Matthias Kerl Diagnosing Vascular Cranial Diseases Using Compted

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Matthias Kerl Diagnosing Vascular Cranial Diseases Using Compted Tomography Institute for Diagnostic and Interventional

Matthias Kerl Diagnosing Vascular Cranial Diseases Using Compted Tomography Institute for Diagnostic and Interventional Radiology Johann Wolfgang Goethe University Frankfurt am Main Dept of Diagnostic & Interventional Radiology, University Clinic, Johann Wolfgang Goethe-University Frankfurt/Main, Germany

CTA of the Carotids: Background Standard of reference Symptomatic patients 1: Standard of reference

CTA of the Carotids: Background Standard of reference Symptomatic patients 1: Standard of reference • DSA High benefit of CEA for • Poor DSAcorrelation to stenosis patients with >70% Poor correlation to 1 postmortem findings 1 • Moderate benefit of CEA for • patients Vascularwith ultrasound 50 -70% stenosis 1 • Poor Vascular ultrasound in assessment of Poor in assessment of filiform stenoses Asymptomatic patients 2: • Unable to display vascular wall / surrounding soft tissue Calcifications cancel the • In complex stenoses >1 angiographic projections needed depiction of the vessel • Small benefitofin terms of absolute risk depiction the vessel lumen But: • Excellent display of vessel lumen regardless of blood flow 1 Rothwell PM, Lancet (2003) 361: 107– 116 • Excellent reproducibility 2 Moore WS, Circulation (1995) 91: 556– 579 1 Schulte-Altedorneburg G, • J Excellent portray arterial anatomy (Aortic arch to cerebral vessels) Neurol (2005) 252 : of 575– 582 1 Polak JF, Radiology (1998) 209: 288– 289 Dept of Diagnostic & Interventional Radiology, University Clinic, Johann Wolfgang Goethe-University Frankfurt/Main, Germany

CTA of the Carotids: Background Alternative non-invasive procedures: • CTA • Filling techniques MRA

CTA of the Carotids: Background Alternative non-invasive procedures: • CTA • Filling techniques MRA CTA - First-pass technique - Passage of a bolus of CM through imaged volume (1) x-ray tubes with-adequate photon flux & cooling capacity Depict lumen & surrounding arterial wall / soft tissues (2) detector technology allowing simultaneous gathering of multiple thin axial profile data sets • „Flow-dependent“ techniques (3) continuous rotating x-ray tubes with continuous US (Doppler, duplex / color-flow)table travel (helical or spiral technology. MRA (TOF / PCA) Measure blood must through volume of interest Dept of Diagnostic & Interventional Radiology, University Clinic, Johann Wolfgang Goethe-University Frankfurt/Main, Germany

CTA of the Carotids: MDCT Spiral-CT 4 -row MDCT Alternative non-invasive procedures: 64 -row

CTA of the Carotids: MDCT Spiral-CT 4 -row MDCT Alternative non-invasive procedures: 64 -row MDCT • CTA Isotropic Voxel Dept of Diagnostic & Interventional Radiology, University Clinic, Johann Wolfgang Goethe-University Frankfurt/Main, Germany

CTA and MRA of the Carotids: MDCT Alternative non-invasive procedures: • CTA Dept of

CTA and MRA of the Carotids: MDCT Alternative non-invasive procedures: • CTA Dept of Diagnostic & Interventional Radiology, University Clinic, Johann Wolfgang Goethe-University Frankfurt/Main, Germany

CTA of the Carotids: MDCT Alternative non-invasive procedures: • CTA Dept of Diagnostic &

CTA of the Carotids: MDCT Alternative non-invasive procedures: • CTA Dept of Diagnostic & Interventional Radiology, University Clinic, Johann Wolfgang Goethe-University Frankfurt/Main, Germany

CTA of the Carotids: Minimal requirements >4 -slice Multidetector-row CT Scanning • >4 x

CTA of the Carotids: Minimal requirements >4 -slice Multidetector-row CT Scanning • >4 x 2. 5 mm collimation • >0. 5 sec rotation time • 100 m. As / 120 k. V • CM: 120 ml @ 3 ml/s 300 mg. I/ml bolus triggering / test bolus Image Reconstruction • slice tickness / increment • 3/3 mm • 3/1. 5 mm (MPR) • medium soft tissue kernel B 30 f Dept of Diagnostic & Interventional Radiology, University Clinic, Johann Wolfgang Goethe-University Frankfurt/Main, Germany

CTA of the Carotids: Recommended scan protocol 64 -slice MDCT • 64 x 0.

