Abstract Invasive coronary angiography is con-

sidered to be the gold standard for diagnosis and

follow-up of coronary artery aneurysms, throm-

bosis and stenosis in patients with Kawasaki

Disease. However, the availability of multi-

detector CT coronary angiography provides a

viable alternative as a non-invasive imaging

modality for sequential follow-up of patients with

Kawasaki disease. High quality multidetector CT

angiography images of coronary arterial anatomy

can be obtained after adequate heart rate control

using beta blockers.

Keywords Kawasaki Disease Æ Coronary CT

angiography Æ Multidetector CT Æ Coronary

aneurysm

Review

Kawasaki Disease (KD) is the leading cause of

acquired heart disease in children under the age

of 5 years in the United States and Japan [1]. KD

is an acute febrile illness due to multi-organ

vasculitis characterized by fever, desquamative

skin rash, conjunctival and pharyngeal injection,

swelling of the hands and feet and cervical lym-

phadenopathy [2, 3]. Despite treatment with

intravenous immunoglobulin and high dose aspi-

rin, coronary artery aneurysms are seen in ~25%

of children with KD, especially those under five

years of age. Approximately, 50% of these

aneurysms may completely regress in the first few

years after diagnosis. The morbidity and mortality

in KD is due to coronary artery aneurysm

thrombosis, coronary artery stenosis, myocardial

ischemia and infarction. Myocarditis, pericarditis

and valvular involvement may also occur. The

initial detection and follow-up of coronary artery

aneurysms is important for long term prognosis

and outcome in children with KD. Although,

echocardiography can be used to assess proximal

coronary arterial aneurysms, cardiac catheteriza-

tion with coronary angiography is considered the

gold standard [3, 4]. However, the recent ad-

vances in multislice CT technology have made it

possible to noninvasively diagnose and sequen-

tially follow patients with KD who have coronary

artery aneurysms.

G. Aggarwala Æ N. Iyengar Æ D. Jagasia (&)Division of Cardiovascular Diseases, University ofIowa Hospitals and Clinics, 200 Hawkins Dr. E618-DGH, 52242 Iowa City, IA, USAe-mail: dinesh-jagasia@uiowa.edu

S. J. Burke Æ E. J. R. van Beek Æ B. ThompsonDepartment of Radiology, University of IowaHospitals and Clinics, 200 Hawkins Dr. E618-D GH,52242 Iowa City, IA, USA

I. LawDepartment of Pediatrics, University of IowaHospitals and Clinics, 200 Hawkins Dr. E618-D GH,52242 Iowa City, IA, USA

Int J Cardiovasc Imaging (2006) 22:803–805

DOI 10.1007/s10554-006-9110-y

123

CASE REPORT

Kawasaki disease: role of coronary CT angiography

Gaurav Aggarwala Æ Nikhil Iyengar Æ Steven J. Burke ÆEdwin J. R. van Beek Æ Brad Thompson Æ Ian Law Æ Dinesh Jagasia

Received: 14 April 2006 / Accepted: 23 May 2006 / Published online: 7 October 2006� Springer Science+Business Media B.V. 2006

Case report

We describe the angiographic correlation be-

tween cardiac catheterization and CT coronary

angiography in a 7 year old Asian male who was

diagnosed with KD and coronary artery aneu-

rysms as a 5 year old child. Our patient was an

asymptomatic child who was electively admitted

for follow-up invasive coronary angiography for

prior known coronary artery aneurysms and sub-

total occlusion of the left anterior descending

artery (LAD). Coronary angiography during the

current admission revealed multiple large, coro-

nary artery aneurysms involving the LAD, left

circumflex (LCX) and right coronary artery

(RCA) with recanalization of previously occluded

LAD. Subsequently, patient underwent CT cor-

onary angiography to assess the coronary artery

aneurysms for thrombosis and calcification and to

acquire a new baseline assessment for future

planned follow-up with sequential CT coronary

angiography.

CT coronary angiography was performed using

a 16-slice multidetector row CT scanner (Siemens

Sensation 16, Erlangen, Germany). Patient re-

ceived 50 mg oral metoprolol 1 h prior to the CT

and additional 15 mg intravenous metoprolol

intravenously. After test bolus for optimal con-

trast timing, a total of 70 ml non-ionic low-

osmolar contrast agent (Visipaque 320, GEHC,

Princeton, NJ) with 40 ml 0.9% saline chaser was

administered. Breath hold time was 12 s and HR

during scan acquisition was 60 beats/min. ECG-

gated CT angiography was performed with a

collimation of 12 · 0.75 mm, table feed of

2.8 mm/rotation, 120 kV with automatic dose

modulation and a rotation speed of 330 ms. Post-

processing was performed using Vitrea cardiac

package (Vital Images, Minnetonka, MN), en-

abling both vessel probe, curved MPR, MIP and

3D reconstructions (Figs. 1 and 2).

