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MRI with MRA in abdominal aortic aneurysm

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61. Autosomal Dominant Polycystic Kidney Disease

of regional structures symptoms VI. Signs With advanced renal or hepatic disease, cyst-related mass effect may be palpable VII. Labs test monitoring tic screening indications Not routinely indicated Young, at risk asymptomatic patients with normal screening Large s with s and no known of ADPKD transplant potential donor who is at risk of ADPKD VIII. Imaging First-Line Renal (effective, lower cost, no radiation) Alternative screening (if non-diagnostic or large body habitus) Abdominal MRI IX. Diagnosis (...) criteria for those at risk of ADPKD Type 1 Age <30 years: 2 or more cysts in one or both s Age 30 to 59 years: 2 or more cysts in each s Age >60 years: 4 or more cysts in each s criteria for those at risk of ADPKD with unknown Age 15 to 39 years: 2 or more cysts in one or both s Age 40 to 59 years: 2 or more cysts in each s Age >60 years: 4 or more cysts in each s MRI criteria for those at risk of ADPKD Age <30 years: 5 or more cysts in each s Age 30 to 44 years: 6 or more cysts in each s Age 45 to 59

2018 FP Notebook

62. Fibromuscular Dysplasia (Overview)

followed later by neck stiffness): May indicate an aneurysm that may be associated with FMD Symptoms suggestive of noncraniocervical FMD, such as hypertension (renal involvement), abdominal pains or a history of ischemic bowel (mesenteric or visceral artery involvement), or intermittent leg claudication (extremity artery involvement) Physical examination should include the following: Thorough neurologic examination Neurovascular examination, including auscultation for carotid and vertebral artery (...) individual known to have FMD Conventional angiography is standard for detecting FMD and its associated vascular lesions Conventional cerebrovascular ultrasonography is unlikely to depict the carotid lesions of FMD The sensitivity and specificity of computed tomography (angiography (CTA), time-of-flight (TOF) magnetic resonance angiography (MRA), or contrast-enhanced MRA (CE MRA) in this setting remain to be established Conventional CT and MRI may be useful in finding ischemic strokes caused by arterial

2014 eMedicine.com

63. Renovascular Hypertension: Surgical Perspective (Follow-up)

, the bypass is connected to the low thoracic aorta and the bifurcation of the iliac arteries. Grafts can also extend from the upper abdominal aorta behind the esophagus to the aortic bifurcation. The appropriate length of graft material must be used so as to allow for growth while avoiding kinking. Placing the graft behind the kidney may help protect the graft. Renal artery bypass grafts may be attached to the aortoaortic bypass graft or to the low aorta. Theoretically, attachment of the renal artery (...) are important in evaluating the patient’s cardiovascular stability under the stress of hypertension. Abdominal aortography and arteriography are necessary, not only to help establish a diagnosis but also to determine the extent of disease and the approach to surgical intervention. Operative approach For unilateral renal artery stenosis, a transverse transperitoneal incision may be used. This allows direct approach to the renal artery. Dissection of the kidney is minimized to limit disruption

Full Text available with Trip Pro

2014 eMedicine Pediatrics

64. Syncope and Related Paroxysmal Spells (Diagnosis)

, congestive heart failure (CHF), lung mass, effusion, or widened mediastinum Computed tomography (CT) of the head (noncontrast) - Has a low diagnostic yield in syncope but may be clinically indicated in patients with new neurologic deficits or in patients with head trauma secondary to syncope CT of the chest and abdomen - Indicated only in select cases (eg, suspected aortic dissection, ruptured abdominal aortic aneurysm, or pulmonary embolism [PE]) Magnetic resonance imaging (MRI) of the brain (...) and magnetic resonance arteriography (MRA) - May be required in select cases to evaluate vertebrobasilar vasculature Ventilation-perfusion (V/Q) scanning - Appropriate for suspected PE Echocardiography - The test of choice for evaluating suspected mechanical cardiac causes of syncope A standard 12-lead ECG is a level A recommendation in the 2007 ACEP consensus guidelines for syncope. [ ] The following considerations are relevant: Normal ECG findings are a good prognostic sign ECG can be diagnostic