CTA of the Carotids: Recommended scan protocol 64 -slice MDCT • 64 x 0. 6 mm collimation • z-flying focal spot technique • 0. 33 sec rotation time • AATCM • 72 m. As(base) • 120 k. V • CM: 90 ml 400 mg. I/ml 30 ml @ 4. 5 ml/s 60 ml @ 2. 5 ml/s 30 ml Saline @ 2. 5 ml/s Infusion via right arm (artefacts) Bolus triggering (160 HU / a. A) • ECG triggering @ Stanford Type A Dept of Diagnostic & Interventional Radiology, University Clinic, Johann Wolfgang Goethe-University Frankfurt/Main, Germany

CTA of the Carotids: Recommended scan protocol 64 -slice MDCT • 64 x 0.

CTA of the Carotids: Recommended scan protocol 64 -slice MDCT • 64 x 0. 6 mm collimation • z-flying focal spot technique • 0. 33 sec rotation time • AATCM • 72 m. As(base) • 120 k. V • CM: 90 ml 400 mg. I/ml 30 ml @ 4. 5 ml/s 60 ml @ 2. 5 ml/s 30 ml Saline @ 2. 5 ml/s Single Bolus Split Bolus Infusion via right arm (artefacts) Bolus triggering (160 HU / a. A) • ECG triggering @ Stanford Type A Dept of Diagnostic & Interventional Radiology, University Clinic, Johann Wolfgang Goethe-University Frankfurt/Main, Germany

CT Angiography - Head Circle of Willis Vascular Malformations Aneurysms Dept of Diagnostic &

CT Angiography - Head Circle of Willis Vascular Malformations Aneurysms Dept of Diagnostic & Interventional Radiology, University Clinic, Johann Wolfgang Goethe-University Frankfurt/Main, Germany

· 3 -mm aneurysm in MCA, at the origin of L’t anterior temporal artery.

· 3 -mm aneurysm in MCA, at the origin of L’t anterior temporal artery. Dept of Diagnostic & Interventional Radiology, University Clinic, Johann Wolfgang Goethe-University Frankfurt/Main, Germany

· 2 -mm aneurysm at R’t pericallosal artery. Dept of Diagnostic & Interventional Radiology,

· 2 -mm aneurysm at R’t pericallosal artery. Dept of Diagnostic & Interventional Radiology, University Clinic, Johann Wolfgang Goethe-University Frankfurt/Main, Germany

Ideal imaging modality for aneurysm detection and characterization: û Non-invasive. û Easy to perform.

Ideal imaging modality for aneurysm detection and characterization: û Non-invasive. û Easy to perform. û Reproducible. û Readily available. û Minimal complications. û High degree of accuracy. Dept of Diagnostic & Interventional Radiology, University Clinic, Johann Wolfgang Goethe-University Frankfurt/Main, Germany

Dept of Diagnostic & Interventional Radiology, University Clinic, Johann Wolfgang Goethe-University Frankfurt/Main, Germany

Dept of Diagnostic & Interventional Radiology, University Clinic, Johann Wolfgang Goethe-University Frankfurt/Main, Germany

Intracerebral haemorrhage on CT · · Is always seen apparent immediately lasts 1 week

Intracerebral haemorrhage on CT · · Is always seen apparent immediately lasts 1 week then disappears and looks like an infarct Dept of Diagnostic & Interventional Radiology, University Clinic, Johann Wolfgang Goethe-University Frankfurt/Main, Germany

Intracerebral Haemorrhage · Usually caused by hypertension · thickening & weakening of walls of

Intracerebral Haemorrhage · Usually caused by hypertension · thickening & weakening of walls of small arteries/arterioles · formation of small aneurysms · rupture produces a large blood filled cavity that acts as a SOL · typically basal ganglia or thalamus Dept of Diagnostic & Interventional Radiology, University Clinic, Johann Wolfgang Goethe-University Frankfurt/Main, Germany

Ischaemic stroke on CT · Infarcts seen as areas of hypodensity · become more

Ischaemic stroke on CT · Infarcts seen as areas of hypodensity · become more obvious as time progresses · small infarcts appear later than large ones · overall, 40% strokes have normal CT · posterior fossa difficult Dept of Diagnostic & Interventional Radiology, University Clinic, Johann Wolfgang Goethe-University Frankfurt/Main, Germany

Cerebral Infarction · Infarction is caused by failure of blood flow to a region

Cerebral Infarction · Infarction is caused by failure of blood flow to a region · damage to the brain is due to: û ischaemia û oedema surrounding the ischaemic area · sources of occlusion of vessels: û thrombosis of small vessels hypertensive lipohyalinosis - lacunar infarcts û thrombosis of larger vessels û embolus from extracranial vessels or heart Dept of Diagnostic & Interventional Radiology, University Clinic, Johann Wolfgang Goethe-University Frankfurt/Main, Germany

Question 1: Mr Y A 72 year old lady with known bladder cancer (transitional

Question 1: Mr Y A 72 year old lady with known bladder cancer (transitional cell carcinoma) presents with mild left sided weakness. CT scan Dept of Diagnostic & Interventional Radiology, University Clinic, Johann Wolfgang Goethe-University Frankfurt/Main, Germany

