W. Taylor Kimberly, HMS 4Gillian Lieberman, MD

NeuroradiologyNeuroradiology

of Hemorrhagic of Hemorrhagic StrokeStroke

W. Taylor KimberlyHarvard Medical School Year 4

Gillian Lieberman, MD

July 2003

2

W. Taylor Kimberly, HMS 4Gillian Lieberman, MD

Goals

1. Mechanisms of stroke

2. What neuroimaging

modalities are available

4. Patient presentation to illustrate the decision algorithm for workup of one type of stroke

3. Uses for neuroimaging

modalities

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W. Taylor Kimberly, HMS 4Gillian Lieberman, MD

Stroke pathogenesisIschemic stroke (80%) The deficits adhere to vessel territories.

Embolic:

usually cardiogenic

in origin, less commonly artery-to-artery.

Thrombotic:

caused by HTN, arteritides.

Hemorrhagic stroke (20%)Intraparenchymal

hemorrhage:

causes include HTN, trauma, cocaine.Gradual onset, with neurologic findings that may cross vessel territories.

Subarachnoid hemorrhage:

causes include arterial aneurysm and AVM.Sudden onset, excruciating headache and changes in mental status.

Rapid diagnosis and intervention is critical for preservation of

brain function.

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W. Taylor Kimberly, HMS 4Gillian Lieberman, MD

Menu of testsHead CT

●

quick ●

sensitive for hemorrhage●

I+ contrast to visualize vascular anatomy●

but cannot detect acute infarction < about 8 hrs old first sign is loss of gray-white differentiation, sulcal

effacementthen decreased attenuation

Brain MR● excellent visualization of anatomy ● sensitive to acute infarct (T2, FLAIR and DWI/ADC sequences) ● can see vessel flow with MRA (better with gadolinium contrast) ● but very slow to acquire images● does not provide vessel anatomy (will overcall tight stenoses)

Cerebral Angiogram● excellent vascular anatomy● permits interventions (clot retrieval, targeted t-PA administration,

coil embolization)

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W. Taylor Kimberly, HMS 4Gillian Lieberman, MD

Stroke imaging algorithmRule out stroke

Head CT without contrast

Hemorrhage No hemorrhage, infarct or masses

CTA MRI/MRA

T1, T2, > 6 hrs FLAIR, > 2 hrsDWI/ADC, > 30 min

Angiogram to study anatomy Hyperacute

ischemic stroke

HTN, aneurysm, AVM?

Intervene, if possible If < 3 hrs, peripheral t-PA

TIME IS EVERYTHING!TIME IS EVERYTHING!

Interventional neuroradsoccludedvessel

clot retrieval, directed t-PA administrationCoil embolization

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W. Taylor Kimberly, HMS 4Gillian Lieberman, MD

Patient Presentation

J. B. is a 63 year old right-handed female who presents with:-

sudden onset of headache

-

left sided weakness-

rapidly diminishing mental status

What imaging test would you perform first?

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W. Taylor Kimberly, HMS 4Gillian Lieberman, MD

Normal neuroanatomy

temporal lobe

cerebellum

pons

frontal lobe

Sylvian

fissure

basal ganglia

corpus callosum

septum pellucidum

caudate nucleuslentiform

nucleus

lateral ventricles

internal capsulethalamus

superior colliculi

falx

cerebri

occipital lobe

gray matter

white matter

Images from BIDMC

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W. Taylor Kimberly, HMS 4Gillian Lieberman, MD

Images from BIDMC

Initial Head CT

temporal lobe

cerebellum

midbrain

falx

cerebriSylvian

fissure

lateral ventricles

pineal gland

occipital lobe

frontal lobe

calcifiedartery

hemorrhage

uncal

herniation

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W. Taylor Kimberly, HMS 4Gillian Lieberman, MD

Images from BIDMC

calcified choroid plexus

internal capsule

thalamus

septum pellucidum

corpus callosum

caudate nucleus

lentiform

nucleus

frontal lobe

parietal lobe

occipital lobe

intraparenchymalhemorrhage

Sulci

(withsubarachnoid hemorrhage)

midline shift

Initial Head CT

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W. Taylor Kimberly, HMS 4Gillian Lieberman, MD

Arterial Phase Capillary Phase Venous Phase

L ICA, AP projection

L ICA

L MCA(M1)

L ACA (A1)

ACommA L ACA (A2)

L MCA (M2)

Sigmoid sinus

Transverse sinus

Sagittal

sinuses

R L

Images from BIDMC

11

W. Taylor Kimberly, HMS 4Gillian Lieberman, MD

Arterial Phase Capillary Phase Venous Phase

L ICA, LAT projection

L ICA

L ACA (A2)

L MCA (M2) Sigmoid sinusTransverse sinus

Superior sagittal

sinusBridgingvein

Images from BIDMC

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W. Taylor Kimberly, HMS 4Gillian Lieberman, MD

R ICA

R MCA(M1)

R ACA (A1)

ACommA

L ACA (A2)

R MCA (M2)

Arterial Phase Capillary Phase Venous Phase

Sigmoid sinus

Transverse sinus

Sagittal

sinuses

R ICA, AP projection

R L

Images from BIDMC

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W. Taylor Kimberly, HMS 4Gillian Lieberman, MD

Arterial Phase Capillary Phase Venous Phase

R ICA, LAT projection

R ICA

L ACA (A2)

R MCA (M2) Sigmoid sinusTransverse sinus

Superior sagittal

sinusBridgingvein

Images from BIDMC

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W. Taylor Kimberly, HMS 4Gillian Lieberman, MD

Post-intervention Head CT

Images from BIDMC

coilscraniotomy

herniation

ventriculostomy

tube

hemorrhage

edema/infarct

drain

new ischemic stroke

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W. Taylor Kimberly, HMS 4Gillian Lieberman, MD

Images from BIDMC

Post-intervention Head CT

craniotomy

ventriculostomy

tube

drainstaples

herniation

new infarction

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W. Taylor Kimberly, HMS 4Gillian Lieberman, MD

Summary

Hemorrhage appears as high attenuation regions on CT.

Rapid diagnosis and intervention is critical in stroke patients.

Head CT is the first line imaging in all suspected stroke patients.

Interventional neuroradiology

can offer interventions that minimize bleeding or rebleeding.

Head CT can also detect masses and infarcts > 8-12 hrs old.

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W. Taylor Kimberly, HMS 4Gillian Lieberman, MD

References

•

Hanaway J, Woolsey TA, Gado MH, Roberts MP. The Brain Atlas: A visual guide to the human central nervous system. Bethesda: Fitzgerald Science Press. 1998.

•

Fix JD. High-Yield Neuroanatomy. Philadelphia: Williams & Wilkins. 1995.

•

Flaherty, AW. The Massachusetts General Hospital Handbook of Neurology. Philadelphia: Lippincott Williams & Wilkins. 2000.

•

Novelline RA. Squire’s Fundamentals of Radiology. Cambridge: Harvard University Press. 1997.

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W. Taylor Kimberly, HMS 4Gillian Lieberman, MD

Acknowledgments

Larry Barbaras Gillian Lieberman, MDPamela Lepkowski