FUNCTIONAL*IMAGING*OF* ATHLETES*hallett/RSNA2014/handout... · Classification(of(PAES(Type+...
Transcript of FUNCTIONAL*IMAGING*OF* ATHLETES*hallett/RSNA2014/handout... · Classification(of(PAES(Type+...
![Page 1: FUNCTIONAL*IMAGING*OF* ATHLETES*hallett/RSNA2014/handout... · Classification(of(PAES(Type+ Anatomy+ I(PA travels aberrantly, medial to normally positioned MHG II(Anomalous lateral](https://reader034.fdocuments.us/reader034/viewer/2022042418/5f33d75b6ec5e43a21768051/html5/thumbnails/1.jpg)
FUNCTIONAL*IMAGING*OF*ATHLETES*
Richard(L.(Hallett,(MD((Chief,(Cardiovascular(Imaging(Northwest(Radiology(Network(Indianapolis,(IN((Clinical(Assistant(Professor(–(Radiology(Stanford(University(Stanford,(CA(
RC#112C#### # # ##30#November#2014 # # #S103CD # ######## # #1400#
![Page 2: FUNCTIONAL*IMAGING*OF* ATHLETES*hallett/RSNA2014/handout... · Classification(of(PAES(Type+ Anatomy+ I(PA travels aberrantly, medial to normally positioned MHG II(Anomalous lateral](https://reader034.fdocuments.us/reader034/viewer/2022042418/5f33d75b6ec5e43a21768051/html5/thumbnails/2.jpg)
Handouts(Available:(
www.stanford.edu/~hallett(
Choose(folder(“RSNA(2014”(
![Page 3: FUNCTIONAL*IMAGING*OF* ATHLETES*hallett/RSNA2014/handout... · Classification(of(PAES(Type+ Anatomy+ I(PA travels aberrantly, medial to normally positioned MHG II(Anomalous lateral](https://reader034.fdocuments.us/reader034/viewer/2022042418/5f33d75b6ec5e43a21768051/html5/thumbnails/3.jpg)
Learning(Objectives(
! (Identify(anatomic(and(functional(lesions(that(predispose(to(vascular(entrapment(and(fibrotic(syndromes(in(athletes.(
! Describe(methods(to(assess(vascular(entrapment(and(fibrotic(syndromes(using(dynamic,(functionally(challenged(CTA(and(MRA.(
! Describe(the(imaging(findings(for(diagnosis.(
![Page 4: FUNCTIONAL*IMAGING*OF* ATHLETES*hallett/RSNA2014/handout... · Classification(of(PAES(Type+ Anatomy+ I(PA travels aberrantly, medial to normally positioned MHG II(Anomalous lateral](https://reader034.fdocuments.us/reader034/viewer/2022042418/5f33d75b6ec5e43a21768051/html5/thumbnails/4.jpg)
What*is*your*experience*with*functional*(dynamic)*cardiovascular*imaging?
A. None B. A little- once or twice C. We perform these exams occasionally D. Extensive experience E. I do not know what functional imaging means
![Page 5: FUNCTIONAL*IMAGING*OF* ATHLETES*hallett/RSNA2014/handout... · Classification(of(PAES(Type+ Anatomy+ I(PA travels aberrantly, medial to normally positioned MHG II(Anomalous lateral](https://reader034.fdocuments.us/reader034/viewer/2022042418/5f33d75b6ec5e43a21768051/html5/thumbnails/5.jpg)
Vascular(Diseases(in(Athletes(
• Upper%Extremity%– Thoracic%Outlet%Syndrome%(TOS)%
• Pelvis%– Iliac%Endofibrosis%%
• Lower%Extremity%– Popliteal%Entrapment%Syndrome%(PAES)%
![Page 6: FUNCTIONAL*IMAGING*OF* ATHLETES*hallett/RSNA2014/handout... · Classification(of(PAES(Type+ Anatomy+ I(PA travels aberrantly, medial to normally positioned MHG II(Anomalous lateral](https://reader034.fdocuments.us/reader034/viewer/2022042418/5f33d75b6ec5e43a21768051/html5/thumbnails/6.jpg)
Background…….(
! Vascular(diseases(are(easily(overlooked(in(athletes(
! Thorough(vascular(H&P(needed(! Deciding(WHEN((or(IF)(to(image(vascular(entrapment(syndromes(requires(clinical(judgment(and(multiYspecialty(coordination!!(
