Vascular conditions and neuropathic arthropathy

Question 1

What are HAEMANGIOMAS?

Answer 1

Greek: Haem = Blood ; Angeio = Vessel; -oma = tumour
A benign and usually self-limiting tumour of the endothelial cells that line blood vessels
Characterised by increased number of normal or abnormal vessels filled with blood – blood vessels forming a birthmark
Congenital or traumatic

Vertebral Haemangiomas:

1. Atypical haemangiomas
   - lower fat content
   - most common benign vertebral neoplasms – NOT true neoplasms but venous malformations
   - Usually, asymptomatic - symptomatic in the 4thdecade of life.
   - Incidentally detected on routine radiographs of the spine
   - Rarely, locally aggressive
   - Slightly more in females than men
2. Two main types:
   - Cavernous (involves relatively large vessels)
   - Capillary (involves small capillaries) angiomas

Vertebral Haemangiomas:

2. Clinical Findings
   - PAIN – due to:
   - collapsed vertebral body or encroachment into the neural canal
   - An increase in activity e.g starting to exercise, housework
   - axial loading through the body of the vertebra.
   - Displacement of the bone due to vascular spacing
   - M/C in thoracic spine but can be found throughout the spine.

Question 2

What is ATHEROSCLEROSIS?

Answer 2

AKA “Hardening of the arteries” where the arterial walls thicken due to build up of fatty materials e.g., cholesterol
Preventable and treatable

CAUSED BY:
- High blood pressure
- High cholesterol
- An irritant e.g., nicotine
- Certain diseases e.g., diabetes
- formation of multiple plaques within the arteries, resulting in:
- Obstruction (restricting blood flow)
- thrombus formation (causing blood clot)
- aneurysmal dilation

Question 3

What are the clinical findings of ATHEROSCLEROSIS?

Answer 3

• Develops gradually (typically begins in early adolescence)
  - Usually found in most major arteries inc.:
  - Aorta
  - Iliac arteries
  - Subclavian
  - Carotid
  - Coronary
  - Femoral

Question 4

What are the radiological findings of ATHEROSCLEROSIS?

Answer 4

• Radiographic evidence depends on the presence of calcification
  - Incidence of calcification increases with age and is seen in about 40% of patients over the age of 45
  - Unusual if seen below the age of 40 and suggest possible undiagnosed Hypertension (HTN) or diabetes mellitus (DM)
  - Degree of calcification DOES NOT correlate with the degree of luminal narrowing

Question 5

What are the two main types of Vertebral Haemangiomas?

Answer 5

• Cavernous (involves relatively large vessels)
  - Capillary (involves small capillaries) angiomas

Question 6

What are the complications of ATHEROSCLEROSIS?

Answer 6

1. Coronary Artery Disease
   - Narrowing of arteries close to heart, causing chest pain (angina) or heart attack

    2. Carotid Artery Disease
            - Narrowing of arteries close to brain, causing transient ischemic attack (TIA) or stroke
   
    3. Peripheral Artery Disease
            - Narrowing of arteries in arms or legs, causing circulation problems e.g. less sensitive to heat and cold and in more severe cases poor circulation causes tissue death (e.g. gangrene)
   
    4. Aneurysms
            - A serious complication due to a bulge in the wall of the artery which if bursts can cause life threatening internal bleeding

Question 7

What is ABDOMINAL AORTIC ANEURYSM (AAA)?

Answer 7

Most commonly seen atherosclerotic vessel
Should measure less than 3.8cm in it’s AP dimension
Calcification is generally seen anterior to the L3 and L4 levels (i.e. just above bifurcation level)

Question 8

What is the EPIDEMIOLOGY of ABDOMINAL AORTIC ANEURYSM (AAA)?

Answer 8

• AAA present in 2-4% of the population > 50
  - Male > female
  - 10,000 deaths/yr – 12th leading cause of death in Western society
  - Silent Killer – no symptoms to indicate an aneurysm is developing in the abdominal aorta
  - Rupture has a > 80% mortality rate

Question 9

What are the signs and symptoms of ABDOMINAL AORTIC ANEURYSM (AAA)?

Answer 9

• Abdominal/back/flank pain (L>R)
  - Testicular or leg pain
  - Stable vital signs

Question 10

What are the risk factors of ABDOMINAL AORTIC ANEURYSM (AAA)?

Answer 10

• Cardiovascular disease
  - Family History increases risk 10-20%
  - Age > 50
  - Smoker

Question 11

What is the RATE OF EXPANSION VARIABLE in AAA?

Answer 11

• 4-4.9 cm AAA - 3.3% risk of rupture
  - 5cm AAA - 14% risk of rupture
  - > 5cm - 20-40% risk of rupture

Question 12

What is COMMON ILIAC ARTERYANEURYSM?

Answer 12

Second most common site for an aneurysm
Typically fusiform
Overlying the sacroiliac joint on the AP and generally seen as a ring-like density anterior to approximately L5 or slightly more inferior

Second most common vessels to calcify
Generally seen at or slightly below the bifurcation, anterior to the L5 level and often seen on end as a circular or ring like density
If seen on AP projection, will be seen as linear, parallel densities oriented inferior and lateral passing into the pelvic basin near the inferior sacroiliac joint
May see calcification of internal and external branches.

