CARDIOVASCULAR IMAGING: Thoracic Imaging
Case Author: Diana Litmanovich, MD, Beth Israel Deaconness Medical Center
History
25-year-old woman with a temperature of 38.0°C, leukocytosis, and 3 weeks of malaise, low-grade fever, and mild to moderate chest pain after being in good health; CT angiography, ultrasound, and MR angiography have been performed, and the next step must be determined.
Imaging Findings
CT angiograms of the lower neck (A) and chest (B) and cross-sectional ultrasound image of the left subclavian artery (C) show uniform circumferential wall thickening of the left common carotid artery (A), aorta (B), and subclavian artery (C) and dilatation of the ascending aorta (B).
Coronal balanced SSFP (steady-state free precession) (D) and oblique sagittal contrast-enhanced 3D (E) MR angiograms of the aortic root and thoracic aorta show dilatation of both the ascending and descending thoracic aorta and aortic wall thickening extending to the abdominal aorta.
Treatment
High-dose steroid therapy
Teaching Points
Diffuse thickening of the wall of the aorta can be caused by an inflammatory or infectious process and atherosclerosis. All of these processes can dilate the aorta.
Takayasu disease can involve both the thoracic and abdominal aorta and aortic branches; in rare cases there is pulmonary arterial involvement. In addition to wall thickening, aortic and branch vessel disease can become manifest as stenosis or luminal narrowing or, less commonly, aneurysmal dilatation. Complete occlusion has also been reported, causing pulseless extremity in the case of subclavian arterial involvement.
Treatment in the acute phase of Takayasu disease is usually restricted to medical therapy with antiinflammatory medications. More aggressive treatment with interventional procedures (e.g., dilation, stent placement) is reserved for the chronic stage, in which fibrosis has set in and strictures and stenosis are present.
Intramural hematoma can be differentiated from inflammatory arteritis, such as Takayasu arteritis, in that it causes eccentric thickening of the aortic wall that is high in attenuation on unenhanced CT images. Vasculitis causes concentric wall thickening that is not high in attenuation, and when the inflammation is active, fat stranding is present around the vessel wall. Both conditions can involve a long segment of the vessel and become complicated by aneurysmal dilation. Strictures do not occur with intramural hematoma.
In young women, dilatation and thickening of the ascending aorta should raise the possibility of inflammatory aortitis, in particular Takayasu arteritis. Differentiating Takayasu from giant cell arteritis on the basis of the radiologic manifestations is difficult, the latter being more common in older men.
Suggested Readings
Gornik HL, Creager MA. Aortitis. Circulation 2008; 117:3039–3051
Restrepo CS, Ocazionez D, Suri R, Vargas D. Aortitis: imaging spectrum of the infectious and inflammatory conditions of the aorta. RadioGraphics2011; 31:435–451
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