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A study of the correlation between roentgenographic and post-mortem calcification of the aorta
A STUDY OF THE CORRELATION BETWEEN ROENTGENOGR JPHIC AND POST-MORTEM CALCIFICPTION OF THE AORTA JULIAN
B. HYMAN,
M.1 I., AND F~DERICK N cw YORK,
H. EPSTEIN,
M.D.
N. Y.
I
N a current study of the preva ence of atherosclerosis in a random sample of a working population over fort r years of age, roentgenograms of the thoracic and abdominal aorta were made in every case. The first 568 patients studied showed radiologic evidence of calcification in 26 per cent of the men and 23 per cent of the women.’ This unex jetted finding led us to test the accuracy of our roentgen diagnoses by studying autopsy specimens of aortas from patients in whom roentgen films of the corresponding areas had been taken during life. An opportunity for such a stud!. presented itself at Francis Delafield Hospital where roentgen films of the chesl and lateral views of the lumbosacral spine are taken on most patients in a search for primary and metastatic neoplastic lesions. Dr. Edith Sproul of the Departr lent of Pathology and Dr. Arnold Bachman of the Department of Radiology galre their cooperation and assistance. MET-HODS
The roentgen films of patie.its recently autopsied were examined, and if a satisfactory chest or lateral abd )minal film or both were available, these were reviewed for the presence of raliologic evidence of calcification of the aorta. The autopsy material was then I tudied without the knowledge of the individual radiologic report. In the last jifteen cases of this study only those showing calcification on the roentgen filr 1 were used. Posteroanterior chest films were taken at a distance of 6 feet at 1120 second, using an average of 300 milliamperes and 70 kilovolts. Lateral abdolninal films were taken with a Bucky grid at a distance of 40 inches, at l-1/2 set mds, using an average of 300 milliamperes and 78 kilovolts, centering the tube at the level of the first and second lumbar spine. Calcification of the thoracic aorta was diagnosed if a definite crescentshaped density in the knob or ;. linear streak over one centimeter long in the descending portion of the aorta was visualized. A density of the aortic knob which was neither typical in &ape or position was classified as questionable. Calcification of the abdomir al aorta was diagnosed in the presence of either linear densities at least one ten timeter in length, or multiple and sometimes parallel linear densities, or solid shadows, in an area parallel and anterior to the lumbar spine. These films were further divided into three subgroups depending From the Research Department Received for publication April
oft me Sidney 20. 19 i4.
Hillman 540
Health
Center.
New
York,
N. Y.
HYMAN
AND
CALCIFICATION
EPSTEIN:
OF
541
AORTA
on the extent of involvement. If there was a linear streak less than one centimeter long in the proper area, the case was classed as questionable. In reviewing pathologic material, attention was paid only to gross calcification. The specimen was carefully palpated and then incised for any plaques of cartilaginous feel. A larger plaque that cracked on bending or a smaller plaque that exuded white crystalline particles on incision, rather than soft yellowish Pathologic specimens atheromatous material, was indicative of calcification. of the thoracic and abdominal aorta were graded into three groups depending Discreet, small, raised lesions were on the degree of atheromatous involvement. considered minimal and classified as Grade 1, larger nonconfluent lesions as moderate and classified as Grade 2, and large confluent, frequently ulcerated lesions were considered as advanced and called Grade 3. RESULTS
Roentgenograms and corresponding specimens of the thoracic aorta were available in seventy-two cases and of the abdominal aorta in fifty-five cases. The findings are summarized in Table I. Eighteen cases gave roentgenologic evidence of calcification of the thoracic aorta and all were verified at post-mortem study. Five cases were classified as questionable, and no calcification was In addition, four cases failing to show any radiodemonstrated in any of them. logic evidence of calcification were found to have calcification of the thoracic aorta on pathologic examination. TABLE
I.
COMPARISON
BETWEEN CALCIFICATION
ROENTGENOGRAPHICAND OF THE AORTA
POST-MORTEM
CALCIFICATION CALCIFICATION
ON ROENTGEN
FILM
TOTAL PRESENT I
I-
I
Thoracic
aorta
__ Abdominal
aorta
Present Absent Doubtful Present Absent Doubtful
INPOST-MORTEMSPECIMEN
-.
