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
Technique : Erect PA Film Focal Distance : 2 m

Sufficient inspiration :
R Hemidiaphragm below ant.end of 6th rib
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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
CTR
Cardiac size : Cardio-Thoracic Ratio

(a+b)/ x
Normally CTR < 50%

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Plain Film
CTR Not valid in : 1. AP film or Portable film

2. Raised diaphragm : ascites, mass, insp.<

3. Flat chest or depressed sternum

4. Obesity
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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

LEFT VENTRICLE

Rounding of LV contour
Apex : left & downwards Lat.view : >2 cm behind IVC (Retrocardial clear space <<)
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Left Ventricle Enlargement

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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
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Left Atrium Enlargement

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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 <<
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Right Ventricle Enlargement

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Specific chamber enlargement

RIGHT ATRIUM

Enlargement to the right (>1/3 R-diaphragm)

Lat.view : increased cardiac shadow in upper & anterior part

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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. : +

:-

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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
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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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
CT ANGIO

aneurysm
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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 Media : echogenic : 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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Time is Brain!

Perfusion CT images

Cerebral Blood Flow

Flow without vessels

Peak Enhancement

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Time is Brain!

Perfusion CT images

Cerebral Blood Volume

Time to start

Time to Peak

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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
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Time is Brain!

Perfusion CT images
Cerebral Blood Flow
Color coding
Vessels

or

Gray matter
White matter Very low flow No calculation

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Time is Brain!

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

Perfusion CT images
Time to Peak
Time to local perfusion peak Provide insight into collateral flow or sluggsih flow Scaled in 0.1 second; eg: a value of 80 = 8 seconds until local peak is reached
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Time is Brain!

Perfusion CT images
Time to Peak
Color coding

time

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Time is Brain!

Perfusion CT images
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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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

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Time is Brain!

Perfusion CT images
CBF with ROIs
Relative Perfusion Index for
prognostic evaluation
< 0.2 : Critical value; fibrinolytic therapy not indicated : 50% response well : Good outcome
Konig, Klotz & Heuser Electromedica 1998 66; 61-67

0.2 - 0.35 0.35 - 0.9

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Time is Brain!

Incomplete MCA Infarction

44 year old male

160 min after symptoms

1 day after therapy

after 3 days
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Time is Brain!

Infarction in Basal Ganglia

26 year old female

CBF

Time to Peak

after therapy
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Time is Brain!

Seizure
56 year old female

Plain CT

CBF

Time to Peak
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Embolization - Alcohol

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Embolization - Coil

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Embolization - Particles

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