5/26/2014

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CARDIOVASCULAR
IMAGING
A.Gunawan Santoso
Dept. of Diagnostic Radiology
Diponegoro Univ./Dr.Kariadi General Hospital

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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

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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
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CARDIAC IMAGING
CT : Longitudinal slices
4 slices
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Plain Film
Erect PA
Film Focal Distance : 2 m
Sufficient inspiration :
R Hemidiaphragm below ant.end of 6
th
rib
Technique :
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Plain Film
PA projection
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Plain Film
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Plain Film
PA
VIEW
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Plain Film
Cardiac size :
Cardio-Thoracic
Ratio
(a+b)/ x
Normally CTR < 50%

CTR
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Plain Film

Not valid in :
1. AP film or Portable film
2. Raised diaphragm : ascites, mass, insp.<
3. Flat chest or depressed sternum
4. Obesity

CTR
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Plain Film
Lateral projection
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Plain Film
Lateral view
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Plain Film
Lateral Film
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Small Cardiac Shadow
Wasting diseases
Malnutrition
Addisons disease
Emphysema
Constrictive Pericarditis
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Specific chamber enlargement
Rounding of LV contour
Apex : left & downwards
Lat.view : >2 cm behind IVC
(Retrocardial clear space <<)
LEFT VENTRICLE
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Left Ventricle Enlargement
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Specific chamber enlargement
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
LEFT ATRIUM
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Left Atrium Enlargement
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Specific chamber enlargement
Usually not visible on plain film
Enlargement to left
Apex points upwards
PA view : displace R.A to right
Retrosternal clear space <<
RIGHT VENTRICLE
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Right Ventricle Enlargement
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Specific chamber enlargement
Enlargement to the right (>1/3 R-diaphragm)
Lat.view : increased cardiac shadow in upper
& anterior part

RIGHT ATRIUM
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Left Atrium Enlargement
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CARDIAC IMAGING
New CT
16 slices
Endovascular imaging
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Congenital Heart Disease
Abnormalities of Position
Abnormalities of Size
Left to Right shunt
Right to Left shunt
Transposition of Great Vessels
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Abnormalities of Position
Dextrocardia
Complete Situs inversus
Right-sided aortic arch
Left-sided SVC
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Left to Right shunt
Main & branch Pulmonary artery
enlargement
Constriction of peripheral pulm.artery
Reversal of shunt (cyanosis,
Eisenmengers syndrome)


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Left to Right shunt
Common to :
Atrial Septal Defect (ASD)
Ventricular Septal Defect (VSD)
Patent Ductus Arteriosus (PDA)
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Atrial Septal Defect (ASD)
R.A. : +
R.V. : +
A : -
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Ventricular Septal Defect (VSD)

R.V. : +
L.V. : +
L.A. : +
A : N
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Patent Ductus Arteriosus (PDA)

A : +
L.V. : +
L.A. : +
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Right to Left shunt
Fallots Tetralogy
Truncus Arteriosus
Eisenmengers complex
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VASCULAR IMAGING
Aorta
Artery
Capilary
Vein
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Pathology
Atherosclerosis : Occlusive - aneurysmal
Intimal hyperplasia (restenosis)
Inflamatory disease
Fibrodysplasia
Neoplasia
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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
Focal narrowing of the lumen
Descriptive features :
Length
Severity
Morphology
Collateral vessel

