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Imaging of Wegener's granulomatosis

Department of Imaging, Imaging Sciences Department, Hammersmith Hospital, Imperial College Faculty of Medicine, Du Cane Road, London W12 ONN, UK

View larger version (152K): [in this window] [in a new window]   Figure 1. 63-year-old man with pulmonary Wegener's granulomatosis. A chest radiograph shows multiple pulmonary masses, some of which are cavitating (arrows).

View larger version (139K): [in this window] [in a new window]   Figure 2. 42-year-old man with pulmonary Wegener's granulomatosis. A coronal CT reformatted image of the chest shows a peripheral pulmonary mass, with early cavitation (arrow). There is a background mosaic pattern of lung attenuation, thought to be due to a mosaic perfusion abnormality caused by a primary vascular abnormality rather than ground-glass attenuation caused by air trapping.

View larger version (109K): [in this window] [in a new window]   Figure 3. 48-year-old woman with pulmonary Wegener's granulomatosis. An axial CT image shows multiple pulmonary lesions (arrows). The largest of these has clearly cavitated. As in Figure 2, there is a background mosaic pattern of lung attenuation, thought to be due to a mosaic perfusion abnormality caused by vasculitis.

View larger version (143K): [in this window] [in a new window]   Figure 4. 52-year-old man with pulmonary Wegener's granulomatosis. An axial CT image showing a right-sided cavitating lesion (arrow). This has an air–fluid level within it, suggesting possible superadded infection. Haemorrhage into the cavity can also cause this appearance.

View larger version (145K): [in this window] [in a new window]   Figure 5. 33-year-old woman with pulmonary Wegener's granulomatosis. An axial CT image shows a large pulmonary mass (arrow), with surrounding ground-glass change, suggesting haemorrhage.

View larger version (115K): [in this window] [in a new window]   Figure 6. 56-year-old man with pulmonary Wegener's granulomatosis presenting with haemoptysis. A chest radiograph shows extensive, patchy bilateral consolidation. This patient had diffuse pulmonary haemorrhage.

View larger version (146K): [in this window] [in a new window]   Figure 7. 28-year-old woman with pulmonary Wegener's granulomatosis presenting with haemoptysis. An axial CT image shows marked ground-glass change bilaterally. This is an appearance of diffuse pulmonary haemorrhage.

View larger version (68K): [in this window] [in a new window]   Figure 8. 54-year-old man with tracheal Wegener's granulomatosis. A coronal CT reformatted image shows bilateral stenoses of the main bronchi. The right bronchus intermedius is stented, with marked intraluminal soft tissue thickening (arrow).

View larger version (94K): [in this window] [in a new window]   Figure 9. 40-year-old man with sinonasal Wegener's granulomatosis. An axial CT image of the sinuses shows marked ethmoidal mucosal disease, with bony thinning and destruction of the medial orbital wall and nasal septum (arrows).

View larger version (152K): [in this window] [in a new window]   Figure 10. 46-year-old man with sinonasal Wegener's granulomatosis. A coronal CT reformatted image of the sinuses shows marked maxillary sinus disease bilaterally.

View larger version (74K): [in this window] [in a new window]   Figure 11. 62-year-old woman with renal Wegener's granulomatosis. A longitudinal ultrasound image shows an echogenic right kidney. Although this is a non-specific finding, it is the most common sign of early glomerulonephritis, implying involvement of the kidney by Wegener's granulomatosis.

View larger version (90K): [in this window] [in a new window]   Figure 12. 43-year-old woman with orbital Wegener's granulomatosis. (a) An axial CT image showing a large right-sided orbital soft tissue mass. This had occurred due to granulomatous orbital invasion from adjacent ethmoidal disease (arrow). (b) An axial T2 weighted image showing inflammatory ethmoidal disease as signal hyperintensity. Granulomatous right orbital disease is shown as signal hypointensity (arrow).

