Cerebrovascular Disease

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Neuroradiology presents..
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Cerebrovascular Disease

• David M. Pelz, MD, FRCPC
• Neuroradiology, LHSC

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Cerebrovascular Disease

• Normal Anatomy
• Stroke
• Hemorrhage - Aneurysms, AVMs
• External Carotid

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Normal Anatomy

• Historical
• Angiography
• Duplex Ultrasound (DUS)
• MR Angiography (MRA)
• CT Angiography (CTA)

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Origins
Roentgen - 1896
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Egas Moniz - 1934
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Moniz - 1934
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Direct Puncture
Carotid
Vertebral
Lateral
AP
Lateral
AP
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Sven Seldinger - 1953
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Modern Angiography - DSA
Digital Subtraction Angiography
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Risks of Angiography

• Stroke - 11000
• Contrast reaction - 11,000,000
• Groin hematoma - 1500
• Vasovagal reactions, etc.

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Auto Angiography
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Normal Anatomy -DSA
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Normal Anatomy - Carotid
AP
Lateral
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Normal Anatomy - Vertebral
AP
Lateral
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3D-CRA
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Duplex Ultrasound (DUS)
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MR Angiography - MRA
TOF -Circle of Willis
CEMRA - Contrast-enhanced
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CT Angiography - CTA
Circle of Willis
Carotid bifurcation
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Stroke
Normal
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NASCET
North American Symptomatic Endarterectomy Trial
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KFC
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John Hunter (1728-1793)
Blood goes where it is needed
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Collateral supply to the brain
Circle of Willis
EC-IC
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Duplex Ultrasound
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DUS and CTA - ? Good enough for surgery
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MRA of carotid disease
? Good enough for surgery
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Carotid Angioplasty/Stenting (CAS)
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Pre-
Post-
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Endarterectomy vs CAS

• Over 12,000 worldwide, symptomatic and
  asymptomatic pts, anecdotal evidence
• CAVATAS - 10 risk for both
• CREST - 5 yrs, 2500 pts, RCT

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Intracranial Disease
Pre-
Post-
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Thrombolysis for acute stroke
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2
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Basilar artery occlusion
Pre-
Post-
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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

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Cerebral Aneurysms
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Endovascular Therapy of Cerebral Aneurysms
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Coiling of Cerebral Aneurysms
Lateral
AP
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Post- GDC Coiling
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Stents and Coils
lateral
AP
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Clipping vs.. Coiling
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International Subarachnoid Aneurysm Trial (ISAT)
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Cerebral Arteriovenous Malformations (AVMs)
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Endovascular Therapy of Brain AVMs
NBCA
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Pre-
Post-
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MRA
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External Carotid Artery
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External Carotid Artery - Lat
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External Carotid Artery - AP
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Epistaxis
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Juvenile Nasal Angiofibroma
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Tumours
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Chemodectomas

• Carotid body tumour
• Glomus Vagale
• Glomus jugulare
• Glomus tympanicum

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Mother - in - Law
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The End