation 12/31/2013 41 .INFLAMMATORY DISEASE • Vasculitis : inflamatory infiltration in wall (media by histocytes) • Edema.

INFLAMMATORY DISEASE • “Mycotic” pseudoaneurysm • Radiation vasculitis : stenoses occlusion beaded areas of narrowing 12/31/2013 42 .

VASCULITIS • Polyarteritis nodosa • Takayasu’s arteritis (Pulseless disease) • Buerger’s disease (Thromboangitis obliterans) • Temporal arteritis (Giant cell arteritis) • Kawasaki’s disease (Mucocutaneus lymph nd syndr • Behcet’s disease 12/31/2013 43 .

media or adventitia by fibrous connective tissue • “String of beads” • Multiple stenoses.FIBRODYSPLASIA • Nonatherosclerotic • Noninflamatory • Replacement of intima. focal stenosis 12/31/2013 44 .

VASCULAR IMAGING • DIAGNOSTIC • TREATMENT VASCULAR & INTERVENTIONAL RADIOLOGY 12/31/2013 45 .

PTA (Percutaneous Tranluminal Angioplasty) b. Dialysis Access intervention 12/31/2013 46 . Central Venous Access i. Management of GI bleeding f. Fibrinolytic Therapy c. Embolization Therapy d. Endovascular Stenting or Stent-Graft e. IVC filter h. Portal Hypertension and TIPS g.Vascular Intervention a.

CT Angio • MR .MR Angio 12/31/2013 47 .VASCULAR IMAGING • Conventional X-Rays / Plain film • Utrasound . • Angiography • CT .Color Doppler – Intravasc.

Plain Film • Relative Radioluscens • Calcification • Abdominal aneurysm 12/31/2013 48 .

Vascular imaging •Carotid artery calcification 12/31/2013 49 .

Vascular imaging CT ANGIO aneurysm 12/31/2013 50 .

Vascular imaging 12/31/2013 51 .

Angioguard filter Interventional Radiology 12/31/2013 52 .

Renal arteriography 12/31/2013 53 .

Color Doppler • Carotid artery 12/31/2013 54 .

Intravascular US • Intima • Media : echogenic : hypoechoic • Adventitia : echoenic 12/31/2013 55 .

Intravascular US 12/31/2013 56 .

Covered stent • Pseudoaneurysm 12/31/2013 57 .

Femoral artery obstruction • Guide wire test 12/31/2013 58 .

Angioplasty balloon cath. • Anatomic 12/31/2013 59 .

Femoral & Pelvic arteries 12/31/2013 60 .

Stenosis of R renal artery 12/31/2013 61 .

COW Aneurysm 12/31/2013 62 .

Pulmonary Embolism 12/31/2013 63 .

Aortic Dissection 12/31/2013 64 .

Abdominal Arteries 12/31/2013 65 .

Abdominal Aorta Aneurysm 12/31/2013 66 .

but what? 71 year old female 90 minutes after onset of symptoms 12/31/2013 67 .No hemorrhage.

Major Vascular Occlusion Vascular CBF Time to Peak 12/31/2013 68 .

Perfusion CT images Maximum Intensity Projection Sum Image 12/31/2013 69 .

Time is Brain! Perfusion CT images Cerebral Blood Flow Flow without vessels Peak Enhancement 12/31/2013 70 .

Time is Brain! Perfusion CT images Cerebral Blood Volume Time to start Time to Peak 12/31/2013 71 .

Time is Brain! Perfusion CT images Cerebral Blood Flow • Directly related to amount of oxygen supplied to the brain tissue Hence. shows ischemic cerebral areas • • Expressed in ml/100ml/min 12/31/2013 72 .

Time is Brain! Perfusion CT images Cerebral Blood Flow Color coding Vessels or Gray matter White matter Very low flow No calculation 12/31/2013 73 .

eg: a value of 30 = 3% blood volume 12/31/2013 74 .Time is Brain! Perfusion CT images Cerebral Blood Volume • • • Relative volume ratio of blood Describe another hemodynamic aspects Scaled in 1/1000.

1 second. eg: a value of 80 = 8 seconds until local peak is reached 12/31/2013 75 .Time is Brain! Perfusion CT images Time to Peak • • • Time to local perfusion peak Provide insight into collateral flow or sluggsih flow Scaled in 0.

Time is Brain! Perfusion CT images Time to Peak Color coding time 12/31/2013 76 .

not HU values CBF • pixel value = blood flow • eg: smaller pixel value = lower blood flow Time to Peak • pixel value = time until bolus peak is reached • eg: higher pixel value = later bolus arrival 12/31/2013 77 .Time is Brain! Perfusion CT images Pixel values represent functional value.

Time is Brain! Perfusion CT images CBF Peak CBV Time to contain most relevant hemodynamic information for classification of type and extent of ischemia and collateral flow 12/31/2013 78 .

35 .2 .9 12/31/2013 79 . 61-67 0. fibrinolytic therapy not indicated : 50% response well : Good outcome Konig.35 0.2 : Critical value.0.0. Klotz & Heuser Electromedica 1998 66.Time is Brain! Perfusion CT images CBF with ROIs Relative Perfusion Index for prognostic evaluation < 0.

Time is Brain! Incomplete MCA Infarction 44 year old male 160 min after symptoms 1 day after therapy after 3 days 12/31/2013 80 .

Time is Brain! Infarction in Basal Ganglia 26 year old female CBF Time to Peak after therapy 12/31/2013 81 .

Time is Brain! Seizure 56 year old female Plain CT CBF Time to Peak 12/31/2013 82 .

Embolization .Alcohol 12/31/2013 83 .

Embolization .Coil 12/31/2013 84 .

Embolization .Particles 12/31/2013 85 .