(
DYNAMIC(EVALUATION((IS(IMPORTANT(!!(
![Page 7: FUNCTIONAL*IMAGING*OF* ATHLETES*hallett/RSNA2014/handout... · Classification(of(PAES(Type+ Anatomy+ I(PA travels aberrantly, medial to normally positioned MHG II(Anomalous lateral](https://reader034.fdocuments.us/reader034/viewer/2022042418/5f33d75b6ec5e43a21768051/html5/thumbnails/7.jpg)
Dynamic(Cross?Sectional(Imaging(
• Principle:(simulate%the%predisposing%moCon%/%posiCon%and%assess%vascular%response%• �Stress�%and%�Relaxed�%Imaging%• Vary%Cming%to%assess%arteries%/%veins%
%
![Page 8: FUNCTIONAL*IMAGING*OF* ATHLETES*hallett/RSNA2014/handout... · Classification(of(PAES(Type+ Anatomy+ I(PA travels aberrantly, medial to normally positioned MHG II(Anomalous lateral](https://reader034.fdocuments.us/reader034/viewer/2022042418/5f33d75b6ec5e43a21768051/html5/thumbnails/8.jpg)
• Thoracic%Outlet%Syndrome%(TOS)%
Handouts(Available: (((www.stanford.edu/~hallett(((((((((((Choose(folder(“RSNA(2014”(
![Page 9: FUNCTIONAL*IMAGING*OF* ATHLETES*hallett/RSNA2014/handout... · Classification(of(PAES(Type+ Anatomy+ I(PA travels aberrantly, medial to normally positioned MHG II(Anomalous lateral](https://reader034.fdocuments.us/reader034/viewer/2022042418/5f33d75b6ec5e43a21768051/html5/thumbnails/9.jpg)
The*most*common*anatomic*location*for*vascular*thoracic*outlet*syndrome*is
A. Costo-clavicular space B. Retro-pectoralis minor space C. Interscalene Triangle D. Coraco-clavicular space
Linda D D et al. Radiographics 2010;30:1373-1400
![Page 10: FUNCTIONAL*IMAGING*OF* ATHLETES*hallett/RSNA2014/handout... · Classification(of(PAES(Type+ Anatomy+ I(PA travels aberrantly, medial to normally positioned MHG II(Anomalous lateral](https://reader034.fdocuments.us/reader034/viewer/2022042418/5f33d75b6ec5e43a21768051/html5/thumbnails/10.jpg)
Thoracic*Outlet*Syndrome*(TOS)*
• SymptomaCc%compression/entrapment%of%neurovascular(structures%by%bone%and/or%soH%Cssue%as%they%pass%through%the%cervicoaxillary%canal%
• 90%%Neurogenic%(PT,%postural%Tx,%NSAIDs)%• 10%%Vascular%
• Venous%%>%%Arterial%
%
![Page 11: FUNCTIONAL*IMAGING*OF* ATHLETES*hallett/RSNA2014/handout... · Classification(of(PAES(Type+ Anatomy+ I(PA travels aberrantly, medial to normally positioned MHG II(Anomalous lateral](https://reader034.fdocuments.us/reader034/viewer/2022042418/5f33d75b6ec5e43a21768051/html5/thumbnails/11.jpg)
Linda D D et al. Radiographics 2010;30:1373-1400
Components(of(Cervico?Axillary(Canal(
! Interscalene(Triangle:(#1(site(of(compression(
! Costoclavicular(Space:(#1(site(for(vascular(TOS(
! RetroYpectoralis(minor(space:(#1(site(for(masses(
![Page 12: FUNCTIONAL*IMAGING*OF* ATHLETES*hallett/RSNA2014/handout... · Classification(of(PAES(Type+ Anatomy+ I(PA travels aberrantly, medial to normally positioned MHG II(Anomalous lateral](https://reader034.fdocuments.us/reader034/viewer/2022042418/5f33d75b6ec5e43a21768051/html5/thumbnails/12.jpg)
The*most*common*anatomic*location*for*vascular*thoracic*outlet*syndrome*is
A. Costo-clavicular space B. Retro-pectoralis minor space C. Interscalene Triangle D. Coraco-clavicular space
CORRECT ANSWER
Linda D D et al. Radiographics 2010;30:1373-1400
