Radioisotope Lung Scanning in

Takayasu's Arteritis
1
Yutaka Suzuki, M.D., Kaoru Konishi, M.D.,
and Kinichi Hisada, M.D.
ABSTRACT-Of 15 patients with Takayasu's arteritis studied by 131l-macro-
aggregated albumin lung scanning, 12 showed perfusion abnormalities. The
lung scan proved very useful in detecting the pulmonary artery disorders as-
sociated with Takayasu's arteritis. The pathogenesis of this disease and clinical
usefulness of this study are discussed.
INDEX TERMS: Lungs, radionuclide studies Pulmonary Arteries Pulseless
Disease
Radiology 109: 133-136, October 1973
Nuclear
Medicine
ALTHOUGH Takayasu's arteritis is a disease
rl. characterized by stenotic lesions of the
aorta and its major branches due to unknown eti-
ology, there are several articles which have re-
ported pulmonary arterial involvement in this
syndrome (3, 6, 8).
Radioisotope lung scanning is a very simple
and safe technique for evaluating pulmonary blood
flow. We have done lung scanning in 15 patients
with Takayasu's arteritis. It is the purpose of
this paper to describe findings at lung scanning
with 131I-macroaggregated albumin (13II-MAA)
and discuss their clinical usefulness.
MATERIALS AND METHODS
A total of 15 patients with Takayasu's arteritis
who had been admitted to the Kanazawa Uni-
versity Hospitals were studied with lung scanning.
All were women and the age at the time of the
admission ranged from 16 to 49, with an average
of 24 years (TABLE I). The diagnosis of Takaya-
su's arteritis was made on the basis of clinical
evidence and arteriography.
Two hundred microcuries of
131
1_MAA was
injected intravenously while patients were lying
supine and a lung scan was done with the iso-
sensitive rectilinear scanner (MUCH).
The lung scans were interpreted by one of the
authors without knowledge of the other clinical
data. The lung scan was divided into six areas
i.e., upper, middle and lower in both lungs and
each area classified into three grades according
TABLE I: SUMMARY OF CLINICAL, ROENTGENOLOGICAL AND SCANNING DATA OF 15 PATIENTS WITH TAKAYASU'S ARTERITIS
Case Age-
No. Sex
Chest X-Ray Findings
------LungScanning Findings*------
.-----Right Lung-.----, .------Left Lung----,
Upper Middle Lower Upper Middle Lower
1 16F Essentially normal (-) (- ) (- ) (+) (- ) (- )
2 25F Essentially normal (+) (- ) (- ) (- ) (+) (- )
3 17F Pleural reaction in the lower left lung (- ) (- ) (++) (- ) (- ) (- )
4 44F Essentially normal (- ) (- ) (- ) (- ) (+) (++)
5 21F Tortuous and dilated descending aorta (++) (++) r- ) (+) (++) (++)
6 18F Essentially normal (- ) (- ) (- ) (- ) (- ) (- )
7 38F Essentially normal (+) (- ) (- ) (- ) (- ) (- )
8 36F Essentially normal (++) (- ) (- ) (- ) (- ) (- )
9 41F Dilated and tortuous aorta; notching in the
left 6th rib (- ) (+) . (- ) (++) (- ) (- )
10 49F Essentially normal (- ) (- ) (++) (- ) (- ) (- )
11 32F Slight bulge of the middle arch of the left heart
border (- ) (++) (++) -) (+) (- )
12 42F Essentially normal (- ) (- ) (++) -) (- ) (- )
13 18F Essentially normal (- ) (- ) (- ) -) (- ) (- )
14 38F Essentially normal (- ) (- ) (- ) -) (- ) (- )
15 32F . Diffuse patchy shadows in the right upper and
middle lung field (++) (- ) (- ) (- ) (- ) (- )
abnormal 5 3 4 3 4 2
perfusion cases cases cases cases cases cases
* ( + +) Absence of perfusion; ( + ) decreased perfusion; (-) normal perfusion.
1 From the Department of Nuclear Medicine, School of Medicine, Kanazawa University, Takara-machi 13-1, Kanazawa-shi, Japan.
Accepted for publication in May 1973. shan
133
134
Y. SUZUKI, K. KONISHI AND K. HISADA
October 1973
-.0 l'
Fig. 1. CASE 2. A. Postero-anterior chest radiograph is essen-
tially normal.