2014 eMedicine.com

65. Syncope (Diagnosis)

mass, effusion, or widened mediastinum Computed tomography (CT) of the head (noncontrast) - Has a low diagnostic yield in syncope but may be clinically indicated in patients with new neurologic deficits or in patients with head trauma secondary to syncope CT of the chest and abdomen - Indicated only in select cases (eg, suspected aortic dissection, ruptured abdominal aortic aneurysm, or pulmonary embolism [PE]) Magnetic resonance imaging (MRI) of the brain and magnetic resonance arteriography (MRA (...) a history of cardiac problems and are symptomatic. Chest pain, dyspnea, decreased exercise tolerance, and fatigue may all be present. Consider cardiac ischemia and medication side effects as additional causes. Cardiac outflow obstruction may also result in sudden-onset syncope with little or no prodrome. One critical clue is the exertional nature, and the other is the presence of a cardiac murmur. Young athletes may present with this etiology for syncope. Specific pathology includes aortic stenosis

2014 eMedicine.com

66. Fibromuscular Dysplasia (Diagnosis)

followed later by neck stiffness): May indicate an aneurysm that may be associated with FMD Symptoms suggestive of noncraniocervical FMD, such as hypertension (renal involvement), abdominal pains or a history of ischemic bowel (mesenteric or visceral artery involvement), or intermittent leg claudication (extremity artery involvement) Physical examination should include the following: Thorough neurologic examination Neurovascular examination, including auscultation for carotid and vertebral artery (...) individual known to have FMD Conventional angiography is standard for detecting FMD and its associated vascular lesions Conventional cerebrovascular ultrasonography is unlikely to depict the carotid lesions of FMD The sensitivity and specificity of computed tomography (angiography (CTA), time-of-flight (TOF) magnetic resonance angiography (MRA), or contrast-enhanced MRA (CE MRA) in this setting remain to be established Conventional CT and MRI may be useful in finding ischemic strokes caused by arterial

2014 eMedicine.com

67. Takayasu Arteritis (Treatment)

cerebral vessels Aortic regurgitation Thoracic or abdominal aneurysms larger than 5 cm in diameter Severe coarctation of the aorta Percutaneous transluminal coronary angioplasty is followed by restenosis at the angioplasty site within 1-2 years in a substantial number of patients. Bypass graft surgery Bypass graft surgery is the procedure with the best long-term patency rate. Bypass surgery has been performed on patients with critical thoracic aortic arch arterial stenosis, upper and lower extremity (...) of thorax of 15-year-old girl with Takayasu arteritis. Note aneurysms of descending aorta. Image courtesy of Christine Hom, MD. Coronal MRI of abdomen of 15-year-old girl with Takayasu arteritis. Note thickening and tortuosity of abdominal aorta proximal to kidneys. Image courtesy of Christine Hom, MD. of 6 Tables Contributor Information and Disclosures Author Jefferson R Roberts, MD Chief of Rheumatology Service, Tripler Army Medical Center; Assistant Clinical Professor of Medicine, Uniformed Services

2014 eMedicine.com

68. Takayasu Arteritis (Treatment)

cerebral vessels Aortic regurgitation Thoracic or abdominal aneurysms larger than 5 cm in diameter Severe coarctation of the aorta Percutaneous transluminal coronary angioplasty is followed by restenosis at the angioplasty site within 1-2 years in a substantial number of patients. Bypass graft surgery Bypass graft surgery is the procedure with the best long-term patency rate. Bypass surgery has been performed on patients with critical thoracic aortic arch arterial stenosis, upper and lower extremity (...) of thorax of 15-year-old girl with Takayasu arteritis. Note aneurysms of descending aorta. Image courtesy of Christine Hom, MD. Coronal MRI of abdomen of 15-year-old girl with Takayasu arteritis. Note thickening and tortuosity of abdominal aorta proximal to kidneys. Image courtesy of Christine Hom, MD. of 6 Tables Contributor Information and Disclosures Author Jefferson R Roberts, MD Chief of Rheumatology Service, Tripler Army Medical Center; Assistant Clinical Professor of Medicine, Uniformed Services