![Page 13: FUNCTIONAL*IMAGING*OF* ATHLETES*hallett/RSNA2014/handout... · Classification(of(PAES(Type+ Anatomy+ I(PA travels aberrantly, medial to normally positioned MHG II(Anomalous lateral](https://reader034.fdocuments.us/reader034/viewer/2022042418/5f33d75b6ec5e43a21768051/html5/thumbnails/13.jpg)
CTA(for(TOS:(Combo(Direct(/(Indirect(CTA(
! Ipsilateral(IV,(arm(over(head(w/(palm(taped(up(! Bolus:(120(mL(fullYstrength(@(4ml/s(! Chase:(100(mL(dilute((10%)(contrast(@2.5(ml/s(
• Can(inject(contralateral(arm(at(same(time((dilute)(
! 65(sec(empiric(delay,(scan(caudoYcranial(! Arm(down,(immediate(reYscan(cranioYcaudal(! Volumetric+Review+
![Page 14: FUNCTIONAL*IMAGING*OF* ATHLETES*hallett/RSNA2014/handout... · Classification(of(PAES(Type+ Anatomy+ I(PA travels aberrantly, medial to normally positioned MHG II(Anomalous lateral](https://reader034.fdocuments.us/reader034/viewer/2022042418/5f33d75b6ec5e43a21768051/html5/thumbnails/14.jpg)
Venous(TOS:(�Effort(Thrombosis�(
! PagetYSchroetter(syndrome((PSS)((! AKA(axilloYsubclavian(venous(thrombosis(
! �Overhead�(athletes(! PE(in(up(to(1/3!!(*(! PostYthrombotic(syndrome((later)(
*(Perlowski((AA.(Vasc(Med((2010)(vol.(15((6)(pp.(469Y79(
![Page 15: FUNCTIONAL*IMAGING*OF* ATHLETES*hallett/RSNA2014/handout... · Classification(of(PAES(Type+ Anatomy+ I(PA travels aberrantly, medial to normally positioned MHG II(Anomalous lateral](https://reader034.fdocuments.us/reader034/viewer/2022042418/5f33d75b6ec5e43a21768051/html5/thumbnails/15.jpg)
Arterial(TOS(! �Overhead(athletes�(! SX:(Coolness,(weakness,(diffuse(arm(
pain((ischemic(neuritis)(! Cause:(Repetitive(compression(injury(
" Anatomic(predisposition((tight(CCS)(" PostYtraumatic,(bony(callus(" Scalene(hypertrophy(
![Page 16: FUNCTIONAL*IMAGING*OF* ATHLETES*hallett/RSNA2014/handout... · Classification(of(PAES(Type+ Anatomy+ I(PA travels aberrantly, medial to normally positioned MHG II(Anomalous lateral](https://reader034.fdocuments.us/reader034/viewer/2022042418/5f33d75b6ec5e43a21768051/html5/thumbnails/16.jpg)
Bilateral(Direct(/(Indirect(CTA(
![Page 17: FUNCTIONAL*IMAGING*OF* ATHLETES*hallett/RSNA2014/handout... · Classification(of(PAES(Type+ Anatomy+ I(PA travels aberrantly, medial to normally positioned MHG II(Anomalous lateral](https://reader034.fdocuments.us/reader034/viewer/2022042418/5f33d75b6ec5e43a21768051/html5/thumbnails/17.jpg)
Effort(Thrombosis:(36(YO(weightlifter(
![Page 18: FUNCTIONAL*IMAGING*OF* ATHLETES*hallett/RSNA2014/handout... · Classification(of(PAES(Type+ Anatomy+ I(PA travels aberrantly, medial to normally positioned MHG II(Anomalous lateral](https://reader034.fdocuments.us/reader034/viewer/2022042418/5f33d75b6ec5e43a21768051/html5/thumbnails/18.jpg)
Post?Op(1st(rib(resection(
![Page 19: FUNCTIONAL*IMAGING*OF* ATHLETES*hallett/RSNA2014/handout... · Classification(of(PAES(Type+ Anatomy+ I(PA travels aberrantly, medial to normally positioned MHG II(Anomalous lateral](https://reader034.fdocuments.us/reader034/viewer/2022042418/5f33d75b6ec5e43a21768051/html5/thumbnails/19.jpg)
Arterial(and(Venous(TOS:(16(YO(Volleyball(Athlete(
REST% STRESS%
![Page 20: FUNCTIONAL*IMAGING*OF* ATHLETES*hallett/RSNA2014/handout... · Classification(of(PAES(Type+ Anatomy+ I(PA travels aberrantly, medial to normally positioned MHG II(Anomalous lateral](https://reader034.fdocuments.us/reader034/viewer/2022042418/5f33d75b6ec5e43a21768051/html5/thumbnails/20.jpg)
