DOI:10.2214/AJR.05.1167
AJR 2007; 188:452-461
© American Roentgen Ray Society
CTA and MRA in Mesenteric Ischemia: Part 1, Role in Diagnosis and Differential Diagnosis
Ming-Chen Paul Shih1,2 and
Klaus D. Hagspiel1
1 Division of Non-invasive Cardiovascular Imaging, Department of Radiology,
University of Virginia Health System, 1215 Lee St., PO Box 800170,
Charlottesville, VA 22908.
2 Present address: Department of Medical Imaging, Kaohsiung Medical University
Hospital, Kaohsiung, Taiwan.
Received July 6, 2006;
accepted after revision December 7, 2005.
Address correspondence to K. D. Hagspiel
(kdh2n{at}virginia.edu).
Abstract
OBJECTIVE. CT angiography and MR angiography are the main techniques
for the noninvasive diagnosis of mesenteric ischemia. High clinical suspicion
and knowledge of the differential diagnostic possibilities in this clinical
setting are essential for the correct interpretation of the scans.
CONCLUSION. CT angiography and MR angiography are well suited for
the workup of patients when mesenteric ischemia is suspected.
Keywords: abdominal imaging • angiography, CT • angiography, MR • gastrointestinal imaging • ischemia • mesentery
Introduction
Multidetector CT angiography (CTA) is probably the most frequently
used technique for the diagnosis of mesenteric ischemia
[1]. Contrast-enhanced 3D MR
angiography (MRA) is also widely used
[2]. In this pictorial essay we
review the roles of CTA and contrast-enhanced MRA for the detection and
differential diagnosis of mesenteric ischemia (part 1) and for treatment
follow-up (part 2) [3]. All
scanning was performed on 4-, 8-, or 16-MDCT scanners and 1.5-T
high-performance MR scanners. Image reconstruction was performed on MediPrime
workstation PACS (Eastman Kodak) and Aquarius (TeraRecon) workstations.
Acute Mesenteric Ischemia
Acute interruption of the blood supply to the gastrointestinal tract is a
catastrophic event, with a mortality rate exceeding 60%
[4]. The four major causes of
acute mesenteric ischemia are superior mesenteric artery (SMA) embolus, SMA
thrombosis, mesenteric venous thrombosis, and nonocclusive mesenteric
vasoconstriction [4]. Aortic
dissections have also been reported to cause acute mesenteric ischemia on rare
occasions [5].
Acute SMA Embolism
Acute emboli to the SMA have accounted for approximately 40-50% of all
episodes of acute mesenteric ischemia. Most emboli in the SMA lodge just
beyond the origin of the middle colic artery. The angiographic hallmark of an
embolic occlusion is the abrupt termination of the vessel (cutoff sign).
Nonocclusive emboli are usually visualized as filling defects in the vessel
lumen. Both CT angiography (CTA) and contrast-enhanced MRA can show these
acute occlusions [6] (Fig.
1A,
1B). Typically, no or only a
paucity of collateral vessels are present. In patients with prior embolic
events, recanalized vessels may be seen.
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Fig. 1A —76-year-old woman with severe abdominal pain and diarrhea. MDCT
angiography (CTA) shows acute embolic occlusion of superior mesenteric artery
(SMA) distal to origin of middle colic artery (arrowhead). Pathologic
thickening of multiple small-bowel loops of jejunum was present (not
shown).
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Fig. 1B —76-year-old woman with severe abdominal pain and diarrhea. Source
image of CTA shows filling defect in SMA (arrowhead) and patent
superior mesenteric vein. Patient underwent emergent embolectomy with SMA
bypass and small-bowel resection and made full recovery.
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Acute Mesenteric Artery Thrombosis
Acute mesenteric artery thrombosis is typically associated with a
preexisting atherosclerotic lesion. It is estimated to be responsible for
20-30% of all cases of acute mesenteric ischemia
[1,
4,
5]. In up to 50% of cases, a
history of intestinal angina is present
[1]. In contrast to the abrupt
catastrophic onset of symptoms associated with an embolus to the SMA, the
abdominal pain and symptoms associated with acute mesenteric artery thrombosis
may be more insidious because of the development of collateral circulation.
Occlusion of the SMA is typically within the first 2 cm of its origin, in
contrast to acute embolic occlusions, which occur more distally. Usually no
defined meniscus or intraluminal filling defect (Fig.