2014 eMedicine.com

69. Renovascular Hypertension (Treatment)

, the bypass is connected to the low thoracic aorta and the bifurcation of the iliac arteries. Grafts can also extend from the upper abdominal aorta behind the esophagus to the aortic bifurcation. The appropriate length of graft material must be used so as to allow for growth while avoiding kinking. Placing the graft behind the kidney may help protect the graft. Renal artery bypass grafts may be attached to the aortoaortic bypass graft or to the low aorta. Theoretically, attachment of the renal artery (...) are important in evaluating the patient’s cardiovascular stability under the stress of hypertension. Abdominal aortography and arteriography are necessary, not only to help establish a diagnosis but also to determine the extent of disease and the approach to surgical intervention. Operative approach For unilateral renal artery stenosis, a transverse transperitoneal incision may be used. This allows direct approach to the renal artery. Dissection of the kidney is minimized to limit disruption

Full Text available with Trip Pro

2014 eMedicine.com

70. Renal Artery Stenosis (Treatment)

loss of GFR becomes far advanced. In some institutions, PTAS is the first-step approach in patients with IRD, and practitioners reserve surgery for the technical failure of percutaneous maneuvers. However, surgery remains the first choice of treatment under certain conditions, including the following: Simultaneous abdominal aortic aneurysm Renal artery aneurysm Renal artery occlusion (with unsuccessful thrombolysis) Renal artery rupture Renal artery stenosis secondary to kinking Peripheral (...) artery stenosis. Nat Rev Nephrol . 2010 Mar. 6(3):151-9. . Tafur JD, White CJ. Renal Artery Stenosis: When to Revascularize in 2017. Curr Probl Cardiol . 2017 Apr. 42 (4):110-135. . Textor SC. Renal Arterial Disease and Hypertension. Med Clin North Am . 2017 Jan. 101 (1):65-79. . Iida M, Maeda H, Yamamoto M, et al. Association of renal artery stenosis with aortic jet velocity in hypertensive patients with aortic valve sclerosis. Am J Hypertens . 2010 Feb. 23(2):197-201. . De Bruyne B, Manoharan G

2014 eMedicine.com

71. Renal Artery Stenosis (Overview)

,the decreased perfusion compromises renal function and structure. Patients with renal artery stenosis may present with one or more of the following (see ): Abdominal bruit Azotemia Sudden worsening of hypertension or renal function Acute kidney injury or decreased renal function after initiation of antihypertensive therapy, especially with angiotensin-converting enzyme (ACE) inhibitors or angiotensin receptor blockers Unexplained renal insufficiency, in elderly patients. Congestive heart failure, with poor (...) exceeds 50%. The degree of renal artery stenosis that would justify any attempt at either surgical intervention or radiologic intervention is not known. One study found that when the pressure distal to renal artery stenosis was less than 90% of aortic pressure, renin release from the affected kidney was significantly elevated (renin being measured in the ipsilateral renal vein). This might be useful as a functional measurement of significant renovascular stenosis leading to hypertension and, thus

2014 eMedicine.com

72. Takayasu Arteritis (Overview)

of descending aorta and dilatation of innominate artery. Image courtesy of Christine Hom, MD. MRI of thorax of 15-year-old girl with Takayasu arteritis. Note aneurysms of descending aorta. Image courtesy of Christine Hom, MD. Coronal MRI of abdomen of 15-year-old girl with Takayasu arteritis. Note thickening and tortuosity of abdominal aorta proximal to kidneys. Image courtesy of Christine Hom, MD. of 6 Tables Contributor Information and Disclosures Author Jefferson R Roberts, MD Chief of Rheumatology (...) with intimal proliferation. Lesions produced by the inflammatory process can be stenotic, occlusive, or aneurysmal. All aneurysmal lesions may have areas of arterial narrowing. Vascular changes lead to the main complications, including hypertension, most often due to renal artery stenosis or, more rarely, stenosis of the suprarenal aorta; aortic insufficiency due to aortic valve involvement; ; and aortic or arterial aneurysm. The renal arteries are involved in 24% to 68% of Takayasu arteritis cases. Renal

