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

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

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

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

5. 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

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

7. 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 2.5 mm collimation >0.5 sec rotation time 100mAs / 120kV CM:120ml @ 3ml/s 300mgI/ml bolus triggering / test bolus Image Reconstruction slice tickness / increment 3/3mm 3/1.5mm (MPR) medium soft tissue kernel B30f

8. Dept of Diagnostic & Interventional Radiology, University Clinic, Johann Wolfgang Goethe-University Frankfurt/Main, Germany 64-slice MDCT 64 x 0.6mm collimation z-flying focal spot technique 0.33sec rotation time AATCM 72mAs (base) 120kV CM: 90ml 400mgI/ml 30ml @ 4.5ml/s 60ml @ 2.5ml/s 30ml Saline @ 2.5ml/s Infusion via right arm (artefacts) Bolus triggering (160 HU / aA) ECG triggering @ Stanford Type A CTA of the Carotids: Recommended scan protocol

9. Dept of Diagnostic & Interventional Radiology, University Clinic, Johann Wolfgang Goethe-University Frankfurt/Main, Germany 64-slice MDCT 64 x 0.6mm collimation z-flying focal spot technique 0.33sec rotation time AATCM 72mAs (base) 120kV CM: 90ml 400mgI/ml 30ml @ 4.5ml/s 60ml @ 2.5ml/s 30ml Saline @ 2.5ml/s Infusion via right arm (artefacts) Bolus triggering (160 HU / aA) ECG triggering @ Stanford Type A Single Bolus Split Bolus CTA of the Carotids: Recommended scan protocol

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

11. 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.

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

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

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

15. Intracerebral haemorrhage on CT  Is always seen  apparent immediately  lasts 1 week  then disappears and looks like an infarct

16. 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 small arteries/arterioles  formation of small aneurysms  rupture produces a large blood filled cavity that acts as a SOL  typically basal ganglia or thalamus

17. 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 obvious as time progresses  small infarcts appear later than large ones  overall, 40% strokes have normal CT  posterior fossa difficult

18. 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  damage to the brain is due to:  ischaemia  oedema surrounding the ischaemic area  sources of occlusion of vessels:  thrombosis of small vessels - hypertensive lipohyalinosis - lacunar infarcts  thrombosis of larger vessels  embolus from extracranial vessels or heart

19. 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 cell carcinoma) presents with mild left sided weakness. CT scan

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

21. 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 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

22. 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 of the event Cerebral infarction 80% Primary intracerebral haemorrhage10% Subarachnoid haemorrhage5% Unknown5% Sudlow & Warlow 1997 Systematic review of world-wide incidence studies

23. 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 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

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

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

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

27. 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 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?

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

29. Dept of Diagnostic & Interventional Radiology, University Clinic, Johann Wolfgang Goethe-University Frankfurt/Main, Germany Question 4 Mrs X69 years old Developed Right hemiparesis and aphasia during breakfast (9am) Husband called GP and sent immediately to A & E department

30. 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 (no understanding or expression of language)

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

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

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