MRA(for(TOS:(Blood(Pool(MRA(
! Anatomic(imaging:(Oblique(sag(and((cor((T1/T2(! Relaxed(and(Challenged(imaging:(
! Gadofosveset((blood(pool(agent)(! BreathYhold(FSPGR,(ECGYgated,(high(resolution((1.8(mm(ST,(448(x(448(matrix)(CORONAL(acquisition(! Challenged:(Arm(Abducted(! Relaxed:(Arm(Down(
![Page 21: FUNCTIONAL*IMAGING*OF* ATHLETES*hallett/RSNA2014/handout... · Classification(of(PAES(Type+ Anatomy+ I(PA travels aberrantly, medial to normally positioned MHG II(Anomalous lateral](https://reader034.fdocuments.us/reader034/viewer/2022042418/5f33d75b6ec5e43a21768051/html5/thumbnails/21.jpg)
Arm UP Arm DOWN
![Page 22: FUNCTIONAL*IMAGING*OF* ATHLETES*hallett/RSNA2014/handout... · Classification(of(PAES(Type+ Anatomy+ I(PA travels aberrantly, medial to normally positioned MHG II(Anomalous lateral](https://reader034.fdocuments.us/reader034/viewer/2022042418/5f33d75b6ec5e43a21768051/html5/thumbnails/22.jpg)
Handouts(Available:((www.stanford.edu/~hallett(
Choose(folder(“RSNA(2014”(
Iliac%Endofibrosis%
![Page 23: FUNCTIONAL*IMAGING*OF* ATHLETES*hallett/RSNA2014/handout... · Classification(of(PAES(Type+ Anatomy+ I(PA travels aberrantly, medial to normally positioned MHG II(Anomalous lateral](https://reader034.fdocuments.us/reader034/viewer/2022042418/5f33d75b6ec5e43a21768051/html5/thumbnails/23.jpg)
Iliac*endofibrosis*is*a(n):
A. Acute inflammatory vasculopathy B. Early (accelerated) atherosclerotic process C. Vasculitis related to HLA-B27 antibodies D. Non-inflammatory, non-atherosclerotic disease
Lim(CS,(et(al.((Eur(J(Vasc(Endovasc(Surg(2009:38:180Y6.(
![Page 24: FUNCTIONAL*IMAGING*OF* ATHLETES*hallett/RSNA2014/handout... · Classification(of(PAES(Type+ Anatomy+ I(PA travels aberrantly, medial to normally positioned MHG II(Anomalous lateral](https://reader034.fdocuments.us/reader034/viewer/2022042418/5f33d75b6ec5e43a21768051/html5/thumbnails/24.jpg)
Flow(limitations(in(the(athletic(pelvis(
! Dynamic:(" Elongated(/(tortuous(vessels(" Kinking(with(or(w/o(stenosis((elongation/tethering)(
" compression((psoas(hypertrophy,(ligaments)(
! Static:(Iliac(endofibrosis(Lim%CS,%et%al.,%%Eur%J%Vasc%Endovasc%Surg%2009:38:180X6.%
![Page 25: FUNCTIONAL*IMAGING*OF* ATHLETES*hallett/RSNA2014/handout... · Classification(of(PAES(Type+ Anatomy+ I(PA travels aberrantly, medial to normally positioned MHG II(Anomalous lateral](https://reader034.fdocuments.us/reader034/viewer/2022042418/5f33d75b6ec5e43a21768051/html5/thumbnails/25.jpg)
! 90%(of(pts(are(cyclists(• >10,000(km/yr(or(150,000(km(lifetime(• Also:(speed(skaters,(runners,(wt(lifters,(
XC(skiers,(and(rugby(players(! 90%(external(iliac(artery(! Smooth,(eccentric,(nonYcalcified(• Pathology:(intimal(fibroplasia,(medial(
hypertrophy,(and(adventitial(hyperplasia.((Involved(segments(universally(free(from(atherosclerosis.(
( Lim(CS,(et(al.((Eur(J(Vasc(Endovasc(Surg(2009:38:180Y6.(
![Page 26: FUNCTIONAL*IMAGING*OF* ATHLETES*hallett/RSNA2014/handout... · Classification(of(PAES(Type+ Anatomy+ I(PA travels aberrantly, medial to normally positioned MHG II(Anomalous lateral](https://reader034.fdocuments.us/reader034/viewer/2022042418/5f33d75b6ec5e43a21768051/html5/thumbnails/26.jpg)
