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Review
. 2020 Nov 19;2(6):e200364.
doi: 10.1148/ryct.2020200364. eCollection 2020 Dec.

Role of Coronary CT Angiography in Spontaneous Coronary Artery Dissection

Sumit Gupta  1 , Nandini M Meyersohn  1 , Malissa J Wood  1 , Michael L Steigner  1 , Ron Blankstein  1 , Brian B Ghoshhajra  1 , Sandeep S Hedgire  1
Affiliations
Review

Role of Coronary CT Angiography in Spontaneous Coronary Artery Dissection

Sumit Gupta et al. Radiol Cardiothorac Imaging. .

Abstract

Spontaneous coronary artery dissection (SCAD) is more common than previously thought and is present in up to 4% of patients presenting with acute coronary syndrome. SCAD predominantly occurs in relatively young women and is an important cause of myocardial infarction in young patients without traditional risk factors of atherosclerotic coronary artery disease. There have been substantial improvements in spatial and temporal resolution and reduction in ionizing radiation dose with new generation scanners. The risk of dissection propagation with an invasive coronary angiogram, improved CT scanner parameters, and predominantly conservative management of SCAD make coronary CT angiography a useful noninvasive imaging modality for the assessment of SCAD. © RSNA, 2020.

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Conflict of interest statement

Disclosures of Conflicts of Interest: S.G. disclosed no relevant relationships. N.M.M. disclosed no relevant relationships. M.J.W. disclosed no relevant relationships. M.L.S. Activities related to the present article: disclosed no relevant relationships. Activities not related to the present article: disclosed money paid to author from Canon Medical-Vital Images for consultancy. Other relationships: disclosed no relevant relationships. R.B. disclosed no relevant relationships. B.B.G. Activities related to the present article: disclosed no relevant relationships. Activities not related to the present article: disclosed grants/grants pending to author’s institution from Siemens and National Institutes of Health for unrelated projects; disclosed money paid to author from Siemens for minor travel reimbursement. Other relationships: disclosed no relevant relationships. S.S.H. disclosed no relevant relationships.