2A,
2B) is seen. Both CTA and
contrast-enhanced MRA can show these findings in addition to visualizing
collateral vessels.
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Fig. 2A —64-year-old man with syncopal episode and abdominal pain. Patient
had history of coronary artery disease after aortocoronary bypass graft and
aortobifemoral bypass surgery for aortic occlusive disease. Volume-rendered
MDCT angiogram shows aortobifemoral graft as well as severe calcified plaque
burden in native vasculature. Note moderate enlargement of ascending branch of
inferior mesenteric artery (arrowhead) as well as pancreaticoduodenal
arcades (arrows).
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Fig. 2B —64-year-old man with syncopal episode and abdominal pain. Patient
had history of coronary artery disease after aortocoronary bypass graft and
aortobifemoral bypass surgery for aortic occlusive disease. Subvolume maximum
intensity projection shows significant vascular wall calcifications in
superior mesenteric artery origin (arrowhead) causing highgrade
stenosis and acute thrombus seen as a small hypodense filling defect
(arrow).
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Mesenteric and Portal Venous Thrombosis
Mesenteric vein thrombosis accounts for 5-15% of all cases of acute
mesenteric ischemia [1,
4,
5]. The most common associated
risk factors are portal hypertension; hypercoagulation; trauma; intraabdominal
inflammatory diseases; and recent surgery, especially splenectomy, affecting
the portomesenteric venous system
[1]. Many cases are idiopathic.
Acute mesenteric ischemia develops when mesenteric vein thrombosis is
associated with a lack of adequate venous collaterals, which results in the
development of intestinal mucosal edema and subsequent arterial hypoperfusion.
Both CTA and contrast-enhanced MRA have been shown to be highly accurate for
the evaluation of superior mesenteric vein and portal vein thrombosis
[2,
7] (Fig.
3A,
3B).
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Fig. 3A—58-year-old man with history of hypercholesterolemia
and nephrolithiasis who presented with severe abdominal pain that began
approximately 6 days previously. Axial images of MDCT angiography (A)
and gadolinium contrast-enhanced axial T1-weighted image (B) show acute
thrombus in superior mesenteric vein (arrowheads) as evidenced by
round nonocclusive filling defect.
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Fig. 3B—58-year-old man with history of hypercholesterolemia
and nephrolithiasis who presented with severe abdominal pain that began
approximately 6 days previously. Axial images of MDCT angiography (A)
and gadolinium contrast-enhanced axial T1-weighted image (B) show acute
thrombus in superior mesenteric vein (arrowheads) as evidenced by
round nonocclusive filling defect.
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Nonocclusive Mesenteric Ischemia
Nonocclusive mesenteric ischemia is thought to be responsible for
approximately 25% of cases of acute mesenteric ischemia, and its mortality
rate has been reported to be as high as 70%
[8]. Nonocclusive mesenteric
ischemia usually develops during an episode of cardiogenic shock or a state of
hypoperfusion in which excessive sympathetic activity results in secondary
vasoconstriction of the mesenteric arteries. The contrast-enhanced MRA
appearance of this entity, to our knowledge, has not been described in humans,
but there is one published report of the CTA findings, which included normal
mesenteric arteries and veins associated with bowel wall thickening and
pneumatosis [7]. We diagnosed
one case in which the diagnostic findings consisted of abnormally small
mesenteric arteries and extremely delayed filling of the mesenteric veins (no
filling at 70 seconds after injection).
Aortic Dissection
Approximately 5% of patients with aortic dissection develop acute
mesenteric ischemia as a complication of the dissection process. Both CTA and
contrast-enhanced MRA are excellent techniques to assess these patients by
clarifying the dissection, defining entry and reentry points, differentiating
thrombus from slow flow, and evaluating branch vessel involvement (Fig.
4A,
4B,
4C,
4D). Isolated dissections of
the visceral arteries usually occur in association with cystic degeneration or
as a complication of catheter angiography and are extremely rare, but they are
well shown with CTA and contrast-enhanced MRA
[9] (Figs.
5A,
5B and
6A,
6B).
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Fig. 4A —58-year-old man with acute onset of severe excruciating back and
abdominal pain due to type II aortic dissection. Contrast-enhanced MR
angiograms show type II dissection with extension of dissection flap
(arrow, A) downward below origin of superior mesenteric artery
(SMA) and occlusion of right renal artery (not shown). There is an occlusion
of ileocolic artery (arrowhead, B).
