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Nontraumatic Emergent Abdominal Vascular Conditions: Advantages of Multi–Detector Row CT and Three-Dimensional Imaging¹

¹ From the Institute of Diagnostic Radiology, University Hospital of Zurich, Raemistrasse 100, 8091 Zurich, Switzerland. Presented as an education exhibit at the 2002 RSNA scientific assembly. Received August 22, 2002; revision requested November 25, 2002, and received May 21, 2003; accepted July 2. Supported by the NCCR CO-ME of the Swiss National Science Foundation. Address correspondence to S.W. (e-mail: simon.wildermuth@usz.ch).

View larger version (132K): [in a new window]   Figure 1a. Ruptured infrarenal aortic aneurysm in a 72-year-old man. (a, b) Axial source image (a) and coronal oblique MPR image (b) show a ruptured aneurysm (diameter, 7 cm) with active bleeding (arrowhead) caudad to the aneurysm neck; a resultant large hematoma has displaced the kidney ventrally. (c, d) Coronal MIP (c) and VR (d) images show the anatomic location and configuration of the aneurysm and the bleeding (arrowhead)—important information for treatment planning.

View larger version (145K): [in a new window]   Figure 1b. Ruptured infrarenal aortic aneurysm in a 72-year-old man. (a, b) Axial source image (a) and coronal oblique MPR image (b) show a ruptured aneurysm (diameter, 7 cm) with active bleeding (arrowhead) caudad to the aneurysm neck; a resultant large hematoma has displaced the kidney ventrally. (c, d) Coronal MIP (c) and VR (d) images show the anatomic location and configuration of the aneurysm and the bleeding (arrowhead)—important information for treatment planning.

View larger version (144K): [in a new window]   Figure 1c. Ruptured infrarenal aortic aneurysm in a 72-year-old man. (a, b) Axial source image (a) and coronal oblique MPR image (b) show a ruptured aneurysm (diameter, 7 cm) with active bleeding (arrowhead) caudad to the aneurysm neck; a resultant large hematoma has displaced the kidney ventrally. (c, d) Coronal MIP (c) and VR (d) images show the anatomic location and configuration of the aneurysm and the bleeding (arrowhead)—important information for treatment planning.

View larger version (164K): [in a new window]   Figure 1d. Ruptured infrarenal aortic aneurysm in a 72-year-old man. (a, b) Axial source image (a) and coronal oblique MPR image (b) show a ruptured aneurysm (diameter, 7 cm) with active bleeding (arrowhead) caudad to the aneurysm neck; a resultant large hematoma has displaced the kidney ventrally. (c, d) Coronal MIP (c) and VR (d) images show the anatomic location and configuration of the aneurysm and the bleeding (arrowhead)—important information for treatment planning.

View larger version (172K): [in a new window]   Figure 2a. Ruptured aneurysm in a 77-year-old man who presented with acute abdominal pain. Coronal VR image (a) and axial source image (b) show an infrarenal aortic aneurysm with a diameter of 4.5 cm and a right common iliac artery aneurysm with a diameter of 8.5 cm (arrowheads in b), as well as a retroperitoneal hematoma (arrows in b). These findings were diagnostic. Note that the mural thrombus and the remaining lumen are evident, but no active bleeding can be seen.

View larger version (167K): [in a new window]   Figure 2b. Ruptured aneurysm in a 77-year-old man who presented with acute abdominal pain. Coronal VR image (a) and axial source image (b) show an infrarenal aortic aneurysm with a diameter of 4.5 cm and a right common iliac artery aneurysm with a diameter of 8.5 cm (arrowheads in b), as well as a retroperitoneal hematoma (arrows in b). These findings were diagnostic. Note that the mural thrombus and the remaining lumen are evident, but no active bleeding can be seen.

View larger version (50K): [in a new window]   Figure 3a. Type B aortic dissection in a 54-year-old woman with acute onset of thoracic and abdominal pain. (a, b) Anterior (a) and posterior (b) shaded surface display images show the true lumen (arrows) and the false lumen (arrowheads), as well as adjacent vessels. (c, d) VR image obtained with a cutting plane (c) and MIP image (d) also depict the two lumina (arrows) but do not permit clear differentiation between them because the entire length of the dissection flap (*) is not visible. (e-i) Contrast-enhanced arterial phase axial source images obtained at successively lower levels show the characteristic signs enabling differentiation between the false (F) and true (T) lumina. In e, the outer, false lumen is wrapped around the inner, true lumen, and the cobweb sign (arrow) is visible. In f and g, the false lumen is clearly larger in diameter than the true lumen and contains a thrombus (arrowheads in g), which is also evident in h (arrows). In h, note the eccentric calcification (arrowhead) alongside the flap facing the true lumen, and, in i, the beak sign (arrowheads) created by the curvature of the flap toward the false lumen.

