Neuroradiology presents…..

Cerebrovascular Disease

David M. Pelz, MD, FRCPC

Neuroradiology, LHSC

Cerebrovascular Disease

• Normal Anatomy

• Stroke

• Hemorrhage - Aneurysms, AVMs

• External Carotid

Normal Anatomy

• Historical

• Angiography

• Duplex Ultrasound (DUS)

• MR Angiography (MRA)

• CT Angiography (CTA)

Origins

Roentgen - 1896

Egas Moniz - 1934

Moniz - 1934

Direct PunctureCarotid Vertebral

AP Lateral AP Lateral

Sven Seldinger - 1953

Modern Angiography - DSA

Digital Subtraction Angiography

Risks of Angiography

• Stroke - 1:1000

• Contrast reaction - 1:1,000,000

• Groin hematoma - 1:500

• Vasovagal reactions, etc.

Auto Angiography

Normal Anatomy -DSA

Normal Anatomy - Carotid

AP Lateral

Normal Anatomy - Vertebral

AP Lateral

3D-CRA

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Duplex Ultrasound (DUS)

MR Angiography - MRA

TOF -Circle of Willis

CEMRA - Contrast-enhanced

CT Angiography - CTA

Circle of WillisCarotid bifurcation

Stroke

Normal

NASCET

North American Symptomatic Endarterectomy Trial

KFC

John Hunter (1728-1793)

“Blood goes where it is needed”

Collateral supply to the brain

Circle of WillisEC-IC

Duplex Ultrasound

DUS and CTA - ? Good enough for surgery

MRA of carotid disease

? Good enough for surgery

Carotid Angioplasty/Stenting (CAS)

Pre- Post-

Endarterectomy vs CAS

• Over 12,000 worldwide, symptomatic and asymptomatic pts, anecdotal evidence

• CAVATAS - 10% risk for both

• CREST - 5 yrs, 2500 pts, RCT

Pre- Post-

Intracranial Disease

Thrombolysis for acute stroke

1

2

3

4

Basilar artery occlusion

Pre-

Post-

Thrombolysis in Acute Stroke

• “Time is brain”

• IV r-TPA within 3 hrs, most practical

• IA - large vessel occlusions (MCA or basilar), up to 6 hrs

• Still no conclusive evidence favouring IA or IV

Cerebral Aneurysms

Endovascular Therapy of Cerebral Aneurysms

Coiling of Cerebral Aneurysms

Lateral AP

Post- GDC Coiling

Stents and Coils

AP lateral

Clipping vs.. Coiling

International Subarachnoid Aneurysm Trial (ISAT)

Cerebral Arteriovenous Malformations (AVMs)

Endovascular Therapy of Brain AVMs

NBCA

Pre- Post-

MRA

External Carotid Artery

External Carotid Artery - Lat

External Carotid Artery - AP

Epistaxis

Juvenile Nasal Angiofibroma

Tumours

Chemodectomas

• Carotid body tumour

• Glomus Vagale

• Glomus jugulare

• Glomus tympanicum

“ Mother - in - Law”

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The End