CT angiography and MRI of hand vascular lesions: technical considerations and spectrum of imaging findings

Abstract

Vascular lesions of the hand are common and are distinct from vascular lesions elsewhere because of the terminal vascular network in this region, the frequent hand exposure to trauma and microtrauma, and the superficial location of the lesions. Vascular lesions in the hand may be secondary to local pathology, a proximal source of emboli, or systemic diseases with vascular compromise. In most cases, ischaemic conditions are investigated with Doppler ultrasonography. However, computed tomography angiography (CTA) or dynamic contrast-enhanced magnetic resonance angiography (MRA) is often necessary for treatment planning. MR imaging is frequently performed with MRA to distinguish between vascular malformations, vascular tumours, and perivascular tumours. Some vascular tumours preferentially affect the hand, such as pyogenic granulomas or spindle cell haemangiomas associated with Maffucci syndrome. Glomus tumours are the most frequent perivascular tumours of the hand. The purpose of this article is to describe the state-of-the-art acquisition protocols and illustrate the different patterns of vascular lesions and perivascular tumours of the hand.

Keywords: Buerger’s disease; Glomus tumour; Occupational disease; Thromboangiitis obliterans; Vascular tumour.

Fig. 1

SHR-CTA of the hand (with GI) in a 69-year-old woman that shows the complex arterial network of the hand with a Type A incomplete SPA. The UA (1) feeds the ulnar side of the SPA (2), while the superficial branch of the RA feeds the radial side of the SPA (3). The SPA gives off branches into the first web space, which supply the radial side of the index finger and the thumb (4). The DPA (5) is constituted mainly from the RA (6), which forms an anastomosis with the deep branch of the UA. It generates the FPMA (7). Note the close relationship between the UA and the hamulus. Note also carpal degenerative changes and joint calcifications due to calcium pyrophosphate deposition disease

Fig. 2

The SPA classification by Coleman and Anson [12] with two groups: group I with complete arch and group II with incomplete arch. In group I, contributing vessels anastomose with each other or the UA extends to the thumb. Group I is further divided into five types: Type A, classical radio ulnar arch, formed by the superficial palmar branch of RA and the main stem of the UA; Type B, arch formed entirely by the UA; Type C, median-ulnar arch, composed of the UA and an enlarged median artery; Type D, radio-median-ulnar arch, three vessels enter into formation of the arch; and Type E, arch initiated by the UA and completed by a large-sized vessel derived from the deep arch. In group II, contributing vessels do not anastomose with each other or the UA fails to reach the thumb. Group II is further divided into four types: A, B, C, and D, similar to group I (except Type E, which has no representation in group II). Some other subtypes have also been described. Types A and B of group I represent 70% of the cases

Fig. 3

Comparison of the image quality between a complete upper extremity run-off and a CTA of the hand in a 52-year-old patient with HHS, presenting with ischaemia of the fourth and fifth fingers. a A complete upper extremity run-off was first obtained showing a probable occlusion of the UA. b, c CTA of the hand showed a 6-cm-long occlusion of the UA, the patency of the deep branch of the UA (curved arrow), which is fed by the DPA, the occlusion of the ulnopalmar artery of the fifth finger and the distal occlusion of the radiopalmar artery of the fourth finger (arrowheads). d GI providing an overview of the lesions and of the arterial configuration of the hand showing the deep branch of the UA (curved arrow) and the occlusion of the ulnopalmar artery of the fifth finger (arrowhead)

Fig. 4

Buerger’s disease in a heavy smoker 41-year-old woman presenting with ischaemic ulcers of the fingers and arthralgia. Bilateral CTA shows occlusion and wall thickening of the right RA and of both UA (straight arrows). Note also a tenosynovitis of the extensor carpi radialis and of the extensor digitorum of the right wrist (arrowheads)

Fig. 5

Traumatic occlusion of the radial digital arteries of the fourth finger in a 29-year-old man. a SHR-CTA at the level of the first phalanx showing the occlusion of the radiopalmar and radiodorsal digital arteries of the fourth finger (arrows) as well as a reduction of the venous flow. b GI showing the occlusion of the radiopalmar artery at the level of the first phalanx and of the ulnopalmar artery associated with corkscrew collaterals (arrowheads)

Fig. 6

Dynamic CTA of an arteriovenous fistula (straight arrow) fed by the ulnopalmar digital artery (curved arrow) of the fourth finger in a 32-year-old patient. a, b Native slice and VRT image with bone subtraction at the early arterial phase showing the fistula and the early enhancement of an ulnopalmar vein (arrowhead). Dynamic CTA allows capturing the lesion at the best vascular phase

Fig. 7

AVM of the hypothenar eminence in a 37 year-old-woman. a Coronal T2-weighted MR image showing the nidus with multiple enlarged vessels with flow void (arrow) indicating a high-flow malformation. b MRA demonstrating the high flow of the malformation with a rapid vascular enhancement of the nidus (arrow), multiple feeding arteries, and early venous drainage through dilated veins