18
18
49 5
:,
20 31 4
I I
ABSENT
4: 5
20 :
2: 0
Twenty cases were diagnosed by our criteria as having calcification of the abdominal aorta on roentgen film, and four were considered to have questionAll of these twenty-four cases were found to have calcification of able evidence. the aorta on post-mortem study. In five cases, pathologically demonstrable calcifications were not visualized on the roentgen film. The age and sex distribution of the patients in this study is shown in Table II. Persons above the age of sixty had a very high incidence of calcification of the aorta independent of sex.
542
a\MERI
In over 80 on post-mortem vanced (Grade of calcification usually signifies 'GABLE
II.
:AN
HEART
JOURN.41,
per cent of the cas :s in which calcification of the aorta was present examination, th : atherosclerotic lesions of the aorta were ad3) while only 10 1 er cent of cases without post-mortem evidence had Grade 3 changes, indicating that the presence of calcification advanced disease POST-MORTEM ___-~~
CALCIFI:.\TIOS
OF THE AORTA
XCC~RDING
~0 :ZGE
SEX
AND
.~____ - __-~
--~~ ~~. CALCIFICATION
AGE
IN YEARS
TOTAI.
SES
PRESENT
Helow
40
40-49 I
___-~---
SO-59 ~--
60 XII
and over ages
Male Female ---;Male Female Male Female
! I I / ,
4 2
I1
12 13
Male Female
I I
15
Male Female
: :
35 37
_
0 0
: :
ABSENT
/
: .:
II
8 7
I ::
4 1
19 19
16 18
12
---____
_-.-
--
DISCUSSION
A number of reports, based >n isolated cases, on the radiologic appearance of calcification of the aorta have been published.2-7 The radiologic finding of aortic calcification in an individua I person seemsto be of little clinical significance, since uncomplicated aortic athe .omatosis causes no symptoms and does not necessarily indicate the presence of atherosclerosis in other arterial beds. In clinical studies and surveys, holiever, the demonstration of calcification may become a useful aid in the diagnosis of atherosclerosis,1~8~g~ even though a considerable number of casesof advz riced aortic atheromata will remain undiagnosable by this method. It does no : detract from the value of electrocardiography that this procedure likewise misse; many instances of advanced coronary disease. Of more serious concern would be. he possibility of making a false-positivediagnosis of aortic calcification. In survey ng large numbers of roentgen films for evidence of aortic calcification, we occasio rally experienced difficulty in deciding whether a given small density indicated tl e presence of an atheromatous plaque or represented calcifications in rib cartilages, lung parenchyma, spinous ligaments, or even artifacts. The data presented here give us confidence that our interpretation of these shadows is correct md that they indicate the presence of advanced aortic ntheromata. Lansing an 1 co-workers lo have described intimal ossification in aortas from senile ind viduals, apparently not preceded by primary atheromatous changes in the int ima. In this study, no such cases have been
HYMAN
AND
EPSTEIN
:
CALCIFICATION
OF
543
XORT.1
encountered. Calcifications always occurred in association with atheromata. These were almost invariably ulcerated. The fact that a number of calcifications are not visuaiized radioIogical1) suggests that the technique of taking roentgen films is important in obtaining best results, as pointed out by Ungerleider.” A definite plaque may fail to show clearly or at all on an improperly taken film. Chest films should be slightly overpenetrated though the present study is based on softer films taken in the usual way. Exposures as used for skeletal surveys appear to be adequate for lateral views of the abdomen; some workers prefer tangential views.Y,iZ CONCLUSIONS
Roentgenologic demonstration of aortic calcification is an accurate method for the diagnosis of aortic atherosclerosis. It usually indicates an advanced degree of atherosclerosis. Although advanced atheromata are frequently missed by this method, a false-positive diagnosis was not made in a single case. The usefulness of this method of diagnosis is pointed out. It is hoped that this study may encourage others to use these radiologic methods more extensively in clinical studies of atherosclerosis. The
authors are
much
indebted
to Dr.
Ernst
P. Boas
for
his encouragement
and
advice
REFERENCES
1.
Boas,
E. I’., and Epstein, F. H.: Prevalence of Manifest Atherosclerosis in a 1Vorking Population; a Preliminary Report, Arch. Int. Med. (In press). 2. Koch, W.: Provinzielle Ausbreitung und Charakter der Arteriosklerose im RoentenAnatomischen Bild, Verhandl. d. deutsch. path. Gesellsch. 23:478, 1928.