Figures

Schematic illustration demonstrates cardiac and extracardiac CT features of spontaneous coronary artery dissection (SCAD). Coronary artery imaging features of SCAD include, A, tapered luminal stenosis, B, abrupt luminal narrowing, C, luminal occlusion, D, intramural hematoma resulting in luminal stenosis, E, dissection flap, F, perivascular fat stranding, G, tortuosity of the coronary artery, and, H, myocardial bridging. Associated fibromuscular dysplasia demonstrates, I, aneurysm and, J, beading of the renal or other visceral arteries.
Figure 1:
Schematic illustration demonstrates cardiac and extracardiac CT features of spontaneous coronary artery dissection (SCAD). Coronary artery imaging features of SCAD include, A, tapered luminal stenosis, B, abrupt luminal narrowing, C, luminal occlusion, D, intramural hematoma resulting in luminal stenosis, E, dissection flap, F, perivascular fat stranding, G, tortuosity of the coronary artery, and, H, myocardial bridging. Associated fibromuscular dysplasia demonstrates, I, aneurysm and, J, beading of the renal or other visceral arteries.
(a) Curved planar reformatted coronary CT and (b) coronary angiograms in a 35-year-old woman who presented with chest pain show tapered, smooth, and diffuse narrowing of distal left anterior descending coronary artery (arrow).
Figure 2a:
(a) Curved planar reformatted coronary CT and (b) coronary angiograms in a 35-year-old woman who presented with chest pain show tapered, smooth, and diffuse narrowing of distal left anterior descending coronary artery (arrow).
(a) Curved planar reformatted coronary CT and (b) coronary angiograms in a 35-year-old woman who presented with chest pain show tapered, smooth, and diffuse narrowing of distal left anterior descending coronary artery (arrow).
Figure 2b:
(a) Curved planar reformatted coronary CT and (b) coronary angiograms in a 35-year-old woman who presented with chest pain show tapered, smooth, and diffuse narrowing of distal left anterior descending coronary artery (arrow).
(a) Curved planar reformatted and (b) volume-rendered three-dimensional coronary CT angiography images in a 42-year-old woman with prior history of apical infarct, who presented to emergency department with chest pain, show irregular tapered severe narrowing of the proximal posterior descending artery with adjacent epicardial fat stranding (arrow).
Figure 3a:
(a) Curved planar reformatted and (b) volume-rendered three-dimensional coronary CT angiography images in a 42-year-old woman with prior history of apical infarct, who presented to emergency department with chest pain, show irregular tapered severe narrowing of the proximal posterior descending artery with adjacent epicardial fat stranding (arrow).
(a) Curved planar reformatted and (b) volume-rendered three-dimensional coronary CT angiography images in a 42-year-old woman with prior history of apical infarct, who presented to emergency department with chest pain, show irregular tapered severe narrowing of the proximal posterior descending artery with adjacent epicardial fat stranding (arrow).
Figure 3b:
(a) Curved planar reformatted and (b) volume-rendered three-dimensional coronary CT angiography images in a 42-year-old woman with prior history of apical infarct, who presented to emergency department with chest pain, show irregular tapered severe narrowing of the proximal posterior descending artery with adjacent epicardial fat stranding (arrow).
Spontaneous coronary artery dissection (SCAD) and coronary artery disease (CAD) cases that manifested as diagnostic conundrums. (a) Curved planar reformatted coronary CT angiography image in a 42-year-old woman, who presented with chest pain waking her from sleep, shows abrupt severe luminal narrowing (arrow) of distal left anterior descending artery with a notable absence of coronary calcium. Presence of tortuosity, perivascular fat stranding (magnified view inset), and review of previous MR angiography (not shown) demonstrating beading of renal arteries indicating fibromuscular dysplasia led to diagnosis of SCAD. (b) Curved planar reformatted coronary CT angiography image in a 69-year-old woman, who presented with several episodes of dull chest pain at exertion and rest, shows abrupt severe luminal narrowing (arrow) of proximal left anterior descending artery. Presence of noncalcified plaque (chevron; magnified view inset) at the level of stenosis and in right coronary artery (not shown) favored atherosclerotic CAD. Noncalcified plaques can mimic intramural hematoma; however, no high attenuation was seen on non–contrast material–enhanced scan to indicate intramural hematoma.
Figure 4a:
Spontaneous coronary artery dissection (SCAD) and coronary artery disease (CAD) cases that manifested as diagnostic conundrums. (a) Curved planar reformatted coronary CT angiography image in a 42-year-old woman, who presented with chest pain waking her from sleep, shows abrupt severe luminal narrowing (arrow) of distal left anterior descending artery with a notable absence of coronary calcium. Presence of tortuosity, perivascular fat stranding (magnified view inset), and review of previous MR angiography (not shown) demonstrating beading of renal arteries indicating fibromuscular dysplasia led to diagnosis of SCAD. (b) Curved planar reformatted coronary CT angiography image in a 69-year-old woman, who presented with several episodes of dull chest pain at exertion and rest, shows abrupt severe luminal narrowing (arrow) of proximal left anterior descending artery. Presence of noncalcified plaque (chevron; magnified view inset) at the level of stenosis and in right coronary artery (not shown) favored atherosclerotic CAD. Noncalcified plaques can mimic intramural hematoma; however, no high attenuation was seen on non–contrast material–enhanced scan to indicate intramural hematoma.