2014 eMedicine.com

73. Takayasu Arteritis (Overview)

of descending aorta and dilatation of innominate artery. Image courtesy of Christine Hom, MD. MRI of thorax of 15-year-old girl with Takayasu arteritis. Note aneurysms of descending aorta. Image courtesy of Christine Hom, MD. Coronal MRI of abdomen of 15-year-old girl with Takayasu arteritis. Note thickening and tortuosity of abdominal aorta proximal to kidneys. Image courtesy of Christine Hom, MD. of 6 Tables Contributor Information and Disclosures Author Jefferson R Roberts, MD Chief of Rheumatology (...) with intimal proliferation. Lesions produced by the inflammatory process can be stenotic, occlusive, or aneurysmal. All aneurysmal lesions may have areas of arterial narrowing. Vascular changes lead to the main complications, including hypertension, most often due to renal artery stenosis or, more rarely, stenosis of the suprarenal aorta; aortic insufficiency due to aortic valve involvement; ; and aortic or arterial aneurysm. The renal arteries are involved in 24% to 68% of Takayasu arteritis cases. Renal

2014 eMedicine.com

74. Syncope (Overview)

mass, effusion, or widened mediastinum Computed tomography (CT) of the head (noncontrast) - Has a low diagnostic yield in syncope but may be clinically indicated in patients with new neurologic deficits or in patients with head trauma secondary to syncope CT of the chest and abdomen - Indicated only in select cases (eg, suspected aortic dissection, ruptured abdominal aortic aneurysm, or pulmonary embolism [PE]) Magnetic resonance imaging (MRI) of the brain and magnetic resonance arteriography (MRA (...) a history of cardiac problems and are symptomatic. Chest pain, dyspnea, decreased exercise tolerance, and fatigue may all be present. Consider cardiac ischemia and medication side effects as additional causes. Cardiac outflow obstruction may also result in sudden-onset syncope with little or no prodrome. One critical clue is the exertional nature, and the other is the presence of a cardiac murmur. Young athletes may present with this etiology for syncope. Specific pathology includes aortic stenosis

2014 eMedicine.com

75. Syncope and Related Paroxysmal Spells (Overview)

, congestive heart failure (CHF), lung mass, effusion, or widened mediastinum Computed tomography (CT) of the head (noncontrast) - Has a low diagnostic yield in syncope but may be clinically indicated in patients with new neurologic deficits or in patients with head trauma secondary to syncope CT of the chest and abdomen - Indicated only in select cases (eg, suspected aortic dissection, ruptured abdominal aortic aneurysm, or pulmonary embolism [PE]) Magnetic resonance imaging (MRI) of the brain (...) and magnetic resonance arteriography (MRA) - May be required in select cases to evaluate vertebrobasilar vasculature Ventilation-perfusion (V/Q) scanning - Appropriate for suspected PE Echocardiography - The test of choice for evaluating suspected mechanical cardiac causes of syncope A standard 12-lead ECG is a level A recommendation in the 2007 ACEP consensus guidelines for syncope. [ ] The following considerations are relevant: Normal ECG findings are a good prognostic sign ECG can be diagnostic

2014 eMedicine.com

76. Hypertensive Heart Disease (Overview)

of pulmonary congestion, such as rales, decreased breath sounds, and dullness to percussion due to pleural effusion. Abdomen The abdominal examination may reveal a renal artery bruit in patients with hypertension secondary to renal artery stenosis, a pulsatile expansile mass of abdominal aortic aneurysm, and hepatomegaly and ascites due to CHF. Extremities Ankle edema may be present in patients with advanced heart failure. Central nervous system and ophthalmologic system Central nervous system (CNS (...) lines, and alveolar infiltrates in the presence of elevated LV end-diastolic pressure and pulmonary congestion; and blunting of the costophrenic angle in the presence of pleural effusion. Computed tomography (CT) scanning, and magnetic resonance imaging (MRI) of the heart, although not used routinely, have been shown in experimental studies to quantify LVH. CT scanning, MRI, and magnetic resonance angiography (MRA) of the abdomen and chest show the presence of adrenal masses, renal artery stenosis