View larger version (43K): [in a new window]   Figure 3b. Type B aortic dissection in a 54-year-old woman with acute onset of thoracic and abdominal pain. (a, b) Anterior (a) and posterior (b) shaded surface display images show the true lumen (arrows) and the false lumen (arrowheads), as well as adjacent vessels. (c, d) VR image obtained with a cutting plane (c) and MIP image (d) also depict the two lumina (arrows) but do not permit clear differentiation between them because the entire length of the dissection flap (*) is not visible. (e-i) Contrast-enhanced arterial phase axial source images obtained at successively lower levels show the characteristic signs enabling differentiation between the false (F) and true (T) lumina. In e, the outer, false lumen is wrapped around the inner, true lumen, and the cobweb sign (arrow) is visible. In f and g, the false lumen is clearly larger in diameter than the true lumen and contains a thrombus (arrowheads in g), which is also evident in h (arrows). In h, note the eccentric calcification (arrowhead) alongside the flap facing the true lumen, and, in i, the beak sign (arrowheads) created by the curvature of the flap toward the false lumen.

View larger version (54K): [in a new window]   Figure 3c. Type B aortic dissection in a 54-year-old woman with acute onset of thoracic and abdominal pain. (a, b) Anterior (a) and posterior (b) shaded surface display images show the true lumen (arrows) and the false lumen (arrowheads), as well as adjacent vessels. (c, d) VR image obtained with a cutting plane (c) and MIP image (d) also depict the two lumina (arrows) but do not permit clear differentiation between them because the entire length of the dissection flap (*) is not visible. (e-i) Contrast-enhanced arterial phase axial source images obtained at successively lower levels show the characteristic signs enabling differentiation between the false (F) and true (T) lumina. In e, the outer, false lumen is wrapped around the inner, true lumen, and the cobweb sign (arrow) is visible. In f and g, the false lumen is clearly larger in diameter than the true lumen and contains a thrombus (arrowheads in g), which is also evident in h (arrows). In h, note the eccentric calcification (arrowhead) alongside the flap facing the true lumen, and, in i, the beak sign (arrowheads) created by the curvature of the flap toward the false lumen.

View larger version (52K): [in a new window]   Figure 3d. Type B aortic dissection in a 54-year-old woman with acute onset of thoracic and abdominal pain. (a, b) Anterior (a) and posterior (b) shaded surface display images show the true lumen (arrows) and the false lumen (arrowheads), as well as adjacent vessels. (c, d) VR image obtained with a cutting plane (c) and MIP image (d) also depict the two lumina (arrows) but do not permit clear differentiation between them because the entire length of the dissection flap (*) is not visible. (e-i) Contrast-enhanced arterial phase axial source images obtained at successively lower levels show the characteristic signs enabling differentiation between the false (F) and true (T) lumina. In e, the outer, false lumen is wrapped around the inner, true lumen, and the cobweb sign (arrow) is visible. In f and g, the false lumen is clearly larger in diameter than the true lumen and contains a thrombus (arrowheads in g), which is also evident in h (arrows). In h, note the eccentric calcification (arrowhead) alongside the flap facing the true lumen, and, in i, the beak sign (arrowheads) created by the curvature of the flap toward the false lumen.

View larger version (97K): [in a new window]   Figure 3e. Type B aortic dissection in a 54-year-old woman with acute onset of thoracic and abdominal pain. (a, b) Anterior (a) and posterior (b) shaded surface display images show the true lumen (arrows) and the false lumen (arrowheads), as well as adjacent vessels. (c, d) VR image obtained with a cutting plane (c) and MIP image (d) also depict the two lumina (arrows) but do not permit clear differentiation between them because the entire length of the dissection flap (*) is not visible. (e-i) Contrast-enhanced arterial phase axial source images obtained at successively lower levels show the characteristic signs enabling differentiation between the false (F) and true (T) lumina. In e, the outer, false lumen is wrapped around the inner, true lumen, and the cobweb sign (arrow) is visible. In f and g, the false lumen is clearly larger in diameter than the true lumen and contains a thrombus (arrowheads in g), which is also evident in h (arrows). In h, note the eccentric calcification (arrowhead) alongside the flap facing the true lumen, and, in i, the beak sign (arrowheads) created by the curvature of the flap toward the false lumen.

View larger version (96K): [in a new window]   Figure 3f. Type B aortic dissection in a 54-year-old woman with acute onset of thoracic and abdominal pain. (a, b) Anterior (a) and posterior (b) shaded surface display images show the true lumen (arrows) and the false lumen (arrowheads), as well as adjacent vessels. (c, d) VR image obtained with a cutting plane (c) and MIP image (d) also depict the two lumina (arrows) but do not permit clear differentiation between them because the entire length of the dissection flap (*) is not visible. (e-i) Contrast-enhanced arterial phase axial source images obtained at successively lower levels show the characteristic signs enabling differentiation between the false (F) and true (T) lumina. In e, the outer, false lumen is wrapped around the inner, true lumen, and the cobweb sign (arrow) is visible. In f and g, the false lumen is clearly larger in diameter than the true lumen and contains a thrombus (arrowheads in g), which is also evident in h (arrows). In h, note the eccentric calcification (arrowhead) alongside the flap facing the true lumen, and, in i, the beak sign (arrowheads) created by the curvature of the flap toward the false lumen.

