MRVAS Score-introducing a standardized magnetic resonance scoring system for assessing the extent of inflammatory burden in giant cell arteritis.

OBJECTIVES: Our aim was to introduce a standardized system for assessing the extent of giant cell arteritis (GCA) on MRI, titled MRVAS (MR Vasculitis Activity score). To obtain a comprehensive view, we used an extensive MRI protocol including cranial vessels and the aorta with its branches. To test reliability, MRI was assessed by 4 readers with different levels of experience. METHODS: 80 patients with suspected GCA underwent MRI of cranial arteries and the aorta/branches (20 vessel segments). Every vessel was rated dichotomous [inflamed (coded as 1) or not 0], providing a summed score from 0 to 20. Blinded readers (two experienced radiologists [ExR], two inexperienced radiologists [InR]) applied the MRVAS on an individual vessel and an overall level (defined as the highest score of any of the individual vessel scores). To determine interrater agreement, Cohen's kappa was calculated for pairwise comparison of each reader for individual vessel segments. Intraclass correlation coefficients (ICC) were used for the MRVAS score. RESULTS: Concordance rates were excellent for both sub-cohorts on an individual vessel-based (GCA, ICC, 0.95; and non-GCA, ICC, 0.96) and Overall MRVAS score level (GCA, ICC, 0.96; and non-GCA, ICC, 1.0). Interrater agreement yielded significant concordance (p< 0.001) for all pairs (kappa range 0.78-0.98). No significant differences between ERs and IRs were observed (p= 0.38). CONCLUSION: The proposed MRVAS score allows standardized scoring of inflammation in GCA and achieved high agreement rates in a prospective setting.

Vasa vasorum of proximal cerebral arteries after dural crossing - potential imaging confounder in diagnosing intracranial vasculitis in elderly subjects on black-blood MRI.

OBJECTIVES: Vessel wall enhancement (VWE) may be commonly seen on MRI images of asymptomatic subjects. This study aimed to characterize the VWE of the proximal internal carotid (ICA) and vertebral arteries (VA) in a non-vasculitic elderly patient cohort. METHODS: Cranial MRI scans at 3 Tesla were performed in 43 patients (aged ≥ 50 years) with known malignancy for exclusion of cerebral metastases. For vessel wall imaging (VWI), a high-resolution compressed-sensing black-blood 3D T1-weighted fast (turbo) spin echo sequence (T1 CS-SPACE prototype) was applied post gadolinium with an isotropic resolution of 0.55 mm. Bilateral proximal intradural ICA and VA segments were evaluated for presence, morphology, and longitudinal extension of VWE. RESULTS: Concentric VWE of the proximal intradural ICA was found in 13 (30%) patients, and of the proximal intradural VA in 39 (91%) patients. Mean longitudinal extension of VWE after dural entry was 13 mm in the VA and 2 mm in the ICA. In 14 of 39 patients (36%) with proximal intradural VWE, morphology of VWE was suggestive of the mere presence of vasa vasorum. In 25 patients (64 %), morphology indicated atherosclerotic lesions in addition to vasa vasorum. CONCLUSIONS: Vasa vasorum may account for concentric VWE within the proximal 2 mm of the ICA and 13 mm of the VA after dural entry in elderly subjects. Concentric VWE in these locations should not be confused with large artery vasculitis. Distal to these segments, VWE may be more likely related to pathologic conditions such as vasculitis. KEY POINTS: • Vasa vasorum may account for concentric VWE within the proximal 2 mm of the ICA and 13 mm of the VA after dural entry in non-vasculitic elderly people. • Concentric enhancement within the proximal 2 mm of the intradural ICA and within the proximal 13 mm of the intradural VA portions should not be misinterpreted as vasculitis. • Distal of this, VWE is likely related to pathologic conditions, in case of concentric VWE suggestive of vasculitis.

Endovascular therapy of arterioureteral fistulas.

Background: Arterioureteral fistulas (AUFs) are severe pathologies of different origin and with increasing incidence frequently appear in patients with underlying extensive malignancy and after pelvic surgery. AUF therapy is challenging since symptoms are frequently non-specific and patients are often unsuitable surgical candidates due to comorbidities. Since experiences with endovascular treatment strategies are limited, the feasibility, effectiveness, and safety were evaluated in a consecutive case series. Patients and methods: A retrospective analysis of five patients with endovascular AUF exclusion was performed. Probable predisposing factors for an AUF included history of pelvic malignancy with oncologic surgery in four patients, radiotherapy in four patients, and indwelling ureteral stents in four patients. Clinical presentation, diagnostic management, and site of fistula were assessed. Furthermore, technical and clinical success as well as complications were evaluated. Results: All patients presented with gross haematuria. In four patients, haematuria occurred during endoscopic ureteral stent manipulation. Affected vessels were the internal pudendal artery in one, intrarenal segmental artery and external iliac artery in two, and internal iliac artery in another two patients. Treatment included coil embolisation (n = 2), plug embolisation (n = 3), particulate embolisation (n = 1), and covered stent implantation (n = 2). Technical success was achieved in all procedures. In two cases, re-intervention was necessary due to AUF recurrence, resulting in a clinical success rate of 60.0%. One major complication class D was documented. Conclusions: AUFs can be treated effectively and safely using endovascular techniques. Diagnostic and therapeutic management of this rare entity requires a high level of awareness for potential risk factors as well as an optimal multidisciplinary coordination.