B. Lung scan demonstrates absence of perfusion in the right apex
and decreased perfusion in the lower left lung.
C. Pulmonary arteriogram showing decreased vascularity in the
upper right and lower left lung.
to the degree of perfusion abnormality: absence of
perfusion, decreased perfusion, and normal. No
attempt was made to reinterpret the chest x-ray
films, and the original report sent at the time of
the study was taken from the chart.
RESULTS
Twelve of 15 patients (80%) showed some ab-
normalities in the lung scan, but the chest films
of all patients except one were interpreted as
normal in the lung field. The abnormal perfusion
was more common in the right lung but there was
no certain area of the lung which had special
tendency to be affected. There were 4 patients
who had abnormal perfusion in both lungs and
one of these patients showed abnormal perfusion
in the entire left lung (TABLE I).
There was no correlation between the incidence
of abnormal lung scans and age of the patients.
Only 2 patients had subjective symptoms in the
chest.
CASE REPORTS
CASE 2. A. H., a 25-year-old woman was admitted to the
Kanazawa University Hospitals because of headache, general
malaise and dull pain in the left arm. On physical examina-
tion, bruit was heard in the left neck, upper abdomen and
left inguinal region and the pulse was not palpable in the
left carotid artery and left radial arteries. Blood pressure
was 160/72 mm Hg in the right arm. The pulsations in the
lower extremities were normal. The erythrocyte sedimenta-
tion rate was 111 mm in an hour. A serological test for sy-
phylis was negative and a C-reactive protein (CRP) test was
positive.
The chest film was interpreted as essentially normal (Fig.
1, A). Lung scanning revealed absence of perfusion in the
right apex and markedly decreased perfusion in the left
lower lung (Fig. 1, B). Pulmonary arteriography showed
decreased vascularity in the right upper and left lower lung
(Fig. 1, C). Aortography demonstrated complete obstruc-
tion in the left subclavian artery and narrowness in the left
Vol. 109 RADIOISOTOPE LUNG SCANNING IN TAKAYASU'S ARTERITIS
Nuclear
135 Medicine
Fig. 2. CASE 11. A. Postero-anterior chest filmshowinga slight
bulge of the middle arch of the left heart border. The lung field is
essentially normal.
B. Lung scan demonstrates absence of perfusion in the lower right
lung and slightly decreased perfusion in the middle left lung.
C. Pulmonary arteriogram demonstrating occlusion of the right
pulmonary descending and the lingular segmental branches.
common carotid artery, radial artery, thoracic aorta, ab-
dominal aorta, both renal arteries and femoral arteries.
CASE 11. M. A., a 32-year-old woman was admitted to
the Kanazawa University Hospitals with complaints of dizzy
spells, fever,and dull pain in the left upper extremity. She
recalled that doctors had difficulty in feeling her radial pulse
for about four years. On examination, bruit was heard over
the left carotid artery and the left radial pulse was dimin-
ished. Blood pressure was 150/76 rnrn Hg in the right arm
and 104/72 mm Hg in the left. Serological examination for
syphilis was negative and the CRP test was negative. The
erythrocyte sedimentation rate was 50 mm in an hour.
On the chest film, a slight bulge of the middle arch of the
left heart border was seen (Fig. 2, A). Lung scanning showed
absence of perfusion in the right lower lung and slightly de-
creased perfusion in the left middle lung (Fig. 2, B). Pul-
monary arteriography demonstrated occlusion of the right
pulmonary descending branch and the lingular segmental
artery (Fig. 2, C). Aortography revealed partial occlusion
in the left subclavian artery and tortuosity in the abdominal
aorta.
DISCUSSION
Takayasu's arteritis is more common in Japan
and the Orient but is not so infrequent in the
United States and European countries as once
believed (1, 3, 4). It most commonly affects
young women and its incidence among thein is 5 r-..J
10 times higher than among males (6, 7, 10).
Its etiology is still unknown, but it might be
classified among the autoimmune diseases (10).
In this disorder, all three layers of the arterial wall
may be involved but the inflammatory process is
most intense in the media, so this disease could
essentially be called mesoarteritis (7). Initially,
attention was focused on the circulatory disturb-
ances of the upper extremities and the brain.
Shimizu and Sano (9) defined the process as
"chronic obliterative brachiocephalic arteries"
and proposed the term' 'pulseless disease." How-
136 Y. SUZUKI, K. KONISHI AND K. HISADA October 1973
ever, it soon became clear that it could spread
further to the entire aorta and any of its branches
(3, 5, 7).