View larger version (98K): [in a new window]   Figure 3g. Type B aortic dissection in a 54-year-old woman with acute onset of thoracic and abdominal pain. (a, b) Anterior (a) and posterior (b) shaded surface display images show the true lumen (arrows) and the false lumen (arrowheads), as well as adjacent vessels. (c, d) VR image obtained with a cutting plane (c) and MIP image (d) also depict the two lumina (arrows) but do not permit clear differentiation between them because the entire length of the dissection flap (*) is not visible. (e-i) Contrast-enhanced arterial phase axial source images obtained at successively lower levels show the characteristic signs enabling differentiation between the false (F) and true (T) lumina. In e, the outer, false lumen is wrapped around the inner, true lumen, and the cobweb sign (arrow) is visible. In f and g, the false lumen is clearly larger in diameter than the true lumen and contains a thrombus (arrowheads in g), which is also evident in h (arrows). In h, note the eccentric calcification (arrowhead) alongside the flap facing the true lumen, and, in i, the beak sign (arrowheads) created by the curvature of the flap toward the false lumen.

View larger version (119K): [in a new window]   Figure 3h. Type B aortic dissection in a 54-year-old woman with acute onset of thoracic and abdominal pain. (a, b) Anterior (a) and posterior (b) shaded surface display images show the true lumen (arrows) and the false lumen (arrowheads), as well as adjacent vessels. (c, d) VR image obtained with a cutting plane (c) and MIP image (d) also depict the two lumina (arrows) but do not permit clear differentiation between them because the entire length of the dissection flap (*) is not visible. (e-i) Contrast-enhanced arterial phase axial source images obtained at successively lower levels show the characteristic signs enabling differentiation between the false (F) and true (T) lumina. In e, the outer, false lumen is wrapped around the inner, true lumen, and the cobweb sign (arrow) is visible. In f and g, the false lumen is clearly larger in diameter than the true lumen and contains a thrombus (arrowheads in g), which is also evident in h (arrows). In h, note the eccentric calcification (arrowhead) alongside the flap facing the true lumen, and, in i, the beak sign (arrowheads) created by the curvature of the flap toward the false lumen.

View larger version (119K): [in a new window]   Figure 3i. Type B aortic dissection in a 54-year-old woman with acute onset of thoracic and abdominal pain. (a, b) Anterior (a) and posterior (b) shaded surface display images show the true lumen (arrows) and the false lumen (arrowheads), as well as adjacent vessels. (c, d) VR image obtained with a cutting plane (c) and MIP image (d) also depict the two lumina (arrows) but do not permit clear differentiation between them because the entire length of the dissection flap (*) is not visible. (e-i) Contrast-enhanced arterial phase axial source images obtained at successively lower levels show the characteristic signs enabling differentiation between the false (F) and true (T) lumina. In e, the outer, false lumen is wrapped around the inner, true lumen, and the cobweb sign (arrow) is visible. In f and g, the false lumen is clearly larger in diameter than the true lumen and contains a thrombus (arrowheads in g), which is also evident in h (arrows). In h, note the eccentric calcification (arrowhead) alongside the flap facing the true lumen, and, in i, the beak sign (arrowheads) created by the curvature of the flap toward the false lumen.

View larger version (123K): [in a new window]   Figure 4a. Spontaneous subcapsular renal hemorrhage in a 70-year-old man who presented, subsequent to oral anticoagulation therapy, with pain in the right side and acute anemia of unknown origin. Nonenhanced axial source image (a), contrast-enhanced coronal MPR (b), and coronal (c) and sagittal (d) VR images depict a subcapsular hematoma (arrowheads) in the right kidney.

View larger version (135K): [in a new window]   Figure 4b. Spontaneous subcapsular renal hemorrhage in a 70-year-old man who presented, subsequent to oral anticoagulation therapy, with pain in the right side and acute anemia of unknown origin. Nonenhanced axial source image (a), contrast-enhanced coronal MPR (b), and coronal (c) and sagittal (d) VR images depict a subcapsular hematoma (arrowheads) in the right kidney.

View larger version (163K): [in a new window]   Figure 4c. Spontaneous subcapsular renal hemorrhage in a 70-year-old man who presented, subsequent to oral anticoagulation therapy, with pain in the right side and acute anemia of unknown origin. Nonenhanced axial source image (a), contrast-enhanced coronal MPR (b), and coronal (c) and sagittal (d) VR images depict a subcapsular hematoma (arrowheads) in the right kidney.

View larger version (160K): [in a new window]   Figure 4d. Spontaneous subcapsular renal hemorrhage in a 70-year-old man who presented, subsequent to oral anticoagulation therapy, with pain in the right side and acute anemia of unknown origin. Nonenhanced axial source image (a), contrast-enhanced coronal MPR (b), and coronal (c) and sagittal (d) VR images depict a subcapsular hematoma (arrowheads) in the right kidney.