What’s the diagnosis? Dept of Diagnostic & Interventional Radiology, University Clinic, Johann Wolfgang Goethe-University

What’s the diagnosis? Dept of Diagnostic & Interventional Radiology, University Clinic, Johann Wolfgang Goethe-University Frankfurt/Main, Germany

What’s the diagnosis? Right frontal lesion is a primary intracerebral haemorrhage stroke The left

What’s the diagnosis? Right frontal lesion is a primary intracerebral haemorrhage stroke The left frontal lesion is an incidental meningioma Lessons Stroke affects older people and co-morbidity is common About 10% of all stroke is due to primary intracerebral haemorrhage Dept of Diagnostic & Interventional Radiology, University Clinic, Johann Wolfgang Goethe-University Frankfurt/Main, Germany

Pathology of stroke can now be reliably established by CT scanning done within hours/days

Pathology of stroke can now be reliably established by CT scanning done within hours/days of the event Cerebral infarction 80% Primary intracerebral haemorrhage 10% Subarachnoid haemorrhage 5% Unknown 5% Sudlow & Warlow 1997 Systematic review of world-wide incidence studies Dept of Diagnostic & Interventional Radiology, University Clinic, Johann Wolfgang Goethe-University Frankfurt/Main, Germany

Question 2 64 year old man was driving his car and he suddenly lost

Question 2 64 year old man was driving his car and he suddenly lost power in his right arm and leg He had no headache No loss of consciousness Called for help and son brought him to casualty No significant medical history Dept of Diagnostic & Interventional Radiology, University Clinic, Johann Wolfgang Goethe-University Frankfurt/Main, Germany

On examination Looked well Blood pressure 200/120 mm. Hg Normal language Slurred speech Complete

On examination Looked well Blood pressure 200/120 mm. Hg Normal language Slurred speech Complete weakness affecting his right face, arm and leg No hemianopia Dept of Diagnostic & Interventional Radiology, University Clinic, Johann Wolfgang Goethe-University Frankfurt/Main, Germany

Is this a stroke? Dept of Diagnostic & Interventional Radiology, University Clinic, Johann Wolfgang

Is this a stroke? Dept of Diagnostic & Interventional Radiology, University Clinic, Johann Wolfgang Goethe-University Frankfurt/Main, Germany

Yes! Due to a Lacunar Infarction Dept of Diagnostic & Interventional Radiology, University Clinic,

Yes! Due to a Lacunar Infarction Dept of Diagnostic & Interventional Radiology, University Clinic, Johann Wolfgang Goethe-University Frankfurt/Main, Germany

Question 3: 85 year old lady Presents with a sudden onset of dizziness and

Question 3: 85 year old lady Presents with a sudden onset of dizziness and headache On examination she had nystagmus Six hours after admission started to complain of worsening headache 24 hours later was unconscious Is this a stroke? Dept of Diagnostic & Interventional Radiology, University Clinic, Johann Wolfgang Goethe-University Frankfurt/Main, Germany

Yes! A cerebellar haemorrhage with acute hydrocephalus Dept of Diagnostic & Interventional Radiology, University

Yes! A cerebellar haemorrhage with acute hydrocephalus Dept of Diagnostic & Interventional Radiology, University Clinic, Johann Wolfgang Goethe-University Frankfurt/Main, Germany

Question 4 Mrs X 69 years old Developed Right hemiparesis and aphasia during breakfast

Question 4 Mrs X 69 years old Developed Right hemiparesis and aphasia during breakfast (9 am) Husband called GP and sent immediately to A & E department Dept of Diagnostic & Interventional Radiology, University Clinic, Johann Wolfgang Goethe-University Frankfurt/Main, Germany

Severe (0/5) right face, arm and leg weakness Dyspraxia (disorganised movement of body) Aphasic

Severe (0/5) right face, arm and leg weakness Dyspraxia (disorganised movement of body) Aphasic (no understanding or expression of language) Dept of Diagnostic & Interventional Radiology, University Clinic, Johann Wolfgang Goethe-University Frankfurt/Main, Germany

Is this a stroke? Dept of Diagnostic & Interventional Radiology, University Clinic, Johann Wolfgang

Is this a stroke? Dept of Diagnostic & Interventional Radiology, University Clinic, Johann Wolfgang Goethe-University Frankfurt/Main, Germany

Is this a stroke? Yes! Dept of Diagnostic & Interventional Radiology, University Clinic, Johann

Is this a stroke? Yes! Dept of Diagnostic & Interventional Radiology, University Clinic, Johann Wolfgang Goethe-University Frankfurt/Main, Germany Dense MCA sign indicating thrombus in the left MCA

Thank you! Dept of Diagnostic & Interventional Radiology, University Clinic, Johann Wolfgang Goethe-University Frankfurt/Main,

Thank you! Dept of Diagnostic & Interventional Radiology, University Clinic, Johann Wolfgang Goethe-University Frankfurt/Main, Germany