aortic cta vs mra: which exam to perform?€¦ · ecg-gated cta tricks cemra 1t shiga et al. arch...
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Aortic CTA vs MRA: which exam to perform?
Thomas M. Grist, MDUniversity of Wisconsin-
Madison
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Objectives
• List the advantages and limitations of MRA and CTA.
• Understand the diagnostic information available form each method.
• Discuss the role for each technique in evaluation of aortic vascular diseases
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Outline
• Differences between CTA and MRA• Contraindications• Scanning• Diagnostic differences
• Artifacts• Resolution• Function
• Cases
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“Contraindications - CTA”
• Intravenous contrast • Prior anaphylactic reaction• Renal insufficiency
• Radiation exposure• Pregnant patients• Young adults and children
Con
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Radiation dose: Growing risk• CT has revolutionized medicine
since its invention in 1967• Main method of diagnosing
many medical problems• Hounsfield and Cormack
received Nobel Prize in 1979
• Increasing concern over radiation exposure from medical imaging
DJ Brenner and EJ Hall. NEJM 2007; 357: 2277-2284.
AJ Einstein et al. JAMA 2007: 317-323.
DJ Brenner and EJ Hall. NEJM 2007; 357: 2277-2284.
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Radiation dose from CTA
Examination Typical Effective Dose (mSv)
Background radiation 3 (per year)
Chest x-ray 0.02 – 0.05
Chest CT 5 – 7
Coronary CTA 5 – 20
Abdominal CTA 5 – 20
Coronary cath (diagnostic) 2 – 6
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AJ Einstein et al. JAMA 2007: 317-323.
DJ Brenner and EJ Hall. NEJM 2007; 357: 2277-2284.
Radiation dose: Cancer riskC
ontra
indi
catio
ns
Caveat: Based on the linear, no-threshold model
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MJ Goske, et al. AJR 2008; 190: 273-274.
• Cancer risk is not constant and varies between men and women
• Implications for cardiovascular CT• In young patients
• Consider imaging modalities that do not use ionizing radiation (MRI/MRA, ultrasound)
• In older patients• Risk from CTA is less than for catheter angiography
• Dose reduction techniques should be used when possible
Radiation dose: Dose reductionC
ontra
indi
catio
ns
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• Magnet• Pacemakers1
• Other implanted devices1
• Claustrophobia
• Gadolinium• Allergies extremely rare• Patients at risk of NSF• Pregnancy
“Contraindications” – MRA
1MRIsafety.com
Con
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NSF risk
University of Wisconsin:
• Any patient with • eGFR ≤ 30 mL/min/1.73m2
• Inpatient with• eGFR ≤ 60 mL/min/1.73m2 AND• Pro-inflammatory condition/event
• Vascular injury• Surgery• Systemic infection
Non-contrast MRA
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Scanning differences
CTA MRA
Coverage Large FOV with single scan Large FOV with multiple scans
Setup time Short Long
Scan time Short Long1
Technical complexity Easy to perform More difficult to perform
Postprocessing time Long Short
Claustrophobia Rare Occasionally
1Many more sequences and much more information acquired with MRA. Actual MRA sequences are short.
Overall,
CTA quicker and easier to perform.
MRA more complex, but with more information.