View larger version (97K): [in this window] [in a new window]   Figure 13. 31-year-old woman with orbital Wegener's granulomatosis. (a) A coronal T1 weighted image of the face, showing a large right-sided isointense orbital mass (black arrow). This had occurred due to granulomatous orbital invasion from significant nasal and maxillary and ethmoidal sinus disease (white arrows). (b) A coronal T1 weighted post-contrast, fat-saturated image of the face, showing the large right-sided orbital mass (black arrow). Signal enhancement has been subtle, though this can be quite variable. The inflammatory sinonasal disease has enhanced significantly (white arrows).

View larger version (77K): [in this window] [in a new window]   Figure 14. 60-year-old man with orbital Wegener's granulomatosis. An axial CT image shows sinonasal and orbital disease. The orbital granulomata have calcified bilaterally which is an uncommon phenomenon in longstanding disease.

View larger version (131K): [in this window] [in a new window]   Figure 15. 44-year-old man with skull base Wegener's granulomatosis. A coronal CT reformatted image of the left mastoid shows soft tissue opacification though no bony destruction of the mastoid air cells.

View larger version (74K): [in this window] [in a new window]   Figure 16. 49-year-old woman with skull base Wegener's granulomatosis. A coronal CT reformatted image of the right petrous temporal bone shows soft tissue opacification of the middle ear cavity, with bony erosion of the incus (arrow).

View larger version (101K): [in this window] [in a new window]   Figure 17. 65-year-old man with skull base Wegener's granulomatosis. (a) An axial T1 weighted image of the skull base shows significant sphenoid sinus disease, with direct extension into the petrous apices bilaterally (black arrows). This patient had multiple cranial nerve neuropathies, which is typical for this disease extent. Bilateral low signal granulomatous orbital disease is also shown (white arrows). (b) An axial T1 weighted image following intravenous gadolinium enhancement shows marked enhancement of inflammatory tissue in the petrous apices and sphenoid sinus (arrows), but to a lesser extent in the orbits, confirming granulomatous rather than active inflammatory tissue in this area.

View larger version (62K): [in this window] [in a new window]   Figure 18. 62-year-old woman with Wegener's granulomatosis. (a) An axial CT image of the skull base shows sinonasal and maxillary sinus disease (black arrows). This has extended into the parapharyngeal space (white arrow), where it has identical appearances to a parapharyngeal abscess. Note is made of a nasal airway. (b) A contiguous CT image inferiorly in the same patient showing the parapharyngeal disease, which actually extended into the soft tissues of the posterior left neck (arrow).

View larger version (108K): [in this window] [in a new window]   Figure 19. 57-year-old woman with central nervous system Wegener's granulomatosis. An axial fluid attenuated inversion recovery (FLAIR) image of the brain shows multiple areas of white matter signal hyperintensity. Although a non-specific finding, these appearances are a common form of cerebral Wegener's granulomatosis, indicative of vasculitis.

View larger version (120K): [in this window] [in a new window]   Figure 20. 41-year-old woman with central nervous system Wegener's granulomatosis. An axial T1 weighted image post intravenous gadolinium enhancement. Frontal sinus disease is shown (black arrow), and adjacent dural thickening is also present in the near and adjacent area (white arrow). Enhancing diffuse or focal dural thickening is the most common manifestation of cerebral Wegener's granulomatosis.

View larger version (57K): [in this window] [in a new window]   Figure 21. 30-year-old woman with Wegener's granulomatosis. (a) An ultrasound image of the spleen shows peripheral low echogenicity (arrow). (b) A colour Doppler image of the spleen in the same patient showing a normal central perfusion. (c) Following administration of 2.4 ml intravenous Sonovue (Bracco, Italy) microbubble contrast imaging was performed in a low MI (mechanical index) contrast pulse sequence mode (CPS; Acuson-Siemens, USA). The left hand image shows microbubble-specific imaging demonstrating perfusion of the central portion of the spleen with sparing of the subcapsular region (arrow). The right hand image depicts the corresponding B mode, once again showing peripheral low echogenicity (arrow). Appearances are consistent with subcapsular infarction secondary to vasculitis.