Question 13

What is VERTEBRAL ARTERYANEURYSM?

Answer 13

Uncommon
Most frequently seen at the C1/2 level
Dilation may result in an erosive defect visible adjacent to the C2 pedicle and transverse process**

Course of normal vertebral artery. (VA)Zones:V1 = before the artery enters the C6 transverse foramen .V2 =within transverse foramen (C6 to C2)V3 = from C2 transverse foramen but before entry into the dura.V4 = after entry into dura.Aneurysn of the VA can occur along its course causing a pressure erosion of a vertebra – usually a slow process.

Question 14

What is FEMORAL ARTERY CALCIFICATION ?

Answer 14

Superimposed over the femoral head and branches seen medial to the femoral neck at times

Question 15

What is SPLENIC ARTERY CALCIFICATION?

Answer 15

Third most common vessel to calcify
Tortuous, serpiginous (snake-like) calcification in the left upper quadrant, outside the splenic shadow and at approximately the L2 level

Question 16

What is CAROTID ARTERY CALCIFICATION?

Answer 16

Most commonly visible at the bifurcation, below the mandible and lateral to the c/s at about the C3 or C4 levels
Note: subtle calcific densities in the soft tissues lateral to cervical vertebral structures.

Question 17

What is SICKLE CELL ANAEMIA?

Answer 17

Hereditary disorder of abnormal blood cell shape
Abnormal molecular structure of hemoglobin
- When under low pressure, RB’s distort and become sickle shaped
+/- clinical S/S or radiographic findings
Homozygous (HbS-S) is usually symptomatic, other types (HbS-A and HbS-Thal) usually clinically silent

Question 18

What are the clinical findings of sickle cell anaemia?

Answer 18

• Onset after 6 months when change from fetal Hb to adult form
  - Weakness and pallor
  - Jaundice
  - Episodic abdominal crisis
  - Acute bone pain
  - Dactylitis
  - Predisposed to salmonella infection (?)

Question 19

What are the Radiological Findings of sickle cell anaemia?

Answer 19

1. Long bones
   - Osteopenia, Large vascular channels, Undertubulation (wide medullary cavity; Erlenmeyer flask)
   2. Skull
      
      • Wide diploic space, Granular appearance or “Hair on end”
   3. Spine
      
      • Osteoporosis, Endplate deformities (central part of endplate involved) of several contiguous vertebra– “H shaped vertebral bodies”
   4. Others
      
      • Prone to infarcts

Question 20

What is NEUROPATHIC ARTHROPATHY?

Answer 20

AKA “Charcot Joint”
A progressive condition of the MSK system, characterised by:
- Joint dislocations
- Pathologic fractures
- Debilitating deformities

Question 21

What is SYNOVIOCHONDROMETAPLACIA?

Answer 21

AKA “Synovial Chondromatosis” or “osteochondromatosis”
A rare benign condition characterised by the presence of cartilaginous nodules in the synovium of the joints, tendon sheaths and bursae which often occur without trauma or inflammation.
Disease progression leads to loose bodies ossifying, forming a density that may be visualized on radiographs.
Secondary form may be present after long standing OA, trauma or infection

Epidemiology:
- Males > Females (2:1)
- 20 – 40 years

Aetiology:
- Primary – Unknown
- Secondary – M/C
- occurs in pre-existent OA, RA, Osteonecrosis, Infection or Trauma

Question 22

What is the pathophysiology of SYNOVIOCHONDROMETAPLACIA?

Answer 22

• Benign process associated with extremely low risks of malignancy
  - Typically monoarticular, affecting large joints inc
  - Knee – M/C (60-70%)
  - Shoulder
  - Elbow
  - Hip

Question 23

What are the signs and symptoms of SYNOVIOCHONDROMETAPLACIA?

Answer 23

• Monoarticular Pain and stiffness
  - Decreased ROM
  - Effusions
  - Crepitation
  - Joint locking

Question 24

What are the radiological findings for SYNOVIOCHONDROMETAPLACIA?

Answer 24

Radiological Findings:
1. Plain radiographs
- may be normal depending on the stage of disease and the extent of calcification or ossification of the cartilaginous nodules
- General Findings:
- Multiple small, well-defined, juxta-articular nodules of uniform size
- soft-tissue mass surrounding the joint
- joint space widening
- erosions of adjacent bones
- early osteoarthritic changes
- Ring arch calcification
2. MRI
- variable and depends on loose bodies formation and extent of calcification or ossification.
- Typical chondroid signal characteristics:
- T1:intermediate to low signal
- T2:high signal
- Focal areas of signal void within these nodules represent areas of mineralisation

Question 25

What are the anatomical classifications of NEUROPATHIC ARTHROPATHY?

Answer 25

1 - forefoot 10-30%
2 - Lisfranc’s joint (most common)
3 - midtarsal joint, often including naviculocunieform joint
4 - ankle and subtalar joints 8-10%
5 - posterior pillar fracture of calcaneus 2%

Question 26

What are the 6 d’s in NEUROPATHIC ARTHROPATHY?

Answer 26

Dense bones
Degeneration
Destruction
Deformity
Debris
Dislocation