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Stroke
Published in Henry J. Woodford, Essential Geriatrics, 2022
Mechanical clot retrieval is a form of endovascular therapy that can directly remove blockages from cerebral arteries to restore blood flow. It can be used in acute ischaemic stroke caused by proximal intracranial vessel occlusion in the anterior circulation when there is significant persisting disability (i.e. NIHSS score six or more). The procedure usually follows intravenous thrombolysis, unless there is a contraindication. In addition to an initial standard CT scan, a CT or MR angiogram study is required to demonstrate the vessel occlusion. Conventional cerebral angiography is then performed, either under sedation or possibly general anaesthesia, usually via the femoral artery and under X-ray guidance. A clot retrieval device, attached to a guidewire, is used to re-establish blood flow. Most commonly, a metallic mesh stent is expanded within the clot to trap it and allow extraction. It should be performed as soon as possible after symptom onset and usually within six hours.15 Occasionally, it is administered between six and 24 hours of symptom onset (including ‘wake up' strokes) if potentially salvageable brain tissue has been detected by imaging techniques such as CT perfusion or DWI-MRI sequences.
Stroke and Transient Ischemic Attacks of the Brain and Eye
Published in Philip B. Gorelick, Fernando D. Testai, Graeme J. Hankey, Joanna M. Wardlaw, Hankey's Clinical Neurology, 2020
Intra-arterial, catheter contrast cerebral angiography demonstrates medium and small arteries that are not seen well with other techniques. It is particularly useful for characterizing small- and medium-vessel arteriopathies that may include dissection (e.g. of the superior cerebellar artery), vasculitis, RCVS, moyamoya, small aneurysm, and AVMs (Figures 12.190, 12.191). It also can help determine collateral flow patterns.
Central nervous system
Published in A Stewart Whitley, Jan Dodgeon, Angela Meadows, Jane Cullingworth, Ken Holmes, Marcus Jackson, Graham Hoadley, Randeep Kumar Kulshrestha, Clark’s Procedures in Diagnostic Imaging: A System-Based Approach, 2020
A Stewart Whitley, Jan Dodgeon, Angela Meadows, Jane Cullingworth, Ken Holmes, Marcus Jackson, Graham Hoadley, Randeep Kumar Kulshrestha
Cerebral angiography may be performed using CT, MRI or direct catheter angiography. Cerebral angiography demonstrates the cerebral blood vessels by opacifying them with a suitable contrast agent. Intra-arterial angiography is normally carried out following selective placement of an angiographic catheter in either a carotid or vertebral artery, following catheterisation of a femoral artery using the Seldinger method. A contrast injector may be employed that enables a bolus of contrast to be injected in a controlled and repeatable fashion. However, hand injection is commonly used, as sufficient pressure can be applied to overcome the patient’s blood pressure and it may be quicker than repeatedly connecting the injector pump. Close co-operation with the radiologist is necessary to obtain optimal timing between injection and the first exposure. The acquisition of one or more mask images allows for image optimisation in the case of movement artefact.
Extensive intracranial arterial dolichoectasia involving distal branches of intracranial arteries: two cases report and review of the literature
Published in International Journal of Neuroscience, 2021
Bo Li, Bing Zhou, Ming-zhao Zhang, Rong-qing Qin, Yang He
We prescribed a Magnetic Resonance (MR) examination for her and made a careful film reading. Both T1WI and T2WI showed a “flow voids” signal in the region of the left lateral fissure, without obvious mass effect. Lacunar infarcts were found in the regions of the right thalamus and left external capsule as the typical imaging manifestations of long T1WI and T2WI signal. Enhanced MRI showed tortuous vascular images in the left lateral fissure cistern, which was more apparent in the sagittal plane image (Figure 2 (a,b)). To make a final diagnosis, we performed cerebral angiography on her. The DSA showed obvious enlargement and tortuosity of M2 and M3 segments of the left MCA, with contrast medium stagnation in the abnormal arteries and visualization delay of distal arteries. Enlarged and tortuous vessels were also shown in A3 and A4 segments of the left ACA, M4 of bilateral MCA, P3 of the right PCA, and P4 of bilateral PCA, which were not as severe as the M2 segment of the left MCA (Figure 2 (c–f)). Surprisingly, the vertebrobasilar arteries（VBA）and bilateral ICA were not involved. The related vascular risk factors such as hypertension, diabetes, hyperlipoidemia, high level of homocysteic acid, were also excluded. Although the diagnostic criteria for branching arteries IADE haven’t been established, the case could still be finally diagnosed by the definition of IADE.
Thrombosis of the draining vein causes intracranial haemorrhage in the natural history of brain arteriovenous malformation: case report
Published in British Journal of Neurosurgery, 2019
Raita Fukaya, Katsuhiro Mizutani, Masahito Fukuchi, Koji Fujii
A 52-year-old man was transported to the emergency department of our hospital following a witnessed convulsion of the right upper extremity and a loss of consciousness. Initial non-contrast computed tomography (CT) revealed a small, high-density lesion in the left parietal lobe (Figure 1(A,B)). The lesion was found to be a cross-section of the intraluminal thrombus of the vein. Follow-up CT and magnetic resonance imaging (MRI), conducted 15 h after the initial CT, showed the presence of a small AVM with subcortical and intraventricular haemorrhage located from the left parietal lobe to the lateral ventricle (Figure 1(C)). Subsequently, cerebral angiography demonstrated a small, left parietal AVM (Figure 1(E–G)). The AVM nidus was supplied by a parietal branch of the left middle cerebral artery, and the venous phase showed a single draining vein, primarily through to the superior sagittal sinus. No pedicle aneurysm was found in the feeding arteries, and no thrombus was observed in the draining vein. The high-density lesion on the initial CT of the left parietal lobe was retrospectively identified as an intraluminal thrombus in the single draining vein of the AVM. A T2-weighted MRI image showed a flow void near the haematoma, indicating that the thrombus was already lysed (Figure 1(D)).
Glioblastoma multiforme presenting as cryptogenic intracerebral hemorrhage
Published in Baylor University Medical Center Proceedings, 2018
Jose M. Soto, Kristopher A. Lyon, Ethan A. Benardete
In the emergency department, the patient had mild weakness in her left upper and lower extremity but otherwise a normal neurologic examination. She denied recent head trauma or anticoagulant use. CT angiography of the brain did not demonstrate an underlying vascular lesion. Magnetic resonance imaging (MRI) of the brain with and without gadolinium contrast, likewise, did not reveal an underlying mass (Figure 2). The patient underwent catheter-based cerebral angiography, which did not show an underlying vascular abnormality. She improved neurologically while in the hospital and was discharged home on levetiracetam for seizure prophylaxis.