2014 eMedicine.com

77. Hypertensive Heart Disease (Treatment)

of pulmonary congestion, such as rales, decreased breath sounds, and dullness to percussion due to pleural effusion. Abdomen The abdominal examination may reveal a renal artery bruit in patients with hypertension secondary to renal artery stenosis, a pulsatile expansile mass of abdominal aortic aneurysm, and hepatomegaly and ascites due to CHF. Extremities Ankle edema may be present in patients with advanced heart failure. Central nervous system and ophthalmologic system Central nervous system (CNS (...) lines, and alveolar infiltrates in the presence of elevated LV end-diastolic pressure and pulmonary congestion; and blunting of the costophrenic angle in the presence of pleural effusion. Computed tomography (CT) scanning, and magnetic resonance imaging (MRI) of the heart, although not used routinely, have been shown in experimental studies to quantify LVH. CT scanning, MRI, and magnetic resonance angiography (MRA) of the abdomen and chest show the presence of adrenal masses, renal artery stenosis

2014 eMedicine.com

78. Renovascular Hypertension (Follow-up)

, the bypass is connected to the low thoracic aorta and the bifurcation of the iliac arteries. Grafts can also extend from the upper abdominal aorta behind the esophagus to the aortic bifurcation. The appropriate length of graft material must be used so as to allow for growth while avoiding kinking. Placing the graft behind the kidney may help protect the graft. Renal artery bypass grafts may be attached to the aortoaortic bypass graft or to the low aorta. Theoretically, attachment of the renal artery (...) are important in evaluating the patient’s cardiovascular stability under the stress of hypertension. Abdominal aortography and arteriography are necessary, not only to help establish a diagnosis but also to determine the extent of disease and the approach to surgical intervention. Operative approach For unilateral renal artery stenosis, a transverse transperitoneal incision may be used. This allows direct approach to the renal artery. Dissection of the kidney is minimized to limit disruption

Full Text available with Trip Pro

2014 eMedicine.com

79. Renal Artery Stenosis (Follow-up)

. Next: Prognosis Researchers have studied the natural history of atherosclerotic renal artery stenosis by obtaining images from sequential abdominal aortographs or duplex ultrasound scans in patients with documented renal artery lesions who have been treated medically. Most studies show that progressive arterial obstruction occurs in 42-53% of patients with atherosclerotic renal artery stenosis, often within the first 2 years of radiographic follow-up. The incidence rate of progression to complete (...) . Association of renal artery stenosis with aortic jet velocity in hypertensive patients with aortic valve sclerosis. Am J Hypertens . 2010 Feb. 23(2):197-201. . De Bruyne B, Manoharan G, Pijls NH, et al. Assessment of renal artery stenosis severity by pressure gradient measurements. J Am Coll Cardiol . 2006 Nov 7. 48(9):1851-5. . Simon JF. Stenting atherosclerotic renal arteries: time to be less aggressive. Cleve Clin J Med . 2010 Mar. 77(3):178-89. . . Jazrawi A, Darda S, Burke P, et al. Is race a risk

2014 eMedicine.com

80. Takayasu Arteritis (Follow-up)

cerebral vessels Aortic regurgitation Thoracic or abdominal aneurysms larger than 5 cm in diameter Severe coarctation of the aorta Percutaneous transluminal coronary angioplasty is followed by restenosis at the angioplasty site within 1-2 years in a substantial number of patients. Bypass graft surgery Bypass graft surgery is the procedure with the best long-term patency rate. Bypass surgery has been performed on patients with critical thoracic aortic arch arterial stenosis, upper and lower extremity (...) of thorax of 15-year-old girl with Takayasu arteritis. Note aneurysms of descending aorta. Image courtesy of Christine Hom, MD. Coronal MRI of abdomen of 15-year-old girl with Takayasu arteritis. Note thickening and tortuosity of abdominal aorta proximal to kidneys. Image courtesy of Christine Hom, MD. of 6 Tables Contributor Information and Disclosures Author Jefferson R Roberts, MD Chief of Rheumatology Service, Tripler Army Medical Center; Assistant Clinical Professor of Medicine, Uniformed Services

2014 eMedicine.com

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