B. HYMAN,
M.1 I., AND F~DERICK N cw YORK,
H. EPSTEIN,
M.D.
N. Y.
I
N a current study of the preva ence of atherosclerosis in a random sample of a working population over fort r years of age, roentgenograms of the thoracic and abdominal aorta were made in every case. The first 568 patients studied showed radiologic evidence of calcification in 26 per cent of the men and 23 per cent of the women.’ This unex jetted finding led us to test the accuracy of our roentgen diagnoses by studying autopsy specimens of aortas from patients in whom roentgen films of the corresponding areas had been taken during life. An opportunity for such a stud!. presented itself at Francis Delafield Hospital where roentgen films of the chesl and lateral views of the lumbosacral spine are taken on most patients in a search for primary and metastatic neoplastic lesions. Dr. Edith Sproul of the Departr lent of Pathology and Dr. Arnold Bachman of the Department of Radiology galre their cooperation and assistance. MET-HODS
The roentgen films of patie.its recently autopsied were examined, and if a satisfactory chest or lateral abd )minal film or both were available, these were reviewed for the presence of raliologic evidence of calcification of the aorta. The autopsy material was then I tudied without the knowledge of the individual radiologic report. In the last jifteen cases of this study only those showing calcification on the roentgen filr 1 were used. Posteroanterior chest films were taken at a distance of 6 feet at 1120 second, using an average of 300 milliamperes and 70 kilovolts. Lateral abdolninal films were taken with a Bucky grid at a distance of 40 inches, at l-1/2 set mds, using an average of 300 milliamperes and 78 kilovolts, centering the tube at the level of the first and second lumbar spine. Calcification of the thoracic aorta was diagnosed if a definite crescentshaped density in the knob or ;. linear streak over one centimeter long in the descending portion of the aorta was visualized. A density of the aortic knob which was neither typical in &ape or position was classified as questionable. Calcification of the abdomir al aorta was diagnosed in the presence of either linear densities at least one ten timeter in length, or multiple and sometimes parallel linear densities, or solid shadows, in an area parallel and anterior to the lumbar spine. These films were further divided into three subgroups depending From the Research Department Received for publication April
oft me Sidney 20. 19 i4.
Hillman 540
Health
Center.
New
York,
N. Y.
HYMAN
AND
CALCIFICATION
EPSTEIN:
OF
541
AORTA
on the extent of involvement. If there was a linear streak less than one centimeter long in the proper area, the case was classed as questionable. In reviewing pathologic material, attention was paid only to gross calcification. The specimen was carefully palpated and then incised for any plaques of cartilaginous feel. A larger plaque that cracked on bending or a smaller plaque that exuded white crystalline particles on incision, rather than soft yellowish Pathologic specimens atheromatous material, was indicative of calcification. of the thoracic and abdominal aorta were graded into three groups depending Discreet, small, raised lesions were on the degree of atheromatous involvement. considered minimal and classified as Grade 1, larger nonconfluent lesions as moderate and classified as Grade 2, and large confluent, frequently ulcerated lesions were considered as advanced and called Grade 3. RESULTS
Roentgenograms and corresponding specimens of the thoracic aorta were available in seventy-two cases and of the abdominal aorta in fifty-five cases. The findings are summarized in Table I. Eighteen cases gave roentgenologic evidence of calcification of the thoracic aorta and all were verified at post-mortem study. Five cases were classified as questionable, and no calcification was In addition, four cases failing to show any radiodemonstrated in any of them. logic evidence of calcification were found to have calcification of the thoracic aorta on pathologic examination. TABLE
I.
COMPARISON
BETWEEN CALCIFICATION
ROENTGENOGRAPHICAND OF THE AORTA
POST-MORTEM
CALCIFICATION CALCIFICATION
ON ROENTGEN
FILM
TOTAL PRESENT I
I-
I
Thoracic
aorta
__ Abdominal
aorta
Present Absent Doubtful Present Absent Doubtful
INPOST-MORTEMSPECIMEN
-.
