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53 Cards in this Set

  • Front
  • Back

What are the 5 main territories of brain blood supply?

ACA


MCA


PCA


Lentoculostriate


Anterior choroidal artery

What are the common causes of ischemia at water shed areas ?


Adults 2


Kids 1

Severe carotid stenosis


Severe hypotension



Moyamoya disease ( idiopathic supraclinoid vaso-occlusove disease)

4 classical signs of ischemic stroke in head ct?

Dense MCA sign


Loss of insular ribbon sign


Loss of grey-white matter differentiation


Mass effect ( 3-5 days)

Fogging phenomenon happened at which date of stroke in CT and in T2

CT 14 days


T2 10 days

Findings


Diagnosis

Bilateral hypodense aspect of the medial thalamus, suggesting subacute ischemia caused by occlusion of the artery of Percheron. No signs of cerebral venous thrombosis. No dense aspect of the basilar artery.



Artery of Percheron stroke

What is artery of Percheron?

It is a normal anatomical variant


Common trunk that supplies the thalami and rostral midbrain that is arising from PCA.


Normally there are multiple branches.

Finding


Diagnosis

Focal hypodensity involving the right caudate head and anterior limb of the internal capsule.



Recurrent artery of Heubner infarction

What is recurrent artery of Heubner ?


When it can get injured ?


What area get infarcted?

Is a deep branch of the proximal ACA.



Clipping of ACOM aneurysm



Caudate nucleus

What is cardioemboloc stroke ?


MRI appearance

A fib or endocarditis showering thrombi



Diffusion restriction at multiple areas

Findings


Diagnosis

Diffusion restriction at the left MCA and left PCA territories



Fetal PCOM stroke

What is fetal PCOM ?

PCA get feeding directly from ICA


Mixed pattern of MCA and PCA territory infarction

Restricted diffusion in ischemic stroke seen between ----- to ----- time

30 minutes to 2 weeks

If a stroke patient shows diffusion restriction with normal T2 this is probably?

Hyperacute stroke <6hours

Hemorrhagic transformation happened between --- hours to ---- days

6 hours


4 days

Predictors of hemorrhagic transformation? 5

Multiple infarcts


Delayed >6hrs recanalisation


> 1/3 of MCA is infarcted


Proximal MCA infarction


Absent collateral flow

Risk factors of venous infarction? 3

Infants Dehydration


Older kids mastoiditis


Adults coagulopathy ( protein c and S deficiency) and oral contraceptive pills

Commonest location for venous infarct?

Superior sagittal sinus

CT findings of venous sinus thrombosis ?

Non contrast hyperdense


Empty delta sign on contrast


Differences BTW arterial and venous stroke?

Arterial cytotoxic edema


Venous both cytotoxic and vasogenic

What happened in chronic venous thrombosis ? 2

Development of dural AVF


Increased CSF pressure from impaired drainage

What is ASPECTS score ?


Drawback is ?

Alberta stroke program early CT score



It is used for giving TPA


Only for MCA infarcts

ASPECTs score favouring TPA


Not favouring TPA?

Above 8 is good


Score of 7 or less is not worth TPA

Who gets aneurysm? 6

Polycystic kidney disease


Smokers


Connective tissue disease( Marfan and Ehler danlos)


Aortic Coarctation


AVMs


NF


FMD


Aneurysm


Where do they occur?


Commonest site?


Second common site ?

At branching point


Anterior circulation ACA


Posterior circulation ( basilar artery then origin of PICA)

Why do persistent trigeminals get more aneurysm?

They have more branch points

Finding

Large persistent trigeminal artery passing from the left ICA to the terminal basilar artery via the cavernous sinus. Note the grossly hypoplastic vertebro-basilar arterial system as a result of this congenital anomaly with most posterior circulation blood coming from the left ICA via the trigeminal artery.

Risk of aneurysm rupture?5

Size .posterior location.


Female


Smoking


Hx of previous SAH


Finding Diagnosis

CT angiogram reveals a dolichoectatic basilar artery occupying the left cerebellopontine angle, which bifurcates at the level of the third ventricle.



Dolichoecrasia of basilar artery

How you assess severity of dolichoectasia?


Complications? 4

Height and lateralisation of the basilar artery



Dissection


Compression of cranial nerves


Brainstem stroke


Hydrocephalus

Commonest type of aneurysm?