Spontaneous coronary artery dissection (SCAD) and coronary artery disease (CAD) cases that manifested as diagnostic conundrums. (a) Curved planar reformatted coronary CT angiography image in a 42-year-old woman, who presented with chest pain waking her from sleep, shows abrupt severe luminal narrowing (arrow) of distal left anterior descending artery with a notable absence of coronary calcium. Presence of tortuosity, perivascular fat stranding (magnified view inset), and review of previous MR angiography (not shown) demonstrating beading of renal arteries indicating fibromuscular dysplasia led to diagnosis of SCAD. (b) Curved planar reformatted coronary CT angiography image in a 69-year-old woman, who presented with several episodes of dull chest pain at exertion and rest, shows abrupt severe luminal narrowing (arrow) of proximal left anterior descending artery. Presence of noncalcified plaque (chevron; magnified view inset) at the level of stenosis and in right coronary artery (not shown) favored atherosclerotic CAD. Noncalcified plaques can mimic intramural hematoma; however, no high attenuation was seen on non–contrast material–enhanced scan to indicate intramural hematoma.
Figure 4b:
Spontaneous coronary artery dissection (SCAD) and coronary artery disease (CAD) cases that manifested as diagnostic conundrums. (a) Curved planar reformatted coronary CT angiography image in a 42-year-old woman, who presented with chest pain waking her from sleep, shows abrupt severe luminal narrowing (arrow) of distal left anterior descending artery with a notable absence of coronary calcium. Presence of tortuosity, perivascular fat stranding (magnified view inset), and review of previous MR angiography (not shown) demonstrating beading of renal arteries indicating fibromuscular dysplasia led to diagnosis of SCAD. (b) Curved planar reformatted coronary CT angiography image in a 69-year-old woman, who presented with several episodes of dull chest pain at exertion and rest, shows abrupt severe luminal narrowing (arrow) of proximal left anterior descending artery. Presence of noncalcified plaque (chevron; magnified view inset) at the level of stenosis and in right coronary artery (not shown) favored atherosclerotic CAD. Noncalcified plaques can mimic intramural hematoma; however, no high attenuation was seen on non–contrast material–enhanced scan to indicate intramural hematoma.
(a) Curved planar reformatted and (b) minimum intensity projection short-axis coronary CT angiography images in a 68-year-old woman, who presented with chest pain, show luminal occlusion of posterior left ventricular branch (arrow in a) with myocardial hypoperfusion in the corresponding territory (arrows in b). Involvement of single coronary artery territory and absence of an embolic source favored diagnosis of spontaneous coronary artery dissection over coronary artery embolism.
Figure 5a:
(a) Curved planar reformatted and (b) minimum intensity projection short-axis coronary CT angiography images in a 68-year-old woman, who presented with chest pain, show luminal occlusion of posterior left ventricular branch (arrow in a) with myocardial hypoperfusion in the corresponding territory (arrows in b). Involvement of single coronary artery territory and absence of an embolic source favored diagnosis of spontaneous coronary artery dissection over coronary artery embolism.
(a) Curved planar reformatted and (b) minimum intensity projection short-axis coronary CT angiography images in a 68-year-old woman, who presented with chest pain, show luminal occlusion of posterior left ventricular branch (arrow in a) with myocardial hypoperfusion in the corresponding territory (arrows in b). Involvement of single coronary artery territory and absence of an embolic source favored diagnosis of spontaneous coronary artery dissection over coronary artery embolism.
Figure 5b:
(a) Curved planar reformatted and (b) minimum intensity projection short-axis coronary CT angiography images in a 68-year-old woman, who presented with chest pain, show luminal occlusion of posterior left ventricular branch (arrow in a) with myocardial hypoperfusion in the corresponding territory (arrows in b). Involvement of single coronary artery territory and absence of an embolic source favored diagnosis of spontaneous coronary artery dissection over coronary artery embolism.
(a) Axial non–contrast material–enhanced CT, (b) axial coronary CT angiography, and (c) curved planar reformatted coronary CT angiography images in a 32-year-old woman, who was 2 weeks postpartum and presented with dyspnea and chest pain radiating to neck, back, jaw, and shoulder, show left anterior descending coronary artery intramural hematoma (arrow in c).
Figure 6a:
(a) Axial non–contrast material–enhanced CT, (b) axial coronary CT angiography, and (c) curved planar reformatted coronary CT angiography images in a 32-year-old woman, who was 2 weeks postpartum and presented with dyspnea and chest pain radiating to neck, back, jaw, and shoulder, show left anterior descending coronary artery intramural hematoma (arrow in c).
(a) Axial non–contrast material–enhanced CT, (b) axial coronary CT angiography, and (c) curved planar reformatted coronary CT angiography images in a 32-year-old woman, who was 2 weeks postpartum and presented with dyspnea and chest pain radiating to neck, back, jaw, and shoulder, show left anterior descending coronary artery intramural hematoma (arrow in c).
Figure 6b:
(a) Axial non–contrast material–enhanced CT, (b) axial coronary CT angiography, and (c) curved planar reformatted coronary CT angiography images in a 32-year-old woman, who was 2 weeks postpartum and presented with dyspnea and chest pain radiating to neck, back, jaw, and shoulder, show left anterior descending coronary artery intramural hematoma (arrow in c).
(a) Axial non–contrast material–enhanced CT, (b) axial coronary CT angiography, and (c) curved planar reformatted coronary CT angiography images in a 32-year-old woman, who was 2 weeks postpartum and presented with dyspnea and chest pain radiating to neck, back, jaw, and shoulder, show left anterior descending coronary artery intramural hematoma (arrow in c).
Figure 6c:
(a) Axial non–contrast material–enhanced CT, (b) axial coronary CT angiography, and (c) curved planar reformatted coronary CT angiography images in a 32-year-old woman, who was 2 weeks postpartum and presented with dyspnea and chest pain radiating to neck, back, jaw, and shoulder, show left anterior descending coronary artery intramural hematoma (arrow in c).
Curved planar reformatted coronary CT angiography image in a 29-year-old man with chest pain and elevated troponin level shows right coronary artery intimal disruption and dissection flap (arrows).
Figure 7:
Curved planar reformatted coronary CT angiography image in a 29-year-old man with chest pain and elevated troponin level shows right coronary artery intimal disruption and dissection flap (arrows).
Maximum intensity projection reformatted coronary CT angiography image shows tortuous left anterior descending coronary artery with myocardial bridging (arrows) in a 68-year-old woman who was later found to have fibromuscular dysplasia.
Figure 8:
Maximum intensity projection reformatted coronary CT angiography image shows tortuous left anterior descending coronary artery with myocardial bridging (arrows) in a 68-year-old woman who was later found to have fibromuscular dysplasia.
Maximum intensity projection images from CT angiogram of the same patient as Figure 3 (42-year-old woman) show beading of the (a) right and (b) left renal arteries (arrow). (b) Focal dissection and beading (chevron) of celiac artery is also seen.
Figure 9a:
Maximum intensity projection images from CT angiogram of the same patient as Figure 3 (42-year-old woman) show beading of the (a) right and (b) left renal arteries (arrow). (b) Focal dissection and beading (chevron) of celiac artery is also seen.
Maximum intensity projection images from CT angiogram of the same patient as Figure 3 (42-year-old woman) show beading of the (a) right and (b) left renal arteries (arrow). (b) Focal dissection and beading (chevron) of celiac artery is also seen.
Figure 9b:
Maximum intensity projection images from CT angiogram of the same patient as Figure 3 (42-year-old woman) show beading of the (a) right and (b) left renal arteries (arrow). (b) Focal dissection and beading (chevron) of celiac artery is also seen.
Coronal images from CT angiogram in the same patient as Figure 3 (42-year-old woman) show fusiform dilation of the (a) right and (b) left internal carotid arteries (arrow). Focal dissection of proximal right internal carotid artery is seen.
Figure 10a:
Coronal images from CT angiogram in the same patient as Figure 3 (42-year-old woman) show fusiform dilation of the (a) right and (b) left internal carotid arteries (arrow). Focal dissection of proximal right internal carotid artery is seen.
Coronal images from CT angiogram in the same patient as Figure 3 (42-year-old woman) show fusiform dilation of the (a) right and (b) left internal carotid arteries (arrow). Focal dissection of proximal right internal carotid artery is seen.
Figure 10b:
Coronal images from CT angiogram in the same patient as Figure 3 (42-year-old woman) show fusiform dilation of the (a) right and (b) left internal carotid arteries (arrow). Focal dissection of proximal right internal carotid artery is seen.
Phase-sensitive inversion recovery cardiac short-axis MR image in a 43-year-old woman with connective tissue disorder and multivessel spontaneous coronary artery dissection shows subendocardial late gadolinium enhancement in left circumflex coronary territory (arrows).
Figure 11:
Phase-sensitive inversion recovery cardiac short-axis MR image in a 43-year-old woman with connective tissue disorder and multivessel spontaneous coronary artery dissection shows subendocardial late gadolinium enhancement in left circumflex coronary territory (arrows).
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