View larger version (101K): [in a new window]   Figure 5a. Angiomyolipoma in a 68-year-old man with hemostatic shock, acute anemia, and right-sided abdominal pain. (a-e) Contrast-enhanced axial source image (a), coronal (b) and sagittal (c) MPR images, posteroanterior MIP image (d), and posterior VR image (e) show contrast material extravasation (arrowheads) from the upper right renal pole into a large retroperitoneal hematoma. The lesion (arrow) in the upper renal pole has attenuation characteristic of angiomyolipoma. Note that the MIP image shows only the vessels and extravasation, whereas the VR image depicts adjacent organs as well as the lesion. (f) Angiogram from catheter angiography performed after therapeutic embolization helps confirm the cessation of bleeding at the lesion site (arrow).

View larger version (106K): [in a new window]   Figure 5b. Angiomyolipoma in a 68-year-old man with hemostatic shock, acute anemia, and right-sided abdominal pain. (a-e) Contrast-enhanced axial source image (a), coronal (b) and sagittal (c) MPR images, posteroanterior MIP image (d), and posterior VR image (e) show contrast material extravasation (arrowheads) from the upper right renal pole into a large retroperitoneal hematoma. The lesion (arrow) in the upper renal pole has attenuation characteristic of angiomyolipoma. Note that the MIP image shows only the vessels and extravasation, whereas the VR image depicts adjacent organs as well as the lesion. (f) Angiogram from catheter angiography performed after therapeutic embolization helps confirm the cessation of bleeding at the lesion site (arrow).

View larger version (157K): [in a new window]   Figure 5c. Angiomyolipoma in a 68-year-old man with hemostatic shock, acute anemia, and right-sided abdominal pain. (a-e) Contrast-enhanced axial source image (a), coronal (b) and sagittal (c) MPR images, posteroanterior MIP image (d), and posterior VR image (e) show contrast material extravasation (arrowheads) from the upper right renal pole into a large retroperitoneal hematoma. The lesion (arrow) in the upper renal pole has attenuation characteristic of angiomyolipoma. Note that the MIP image shows only the vessels and extravasation, whereas the VR image depicts adjacent organs as well as the lesion. (f) Angiogram from catheter angiography performed after therapeutic embolization helps confirm the cessation of bleeding at the lesion site (arrow).

View larger version (92K): [in a new window]   Figure 5d. Angiomyolipoma in a 68-year-old man with hemostatic shock, acute anemia, and right-sided abdominal pain. (a-e) Contrast-enhanced axial source image (a), coronal (b) and sagittal (c) MPR images, posteroanterior MIP image (d), and posterior VR image (e) show contrast material extravasation (arrowheads) from the upper right renal pole into a large retroperitoneal hematoma. The lesion (arrow) in the upper renal pole has attenuation characteristic of angiomyolipoma. Note that the MIP image shows only the vessels and extravasation, whereas the VR image depicts adjacent organs as well as the lesion. (f) Angiogram from catheter angiography performed after therapeutic embolization helps confirm the cessation of bleeding at the lesion site (arrow).

View larger version (95K): [in a new window]   Figure 5e. Angiomyolipoma in a 68-year-old man with hemostatic shock, acute anemia, and right-sided abdominal pain. (a-e) Contrast-enhanced axial source image (a), coronal (b) and sagittal (c) MPR images, posteroanterior MIP image (d), and posterior VR image (e) show contrast material extravasation (arrowheads) from the upper right renal pole into a large retroperitoneal hematoma. The lesion (arrow) in the upper renal pole has attenuation characteristic of angiomyolipoma. Note that the MIP image shows only the vessels and extravasation, whereas the VR image depicts adjacent organs as well as the lesion. (f) Angiogram from catheter angiography performed after therapeutic embolization helps confirm the cessation of bleeding at the lesion site (arrow).

View larger version (142K): [in a new window]   Figure 5f. Angiomyolipoma in a 68-year-old man with hemostatic shock, acute anemia, and right-sided abdominal pain. (a-e) Contrast-enhanced axial source image (a), coronal (b) and sagittal (c) MPR images, posteroanterior MIP image (d), and posterior VR image (e) show contrast material extravasation (arrowheads) from the upper right renal pole into a large retroperitoneal hematoma. The lesion (arrow) in the upper renal pole has attenuation characteristic of angiomyolipoma. Note that the MIP image shows only the vessels and extravasation, whereas the VR image depicts adjacent organs as well as the lesion. (f) Angiogram from catheter angiography performed after therapeutic embolization helps confirm the cessation of bleeding at the lesion site (arrow).

