Neuroradiology presents Cerebrovascular Disease David M Pelz MD

Neuroradiology presents…. .

Cerebrovascular Disease David M. Pelz, MD, FRCPC Neuroradiology, LHSC

Cerebrovascular Disease • • Normal Anatomy Stroke Hemorrhage - Aneurysms, AVMs External Carotid

Normal Anatomy • • • Historical Angiography Duplex Ultrasound (DUS) MR Angiography (MRA) CT Angiography (CTA)

Origins Roentgen - 1896

Egas Moniz - 1934

Moniz - 1934

Direct Puncture Carotid AP Lateral Vertebral AP Lateral

Sven Seldinger - 1953

Modern Angiography - DSA Digital Subtraction Angiography

Risks of Angiography • • Stroke - 1: 1000 Contrast reaction - 1: 1, 000 Groin hematoma - 1: 500 Vasovagal reactions, etc.

Auto Angiography

Normal Anatomy -DSA

Normal Anatomy - Carotid AP Lateral

Normal Anatomy - Vertebral AP Lateral

3 D-CRA

Duplex Ultrasound (DUS)

MR Angiography - MRA TOF -Circle of Willis CEMRA - Contrast-enhanced

CT Angiography - CTA Circle of Willis Carotid bifurcation

Stroke Normal

NASCET North American Symptomatic Endarterectomy Trial

KFC

John Hunter (1728 -1793) “Blood goes where it is needed”

Collateral supply to the brain Circle of Willis EC-IC

Duplex Ultrasound

DUS and CTA - ? Good enough for surgery

MRA of carotid disease ? Good enough for surgery

Carotid Angioplasty/Stenting (CAS)

Pre- Post-

Endarterectomy vs CAS • Over 12, 000 worldwide, symptomatic and asymptomatic pts, anecdotal evidence • CAVATAS - 10% risk for both • CREST - 5 yrs, 2500 pts, RCT

Intracranial Disease Pre- Post-

Thrombolysis for acute stroke

1 3 2 4

Basilar artery occlusion Pre. Post-

Thrombolysis in Acute Stroke • “Time is brain” • IV r-TPA within 3 hrs, most practical • IA - large vessel occlusions (MCA or basilar), up to 6 hrs • Still no conclusive evidence favouring IA or IV

Cerebral Aneurysms

Endovascular Therapy of Cerebral Aneurysms

Coiling of Cerebral Aneurysms Lateral AP

Post- GDC Coiling

Stents and Coils AP lateral

Clipping vs. . Coiling

International Subarachnoid Aneurysm Trial (ISAT)

Cerebral Arteriovenous Malformations (AVMs)

Endovascular Therapy of Brain AVMs NBCA

Pre- Post-

MRA

External Carotid Artery

External Carotid Artery - Lat

External Carotid Artery - AP

Epistaxis

Juvenile Nasal Angiofibroma

Tumours

Chemodectomas • • Carotid body tumour Glomus Vagale Glomus jugulare Glomus tympanicum

“ Mother - in - Law”

The End