Scan
ning
diff
eren
ces
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Artifacts• Metal –
• CT – beam hardening• MR – susceptibility
• Severity depends on type, size, location • CAUTION when grading in-stent stenosis
Right THA
CTA
Left renal artery stent
CTA MRA
Dia
gnos
tic d
iffer
ence
s
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MRA: Stent Artifact
• Stainless steel a problem
• Nitinol generally OK
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Artifacts
• Calcifications• CT – beam hardening overestimates
stenosis• MR – calcifications not a problem
• Metal –• CT – beam hardening• MR – susceptibility
• Severity depends on type, size, location • CAUTION when grading in-stent stenosis
Non-contrast CT
CTA
Dia
gnos
tic d
iffer
ence
s
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Resolution
• Spatial resolution• Ability to resolve adjacent objects• CTA: 0.7 x 0.7 x 1.0 mm3
• MRA: 0.5 x 1.0 x 2.0 mm3
• Contrast resolution
CTA MRA DSA
Dia
gnos
tic d
iffer
ence
s
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Resolution
• Ability to detect lesion• More than spatial resolution• Also depends on
difference in density/intensity between vessel and surrounding tissues
• Spatial resolution• Ability to resolve adjacent objects• CTA: 0.7 x 0.7 x 1.0 mm3
• MRA: 0.5 x 1.0 x 2.0 mm3
• Contrast resolution
T2-weighted MRI
CTA
Dia
gnos
tic d
iffer
ence
s
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Function
• CTA is static• Anatomical information only
• No hemodynamic information
• MRA is dynamic• Anatomical and hemodynamic information
• Phase contrast• Time resolved (TRICKS) MRA
Dia
gnos
tic d
iffer
ence
s
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Function: CTA vs. MRA
2 month old male with aortic coarctation
Phase-contrast MRA using VIPR7 minute exam
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Function: CTA vs MRAD
iagn
ostic
diff
eren
ces
Time resolved CE-MRA can be used to assess hemodynamics of vascular lesions
CTA 3D SPGR CE-MRA Time-resolved CE-MRA
37 year-old female with pulmonary sequestration
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Case 1C
ases
–Th
orac
ic
• 45 year-old male in MVC
Widened mediastinum – CTA to rule out traumatic aortic dissection
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Case 1C
ases
–Th
orac
ic
• 45 year-old male in MVC
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Traumatic aortic dissection• Rapid diagnosis and high NPV required
• CTA preferred• Performed at same time as other CT imaging• Sensitivity 100%1
• In absence of direct evidence of tear, likelihood of injury is 0%2
1M Scaglione et al. Eur Radiol 2001; 11:2444-2448.2M Sammer et al. AJR 2007; 189: 603-608.
Cas
es –
Thor
acic
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Case 2
• 73 year-old male with chest pain radiating to back
Cas
es –
Thor
acic
Widened mediastinum – CTA to rule aortic dissection
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Case 2
• 73 year-old male with chest pain radiating to back
Cas
es –
Thor
acic
Type A dissection
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Acute aortic syndrome: dissection
ECG-gated CTA TRICKS CEMRA
1T Shiga et al. Arch Intern Med 2006; 166: 1350-1356. (Meta-analysis)
• Rapid diagnosis and high NPV required• CTA preferred1
• Sensitivity 100% Specificity 98%• ECG-gating required to compensate for cardiac motion in
ascending aorta• MRA for patients who cannot have CTA
• Sensitivity 98% Specificity 98%
Cas
es –
Thor
acic
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Acute aortic syndrome: dissection
Non-contrast MRA
• FS Pereles, et al. Radiology 2002; 223: 270-274.• Retrospective review of
29 studies.• Single-shot SSFP images
had accuracy of 100%
Cas
es –
Thor
acic
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Lt renal artery doppler in normal volunteer
Rt renal artery
Lt renal artery
Case 3
• 24 year-old female with hypertension
Cas
es –
Thor
acic
Bilateral tardus parvus waveforms indicating either bilateral renal artery stenosis or obstruction proximally – MRA to rule out RAS and aortic coarctation
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Case 3
• 24 year-old female with hypertension
Cas
es –
Thor
acic
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• MRA preferred• No radiation exposure• Able to evaluate hemodynamics through abnormalities• Evaluation of congenital heart abnormalities, if present
Congenital
Sequestration Coarctation Patent ductus arteriosus
Cas
es –
Thor
acic
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• Circumferential wall thickening, aneurysm, stenosis• MRA preferred
• Greater soft tissue contrast increases sensitivity and specificity
Aortitis
CTA
bSSFP DIR T2 w FS FSPGR w Gd
Cas
es –
Thor
acic
aor
ta
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Case 4C
ases
–Ab
dom
inal
• 92 year-old female in ED with abdominal pain
Mass in abdomen displacing bowel peripherally – CT to rule out mass
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Case 4C
ases
–Ab
dom
inal
• 92 year-old female in ED with abdominal pain
AAA
Impending rupture
Thrombosed Right CIA
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Abdominal aortic aneurysm: DxC
ases
–Ab
dom
inal
• Ultrasound – screening• U.S. Preventive Services Task Force recommends screening with
ultrasound men 65-75 years old who have history of smoking1
• CT angiography – acute AAA rupture, follow-up• Endovascular Rx planning
• MR angiography – follow-up• Size• Type (saccular, fusiform, mycotic)• Location (suprarenal, infrarenal)• Extent
• Digital subtraction angiography – endovascular treatment
1C Fleming et al. Ann Intern Med 2005; 142: 203-211.