View larger version (159K): [in a new window]   Figure 6a. Aortoduodenal fistula in a 70-year-old man who presented with anemia caused by intestinal bleeding of unknown origin, 10 years after aortoiliac graft implantation. (a, b) Contrast-enhanced axial source image (a) and coronal MPR image (b) show extravasation of contrast material (arrowheads) into the horizontal or inferior duodenum. (c, d) Coronal MIP image (c) and coronal VR image (d) from venous phase imaging show the advantage of two-phase CT: On an arterial phase image, only a small amount of contrast material is evident in the duodenum, whereas the venous phase images show active bleeding (arrow) into the duodenum. (Blood is depicted in yellow.) (e, f) Axial VR image (e) and sagittal MPR image (f) show the exact location of the fistula (arrow).

View larger version (170K): [in a new window]   Figure 6b. Aortoduodenal fistula in a 70-year-old man who presented with anemia caused by intestinal bleeding of unknown origin, 10 years after aortoiliac graft implantation. (a, b) Contrast-enhanced axial source image (a) and coronal MPR image (b) show extravasation of contrast material (arrowheads) into the horizontal or inferior duodenum. (c, d) Coronal MIP image (c) and coronal VR image (d) from venous phase imaging show the advantage of two-phase CT: On an arterial phase image, only a small amount of contrast material is evident in the duodenum, whereas the venous phase images show active bleeding (arrow) into the duodenum. (Blood is depicted in yellow.) (e, f) Axial VR image (e) and sagittal MPR image (f) show the exact location of the fistula (arrow).

View larger version (163K): [in a new window]   Figure 6c. Aortoduodenal fistula in a 70-year-old man who presented with anemia caused by intestinal bleeding of unknown origin, 10 years after aortoiliac graft implantation. (a, b) Contrast-enhanced axial source image (a) and coronal MPR image (b) show extravasation of contrast material (arrowheads) into the horizontal or inferior duodenum. (c, d) Coronal MIP image (c) and coronal VR image (d) from venous phase imaging show the advantage of two-phase CT: On an arterial phase image, only a small amount of contrast material is evident in the duodenum, whereas the venous phase images show active bleeding (arrow) into the duodenum. (Blood is depicted in yellow.) (e, f) Axial VR image (e) and sagittal MPR image (f) show the exact location of the fistula (arrow).

View larger version (159K): [in a new window]   Figure 6d. Aortoduodenal fistula in a 70-year-old man who presented with anemia caused by intestinal bleeding of unknown origin, 10 years after aortoiliac graft implantation. (a, b) Contrast-enhanced axial source image (a) and coronal MPR image (b) show extravasation of contrast material (arrowheads) into the horizontal or inferior duodenum. (c, d) Coronal MIP image (c) and coronal VR image (d) from venous phase imaging show the advantage of two-phase CT: On an arterial phase image, only a small amount of contrast material is evident in the duodenum, whereas the venous phase images show active bleeding (arrow) into the duodenum. (Blood is depicted in yellow.) (e, f) Axial VR image (e) and sagittal MPR image (f) show the exact location of the fistula (arrow).

View larger version (162K): [in a new window]   Figure 6e. Aortoduodenal fistula in a 70-year-old man who presented with anemia caused by intestinal bleeding of unknown origin, 10 years after aortoiliac graft implantation. (a, b) Contrast-enhanced axial source image (a) and coronal MPR image (b) show extravasation of contrast material (arrowheads) into the horizontal or inferior duodenum. (c, d) Coronal MIP image (c) and coronal VR image (d) from venous phase imaging show the advantage of two-phase CT: On an arterial phase image, only a small amount of contrast material is evident in the duodenum, whereas the venous phase images show active bleeding (arrow) into the duodenum. (Blood is depicted in yellow.) (e, f) Axial VR image (e) and sagittal MPR image (f) show the exact location of the fistula (arrow).

View larger version (186K): [in a new window]   Figure 6f. Aortoduodenal fistula in a 70-year-old man who presented with anemia caused by intestinal bleeding of unknown origin, 10 years after aortoiliac graft implantation. (a, b) Contrast-enhanced axial source image (a) and coronal MPR image (b) show extravasation of contrast material (arrowheads) into the horizontal or inferior duodenum. (c, d) Coronal MIP image (c) and coronal VR image (d) from venous phase imaging show the advantage of two-phase CT: On an arterial phase image, only a small amount of contrast material is evident in the duodenum, whereas the venous phase images show active bleeding (arrow) into the duodenum. (Blood is depicted in yellow.) (e, f) Axial VR image (e) and sagittal MPR image (f) show the exact location of the fistula (arrow).

View larger version (132K): [in a new window]   Figure 7a. Nonocclusive mesenteric ischemia in a 51-year-old woman with a history of left-sided heart failure. (a) Abdominal radiograph shows signs of pneumatosis coli (arrowheads). (b-d) Coronal VR image (b), sagittal MPR image (c), and curved MPR image (d) show air in the wall of the small bowel and ascending colon (arrowheads). (e, f) Axial source images show air collections in the intrahepatic vessels (arrows in e) and in the portal confluence (arrow in f) and an intraaortic balloon pump device in the aortic lumen (arrowhead in f). The device is shown in a to be in the correct position, and no occlusion is visible in the mesenteric arteries (arrow in d). The absence of occlusion was confirmed at pathologic analysis. The ischemia from low cardiac output probably was exacerbated by a reduction in peak systolic pressure caused by the intraaortic balloon pump.