Saccular aneurysm at bifurcation or branch points

Mention types of aneurysm? 5

Saccular


Fusiform


Blister


Pedicle


Mycotic

Fusiform aneurysm associated with ? 3


Common site ?


Mimic ?

Syphilis


PAN


Connective tissue disease



Posterior circulation



CPA tumor


When to suspect pseudoaneurysm?


Causes? 2

Atypical location


Focal hematoma next to it



Traumatic


Mycotic ( MCA ) endocarditis, meningitis, thrombophlebitis

What type of aneurysm is sneaky and often have negative CTA ?


Commonest site?

Blister aneurysm


ICA ( supraclinoidal segment)

What is infundibular widening ?

Not a true aneurysm but it is funneling of PCA origin no more than 3 mm

What you aneurysm associated with AVM?


Where it is found?

Pedicle aneurysm



In the artery feeding AVM


They have higher risk to bleed than aneurysm themselves

What is the treatment cut off of anterior circulation aneurysm?


7 mm

Maximum bleeding site according to aneurysm location?


ACOM


PCOM


MCA trifurcation


Basilar tip


PICA

ACOM interhemispheric fissure



PCOM ipsilateral basal cisterns



MCA trifurcation sylvian fissure



Basilar tip interpeduncular cistern interaventricular



PICA posterior fossa or intraventricular

What are the vascular malformations ? 5

High flow


AVM


Dural AVF



Low flow


Dural AVF


DVA


Cavernoma ( cavernous malformation)


Capillary telengiectasia


Most common type of high flow vascular malformation?


Common location ?


Most common complication?

AVM


Supratentorial


Bleeding 3% every year

What are the risk factors for AVM to bleed ? 4



Clinical presentation? 2

Small AVM ( high pressure)


Small draining vein( bo pressure relief)


Peri- nidal aneurysm


Basal ganglia location



Headache and seizure

Finding


Diagnosis

MIP CTA confirms the presence of a left temporal lobe arteriovenous malformation (AVM) which appears to receive the vast majority of its supply from the left middle cerebral artery. Contribution from the posterior cerebral artery is although likely via the lateral posterior choroidal arteries. Contribution from anterior cerebral artery and meningeal arteries cannot be excluded. Drainage appears to be predominantly superficial, over the temporal lobe and into the transverse / sigmoid sinus. The superior petrosal sinus appears plump and likely also provides some drainage.


Fig 1: nidus (blue arrows) and enlarged middle cerebral arteries (orange arrows).Fig 2: draining veins (blue arrows)Fig 3: enlarged posterior cerebral artery (blue arrow) with likely contribution via the lateral posterior choroidal arteries. Small branches can be seen extending from the choroid plexus to the nidus (orange arrow).

Dural AVF


Most common type?


Classic history?


Is it congenital or acquired

Spinal dural AVF



Progressive lower extremity weakness with sphincter dysfunction


They might have unexplained SAH



Usually acquired


Complications from spinal dural AVF?


How they are acquired?

Ischemia and infarction



From recanalisation of previous dural sinus thrombosis

Finding


Diagnosis

The lower half of the thoracic cord demonstrates extensive central cord high T2 signal. On the dorsal surface of the cord numerous flow voids are noted.

In spinal dural AVF, what is the next step? Why?

Conventional angiography



To detect other fistula and usually the fistula is at different site than the images

Finding

Developmental venous anomalies and cavernous malformations frequently co-exist as in this case.

DVA is Associated with ?

Cavernomas

How DVA appears in MRA?

Caput medusa


Collection of vessels converging toward an enlarged vein ( seen only in venous phase)

What is cavernoma?2


Risk factor?


Appearance?

Low flow vascular malformation


Without intervening tissue



Radiotherapy



Popcorn like with peripheral hemosiderin


Best sequence to look for cavernoma?


Associated with ?


Complication?

Gradient


DVA


It may ooz but no significant bleeding


May have fluid fluid levels

Finding


Diagnosis

There is an area of signal abnormality in the anterior aspect of the pons, which crosses the midline and is not associated with any mass effect. It is slightly hyperintense on T2 weighted images, and isointense on T1. Following administration of contrast it demonstrates an ill-defined blush of contrast. Susceptibility weighted imaging demonstrate signal drop out.




Capillary telengiectasia

What is capillary telengiectasia?2


Risk factor?


Classical appearance?

Low flow vascular malformation


With intervening normal tissue



Radiotherapy



Single lesion in the pons