Sign of Stenoses
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ATHEROSCLEROSIS
Luminal diameter -adjacent or standard
Loss Normal vascular tapering
Descriptive features :
Luminal diameter
Location
Limitation : partially filled with thrombus
Aneurysm
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INFLAMMATORY DISEASE
Vasculitis : inflamatory infiltration in wall
(media by histocytes)
Edema, fibrin precipitation
Narrowing of the lumen
Thrombus & vessel rupture
Pseudoaneuryms formation
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INFLAMMATORY DISEASE
Mycotic pseudoaneurysm
Radiation vasculitis : stenoses
occlusion
beaded areas of narrowing
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VASCULITIS
Polyarteritis nodosa
Takayasus arteritis (Pulseless disease)
Buergers disease (Thromboangitis obliterans)
Temporal arteritis (Giant cell arteritis)
Kawasakis disease (Mucocutaneus lymph nd syndr
Behcets disease
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FIBRODYSPLASIA
Nonatherosclerotic
Noninflamatory
Replacement of intima, media or
adventitia by fibrous connective tissue
String of beads
Multiple stenoses, focal stenosis
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VASCULAR IMAGING
DIAGNOSTIC
TREATMENT
VASCULAR & INTERVENTIONAL
RADIOLOGY
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Vascular Intervention
a. PTA (Percutaneous Tranluminal Angioplasty)
b. Fibrinolytic Therapy
c. Embolization Therapy
d. Endovascular Stenting or Stent-Graft
e. Management of GI bleeding
f. Portal Hypertension and TIPS
g. IVC filter
h. Central Venous Access
i. Dialysis Access intervention
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VASCULAR IMAGING
Conventional X-Rays / Plain film
Utrasound - Color Doppler Intravasc.
Angiography
CT - CT Angio
MR - MR Angio
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Plain Film
Relative Radioluscens
Calcification
Abdominal aneurysm

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Vascular imaging
Carotid artery calcification
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Vascular imaging
aneurysm
CT ANGIO
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Vascular imaging
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Angioguard filter
Interventional
Radiology
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Renal arteriography

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Color Doppler
Carotid artery
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Intravascular US
Intima : echogenic
Media : hypoechoic
Adventitia : echoenic

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Intravascular US

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Covered stent
Pseudoaneurysm

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Femoral artery obstruction
Guide wire test
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Angioplasty balloon cath.
Anatomic
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Femoral & Pelvic arteries
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Stenosis of R renal artery
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COW Aneurysm
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Pulmonary Embolism
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Aortic Dissection
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Abdominal Arteries
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Abdominal Aorta Aneurysm
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No hemorrhage, but what?
71 year old female 90 minutes after onset of symptoms
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Major Vascular Occlusion
Vascular CBF Time to Peak
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Perfusion CT images
Maximum Intensity Projection Sum Image
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Perfusion CT images
Time is Brain!
Cerebral Blood Flow Flow without vessels Peak Enhancement
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Perfusion CT images
Time is Brain!
Cerebral Blood Volume Time to start Time to Peak

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Perfusion CT images
Time is Brain!
Directly related to amount of
oxygen supplied to the brain
tissue
Hence, shows ischemic
cerebral areas
Expressed in ml/100ml/min
Cerebral Blood Flow
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Perfusion CT images
Time is Brain!
Cerebral Blood Flow
or
Color coding
Vessels

Gray matter

White matter

Very low flow

No calculation
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Perfusion CT images
Time is Brain!
Relative volume ratio of blood
Describe another
hemodynamic aspects
Scaled in 1/1000;
eg: a value of 30 = 3% blood
volume
Cerebral Blood Volume
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Perfusion CT images
Time is Brain!
Time to local perfusion peak
Provide insight into collateral
flow or sluggsih flow
Scaled in 0.1 second;
eg: a value of 80 = 8 seconds
until local peak is reached
Time to Peak
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Perfusion CT images
Time is Brain!
Time to Peak
Color coding
time
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Perfusion CT images
Time is Brain!
Pixel values represent functional value, 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
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Perfusion CT images
Time is Brain!
CBF CBV Time to
Peak
contain most relevant hemodynamic information for classification of
type and extent of ischemia and collateral flow

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Perfusion CT images
Time is Brain!
CBF with ROIs
Relative Perfusion Index for
prognostic evaluation
< 0.2 : Critical value;
fibrinolytic therapy not
indicated

0.2 - 0.35 : 50% response well

0.35 - 0.9 : Good outcome

Konig, Klotz & Heuser
Electromedica 1998 66; 61-67


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Incomplete MCA Infarction
44 year old male
160 min after
symptoms
1 day after
therapy
after
3 days
Time is Brain!
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Infarction in Basal Ganglia
CBF Time to Peak after therapy
26 year old female
Time is Brain!
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Seizure
Plain CT CBF Time to Peak
56 year old female
Time is Brain!
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Embolization - Alcohol

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Embolization - Coil

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Embolization - Particles