Iliac*endofibrosis*is*a(n):
A. Acute inflammatory vasculopathy B. Early (accelerated) atherosclerotic process C. Vasculitis related to HLA-B27 antibodies D. Non-inflammatory, non-atherosclerotic disease ANSWER
Lim(CS,(et(al.((Eur(J(Vasc(Endovasc(Surg(2009:38:180Y6.(
![Page 27: FUNCTIONAL*IMAGING*OF* ATHLETES*hallett/RSNA2014/handout... · Classification(of(PAES(Type+ Anatomy+ I(PA travels aberrantly, medial to normally positioned MHG II(Anomalous lateral](https://reader034.fdocuments.us/reader034/viewer/2022042418/5f33d75b6ec5e43a21768051/html5/thumbnails/27.jpg)
Endofibrosis(CTA:(Imaging(technique(
! Two(phases:(relaxation(and(hip(flexion(! Coverage(~((40(cm(! Relaxation(–(100(kVp,(flexion(–(120(kVp(! ~(80(mL(of(IV(contrast((at(4(Y5(mL/s(for(each(
phase((20(sec(injection)(! Saline(flush(at(same(rate(! Scan(time(10(Y(12(sec(! Volumetric(Review(
![Page 28: FUNCTIONAL*IMAGING*OF* ATHLETES*hallett/RSNA2014/handout... · Classification(of(PAES(Type+ Anatomy+ I(PA travels aberrantly, medial to normally positioned MHG II(Anomalous lateral](https://reader034.fdocuments.us/reader034/viewer/2022042418/5f33d75b6ec5e43a21768051/html5/thumbnails/28.jpg)
CTA:(Positioning(! Simulate(cycling(position(as(closely(as(possible(
considering(space(within(CT(gantry((almost(900)(
![Page 29: FUNCTIONAL*IMAGING*OF* ATHLETES*hallett/RSNA2014/handout... · Classification(of(PAES(Type+ Anatomy+ I(PA travels aberrantly, medial to normally positioned MHG II(Anomalous lateral](https://reader034.fdocuments.us/reader034/viewer/2022042418/5f33d75b6ec5e43a21768051/html5/thumbnails/29.jpg)
Case(1(
! 45(yo(avid(cyclist((! Proximal(thigh(pain,(cramping(with(exertion(! ABI(drops(with(exertion(
![Page 30: FUNCTIONAL*IMAGING*OF* ATHLETES*hallett/RSNA2014/handout... · Classification(of(PAES(Type+ Anatomy+ I(PA travels aberrantly, medial to normally positioned MHG II(Anomalous lateral](https://reader034.fdocuments.us/reader034/viewer/2022042418/5f33d75b6ec5e43a21768051/html5/thumbnails/30.jpg)
Supine,(legs(extended((
![Page 31: FUNCTIONAL*IMAGING*OF* ATHLETES*hallett/RSNA2014/handout... · Classification(of(PAES(Type+ Anatomy+ I(PA travels aberrantly, medial to normally positioned MHG II(Anomalous lateral](https://reader034.fdocuments.us/reader034/viewer/2022042418/5f33d75b6ec5e43a21768051/html5/thumbnails/31.jpg)
Hip(flexion(Dynamic%Flow%RestricCon%
![Page 32: FUNCTIONAL*IMAGING*OF* ATHLETES*hallett/RSNA2014/handout... · Classification(of(PAES(Type+ Anatomy+ I(PA travels aberrantly, medial to normally positioned MHG II(Anomalous lateral](https://reader034.fdocuments.us/reader034/viewer/2022042418/5f33d75b6ec5e43a21768051/html5/thumbnails/32.jpg)
Case((2(
! 26(yo(elite(female(cyclist(! left(thigh(and(buttock(pain(at(high(performance(levels.(
(
![Page 33: FUNCTIONAL*IMAGING*OF* ATHLETES*hallett/RSNA2014/handout... · Classification(of(PAES(Type+ Anatomy+ I(PA travels aberrantly, medial to normally positioned MHG II(Anomalous lateral](https://reader034.fdocuments.us/reader034/viewer/2022042418/5f33d75b6ec5e43a21768051/html5/thumbnails/33.jpg)
Case(2(NEUTRAL( FLEXION(