View larger version (136K): [in a new window]   Figure 7b. Nonocclusive mesenteric ischemia in a 51-year-old woman with a history of left-sided heart failure. (a) Abdominal radiograph shows signs of pneumatosis coli (arrowheads). (b-d) Coronal VR image (b), sagittal MPR image (c), and curved MPR image (d) show air in the wall of the small bowel and ascending colon (arrowheads). (e, f) Axial source images show air collections in the intrahepatic vessels (arrows in e) and in the portal confluence (arrow in f) and an intraaortic balloon pump device in the aortic lumen (arrowhead in f). The device is shown in a to be in the correct position, and no occlusion is visible in the mesenteric arteries (arrow in d). The absence of occlusion was confirmed at pathologic analysis. The ischemia from low cardiac output probably was exacerbated by a reduction in peak systolic pressure caused by the intraaortic balloon pump.

View larger version (140K): [in a new window]   Figure 7c. Nonocclusive mesenteric ischemia in a 51-year-old woman with a history of left-sided heart failure. (a) Abdominal radiograph shows signs of pneumatosis coli (arrowheads). (b-d) Coronal VR image (b), sagittal MPR image (c), and curved MPR image (d) show air in the wall of the small bowel and ascending colon (arrowheads). (e, f) Axial source images show air collections in the intrahepatic vessels (arrows in e) and in the portal confluence (arrow in f) and an intraaortic balloon pump device in the aortic lumen (arrowhead in f). The device is shown in a to be in the correct position, and no occlusion is visible in the mesenteric arteries (arrow in d). The absence of occlusion was confirmed at pathologic analysis. The ischemia from low cardiac output probably was exacerbated by a reduction in peak systolic pressure caused by the intraaortic balloon pump.

View larger version (101K): [in a new window]   Figure 7d. Nonocclusive mesenteric ischemia in a 51-year-old woman with a history of left-sided heart failure. (a) Abdominal radiograph shows signs of pneumatosis coli (arrowheads). (b-d) Coronal VR image (b), sagittal MPR image (c), and curved MPR image (d) show air in the wall of the small bowel and ascending colon (arrowheads). (e, f) Axial source images show air collections in the intrahepatic vessels (arrows in e) and in the portal confluence (arrow in f) and an intraaortic balloon pump device in the aortic lumen (arrowhead in f). The device is shown in a to be in the correct position, and no occlusion is visible in the mesenteric arteries (arrow in d). The absence of occlusion was confirmed at pathologic analysis. The ischemia from low cardiac output probably was exacerbated by a reduction in peak systolic pressure caused by the intraaortic balloon pump.

View larger version (131K): [in a new window]   Figure 7e. Nonocclusive mesenteric ischemia in a 51-year-old woman with a history of left-sided heart failure. (a) Abdominal radiograph shows signs of pneumatosis coli (arrowheads). (b-d) Coronal VR image (b), sagittal MPR image (c), and curved MPR image (d) show air in the wall of the small bowel and ascending colon (arrowheads). (e, f) Axial source images show air collections in the intrahepatic vessels (arrows in e) and in the portal confluence (arrow in f) and an intraaortic balloon pump device in the aortic lumen (arrowhead in f). The device is shown in a to be in the correct position, and no occlusion is visible in the mesenteric arteries (arrow in d). The absence of occlusion was confirmed at pathologic analysis. The ischemia from low cardiac output probably was exacerbated by a reduction in peak systolic pressure caused by the intraaortic balloon pump.

View larger version (157K): [in a new window]   Figure 7f. Nonocclusive mesenteric ischemia in a 51-year-old woman with a history of left-sided heart failure. (a) Abdominal radiograph shows signs of pneumatosis coli (arrowheads). (b-d) Coronal VR image (b), sagittal MPR image (c), and curved MPR image (d) show air in the wall of the small bowel and ascending colon (arrowheads). (e, f) Axial source images show air collections in the intrahepatic vessels (arrows in e) and in the portal confluence (arrow in f) and an intraaortic balloon pump device in the aortic lumen (arrowhead in f). The device is shown in a to be in the correct position, and no occlusion is visible in the mesenteric arteries (arrow in d). The absence of occlusion was confirmed at pathologic analysis. The ischemia from low cardiac output probably was exacerbated by a reduction in peak systolic pressure caused by the intraaortic balloon pump.

View larger version (160K): [in a new window]   Figure 8a. Cardiac pseudoaneurysm and thrombus in a 59-year-old man who presented with diffuse abdominal pain, vomiting, and diarrhea accompanied by hematochezia. (a, b) Axial source image (a) and coronal VR image (b) depict pseudoaneurysm with thrombus (arrow) in the left cardiac apex, as well as extensive infarction in the spleen (arrowhead in a). (c, d) Ax- ial source image (c) and VR image (d) depict atrophy of the left kidney (arrows) with chronic infarction and partial occlusion of the left common iliac artery (arrowheads in d). (e) Axial source image shows ileal wall thickening caused by ischemia (arrowheads) and partial occlusion of the left common iliac artery (arrow).