A lesion in the pulmonary artery was first
describedin 1940 by Oota (8) and several articles
about this entity have been published since that
time (3, 5-8). The lesion was often found. at the
trunk or main branches of the pulmonary artery
(7). Kozuka et al. (6) reported that the lesion
was more likely to affect the upper part of the
right lung. In our study, we also noted a slightly
higher incidence in the right lung, but no particu-
lar part of the lung had a special tendency to be
affected.
Chest x ray may show decreased or sparse
areas of lung vascularity in Takayasu's arteri-
tis but it may often be difficult to detect such
subtle changes in the lung field. In our study,
all chest x-ray reports except one did not mention
any abnormal :findings in the lung field and no
change could be found retrospectively either.
Without doubt, the chest film is very important
in the diagnosis of Takayasu's arteritis, but one
should also .rcmember that chest x-ray alone is
not a sufficient screening test for the pulmonary
lesion of Takayasu's arteritis.
Lung scanning is a nonspecific examination and
any kind of lung disease may cause an abnormality
in the scan. Most lung diseases, however, could
be ruled out by the chest radiograph taken at the
time of scanning. The abnormal lung scan in
Takayasu's arteritis is similar to that in pulmonary
embolism, which shows decreased or absent per-
fusion corresponding to specific blood vessels, i.e.,
subsegrnental, segmental, and lobar arteries, be-
cause the lesions are mainly in the pulmonary
arteries. Although it could be difficult to differ-
entiate Takayasu's arteritis from pulmonary
embolism without clinical findings, there are some
differences in the lung scans between these two
diseases. In pulmonary embolism, perfusion
defects often resolve, particularly in younger
patients (2). On the other hand, perfusion de-
fects in Takayasu's arteritis do not change for a
long time. These findings might be useful in
ruling out pulmonary embolism.
Although pulmonary angiography should be
done to confirm pulmonary artery disorders in
Takayasu's arteritis, the technique is not simple.
Moreover, pulmonary angiography might not de-
tect the lesion involving arteries smaller than 2 mm
in diameter (2). Lung scanning is quite sensitive
in the evaluation of pulmonary blood flow and the
technique is simple and safe.
Our results have shown the high incidence of
pulmonary artery disorders in Takayasu's arter-
itis, so it seems reasonable to Screen these patients
by means of lung scanning. In the appropriate
clinical setting, the abnormal lung scan with clear
lungs on the chest radiograph makes the diagno-
sis of pulmonary artery disorders in Takayasu's
arteritis highly probable and pulmonary angiog-
raphy should be done in these cases.
Department of Nuclear Medicine
Kanazawa University School of Medicine
Takara-machi 13-1, Kanazawa-shi
Japan
REFERENCES
1. Ask-Vpmark E: On the "pulseless disease" outside of
Japan. Acta Med Scandinav 149:161-178,1954
2. Deland FH, 'Wagner HN Jr: Atlas of Nuclear Medicine.
Vol 2, Lung and Heart. Philadelphia, W. B. Saunders, 1st ed,
1970, pp 54-55
3. Gotsman MS, Beck W, Schrire V: Selective angiog-
raphy in arteritis of the aorta and its major branches. Radiol-
ogy 88:232-248, Feb 1967
4. Grollman JH, Hanafee W: The roentgen diagnosis of
Takayasu's arteritis. Radiology 83:387-395, Sep 1964
5. Hachiya J: Current concepts of Takayasu's arteritis.
Semin Roentgen 52:245-259, Jul1970
6. Kozuka T, Nosaki T, Sato K, et alr; Aortitis syndrome
with special reference to pulmonary vascular changes. Acta
Radiol [Diag] 7:25-32, Jan 1968
7. Nasu T: Pathology of pulseless disease. A systematic
study and critical review of twenty-one autopsy cases reported
in Japan. Angiology 14:225-242, May 1963
8. Oota K: Ein seltener Fall von beiderseitegern Carotis-
Subclaviaverschluss. Trans Soc Path Tap 30:680-690, 1940
9. Shimizu K, Sano K: Pulseless disease. J Neuropath
Clin Neuroll:37-47, Jan 1951
10. Veda H, Morooka S, Ito I, et al: Clinical observation
of 52 cases of aortitis syndrome. Jap Heart J 10:277-288, Jul
1969