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Case Report |
1 Department of Diagnostic Radiology, University of Maryland Medical Center, 22
S Greene St., Baltimore, MD 21201.
2 Department of Radiology, University Hospital, Cleveland, Ohio.
Received December 19, 2003;
accepted after revision June 17, 2004.
Address correspondence to C. S. White
(cwhite{at}umm.edu).
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The patient was referred to cardiac surgery for bypass grafting. A preoperative CT scan was performed to better define the size and location of the coronary artery aneurysms (Figs. 1A, 1B, 1C). CT scan was acquired using a 16-MDCT scanner (Philips Medical Systems) with retrospective ECG gating. Reconstructions at various phases of the cardiac cycle were performed and images at 75% of the R-R interval were found to be optimal for analysis of the coronary vessels. A single breath-hold technique was used. Scanning time was 30 sec, with approximately 5 additional min for preprocedure placement and adjustment of ECG leads. Slice thickness was 0.75 mm. One hundred twenty milliliters of iodinated contrast material was injected through an antecubital vein at 4 mL/sec. Automated bolus timing was used. ß-blockers were not used to control the heart rate (72 beats per minute). Radiographic parameters were 140 kvp, 400 mAs, and a rotation time of 0.42 sec with an estimated effective radiation dose of 9 mSv.
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Kawasaki's disease is the most frequent cause of coronary aneurysms worldwide, whereas atherosclerotic coronary disease is the most common cause in the United States. In a prospective study of nearly 5,000 cardiac catheterizations, Hartnell et al. [5] found coronary artery dilatation in 70 patients (1.4%). Fifty-eight of the 70 patients (83%) had significant coronary obstruction.
The right coronary artery is most frequently involved, followed by the left anterior descending artery. Patients with coronary artery aneurysms can be symptomatic or asymptomatic. Symptomatic patients usually present with ischemic or congestive heart failure symptoms that may be caused by the aneurysm or concomitant coronary artery disease. Differential diagnosis of a coronary artery aneurysm includes aneurysm of the cardiac wall, posttraumatic pseudoaneurysms of the ascending aorta or the pulmonary trunk, tumor of the heart or pericardium, and, less likely, thymoma [6].
Coronary angiography remains the standard reference technique for diagnosing coronary aneurysms but is invasive and expensive. Moreover, only flow within the lumen is detected after contrast agent injection. As shown by the present case, the true size of the aneurysm may be underestimated if it contains substantial thrombus. CT provides a noninvasive approach that permits an accurate assessment of aneurysm size and location and the amount of thrombus and calcification.
Most descriptions of coronary artery aneurysms on CT consist of isolated case reports using electron beam or single-detector spiral technology. As shown in the present study, MDCT allows a rapid and accurate delineation of the size and shape of the aneurysm. Thin-section or thin-slab axial images provide the primary diagnostic information. MDCT also enables high-quality 2D and 3D reformations. These multiplanar and volumetric displays may be valuable in preoperative planning by showing spatial relations among the aneurysm, great vessels, and the heart, and by providing an estimate of its volume. The extent of thrombus compared with luminal flow can also be depicted with confidence.
Three-phase CT arteriography has also been reported as helpful in confirming large aneurysms. This technique shows homogeneous and similar densities of a mass and cardiac chambers in the unenhanced (first) and equilibrium (third) phases, and turbulent enhancement in the arterial (second) phase. Radiologists should be familiar with these CT angiographic features because the turbulence of enhanced blood in a large aneurysm may simulate an inhomogeneous mass [7].
MRI offers an alternative cross-sectional technique for evaluating coronary artery aneurysm and obviates the large radiation dose associated with MDCT. However, the spatial resolution of MRI is inferior in relation to that of CT, and MRI cannot detect calcification in the wall of the aneurysm or adjacent coronary artery.
The prognosis of coronary artery aneurysm is related to the severity of concomitant obstructive coronary disease. In the Coronary Artery Surgery Study registry, no significant difference with regard to survival was noted between the cases with and without coronary artery aneurysm [4].
If medical therapy with anticoagulants and antiplatelet agents fails, coronary artery bypass graft or intracoronary stent placement should be considered. Most authors agree that surgery should be reserved for those patients with significant coronary stenosis or angina despite adequate medical treatment [8]. The literature details only a few instances of surgically treated coronary artery aneurysms, with an excellent outcome in selected cases.
In conclusion, coronary artery aneurysm is an uncommon lesion that is sometimes associated with obstructive coronary artery disease or sudden death. MDCT appears to be an easy and reliable technique to confirm the diagnosis and plan treatment.
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