Fig. 8

Distal emboli due to an aneurysm of the axillary artery in a 29-year-old female professional volleyball player. a Axial contrast-enhanced T1-weighted fat-suppressed sequence showing some emboli in the UA and RA (arrows). b CTA of the entire upper limb showing an aneurysm of the axillary artery

Fig. 9

Occluded pseudoaneurysm of the radiopalmar artery of the index finger in a 79-year-old woman with repetitive microtrauma. a Photograph showing a blue mass under the skin at the level of the metacarpophalangeal joint (arrow). b Axial T2-weighted MR image showing the pseudoaneurysm (arrow) with an intraluminal thrombus

Fig. 10

HHS in a 55-year-old manual worker exposed to different causative factors, including vibrating tools. a, b Axial and coronal T2-weighted MR images showing an occluded aneurysm (arrow) of the distal portion of the distal UA and severe osteoarthritis affecting the trapeziometacarpal joint. c, d Axial image and GI with dynamic CTA showing the distal occlusion of the UA, the patency of the SPA fed by the FPMA, a corkscrew deformity of common digital arteries, and the UA at the level of the ulnar head (curved arrow). Note the close relationship between the aneurysm and the superficial branch of the ulnar nerve (arrowhead)

Fig. 11

A pitfall in a case of HHS in a 45-year-old manual worker with an occlusion of the UA. a–c Axial T1-weighted (a) and T2-weighted (b) MR images and contrast-enhanced T1-weighted fat-suppressed sequence (c) showing a subtle thickening and parietal enhancement of the UA (arrow). The thrombus should not be confused with a flow phenomenon

Fig. 12

HAVS in a 62-year-old man. a Coronal T2-weighted MR image showing isolated osteoarthritis of the radioscaphoid compartment of the radiocarpal joint. b Contrast-enhanced T1-weighted fat-suppressed sequence showing a focal occlusion at the junction of the UA and the SPA (straight arrow) and a tenosynovitis of the flexor digitorum tendons (curved arrow). The UA was otherwise preserved

Fig. 13

Persistent median artery occlusion in a 48-year-old woman. Axial T2-weighted MR image showing an occlusion of the persistent median artery (straight arrow) and a bifid median nerve (arrowheads). Note also the small median artery satellite veins (dotted arrows)

Fig. 14

Pseudoaneurysm of the RA (arrow), after intra-arterial injection of buprenorphine, demonstrated with CTA

Fig. 15

Pyogenic granuloma of the third finger in a 39-year-old woman who recently gave birth. a Photograph showing fleshy vascular, haemorrhagic exophytic tumour of the distal phalanx, and an enlargement of the finger. b Dynamic CTA showing an increased vascularity of the entire finger associated with a hypervascular exophytic soft tissue tumour. c Axial T2-weighted MR image showing an exophytic tumour without clear margins associated with oedema and vessels dilations with flow void (arrows) in the soft tissues

Fig. 16

Intramuscular haemangioma in a 41-year-old man. a, b Axial T1-weighted (a) and T2-weighted (b) MR images showing a large mass infiltrating the flexor digitorum profundus muscle, composed of fatty tissue (curved arrow) and vascular lakes containing thrombi and calcifications (straight arrow)

Fig. 17

Maffucci syndrome in a 36-year-old woman. (a) Standard radiography showing the typical multiple enchondroma of the bones of the hand. (b) Axial T2-weighted MR image showing a haemangioma characterised by cavernous vascular spaces containing phleboliths (arrow)

Fig. 18

Secondary intravascular papillary endothelial hyperplasia in a 45-year-old woman taking the aspect of a low-flow vascular malformation affecting the thenar eminence. Axial T2-weighted MR image showing a polylobular mass with multiple cavernous lakes containing phleboliths

Fig. 19

Epithelioid haemangioma of the RA. Axial T2-weighted MR image showing a hypervascular tumour arising from the arterial wall of the RA associated with narrowing of the vessel lumen (arrow)

Fig. 20

Epidemic Kaposi’s sarcoma in a 40-year-old man. (a) Standard radiography showing bone lytic tumours of the radius, scaphoid, and trapezoid bones. (b, c) Axial T2-weighted MR images showing a small cutaneous tumour of the palm (straight arrow), a tumour invading the scaphoid bone (curved arrow) and soft tissue infiltration

Fig. 21

Stewart–Treves syndrome in a 78-year-old woman with a history of mastectomy with axillary lymph node dissection for breast cancer and chronic lymphoedema. Axial T2-weighted MR image showing a skin exophytic tumour developing at the palm of the wrist corresponding to an angiosarcoma (arrow). Note also the subcutaneous infiltration of soft tissue with a honeycomb pattern and the thickening of dermis indicating a chronic lymphoedema

Fig. 22

Glomus tumour of the third finger in a 32-year-old woman. a, b Axial T2-weighted MR images and contrast-enhanced T1-weighted fat-suppressed sequence showing a small hypervascularised nodule (arrow) of the ulnar side of the nail matrix

Fig. 23

Glomus tumour of the thumb in a 68-year-old man. Dynamic CTA with bone subtraction showing a small hypervascularised tumour (arrow) of the nail bed