View larger version (147K): [in a new window]   Figure 8b. Cardiac pseudoaneurysm and thrombus in a 59-year-old man who presented with diffuse abdominal pain, vomiting, and diarrhea accompanied by hematochezia. (a, b) Axial source image (a) and coronal VR image (b) depict pseudoaneurysm with thrombus (arrow) in the left cardiac apex, as well as extensive infarction in the spleen (arrowhead in a). (c, d) Ax- ial source image (c) and VR image (d) depict atrophy of the left kidney (arrows) with chronic infarction and partial occlusion of the left common iliac artery (arrowheads in d). (e) Axial source image shows ileal wall thickening caused by ischemia (arrowheads) and partial occlusion of the left common iliac artery (arrow).

View larger version (148K): [in a new window]   Figure 8c. Cardiac pseudoaneurysm and thrombus in a 59-year-old man who presented with diffuse abdominal pain, vomiting, and diarrhea accompanied by hematochezia. (a, b) Axial source image (a) and coronal VR image (b) depict pseudoaneurysm with thrombus (arrow) in the left cardiac apex, as well as extensive infarction in the spleen (arrowhead in a). (c, d) Ax- ial source image (c) and VR image (d) depict atrophy of the left kidney (arrows) with chronic infarction and partial occlusion of the left common iliac artery (arrowheads in d). (e) Axial source image shows ileal wall thickening caused by ischemia (arrowheads) and partial occlusion of the left common iliac artery (arrow).

View larger version (124K): [in a new window]   Figure 8d. Cardiac pseudoaneurysm and thrombus in a 59-year-old man who presented with diffuse abdominal pain, vomiting, and diarrhea accompanied by hematochezia. (a, b) Axial source image (a) and coronal VR image (b) depict pseudoaneurysm with thrombus (arrow) in the left cardiac apex, as well as extensive infarction in the spleen (arrowhead in a). (c, d) Ax- ial source image (c) and VR image (d) depict atrophy of the left kidney (arrows) with chronic infarction and partial occlusion of the left common iliac artery (arrowheads in d). (e) Axial source image shows ileal wall thickening caused by ischemia (arrowheads) and partial occlusion of the left common iliac artery (arrow).

View larger version (121K): [in a new window]   Figure 8e. Cardiac pseudoaneurysm and thrombus in a 59-year-old man who presented with diffuse abdominal pain, vomiting, and diarrhea accompanied by hematochezia. (a, b) Axial source image (a) and coronal VR image (b) depict pseudoaneurysm with thrombus (arrow) in the left cardiac apex, as well as extensive infarction in the spleen (arrowhead in a). (c, d) Ax- ial source image (c) and VR image (d) depict atrophy of the left kidney (arrows) with chronic infarction and partial occlusion of the left common iliac artery (arrowheads in d). (e) Axial source image shows ileal wall thickening caused by ischemia (arrowheads) and partial occlusion of the left common iliac artery (arrow).

View larger version (110K): [in a new window]   Figure 9a. Wegener granulomatosis in a 48-year-old woman with recurrent epigastric pain and with c-ANCA in blood serum. (a, b) Axial source images depict multiple hypoattenuating lesions in the spleen (arrow in a), which indicate infarction, and thickening of the jejunal bowel wall (arrow in b). (c, d) Axial source image (c) and coronal MPR image (d) show occlusion (arrowheads) in a branch of the superior mesenteric artery. These CT findings are nonspecific, but, when combined with the finding of c-ANCA in blood serum, are highly suggestive of Wegener granulomatosis.

View larger version (109K): [in a new window]   Figure 9b. Wegener granulomatosis in a 48-year-old woman with recurrent epigastric pain and with c-ANCA in blood serum. (a, b) Axial source images depict multiple hypoattenuating lesions in the spleen (arrow in a), which indicate infarction, and thickening of the jejunal bowel wall (arrow in b). (c, d) Axial source image (c) and coronal MPR image (d) show occlusion (arrowheads) in a branch of the superior mesenteric artery. These CT findings are nonspecific, but, when combined with the finding of c-ANCA in blood serum, are highly suggestive of Wegener granulomatosis.

View larger version (131K): [in a new window]   Figure 9c. Wegener granulomatosis in a 48-year-old woman with recurrent epigastric pain and with c-ANCA in blood serum. (a, b) Axial source images depict multiple hypoattenuating lesions in the spleen (arrow in a), which indicate infarction, and thickening of the jejunal bowel wall (arrow in b). (c, d) Axial source image (c) and coronal MPR image (d) show occlusion (arrowheads) in a branch of the superior mesenteric artery. These CT findings are nonspecific, but, when combined with the finding of c-ANCA in blood serum, are highly suggestive of Wegener granulomatosis.