![Page 34: FUNCTIONAL*IMAGING*OF* ATHLETES*hallett/RSNA2014/handout... · Classification(of(PAES(Type+ Anatomy+ I(PA travels aberrantly, medial to normally positioned MHG II(Anomalous lateral](https://reader034.fdocuments.us/reader034/viewer/2022042418/5f33d75b6ec5e43a21768051/html5/thumbnails/34.jpg)
Case((3(
! 49(yo(avid(cyclist(x(30(yrs(! left(thigh(and(buttock(pain(at(high(performance(levels.(
! Pain(described(as(a(�deep(burn�((((! ABI(R/L:(1.3/1.2(! Exercise(ABI(R/L:(1.5/1.2(
![Page 35: FUNCTIONAL*IMAGING*OF* ATHLETES*hallett/RSNA2014/handout... · Classification(of(PAES(Type+ Anatomy+ I(PA travels aberrantly, medial to normally positioned MHG II(Anomalous lateral](https://reader034.fdocuments.us/reader034/viewer/2022042418/5f33d75b6ec5e43a21768051/html5/thumbnails/35.jpg)
CTA(at(Rest(
• Pathology:%inCmal%thickening%and%fibrosis%%• No%inflammatory%change%
![Page 36: FUNCTIONAL*IMAGING*OF* ATHLETES*hallett/RSNA2014/handout... · Classification(of(PAES(Type+ Anatomy+ I(PA travels aberrantly, medial to normally positioned MHG II(Anomalous lateral](https://reader034.fdocuments.us/reader034/viewer/2022042418/5f33d75b6ec5e43a21768051/html5/thumbnails/36.jpg)
Endofibrosis(MRA:(Imaging(technique(
! Anatomic(imaging(–(T1/T2(! Arterial(Phase(FSPGR(MRA((bolus(track)(! Relaxed(and(Hip(Flexion(imaging(–((
! Respiratory(gated,(steady(state(acquisition(! NearYIsotropic(! Blood(Pool(contrast(Agent((Gadofosveset)(
! Volumetric(Review(
Naehle CP. J Am Coll Cardiol Img. 3 2010:504-513
![Page 37: FUNCTIONAL*IMAGING*OF* ATHLETES*hallett/RSNA2014/handout... · Classification(of(PAES(Type+ Anatomy+ I(PA travels aberrantly, medial to normally positioned MHG II(Anomalous lateral](https://reader034.fdocuments.us/reader034/viewer/2022042418/5f33d75b6ec5e43a21768051/html5/thumbnails/37.jpg)
Vascular*Diseases*in*Athletes*
• Lower%Extremity%Popliteal%Entrapment%Syndrome%(PAES)%
Handouts(Available: ((((
www.stanford.edu/~hallett((((((((((((
Choose(folder(“RSNA(2014”(
![Page 38: FUNCTIONAL*IMAGING*OF* ATHLETES*hallett/RSNA2014/handout... · Classification(of(PAES(Type+ Anatomy+ I(PA travels aberrantly, medial to normally positioned MHG II(Anomalous lateral](https://reader034.fdocuments.us/reader034/viewer/2022042418/5f33d75b6ec5e43a21768051/html5/thumbnails/38.jpg)
Most*cases*of*Popliteal*entrapment*syndrome*arise*from:
A. Chronic repetitive trauma to popliteal artery / vein B. Embryologic conflict between muscles and vessels C. Premature atherosclerotic disease D. Chronic exertional compartment syndrome
Macedo TA, et al. Popliteal Artery Entrapment Syndrome: Role of Imaging in the Diagnosis. American Journal of Roentgenology. 2003 Nov;181(5):1259–65. %
![Page 39: FUNCTIONAL*IMAGING*OF* ATHLETES*hallett/RSNA2014/handout... · Classification(of(PAES(Type+ Anatomy+ I(PA travels aberrantly, medial to normally positioned MHG II(Anomalous lateral](https://reader034.fdocuments.us/reader034/viewer/2022042418/5f33d75b6ec5e43a21768051/html5/thumbnails/39.jpg)
Popliteal(Space(?(Embryology(
! In#utero:(competition(between(popliteal(neurovascular(bundle(and(migrating(muscles((medial(head(gastrocnemius)(for(space(
! If(delayed(or(abnormal(migration(#(MHG+too+far+lateral(
" space(is(limited(
