The assessment of achilles tendon size in primary hypercholesterolaemia by computed tomography

doi:10.1016/0021-9150(82)90235-0

Atherosclerosis

Volume 45, Issue 3, December 1982, Pages 345-358

https://doi.org/10.1016/0021-9150(82)90235-0 Get rights and content

Abstract

The Achilles tendons of 43 men and women were examined by conventional radiography and by computed tomography (CT). Eleven subjects were normolipidaemic and 32 had familial hypercholesterolaemia, of whom 19 were considered to have polygenic hypercholesterolaemia and 13 monogenic. Achilles tendon xanthomata were identifiable by both radiography and CT. In assessing the size of xanthomata, CT had advantages since the junction between muscle and tendon was easily identified and all the dimensions and the cross-sectional area of the tendon could be measured. The area of Achilles tendons was closely correlated with body height in normolipidaemic men and women and patients with polygenic hypercholesterolaemia. In monogenic hypercholesterolaemia this relationship was lost. The tendons of the normolipidaemic group and of patients with polygenic hypercholesterolaemia were indistinguishable, whereas those of patients with monogenic hypercholesterolaemia were significantly larger. Neither the maximum nor the average CT attenuation values of the tendons differed significantly between the 3 groups. Of the patients with monogenic hypercholesterolaemia, those whose Achilles tendons were less than 200 mm² in area had received treatment longer than those with larger tendons. CT shows promise as a means of assessing the therapeutic response of patients with monogenic familial hypercholesterolaemia.

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Cited by (31)

