Post on 16-Jan-2016
Dept of Diagnostic & Interventional Radiology, University Clinic, Johann Wolfgang Goethe-University Frankfurt/Main, Germany
Matthias KerlMatthias Kerl
Institute for Diagnostic and Institute for Diagnostic and
Interventional RadiologyInterventional Radiology
Johann Wolfgang Goethe Johann Wolfgang Goethe
University University
Frankfurt am MainFrankfurt am Main
Diagnosing Vascular Cranial Diseases Using Compted Tomography
Dept of Diagnostic & Interventional Radiology, University Clinic, Johann Wolfgang Goethe-University Frankfurt/Main, Germany
Symptomatic patients1:
• High benefit of CEA for patients with >70% stenosis
• Moderate benefit of CEA for patients with 50-70% stenosis
Asymptomatic patients2:
• Small benefit in terms of absolute risk
1Rothwell PM, Lancet (2003) 361:107–1162Moore WS, Circulation (1995) 91:556–579
Standard of reference
• DSA Poor correlation to postmortem findings1
• Vascular ultrasound Poor in assessment of filiform stenoses
Calcifications cancel the depiction of the vessel lumen
1Schulte-Altedorneburg G, J Neurol (2005) 252 : 575–5821Polak JF, Radiology (1998) 209:288–289
Standard of reference
• DSA Poor correlation to postmortem findings1
• Vascular ultrasound1
Poor in assessment of filiform stenoses
Calcifications cancel the depiction of the vessel lumen
CTA of the Carotids: BackgroundCTA 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)
Dept of Diagnostic & Interventional Radiology, University Clinic, Johann Wolfgang Goethe-University Frankfurt/Main, Germany
CTA of the Carotids: BackgroundCTA of the Carotids: Background
Alternative non-invasiveprocedures:
• CTA
• Filling techniques- First-pass technique- Passage of a bolus of CM through imaged volume- Depict lumen & surrounding arterial wall / soft tissues
• „Flow-dependent“ techniquesUS (Doppler, duplex / color-flow)MRA (TOF / PCA)Measure blood must through volume of interest
MRA CTA
Alternative non-invasiveprocedures:
• 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-invasiveprocedures:
• CTA
Dept of Diagnostic & Interventional Radiology, University Clinic, Johann Wolfgang Goethe-University Frankfurt/Main, Germany
CTA of the Carotids: MDCTCTA of the Carotids: MDCT
Alternative non-invasiveprocedures:
• CTA
Spiral-CT
4-row MDCT
64-row MDCT
IsotropicVoxel
Dept of Diagnostic & Interventional Radiology, University Clinic, Johann Wolfgang Goethe-University Frankfurt/Main, Germany
CTA and MRA of the Carotids: MDCTCTA and MRA of the Carotids: MDCT
Alternative non-invasiveprocedures:
• CTA
Dept of Diagnostic & Interventional Radiology, University Clinic, Johann Wolfgang Goethe-University Frankfurt/Main, Germany
CTA of the Carotids: MDCTCTA of the Carotids: MDCT
Alternative non-invasiveprocedures:
• CTA
Dept of Diagnostic & Interventional Radiology, University Clinic, Johann Wolfgang Goethe-University Frankfurt/Main, Germany
CTA of the Carotids: Minimal requirementsCTA of the Carotids: Minimal requirements
>>4-slice Multidetector-row CT4-slice Multidetector-row CTScanning • >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
Dept of Diagnostic & Interventional Radiology, University Clinic, Johann Wolfgang Goethe-University Frankfurt/Main, Germany
64-slice MDCT64-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/s60ml @ 2.5ml/s30ml Saline @ 2.5ml/sInfusion via right arm (artefacts) Bolus triggering (160 HU / aA)
• ECG triggering @ Stanford Type A
CTA of the Carotids: Recommended scan protocolCTA of the Carotids: Recommended scan protocol
Dept of Diagnostic & Interventional Radiology, University Clinic, Johann Wolfgang Goethe-University Frankfurt/Main, Germany
64-slice MDCT64-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/s60ml @ 2.5ml/s30ml Saline @ 2.5ml/sInfusion via right arm (artefacts) Bolus triggering (160 HU / aA)
• ECG triggering @ Stanford Type A
Single BolusSplit Bolus
CTA of the Carotids: Recommended scan protocolCTA of the Carotids: Recommended scan protocol
Dept of Diagnostic & Interventional Radiology, University Clinic, Johann Wolfgang Goethe-University Frankfurt/Main, Germany
CT Angiography - HeadCT Angiography - HeadCircle of WillisCircle of Willis
AneurysmsAneurysms
Vascular MalformationsVascular Malformations
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.
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, 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.
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 CTIntracerebral 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 HaemorrhageIntracerebral 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 CTIschaemic 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 InfarctionCerebral 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
Dept of Diagnostic & Interventional Radiology, University Clinic, Johann Wolfgang Goethe-University Frankfurt/Main, Germany
Question 1: Mr YQuestion 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?What’s the diagnosis?
Dept of Diagnostic & Interventional Radiology, University Clinic, Johann Wolfgang Goethe-University Frankfurt/Main, Germany
What’s the diagnosis?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 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 2Question 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 examinationOn examination
Looked well
Blood pressure 200/120 mmHg
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?Is this a stroke?
Dept of Diagnostic & Interventional Radiology, University Clinic, Johann Wolfgang Goethe-University Frankfurt/Main, Germany
Yes! Due to a Lacunar InfarctionYes! Due to a Lacunar Infarction
Dept of Diagnostic & Interventional Radiology, University Clinic, Johann Wolfgang Goethe-University Frankfurt/Main, Germany
Question 3: 85 year old ladyQuestion 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
Yes! A cerebellar
haemorrhage with acute
hydrocephalus
Dept of Diagnostic & Interventional Radiology, University Clinic, Johann Wolfgang Goethe-University Frankfurt/Main, Germany
Question 4Question 4
Mrs X 69 years old
Developed Right hemiparesis and aphasia during breakfast (9am)
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 (no understanding or expression of language)
Dept of Diagnostic & Interventional Radiology, University Clinic, Johann Wolfgang Goethe-University Frankfurt/Main, Germany
Is this a stroke?Is this a stroke?
Dept of Diagnostic & Interventional Radiology, University Clinic, Johann Wolfgang Goethe-University Frankfurt/Main, Germany
Is this a stroke?Is this a stroke?
Yes! Dense MCA sign indicating thrombus in the left MCA
Dept of Diagnostic & Interventional Radiology, University Clinic, Johann Wolfgang Goethe-University Frankfurt/Main, Germany
Thank you!