![Page 40: FUNCTIONAL*IMAGING*OF* ATHLETES*hallett/RSNA2014/handout... · Classification(of(PAES(Type+ Anatomy+ I(PA travels aberrantly, medial to normally positioned MHG II(Anomalous lateral](https://reader034.fdocuments.us/reader034/viewer/2022042418/5f33d75b6ec5e43a21768051/html5/thumbnails/40.jpg)
Causes(of(Popliteal(Entrapment(
! Anatomic(Compression(• Abnormal(popliteal(artery(course(• Abnormal(muscle((MHG)(• Both(
! �Functional�(compression(
![Page 41: FUNCTIONAL*IMAGING*OF* ATHLETES*hallett/RSNA2014/handout... · Classification(of(PAES(Type+ Anatomy+ I(PA travels aberrantly, medial to normally positioned MHG II(Anomalous lateral](https://reader034.fdocuments.us/reader034/viewer/2022042418/5f33d75b6ec5e43a21768051/html5/thumbnails/41.jpg)
Most*cases*of*Popliteal*entrapment*syndrome*arise*from:
A. Chronic repetitive trauma to popliteal artery / vein B. Embryologic conflict between muscles and vessels C. Premature atherosclerotic disease D. Chronic exertional compartment syndrome
ANSWER
Macedo TA, et al. Popliteal Artery Entrapment Syndrome: Role of Imaging in the Diagnosis. American Journal of Roentgenology. 2003 Nov;181(5):1259–65. %
![Page 42: FUNCTIONAL*IMAGING*OF* ATHLETES*hallett/RSNA2014/handout... · Classification(of(PAES(Type+ Anatomy+ I(PA travels aberrantly, medial to normally positioned MHG II(Anomalous lateral](https://reader034.fdocuments.us/reader034/viewer/2022042418/5f33d75b6ec5e43a21768051/html5/thumbnails/42.jpg)
Classification(of(PAES(Type+ Anatomy+
I( PA travels aberrantly, medial to normally positioned MHG
II( Anomalous lateral and inferior origin of MHG, PA displaced medially
III( Normal PA compressed by muscular slip or aberrant band from MHG
IV( PA deep in popliteal fossa, entrapment from aberrant band or popliteus muscle
V( Any type of entrapment involving popliteal vein
VI( �Functional� Entrapment
*%Whelan%TJ.%In:%Haimovici%H,%Ed.%Vascular%surgery:%principles%and%techniques.%New%York:%%McGrawXHill,%1984:%557X67%
![Page 43: FUNCTIONAL*IMAGING*OF* ATHLETES*hallett/RSNA2014/handout... · Classification(of(PAES(Type+ Anatomy+ I(PA travels aberrantly, medial to normally positioned MHG II(Anomalous lateral](https://reader034.fdocuments.us/reader034/viewer/2022042418/5f33d75b6ec5e43a21768051/html5/thumbnails/43.jpg)
! Younger(population,(highly(conditioned(athletes(! Neurovascular(compression(by(hypertrophic(gastrocnemius(+/Y(soleal(sling(
! Longer(segment(involvement((vs.(anatomic(PAES)(
! Conservative(Tx(first,(debulking(if(needed(
(
Functional(Popliteal(Entrapment((Type(VI)(
![Page 44: FUNCTIONAL*IMAGING*OF* ATHLETES*hallett/RSNA2014/handout... · Classification(of(PAES(Type+ Anatomy+ I(PA travels aberrantly, medial to normally positioned MHG II(Anomalous lateral](https://reader034.fdocuments.us/reader034/viewer/2022042418/5f33d75b6ec5e43a21768051/html5/thumbnails/44.jpg)
! 3(phases(–(relaxed,(active(plantar(flexion,(venous(• Active(plantarYflexion(without(bearing(down((straps)(
! ~(80(mL(of(contrast((4mL/s)(for(2(phases(followed(by(saline(flush(at(same(rate(
! Bolus(track(distal(SFA(! Scan(time:(12Y15(sec(on(64YMDCT(! Pulse(oximeter(on(symptomatic(large(toe(
![Page 45: FUNCTIONAL*IMAGING*OF* ATHLETES*hallett/RSNA2014/handout... · Classification(of(PAES(Type+ Anatomy+ I(PA travels aberrantly, medial to normally positioned MHG II(Anomalous lateral](https://reader034.fdocuments.us/reader034/viewer/2022042418/5f33d75b6ec5e43a21768051/html5/thumbnails/45.jpg)