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Fig. 4B —58-year-old man with acute onset of severe excruciating back and
abdominal pain due to type II aortic dissection. Contrast-enhanced MR
angiograms show type II dissection with extension of dissection flap
(arrow, A) downward below origin of superior mesenteric artery
(SMA) and occlusion of right renal artery (not shown). There is an occlusion
of ileocolic artery (arrowhead, B).
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Fig. 4C —58-year-old man with acute onset of severe excruciating back and
abdominal pain due to type II aortic dissection. Catheter angiograms in
lateral (C) and anteroposterior (D) projections with catheter in
anterior false lumen show that dissection ends just below SMA and filling of
distal aorta is via nonopacified (from this catheter position) distal aorta.
Note also embolus in ileocolic artery (arrowhead, D) of SMA
seen on both subvolume maximum intensity projection (B) and catheter
angiogram (D).
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Fig. 4D —58-year-old man with acute onset of severe excruciating back and
abdominal pain due to type II aortic dissection. Catheter angiograms in
lateral (C) and anteroposterior (D) projections with catheter in
anterior false lumen show that dissection ends just below SMA and filling of
distal aorta is via nonopacified (from this catheter position) distal aorta.
Note also embolus in ileocolic artery (arrowhead, D) of SMA
seen on both subvolume maximum intensity projection (B) and catheter
angiogram (D).
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Fig. 5A —59-year-old man with spontaneous dissection of celiac artery.
Contrast-enhanced MR angiogram (A) shows ectasia of celiac artery
(arrow), and coronal steadystate free precession image (B)
shows dissection flap (arrowhead).
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Fig. 5B —59-year-old man with spontaneous dissection of celiac artery.
Contrast-enhanced MR angiogram (A) shows ectasia of celiac artery
(arrow), and coronal steadystate free precession image (B)
shows dissection flap (arrowhead).
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Fig. 6A —36-year-old woman with acute onset of abdominal pain and bowel
perforation. Axial source image of MDCT angiography shows focal dissection of
superior mesenteric artery (SMA) (solid arrowhead). Patient also had
free air in peritoneum (arrow) due to bowel perforation as well as
air in mesenteric veins (open arrowhead).
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Chronic Mesenteric Ischemia
Atherosclerotic Chronic Mesenteric Ischemia
Chronic mesenteric ischemia is almost always caused by severe
atherosclerotic disease and is characterized by a classic clinical triad of
postprandial abdominal pain, weight loss, and food avoidance that is present
in nearly half the patients with chronic mesenteric ischemia
[1]. With advanced age, the
abdominal aorta and mesenteric arteries are frequently involved with
atherosclerosis. Although atherosclerosis of the mesenteric branches is
frequent, chronic mesenteric ischemia is relatively uncommon, mainly because
of the rich mesenteric collateral circulation. It is generally thought that at
least two of the three main vessels must be affected either by occlusive or
stenotic disease to produce clinical symptoms, although exceptions to this
rule exist [1,
10] (Figs.
7A,
7B,
8A,
8B,
9).
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Fig. 7A —73-year-old woman with 2-year history of postprandial abdominal pain
and 50-lb (22.5-kg) weight loss. Contrast-enhanced MR angiogram of abdomen
(A) and abdominal aortogram (B) show atherosclerotic occlusion
of celiac trunk and superior mesenteric artery. Collateralization is
maintained via inferior mesenteric artery (arrowhead).
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Fig. 7B —73-year-old woman with 2-year history of postprandial abdominal pain
and 50-lb (22.5-kg) weight loss. Contrast-enhanced MR angiogram of abdomen
(A) and abdominal aortogram (B) show atherosclerotic occlusion
of celiac trunk and superior mesenteric artery. Collateralization is
maintained via inferior mesenteric artery (arrowhead).
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Fig. 8A —60-year-old woman with clinical symptoms of chronic mesenteric
ischemia and severe bilateral claudication. Lateral subvolume maximum
intensity projection of MDCT angiogram shows occlusion of celiac artery and
superior mesenteric artery and high-grade stenosis of inferior mesenteric
artery (IMA) (arrow).
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Fig. 8B —60-year-old woman with clinical symptoms of chronic mesenteric
ischemia and severe bilateral claudication. Volume-rendered image shows that
collateral flow to iliac and superior mesenteric arteries was through IMA via
Riolan's arch (arrowhead).
