1. Vascular p136-141 (Vasculitis)

Question 1

Vasculitis - imaging (5)

Answer 1

All types look similar.
Wall thickening,
Occlusions,
Dilatations,
Aneurysm formation

Question 2

Vasculitis - types (4)

Answer 2

Large vessel (Takayasu, Giant cell, Cogan syndrome),
Medium vessel (PAN, Kawasaki),
Small vessel ANCA + (Wegeners, Churg strauss, Microscopic polyangiitis),
Small vessel ANCA negative (HSP, Behcets, Burgers)

Question 3

Takayasu Arteritis - trivia (3)

Answer 3

Commonest in 15-30YO Asian women.
Asian or Involving aorta is most likely takayasu.
5 types, beyond scope of FRCR, but type 3 (involving arch and abdominal aorta) is most common.

Question 4

Giant cell arteritis - trivia (2)

Answer 4

Commonest primary system vasculitis.
Commonest in older men (70-80).

Question 4

Takayasu arteritis - imaging (5)

Answer 4

Acute phase:
Wall thickening and enhancement.
Occlusions of major aortic branches, or dilatation of aorta and major branches.
Aortic valve often involved (stenosis or insufficiency).
Late phase:
Diffuse narrowing distally.
Peripheral pruning of pulmonary arteries.

Question 5

Giant cell arteritis - features (4)

Answer 5

Commonly involves aorta, major branches and particularly branches of external carotid (Temporal Artery).
ESR and CRP markedly elevated.
Rx: Responds to steroids.
Gold standard for diagnosis is temporal artery biopsy (often negative)

Question 6

Giant cell arteritis - imaging (2)

Answer 6

US: thickening of wall of temporal artery
CT/MRA/angiogram of armpit area: Wall thickening, occlusions, dilatation, aneurysms.

Question 7

Cogan syndrome (4)

Answer 7

Rare, large vessel vasculitis affecting children and young adults.
Favours eyes, causing optic neuritis, uveitis and audiovestivular symptosm (resembles Menieres).
Can get aortitis - worse prognosis.
“kid with eye and ear symptoms +/- aortitis”

Question 8

PAN - features (4)

Answer 8

More common in men.
Commonly affects renal (90%), cardiac (70%) and GI (50-70%).
Microaneurysm formation, mainly at branch points, followed by infarction.
Imaging: Kidneys with microaneurysms and multiple areas of wedge shaped infarct.

Question 9

PAN - trivia (2)

Answer 9

Associated with Hep B.
Microaneurysm formation in kidneys can also be seen in people who abuse crystal meth.

Question 10

Kawasaki disease

Answer 10

Commonest vasculitis in kids.
Common cause of coronary artery aneurysm (Calcified coronary artery aneurysm on CXR is an aunt minnie).
Other buzzwords
“Mucocotaneous lymph node syndrome”
“Fever for 5 days”

Question 11

Coronary artery aneurysms - prognosis (2)

Answer 11

> 8mm are Giant, prone to poor outcomes including MI
<8mm may regress

Question 12

Wegeners (Granulomatosis with Polyangiitis) - (3)

Answer 12

Affects upper resp tract (sinuses), lower resp tract (lungs) and kidneys.
cANCA + (90%).
Imaging: nasal perforation and cavitating lung lesions.

Question 13

Churg strauss - (5)

Answer 13

Necrotising pulmonary vasculitis, within spectrum of eosinophilic lung disease.
Always have asthma and eosinophilia.
Imaging: Transient peripheral consolidation or ground glass.
Cavitation is rare (think Wegeners instead).
pANCA + (75%)

Question 14

Microscopic polyangiitis - (3)

Answer 14

Affects kidneys and lungs.
1/3 get diffuse pulmonary haemorrhage.
pANCA + (80%)

Question 15

HSP (Henoch-Schlonlein Purpura) - trivia (3)

Answer 15

Commonest vasculitis in kids (common age 4-11).
Systemic disease. GI symptoms most common (pain, bloody diarrhoea).
Common lead point for intussusception.

Question 16

HSP - imaging (3)

Answer 16

US: donut sign of intussusception
US: scrotum showing massive skin oedema
Can get multifocal bowel wall thickening.

Question 17

Behcets (2)

Answer 17

Mouth ulcers and genital ulcers in Turkish person.
Can cause aortic thickening, and pulmonary artery aneurysm.

Question 18

Buergers (4)

Answer 18

Vasculitis, strong smoking association.
Affects small and medium vessels in arms and legs (most commonly legs).
Imaging: hand angio showing extensive arterial occlusions with corkscrew collaterals developing.
Usually affects multiple limbs, can lead to “Auto-amputation”

Question 19

Hand angiogram DDx (4)

Answer 19

Will usually be either Buergers or Hypothenar Hammer Syndrome (HHS).
Ulnar artery involved = HHS (look for pseudo-aneurysm of ulnar artery).
Ulnar artery not involved - look at fingers
- If occlusions within fingers, suggests Buergers. May have corkscrew collaterals to confirm.
HHS can cause finger occlusions from distal emboli, but the ulnar artery will also be affected.

Question 20

Vasculitis - location DDx

Answer 20

Most commonly:
Central = Takayasu
Mid clavicle = Thoracic outlet syndrome
Armpit = Giant Cell

Question 21

SAM (Segmental arterial mediolysis) - (4)

Answer 21

Affects splanchnic arteries in elderly, coronaries in young adults.
Not true vasculitis, no significant inflammation.
Degeneration of tunica media, causing often multiple aneurysms.
Imaging - Multiple abdominal splanchnic artery saccular aneurysms.

Question 22

Cystic adventitial disease (3)

Answer 22

Rare, affects popliteal artery in young men.
Multiple mucoid filled cysts in outer media and adventitia.
Cysts compress the artery as they grow.