Regression of Achilles tendon thickness after statin treatment in patients with familial hypercholesterolemia: An ultrasonographic study
2009, Atherosclerosis
Citation Excerpt :
Clinical evaluation of ATX is subjective and has low sensitivity to detect lesions at early stages [1]. Imaging techniques that have been used for the evaluation of ATX are ultrasonography (US), computed tomography (CT) [17,18] and magnetic resonance imaging (MRI) [19]. Among these techniques US has been proposed as the modality of choice, because it is the less expensive nonradiating cross-sectional imaging method and depicts focal lesions that others fail to detect [1].
Achilles tendon xanthomas (ATX) have been associated with increased cardiovascular risk in patients with familial hypercholesterolemia (FH). The aim of this study was to evaluate clinical and ultrasonographic changes of ATX in patients with FH under statin treatment.
Achilles tendon thickness (ATT) and echostructure were studied by ultrasonography (US) in 80 unrelated heterozygous FH patients and in 80 age- and sex-matched controls. For ATT measurements the anterioposterior diameter (mm) of the Achilles tendon was measured on sagittal scans. Patients were treated with atorvastatin (mean dose 20 ± 10 mg/day) and a follow-up examination was performed 12 months later.
Clinical examination revealed xanthomas in 15 patients. On US normal fibrillar echostructure (grade 1) of the Achilles tendon (AT) was observed in 42 patients, abnormal echostructure with diffuse heterogeneous echo pattern (grade 2) in 30 patients and focal hypoechoic lesions (grade 3) in 8 patients. At baseline, ATT of all patients (5.23 ± 0.91 mm) was significantly larger compared with controls (4.20 ± 0.70 mm) (p < 0.05). Patients with grades 2 (5.20 ± 0.60 mm) and 3 (6.98 ± 1.07 mm) had significantly larger ATT than those with grade 1 (4.90 ± 0.55 mm), p < 0.05. Patients with grade 1 showed significant reduction in ATT after statin treatment (from 4.90 ± 0.55 mm to 4.50 ± 0.43 mm, p < 0.01). In patients with grades 2 and 3 abnormal echostructure remained unchanged and no significant reduction in ATT was observed.
Statin treatment reduces ATT in FH patients with normal AT echostructure. Ultrasound detects AT structural involvement and is useful in the monitoring of response to treatment.
Imaging of tendons - Adaptation, degeneration, rupture
1997, European Journal of Radiology
Tendon imaging is mainly performed with ultrasonography (US) and magnetic resonance imaging (MRI) and has been improved within the last years because of technical advancements and a better understanding of tendon pathology. Several concepts concerning the etiology and the course of tendon diseases have influenced image interpretation and vice versa. Adaptive mechanisms within the tendon tissue against stress can be observed mainly on histologic specimens and not macroscopically or with in-vivo imaging. Degeneration may occur in the form of tendinitis, peritendinitis, enthesitis, or myotendinal junction abnormality. Distinct imaging findings exist for most of these forms. Many concepts that have been developed to explain tendon degeneration have been applied on virtually all tendons in the human body. They can be grouped into those which focus on hypovascularization, on biomechanical overload, and on degeneration secondary to other underlying disease. Tendon rupture seems, in many cases, to be the final stage of tendinitis. From this point of view, imaging may be used to predict the risk of tendon rupture together with other intrinsic and with extrinsic parameters. These considerations result in the concept of the ‘vulnerable zone’ and of the ‘critical phase’ in which tendon ruptures may predominantly occur.
Detection of achilles tendon xanthomas in familial hypercholesterolemia: Sonography vs. radiography
1997, European Journal of Ultrasound
Objective: To compare high frequency linear array sonography and radiography for the detection of Achilles tendon xanthomas. Methods: Same-day high frequency linear array sonography and radiography were prospectively performed upon 42 Achilles tendons in 21 individuals with heterozygous familial hypercholesterolemia. Xanthomas were detected by the presence of intratendinous hypoechoic regions sonographically and by tendon enlargement radiographically. Results: Radiography detected xanthomas in 24 of 40 (60%) tendons, and was technically inadequate in two tendons. Sonography was superior to radiography, detecting xanthomas in 38 of 42 tendons (90%), and in all radiographically abnormal tendons. Conclusion: Sonography is superior to radiography for detecting Achilles tendon xanthomas. Radiography should only be considered for xanthoma detection if sonography is unavailable or if costs are so constrained that sonography cannot be justified.
Relation of cholesterol-year score to severity of calcific atherosclerosis and tissue deposition in homozygous familial hypercholesterolemia
1996, American Journal of Cardiology
The high concentrations of low-density lipoprotein cholesterol in plasma lead to accelerated atherosclerosis in patients homozygous for familial hypercholesterolemia (FH). We addressed the hypothesis that lipid deposition in the arterial vasculahire and in nonvascular tissues in these patients correlates with both the duration and severity of their hypercholesterolemia. The severity of calcific atherosclerosis was defined by calcification scores and a calcified volume determined by electron beam tomography. The extent of tendinous xanthomatosis was quantitated by computed tomography. A cholesterolyear score was calculated based on the age and the yearly mean serum cholesterol concentration of each patient. Seventeen patients homozygous for FH were followed up. The average total cholesterol concentration in the study group was 780 ± 231 mg/dl (20.2 mmol/L), and the cholesterol-year scores ranged from 2,172 mg-year/dl (56 mmol-year/L) to 32,260 mg-year/dl (834 mmol-year/L). Achilles tendon width (r = 0.86) and cross-sectional area (r = 0.81; both p < 0.001) were best correlated with the cholesterol-year score. In addition, the coronary (r = 0.61; p < 0.05), ostial (r = 0.45; p < 0.05), and total (r = 0.77; p < 0.001) calcification atherosclerosis scores all were best correlated with the cholesterol-year score. Calcific atherosclerosis was not observed in these patients until the cholesterol-year score exceeded 10,000 mg-year/dl (260 mmol-year/ L). These findings establish a direct association of cholesterol-year with extravascular lipid deposition in tissues of patients with FH. The cholesterol-year score may be useful in defining the risk of atherosclerosis in patients with more common forms of hypercholesterolemia.
Magnetic resonance imaging of Achilles tendon xanthomas using a fat-water discrimination technique at 0.1 T
1995, Academic Radiology
Tendon xanthomas are atherosclerotic plaquelike collections of lipids that develop with age in the Achilles tendons of patients having familial hypercholesterolemia (FH). We tested a fat—water discrimination technique for imaging Achilles tendon xanthomatosis.
We used the spin-warp imaging technique optimized for low-field magnetic resonance (MR) imaging to obtain separate fat and water images of the Achilles tendon. Seven patients with FII, two patients with normal tendons, and three patients with other tendon pathology were studied.
Normal tendons showed an intensity near or equal to that of the noisy background in all images. Compared with the background, the intensity of the FH tendons was approximately fivefold greater in magnitude images, fourfold in fat images, and 10-fold in water images.
The method sensitively detected even subtle xanthomatosis in young patients, but differentiation of xanthomas from other pathologic lesions was possible with this method only when the tendons were significantly thickened.
Ultrasonography in the detection of achilles tendon xanthomata in heterozygous familial hypercholesterolemia
1992, Atherosclerosis
We have examined the usefulness of ultrasound (US) in the detection of achilles tendon (AT) xanthomata in heterozygous familial hypercholesterolemia. Our study is based on 30 adult subjects with heterozygous familial hypercholesterolemia (FH) (16 men, 14 women), 27 subjects with other non-familial forms of severe hypercholesterolemia (non-FH) with serum total cholesterol levels ⩾8 mmol/1 (13 men and 14 women) and 31 subjects without marked hypercholesterolemia of the same age (control group; serum total cholesterol < 8 mmol/1) (15 men, 16 women). The three groups were comparable with respect to age, sex and body mass index. In the control group the mean sagittal thickness of AT was 4.5 mm (95% CI 3.2, 5.9 mm) and the mean coronal breadth of AT 11.0 (95% CI 9.0, 13.0 mm). Mean thickness of AT was 4.9 (range 4–7) mm in the non-FH group and 11.1 (5–16) mm in the FH group. The mean breadth of AT was in these groups 12.0 (10–17) mm and 19.2 (12–27) mm, respectively. Using the upper 95% confidence interval cut-off point in the control group as a criterion for normal AT thickness and breadth, 6 (22%) of non-FH and 29 (97%) of FH patients had increased AT thickness and 5 (19%) vs. 26 (87%) patients had increased AT breadth, respectively. The sensitivity of AT thickness for identifying FH was 0.97, specificity 0.78 and positive predictive value 0.83. The sensitivity of AT breadth in identifying FH was 0.87, specificity 0.81 and positive predictive value 0.84. None of the control subjects and none of the non-FH patients showed structural abnormalities of AT in the US, whereas 89% of FH-patients showed hypoechogenicity of AT. FH-score obtained by summing up the number of abnormal US findings gave a sensitivity of 0.93, a specificity of 0.96 and a positive predictive value of 0.96 for AT US in discriminating FH from non-FH. In conclusion, US examination of AT is a useful method in the detection of AT xanthomata and thus of help in the diagnosis of heterozygous FH.

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Research paperThe assessment of achilles tendon size in primary hypercholesterolaemia by computed tomography

Abstract

Atherosclerosis

Lancet

Metabolism

Brit. Med. Bull.

Lipoproteins and lipid transport

Familial hypercholesterolaemia - Genetic, biochemical and pathophysiologic considerations

Adv. Intern. Med.

Lessons from serum cholesterol studies in Japan, Hawaii and Los Angeles

Ann. Intern. Med.

Determinants of atherosclerosis progression and regression

Arch. Surg.

Xanthomatous diseases of the skin

Trans. Path. Soc. London

Research paper
The assessment of achilles tendon size in primary hypercholesterolaemia by computed tomography