View larger version (146K): [in a new window]   Figure 9d. Wegener granulomatosis in a 48-year-old woman with recurrent epigastric pain and with c-ANCA in blood serum. (a, b) Axial source images depict multiple hypoattenuating lesions in the spleen (arrow in a), which indicate infarction, and thickening of the jejunal bowel wall (arrow in b). (c, d) Axial source image (c) and coronal MPR image (d) show occlusion (arrowheads) in a branch of the superior mesenteric artery. These CT findings are nonspecific, but, when combined with the finding of c-ANCA in blood serum, are highly suggestive of Wegener granulomatosis.

View larger version (139K): [in a new window]   Figure 10a. Arteriovenous fistula in an 84-year-old man after abdominal aortic stent-graft implantation. (a, b) Coronal (a) and sagittal (b) MIP images show early filling in the left iliac and inferior caval veins (arrowheads in a) and the ascending lumbar vein (arrow), which indicates iatrogenic arteriovenous fistula from stent-graft implantation. (c, d) The location of the small fistula (arrowhead in d) between the left common iliac artery and the corresponding vein was not evident on the MIP images or the VR image (c) but only on the curved MPR image (d). Note that no contrast enhancement is seen in the lower abdominal venous system in this early scanning phase.

View larger version (156K): [in a new window]   Figure 10b. Arteriovenous fistula in an 84-year-old man after abdominal aortic stent-graft implantation. (a, b) Coronal (a) and sagittal (b) MIP images show early filling in the left iliac and inferior caval veins (arrowheads in a) and the ascending lumbar vein (arrow), which indicates iatrogenic arteriovenous fistula from stent-graft implantation. (c, d) The location of the small fistula (arrowhead in d) between the left common iliac artery and the corresponding vein was not evident on the MIP images or the VR image (c) but only on the curved MPR image (d). Note that no contrast enhancement is seen in the lower abdominal venous system in this early scanning phase.

View larger version (126K): [in a new window]   Figure 10c. Arteriovenous fistula in an 84-year-old man after abdominal aortic stent-graft implantation. (a, b) Coronal (a) and sagittal (b) MIP images show early filling in the left iliac and inferior caval veins (arrowheads in a) and the ascending lumbar vein (arrow), which indicates iatrogenic arteriovenous fistula from stent-graft implantation. (c, d) The location of the small fistula (arrowhead in d) between the left common iliac artery and the corresponding vein was not evident on the MIP images or the VR image (c) but only on the curved MPR image (d). Note that no contrast enhancement is seen in the lower abdominal venous system in this early scanning phase.

View larger version (133K): [in a new window]   Figure 10d. Arteriovenous fistula in an 84-year-old man after abdominal aortic stent-graft implantation. (a, b) Coronal (a) and sagittal (b) MIP images show early filling in the left iliac and inferior caval veins (arrowheads in a) and the ascending lumbar vein (arrow), which indicates iatrogenic arteriovenous fistula from stent-graft implantation. (c, d) The location of the small fistula (arrowhead in d) between the left common iliac artery and the corresponding vein was not evident on the MIP images or the VR image (c) but only on the curved MPR image (d). Note that no contrast enhancement is seen in the lower abdominal venous system in this early scanning phase.

View larger version (158K): [in a new window]   Figure 11a. Segmental arterial mediolysis in a 51-year-old man with pain in the right upper abdominal quadrant. (a, b) Sagittal MPR image (a) and its magnified view (b) depict thickening of the superior mesenteric artery wall (arrowheads). (c, d) Axial source image (c) and VR image (d) show dissection of the dilated celiac trunk (arrow), as well as mesenteric artery wall thickening (arrowheads).

View larger version (114K): [in a new window]   Figure 11b. Segmental arterial mediolysis in a 51-year-old man with pain in the right upper abdominal quadrant. (a, b) Sagittal MPR image (a) and its magnified view (b) depict thickening of the superior mesenteric artery wall (arrowheads). (c, d) Axial source image (c) and VR image (d) show dissection of the dilated celiac trunk (arrow), as well as mesenteric artery wall thickening (arrowheads).

View larger version (165K): [in a new window]   Figure 11c. Segmental arterial mediolysis in a 51-year-old man with pain in the right upper abdominal quadrant. (a, b) Sagittal MPR image (a) and its magnified view (b) depict thickening of the superior mesenteric artery wall (arrowheads). (c, d) Axial source image (c) and VR image (d) show dissection of the dilated celiac trunk (arrow), as well as mesenteric artery wall thickening (arrowheads).

View larger version (138K): [in a new window]   Figure 11d. Segmental arterial mediolysis in a 51-year-old man with pain in the right upper abdominal quadrant. (a, b) Sagittal MPR image (a) and its magnified view (b) depict thickening of the superior mesenteric artery wall (arrowheads). (c, d) Axial source image (c) and VR image (d) show dissection of the dilated celiac trunk (arrow), as well as mesenteric artery wall thickening (arrowheads).