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Pre-operative planning for stent graft
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Aneurysm Volume Measurement: CTA
• Non-contrast CTA• If change in aneurysm
size >2%, consider endoleak
• Then perform contrast CTA
• Bley et al, Radiology 2009
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Aortic aneurysm• Detect and measure aneurysm
• CTA and MRA equivalent
• Detect and measure affect on AV• MRI with cine bSSFP and PC
better than
• ECG-gated CTA
Cas
es –
Thor
acic
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Aortic aneurysm: measurements
*
• CE-MRA, like DSA, shows lumen, not true wall-to-wall diameter• Need to look at other sequences to get wall-to-wall measurement
Cas
es –
Thor
acic
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Artery of Adamkiewicz
Artery of Adamkiewicz- diameter 0.6 mm
- supplied byintercostal/lumbar arteries
- origin highly variable
= Great Radiculomedullary Artery
Albert Adamkiewicz 1850 - 1921
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TAA repair
1Black JH 3rd et al. J Vasc Surg. 2006 Feb;43 Suppl A:6A-11A.
Thoracoabdominal Aortic Aneurysm Repair- intercostal/lumbar arteries ligated- injury artery of Adamkiewicz
spinal cord infarction- 5-10% in centers of excellence1
measures to avoid paralysis- CSF drainage- intraoperative hypothermia- pharmacologic protection
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Intercostal artery anastomosis
Aortic Graft
Reducing Paralysis Risk During TAA Repair
TAA repair
Intercostal artery reimplantation1, 2
paralysis decreased from 4.83% to 0.88%
1Acher CW et al. Ann Surg. 2008 Oct;248(4):529-40.2Mell MW et al. J Surg Res. 2008 Jun 20. [Epub ahead of print]
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Challenges
Artery of Adamkiewiczsupplied by radiculomedullary arteries
tiny artery: 0.6 mm diameter high spatial resolution
variable supply: 70 left : 30 right, T7 -L2
large FoV
great anterior radiculomedullary vein - similar appearance- different location - difficult to identify vein & artery
VeinArtery
Nijenhuis et al, AJNR 2006
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Technique
artery of Adamkiewicz
anterior spinal artery
great anterior radiculomedullary
vein
•• 3T with spine coil3T with spine coil•• 40 ml Multihance40 ml Multihance•• Sublingual Sublingual
NitroglycerineNitroglycerine•• High resolution High resolution
Sagittal TRICKS Sagittal TRICKS acquisitionacquisition
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How To Choose???
• Depends on…• Application• Technology• Availability• Patient Population• Contraindications
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Specific Applications (the easy ones)
• Aortic dissection, acute vascular injury, acute ischemia• CTA
• Rapid diagnosis
• Congenital• MRA
• Avoids radiation and can evaluate hemodynamics
• Vasculitis • MRA
• Better contrast resolution
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Acknowledgments
• Scott Reeder, MD, PhD• Chris Francois, MD• Mark Schiebler, MD
Disclosures:GE Health Care: Research supportConsultant: Bracco, Bayer
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Specific Applications (our preference)
• Aneurysm• CTA or MRA
• MRA avoids radiation and nephrotoxic contrast material
• Peripheral vascular disease• MRA preferred
• Easier image post-processing• Calcified plaque not a problem with MRA
• Arteriovenous malformations• MRA preferred
• Time resolved MRA