PAES:(CTA(Imaging(Technique(
![Page 46: FUNCTIONAL*IMAGING*OF* ATHLETES*hallett/RSNA2014/handout... · Classification(of(PAES(Type+ Anatomy+ I(PA travels aberrantly, medial to normally positioned MHG II(Anomalous lateral](https://reader034.fdocuments.us/reader034/viewer/2022042418/5f33d75b6ec5e43a21768051/html5/thumbnails/46.jpg)
Soccer Player - Type I PAES
![Page 47: FUNCTIONAL*IMAGING*OF* ATHLETES*hallett/RSNA2014/handout... · Classification(of(PAES(Type+ Anatomy+ I(PA travels aberrantly, medial to normally positioned MHG II(Anomalous lateral](https://reader034.fdocuments.us/reader034/viewer/2022042418/5f33d75b6ec5e43a21768051/html5/thumbnails/47.jpg)
Type%III%PAES%X%Thrombosis%of%leH%popliteal%artery%%
prov
ocation(
Relaxe
d(–p
osterio
r(view(
LEFT+ RIGHT+
![Page 48: FUNCTIONAL*IMAGING*OF* ATHLETES*hallett/RSNA2014/handout... · Classification(of(PAES(Type+ Anatomy+ I(PA travels aberrantly, medial to normally positioned MHG II(Anomalous lateral](https://reader034.fdocuments.us/reader034/viewer/2022042418/5f33d75b6ec5e43a21768051/html5/thumbnails/48.jpg)
FuncConal%(Type%VI)%PAES%
prov
ocation(
relaxe
d(
![Page 49: FUNCTIONAL*IMAGING*OF* ATHLETES*hallett/RSNA2014/handout... · Classification(of(PAES(Type+ Anatomy+ I(PA travels aberrantly, medial to normally positioned MHG II(Anomalous lateral](https://reader034.fdocuments.us/reader034/viewer/2022042418/5f33d75b6ec5e43a21768051/html5/thumbnails/49.jpg)
PAES:(Challenged(MRA(technique(
! Anatomic(imaging((axial/coronal(T1/T2)(
! Challenged(and(Relaxed(Acquisition((like(CTA)(
! blood(pool(agent(gadofosveset((! ThinYslice(Coronal((1.4mm)(steadyY
state(acquisition((576x576(matrix)((! 3D(assessment(
![Page 50: FUNCTIONAL*IMAGING*OF* ATHLETES*hallett/RSNA2014/handout... · Classification(of(PAES(Type+ Anatomy+ I(PA travels aberrantly, medial to normally positioned MHG II(Anomalous lateral](https://reader034.fdocuments.us/reader034/viewer/2022042418/5f33d75b6ec5e43a21768051/html5/thumbnails/50.jpg)
STRESS
PAES:(Challenged(MRA(technique(
![Page 51: FUNCTIONAL*IMAGING*OF* ATHLETES*hallett/RSNA2014/handout... · Classification(of(PAES(Type+ Anatomy+ I(PA travels aberrantly, medial to normally positioned MHG II(Anomalous lateral](https://reader034.fdocuments.us/reader034/viewer/2022042418/5f33d75b6ec5e43a21768051/html5/thumbnails/51.jpg)
Conclusions(! Vascular(diseases(in(athletes(can(be(a(significant(source(of(disability(and(performance(loss(
! Functional(imaging(is(important(for(accurate(detection(and(characterization(of(vascular(entrapment(/(stenotic(syndromes(
! CTA(and(MRA(with(functional(techniques(allow(nonYinvasive(assessment(
![Page 52: FUNCTIONAL*IMAGING*OF* ATHLETES*hallett/RSNA2014/handout... · Classification(of(PAES(Type+ Anatomy+ I(PA travels aberrantly, medial to normally positioned MHG II(Anomalous lateral](https://reader034.fdocuments.us/reader034/viewer/2022042418/5f33d75b6ec5e43a21768051/html5/thumbnails/52.jpg)
Thanks(for(Your(ABenCon(!!(
www.stanford.edu/~hallett Choose folder “RSNA 2014”
Special Thanks to: Dominik Fleischmann, MD Frandics Chan MD, PhD Deirdre Sheahan, MD Kevin Sheridan, MD