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Fig. 9 —67-year-old man with vasculopathy and history of left hemispheric
stroke, chronic claudication, and clinical signs of mesenteric ischemia.
Contrast-enhanced MR angiogram shows total occlusion of infrarenal abdominal
aorta, high-grade stenosis of celiac artery origin (solid arrow), and
segmental superior mesenteric artery stenosis (arrowhead). Inferior
mesenteric artery (open arrowhead) was reconstituted via Riolan's
arch (arrow).
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Chronic mesenteric ischemia in the setting of proximal or segmental
mesenteric artery stenosis or occlusion in only one affected vessel is rare
but can occur (Fig. 10A,
10B,
10C). On the basis of our
personal experience with thousands of abdominal CTA and MRA examinations, the
inferior mesenteric artery and the periphery of the other splanchnic vessels
are currently better assessed with CTA than with contrast-enhanced MRA because
of the higher spatial and temporal resolution of the former. No direct
comparison has been published for the mesenteric vessels, but the superiority
of CTA over contrast-enhanced MRA has been shown for the renal arteries
[11].
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Fig. 10A —75-year-old man with peripheral vascular and coronary artery disease
who was admitted for postprandial abdominal pain and food avoidance. Subvolume
maximum intensity projection of MDCT angiogram shows 60% stenosis of proximal
superior mesenteric artery caused by eccentric noncalcified plaque.
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Fig. 10B —75-year-old man with peripheral vascular and coronary artery disease
who was admitted for postprandial abdominal pain and food avoidance. Selective
superior mesenteric arteriogram (B) and volume-rendered MDCT angiogram
(C) both show high-grade stenosis, which was successfully treated with
percutaneous transluminal angioplasty (PTA).
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Fig. 10C —75-year-old man with peripheral vascular and coronary artery disease
who was admitted for postprandial abdominal pain and food avoidance. Selective
superior mesenteric arteriogram (B) and volume-rendered MDCT angiogram
(C) both show high-grade stenosis, which was successfully treated with
percutaneous transluminal angioplasty (PTA).
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Nonatherosclerotic Causes of Chronic Mesenteric Ischemia
Fibromuscular dysplasia—Fibromuscular dysplasia is a rare
but well-recognized cause of chronic mesenteric ischemia. The CTA and
contrast-enhanced MRA appearances of the mesenteric circulation are identical
to the renal manifestation
[12]
(Fig. 11). Accuracy of these
imaging techniques is unknown, but it is likely higher for CTA.
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Fig. 11 —61-year-old woman with history of right nephrectomy and
fibromuscular dysplasia of left renal artery that was treated previously with
angioplasty. Contrast-enhanced MR angiogram shows beaded appearance typical of
fibromuscular dysplasia at origin of superior mesenteric artery
(arrow). Patient had no symptoms related to this finding, which was
confirmed at catheter angiography (not shown).
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Median arcuate ligament syndrome—Median arcuate ligament
syndrome is caused by extrinsic compression of the celiac artery or the celiac
neural plexus by the central tendon of the crura of the diaphragm
[2]. The angiographic findings
are best seen on a lateral aortogram and consist of a smooth indentation of
the superior aspect of the proximal celiac artery. This indentation is
classically more marked on expiration than on inspiration. This entity has
been shown with both CTA and contrast-enhanced MRA, both of which also allow
identification of the ligament causing the compression
(Fig. 12). The ligament can
compress the celiac artery and the SMA and, in rare cases, even the renal
arteries. CTA may be superior in this setting to catheter angiography
[13]. Because this finding can
be seen in many patients without symptoms, clinical correlation is
important.
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Fig. 12 —56-year-old woman with postprandial epigastric pain, weight loss,
and abdominal bruit. Patient underwent MDCT angiography and was found to have
abdominal aneurysm with both celiac and superior mesenteric artery origin
(arrowhead) compression caused by median arcuate ligament of
diaphragm. This finding on this maximum-intensity-projection image was
consistent with classic median arcuate ligament syndrome.
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Vasculitis, Connective Tissue Disorders, and Other Rare Causes
Chronic mesenteric ischemia has been described as one of the protean
manifestations of vasculitides and connective tissue disorders. The most
frequent disease in this respect is Takayasu's arteritis
[14] (Fig.
