Image Predictors of Treatment Outcome after Thoracic Aortic Dissection Repair.

Treatment of thoracic aortic dissection remains highly challenging and is rapidly evolving. Common classifications of thoracic aortic dissection include the Stanford classification (types A and B) and the DeBakey classification (types I to III), as well as a new supplementary classification geared toward endovascular decision making. By using various imaging techniques, the extent of the dissection, the location of the primary intimal tear, the shape of the aortic arch, and the zonal involvement of the aortic arch-factors that affect the treatment strategy-can easily be identified. Thoracic endovascular aortic repair (TEVAR) is generally performed in two groups of patients: (a) those with a surgically repaired type A dissection, and (b) those with a complicated type B dissection. Several imaging findings can help predict the course of remodeling of the dissected aorta after a repaired type A dissection and TEVAR. A spectrum of imaging findings exist with regard to favorable (positive) or failing (negative) remodeling. A schematic model with imaging support allows the classification of important causes of failing remodeling into proximal and distal groups, on the basis of the origin of the refilling of the false lumen and the underlying pathophysiology of pressurization. Refilling of the false lumen of the aorta after repair of a type A dissection is usually secondary to a persistent intimal tear at the aortic arch, a leak of the distal graft anastomosis, or refilling from the false lumen of a dissected aortic arch vessel. After TEVAR, false lumen refilling is most commonly due to an incomplete seal of the proximal landing related to the aortic tortuosity, an arch branch stump, a supra-arch chimney stent, or the TEVAR technique. Online supplemental material is available for this article. ©RSNA, 2018.

Computed Tomographic Diagnosis of Myocardial Fat Deposits in Sarcoidosis.

OBJECTIVE: Fat deposits in the left ventricle (LV) myocardium are uncommon and usually indicate scar due to chronic myocardial infarction. The purpose of this study was to determine the incidence of fatty lesions in the LV of patients with sarcoidosis. MATERIALS AND METHODS: Review of noncontrast computed tomographic images (2-mm thickness) in 133 patients with documented extracardiac sarcoidosis (age, 35-82 years, 55 ± 10 years, 67% female) with no history of significant coronary artery disease (clinical and coronary calcium) was performed. A control group included noncontrast computed tomographies with no coronary calcium in 133 patients with age/sex (59 ± 6 years, 73% female) similar to the sarcoid target group. Locations and morphology (linear vs bulky) of fat deposits (-30 to -180 Hounsfield units) and relevant intrathoracic findings were recorded. RESULTS: We found 35 fat deposits in 19 (14.3%) of sarcoid patients (target group: age, 59 ± 7 years, 78% female). Lesions were mainly at the LV apical level (n = 14). In the control group, 15 lesions in 13 (9.7%) patients were found. Numbers of fatty lesions in sarcoid targets were significantly higher than those in the control group (P = 0.015). The number of bulky lesions was significantly higher in sarcoid (n = 9) than in control (n = 1; P < 0.05). No significant difference was found for the rate of linear lesions. Interstitial lung disease was seen in 9 and enlarged lymph nodes in 9 of the sarcoid target group. There was no significant correlation between the severity of interstitial lung disease and the number of fatty lesions. CONCLUSIONS: Sarcoid patients demonstrate a higher chance of having LV fat deposits with a characteristic bulky morphology.

Imaging appearance in acute liver failure: correlation with clinical and pathology findings.

BACKGROUND AND AIM: Acute liver failure (ALF) is characterized by sudden liver injury without underlying chronic liver disease. Excluding underlying cirrhosis in these patients is often difficult and liver biopsy may be impractical. We review the imaging appearance of acute hepatic failure in patients who underwent transplant and correlate these findings with clinical, laboratory and pathology parameters. METHODS: This is a retrospective review of 47 patients without known chronic liver disease who presented to three institutions between 2002 and 2010 with ALF, 46 of which underwent subsequent orthotopic liver transplantation. Pre-transplant ultrasound, computed tomography and magnetic resonance imaging scans were reviewed for parenchymal homogeneity, surface nodularity and evidence of portal hypertension. Explant histopathology, laboratory values and time intervals between symptom onset to initial imaging and transplant were correlated with imaging findings. RESULTS: The majority of patients with ALF had abnormal radiographic findings. Ascites was seen in 65% of patients. Splenomegaly, collateral vessel formation and hepatofugal flow in the portal vein were present in 28, 15 and 9% of patients, respectively. Nodular liver surface was noted in 23% of patients, more commonly in patients who had been ill for more than 7 days. Liver surface nodularity correlated with massive hepatic necrosis on histology and wrinkled capsule on visual inspection of explanted liver specimen. CONCLUSION: Imaging findings in ALF was variable and can resemble cirrhosis. Assessment for underlying cirrhosis in the setting of liver failure should not be based on imaging findings.

Hepatic angiosarcoma with clinical and histological features of Kasabach-Merritt syndrome.

Hepatic angiosarcoma is a mesenchymal tumor originating from liver sinusoidal endothelial cells. It is an extremely rare malignant neoplasm accounting for less than 1% of primary malignant liver tumors. The deregulated coagulopathy that can be seen in hepatic angiosarcoma fulfills the clinical diagnostic criteria of disseminated intravascular coagulation. However, the mechanism that governs this coagulopathy has been poorly understood. This case report provides histological evidence of the consumption of coagulation factors along with trapped platelets occurring within the tumor, which is the foundation for the concept of Kasabach-Merritt syndrome (KMS). KMS is characterized by thrombocytopenia and hyperconsumption of coagulation factors within a vascular tumor. However, KMS associated with angiosarcoma has not been well recognized. This case report describes, for the first time, the histological evidence of KMS that occurred in an extremely rare mesenchymal malignant tumor of the liver.

A correlative study of aortic valve rotation angle and thoracic aortic sizes using ECG gated CT angiography.

OBJECTIVE: Various degrees of aortic valve rotation may be seen in individuals with no history of congenital cardiovascular malformations, but its association with aortic sizes has not been studied. METHODS: Gated computed tomographic (CT angiograms in 217 patients were studied (66.7±15; 22-97 years old)). Aortic diameters were determined at 5 anatomic locations. The length of the aorta from sinus to left subclavian artery was measured. The angle of valve rotation was recorded by measuring the angle between a line connecting the midpoint of the non-coronary sinus to the anterior commissure and another line along the interatrial septum. Rotation angles were correlated with aortic measurements. Patients were separated into two groups based on aortic sizes and into three groups based on age. The threshold for aortic dilatation was set at maximum ascending aorta diameter ≥40mm (≥21mm body surface area [BSA] indexed). RESULTS: No significant difference in rotation angles was seen between the three age groups or between genders. Rotation angles were significantly correlated with maximal, average, and BSA adjustment of the aortic root and ascending aortic measurements. The aortic root angles were significantly different between the dilated versus nondilated aortas. There was no significant association between the rotation angles and age, length of ascending aorta, or diameters of descending aorta. Multivariate adaptive regression splines showed 25° of aortic root rotation as the diagnostic cut off for ascending aorta dilation. Above the 25° rotation, every 10° of increasing rotation was associated with a 3.78±0.87mm increase in aortic diameter (p<0.01) and a 1.73±0.25 times increased risk for having a dilated aorta (p<0.01). CONCLUSION: Rotation angles of the aortic valve may be an independent non-invasive imaging marker for dilatation of the ascending aorta. Patients with increased rotation angle of the aortic valve may have higher risk for development or acceleration of an ascending aortic dilatation.