CT coronary angiography showed three

sequential aneurysms in the right coronary artery.

Large aneurysms were also detected in the LCX

and LAD arteries (Figs. 3 and 4).

Conventional coronary angiography showed a

normal left main coronary artery. There was

normal caliber of the very proximal left anterior

descending and left circumflex coronary arteries.

There was a large aneurysm formation of the

proximal circumflex coronary artery with rela-

tively sluggish flow throughout the aneurysm. The

mid and distal circumflex and obtuse marginal

branches appeared normal. The left anterior

descending artery had a large aneurysm. The

distal LAD filled slowly and did not have any

significant stenosis or aneurysm. Selective right

coronary artery injection showed large aneurysm

involving the proximal, mid and distal segments.

The mid and distal aneurysms filled slowly.

Discussion

We found excellent correlation in our patient

between invasive coronary angiography and CT

Fig. 1 Multislice CT angiogram demonstrating largeaneurysms in the left anterior descending and thecircumflex coronary arteries

Fig. 2 Multislice CT angiogram demonstrating giantaneurysms in the right coronary artery

804 Int J Cardiovasc Imaging (2006) 22:803–805

123

angiography findings in terms of number, size and

location of coronary aneurysms and absence of

coronary arterial stenoses in the distal vessel.

Recent studies investigating radiation doses

estimate that the current scanners using EKG

dependent dose modulation and reduced tube

voltage expose the patient to 6.4±1.9 and

11.0±4.1 mSv in a 16 slice and 64 slice scan-

ner, respectively [5]. The mean effective dose

administered during a coronary angiography is

about 5.6 mSv [6].

Although, CT coronary angiography does not

obviate the risk of contrast and radiation associ-

ated with conventional angiography; it does not

expose children to the attendant procedural and

vascular complications associated with invasive

coronary angiography. Also, the need for repeti-

tive procedures for follow-up of the coronary

aneurysms increases the risk of the above men-

tioned procedural complications. Furthermore, CT

can be performed without the need for hospital-

ization that is required prior to and after invasive

coronary angiography in order to administer

intravenous anticoagulants and then restart oral

anticoagulants after an invasive angiogram.

It must be emphasized that optimal heart rate

control (HR < 60–65/min) and a cooperative

subject to follow breath hold instructions are

critical to obtaining a high quality scan. CT cor-

onary angiography maybe considered a viable

alternative to conventional, catheter based inva-

sive coronary angiography for the diagnosis and

follow-up of coronary artery aneurysms in pa-

tients with Kawasaki Disease.

References

1. Kawasaki T, Kosaki F, Okawa S et al (1974) A newinfantile acute febrile mucocutaneous lymph node syn-drome prevailing in Japan. Pediatrics 54:271–276

2. Kato H, Sugimura T et al (1996) Long term conse-quences of Kawasaki disease. A 10–21 year follow-upstudy of 594 patients. Circulation 94:1379–1385

3. Frey E, Matherne G, Mahoney L, Sato Y, Stanford W,Smith W (1988) Coronary artery aneurysms due toKawasaki disease: diagnosis with ultrafast CT. Radiol-ogy 167:725–726

4. Capanari T, Daniels S, Meyer R, Schwartz D, Kaplan S(1986) Sensitivity, specificity and predictive value oftwo-dimensional echocardiography in detecting coro-nary artery aneurysms in patients with Kawasaki dis-ease. J Am Coll Cardiol 7:355–360

5. Hausleiter J, Meyer T et al (2006) Radiation dose esti-mates from cardiac multislice computed tomography indaily practice. Circulation 113:1305–1310

6. Coles D, Smail M et al (2006) Comparison of radiationdoses from multislice computed tomography coronaryangiography and convential diagnostic angiography.J Am Coll Cardiol 47:1840–1845

Fig. 3 (L) Coronary injection demonstrates large aneu-rysm in the proximal LAD and LCX

Fig. 4 (R) Coronary injection demonstrates three consec-utive large aneurysms in the RCA

Int J Cardiovasc Imaging (2006) 22:803–805 805

123