13A,
13B), but other vasculitides,
such as polyarteritis nodosa and segmental mediolytic arteriopathy, can also
cause both acute mesenteric ischemia and chronic mesenteric ischemia
[1,
13] because of the stenotic
and occlusive processes involving the mesenteric arteries. Connective tissue
diseases such as Ehlers-Danlos syndrome can also cause mesenteric ischemia
[15] (Fig.
14A,
14B). Both CTA and
contrast-enhanced MRA are well suited for imaging when these diseases are
suspected because of their ability to assess both luminal and vascular wall
changes. Stenosis, occlusion, aneurysm formation, vascular wall thickening,
and wall enhancement have been reported in vasculitides. Abdominal
coarctation, neurofibromatosis, postirradiation arteritis, and idiopathic
fibrosis (Fig. 15A,
15B) are less common causes of
mesenteric ischemia.
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Fig. 13A —22-year-old woman with history of claudication, hypotension, and
postprandial pain who was diagnosed with Takayasu's arteritis. Conventional
abdominal angiogram (A) and contrast-enhanced MR angiogram (B) show
marked narrowing and occlusion of distal abdominal aorta as well as occlusion
of both renal arteries, inferior mesenteric artery (IMA) (arrowhead),
and both common iliac arteries. Collaterals reconstitute renal arteries
(arrows, B), IMA (arrowhead), and external iliac
artery.
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Fig. 13B —22-year-old woman with history of claudication, hypotension, and
postprandial pain who was diagnosed with Takayasu's arteritis. Conventional
abdominal angiogram (A) and contrast-enhanced MR angiogram (B) show
marked narrowing and occlusion of distal abdominal aorta as well as occlusion
of both renal arteries, inferior mesenteric artery (IMA) (arrowhead),
and both common iliac arteries. Collaterals reconstitute renal arteries
(arrows, B), IMA (arrowhead), and external iliac
artery.
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Fig. 14A —69-year-old woman with Ehlers-Danlos syndrome who presented with
postprandial epigastric pain. Volume-rendered MDCT angiograms of abdomen and
pelvis (A) and mesenteric artery (B) reveal numerous aneurysms
of branches of superior mesenteric artery, thrombosed splenic artery aneurysm
(arrowhead, A), and aneurysms of right profunda femoral
branches (arrows, A).
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Fig. 14B —69-year-old woman with Ehlers-Danlos syndrome who presented with
postprandial epigastric pain. Volume-rendered MDCT angiograms of abdomen and
pelvis (A) and mesenteric artery (B) reveal numerous aneurysms
of branches of superior mesenteric artery, thrombosed splenic artery aneurysm
(arrowhead, A), and aneurysms of right profunda femoral
branches (arrows, A).
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Fig. 15A —41-year-old man with history of antiphospholipid antibody syndrome
and retroperitoneal fibrosis who presented to emergency department with 1-week
history of low-grade fever, nausea, vomiting, mild diarrhea, and constant
postprandial abdominal pain. Oblique sagittal multiplanar reformatted
(A) and volume-rendered (B) MDCT angiograms show illdefined soft
tissue surrounding abdominal aorta and superior mesenteric artery (SMA) roots
(arrowheads, A) and leading to focal stenosis of distal SMA
(arrows).
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Fig. 15B —41-year-old man with history of antiphospholipid antibody syndrome
and retroperitoneal fibrosis who presented to emergency department with 1-week
history of low-grade fever, nausea, vomiting, mild diarrhea, and constant
postprandial abdominal pain. Oblique sagittal multiplanar reformatted
(A) and volume-rendered (B) MDCT angiograms show illdefined soft
tissue surrounding abdominal aorta and superior mesenteric artery (SMA) roots
(arrowheads, A) and leading to focal stenosis of distal SMA
(arrows).
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Summary
CTA and contrast-enhanced MRA are excellent noninvasive screening
techniques for patients suspected of having mesenteric ischemia of all causes.
CTA has higher spatial resolution and faster acquisition times, allowing
assessment of the peripheral visceral branches and the inferior mesenteric
artery with greater accuracy than contrast-enhanced MRA. In addition, it
allows the identification of calcified plaques. contrast-enhanced MRA is
therefore our clear second choice in this clinical setting, but the lack of
radiation and iodinated contrast agents make it the technique of choice for
children and patients with azotemia.
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H. P. Forman
Back to the Beginning
Am. J. Roentgenol.,
February 1, 2007;
188(2):
295 - 296.
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Top
Abstract
Introduction