18
18
49 5
:,
20 31 4
I I
ABSENT
4: 5
20 :
2: 0
Twenty cases were diagnosed by our criteria as having calcification of the abdominal aorta on roentgen film, and four were considered to have questionAll of these twenty-four cases were found to have calcification of able evidence. the aorta on post-mortem study. In five cases, pathologically demonstrable calcifications were not visualized on the roentgen film. The age and sex distribution of the patients in this study is shown in Table II. Persons above the age of sixty had a very high incidence of calcification of the aorta independent of sex.
542
a\MERI
In over 80 on post-mortem vanced (Grade of calcification usually signifies 'GABLE
II.
:AN
HEART
JOURN.41,
per cent of the cas :s in which calcification of the aorta was present examination, th : atherosclerotic lesions of the aorta were ad3) while only 10 1 er cent of cases without post-mortem evidence had Grade 3 changes, indicating that the presence of calcification advanced disease POST-MORTEM ___-~~
CALCIFI:.\TIOS
OF THE AORTA
XCC~RDING
~0 :ZGE
SEX
AND
.~____ - __-~
--~~ ~~. CALCIFICATION
AGE
IN YEARS
TOTAI.
SES
PRESENT
Helow
40
40-49 I
___-~---
SO-59 ~--
60 XII
and over ages
Male Female ---;Male Female Male Female
! I I / ,
4 2
I1
12 13
Male Female
I I
15
Male Female
: :
35 37
_
0 0
: :
ABSENT
/
: .:
II
8 7
I ::
4 1
19 19
16 18
12
---____
_-.-
--
DISCUSSION
A number of reports, based >n isolated cases, on the radiologic appearance of calcification of the aorta have been published.2-7 The radiologic finding of aortic calcification in an individua I person seemsto be of little clinical significance, since uncomplicated aortic athe .omatosis causes no symptoms and does not necessarily indicate the presence of atherosclerosis in other arterial beds. In clinical studies and surveys, holiever, the demonstration of calcification may become a useful aid in the diagnosis of atherosclerosis,1~8~g~ even though a considerable number of casesof advz riced aortic atheromata will remain undiagnosable by this method. It does no : detract from the value of electrocardiography that this procedure likewise misse; many instances of advanced coronary disease. Of more serious concern would be. he possibility of making a false-positivediagnosis of aortic calcification. In survey ng large numbers of roentgen films for evidence of aortic calcification, we occasio rally experienced difficulty in deciding whether a given small density indicated tl e presence of an atheromatous plaque or represented calcifications in rib cartilages, lung parenchyma, spinous ligaments, or even artifacts. The data presented here give us confidence that our interpretation of these shadows is correct md that they indicate the presence of advanced aortic ntheromata. Lansing an 1 co-workers lo have described intimal ossification in aortas from senile ind viduals, apparently not preceded by primary atheromatous changes in the int ima. In this study, no such cases have been
HYMAN
AND
EPSTEIN
:
CALCIFICATION
OF
543
XORT.1
encountered. Calcifications always occurred in association with atheromata. These were almost invariably ulcerated. The fact that a number of calcifications are not visuaiized radioIogical1) suggests that the technique of taking roentgen films is important in obtaining best results, as pointed out by Ungerleider.” A definite plaque may fail to show clearly or at all on an improperly taken film. Chest films should be slightly overpenetrated though the present study is based on softer films taken in the usual way. Exposures as used for skeletal surveys appear to be adequate for lateral views of the abdomen; some workers prefer tangential views.Y,iZ CONCLUSIONS
Roentgenologic demonstration of aortic calcification is an accurate method for the diagnosis of aortic atherosclerosis. It usually indicates an advanced degree of atherosclerosis. Although advanced atheromata are frequently missed by this method, a false-positive diagnosis was not made in a single case. The usefulness of this method of diagnosis is pointed out. It is hoped that this study may encourage others to use these radiologic methods more extensively in clinical studies of atherosclerosis. The
authors are
much
indebted
to Dr.
Ernst
P. Boas
for
his encouragement
and
advice
REFERENCES
1.
Boas,
E. I’., and Epstein, F. H.: Prevalence of Manifest Atherosclerosis in a 1Vorking Population; a Preliminary Report, Arch. Int. Med. (In press). 2. Koch, W.: Provinzielle Ausbreitung und Charakter der Arteriosklerose im RoentenAnatomischen Bild, Verhandl. d. deutsch. path. Gesellsch. 23:478, 1928.