Vascular neuroroadiology

Question 1

Classically where is SAH in trauma vs. aneurysm

Answer 1

Trauma - vertex Aneurysm - basilary/dependent

Question 2

Where do these aneurysms bleed?

Acom

Pcom

MCA

Basilar tip

PICA

Answer 2

Acom - interhemispheric fissure

Pcom - Ipsilateral basal cistern

MCA - Sylvian fissure

Basilar Tip - Interpeduncular cistern

PICA - Posterior fossa

Question 3

Aneurysms are associated with what diseases? (3 diseases/catagories)

Answer 3

PCKD

collagen vascular diseases

coarctations

Question 4

SAH

Ealry sideffects

mid - side effects

late side effects

Answer 4

Early; hydrocephalus

mid; vasospasm (4-14 days after)

late; Superficial siderosis

Question 5

Things other than SAH that also cause vasospasm

Answer 5

Meningitis

PRES

RCVS (reversible cerebral vasospasm syndrome) (a/w pregnancy and a thurnderclap headache)

Migraine

Question 6

What is superficial siderosis?

(clinical history, classic imaging).

What is next step?

Answer 6

Sideffect of repeated episodes of SAH.

Classic presentation is sensorineural hearing loss and ataxia.

“Staining the surface of brain w/ hemosidern.’ classic look is curvilinear low signal on GRADIENT which is coating the surface of the brain.

Next step is CTA or MRA

Question 7

pseudo SAH

Answer 7

Edema make the cisterns look relatively more bright.

The tricks to tell it is Pseudo SAH are that there will be no sulcal density, its just in basal cisterns. and the hounsfield units will not be high enough.

Question 8

Hypertensive hemorrhage classic findings

Answer 8

Basal ganglia, Pons, Cerebellum.

Putamen is very commonlocation.

Intraventricular extension is common.

Question 9

Ddx for lobar hemorrhage

Answer 9

Amyloid hemorrhage, hypertensive hemorrhage, hemorrhage from a mass

Question 10

3 classic findings with susceptibility sequencews

Answer 10

Amyloid

Cavernoma

Bleeding

Question 11

Old person w/ multiple head bleeds

Answer 11

Amyloid angiopathy

Old, multiple bleeds in multiple lobes of different ages. Subcortical microhemorrhages. Lobar bleed with normal blood pressure

Question 12

What does Flair look like on hyperacute stroke?

Answer 12

Normal. It only begins to intensify after the first 6 hours.

Question 13

Infarct that involves bilateral thalami

Answer 13

Artery of percheron infarct.

Classically involves Bilateral paramedian thalamus w/ or w/o midbrain involvement. Artery of Percheron comes off of PCA.

The artery of Percheron is a rare variant of the posterior cerebral circulationcharacterised by a solitary arterial trunk that supplies blood to the paramedian thalamiand the rostral midbrain bilaterally.

Question 14

Infarct of caudate head

Answer 14

Recurrent artery of hubener infarct.

Originates from proximal ACA

Classic history - s/p acom aneurysm clipping.

Question 15

Ddx hypdense lesion in thalami

Answer 15

Artery of percheron infarct

Wernicke’s encephalopathy

internal cerebral vein thrombosis.

Question 16

Which types of people/strokes are likely to have hemorrhagic conversion of stroke?

Answer 16

people with anticoagulation

large territory bleed, proximal MCA stroke

multiple strokes

venous infarcts

Question 17

T1 Curvilinear/gyriform hyperintense signal

Answer 17

Cortical laminar necrosis.

Occurs after a stroke. Starts after 2 weeks. Peaks at 1-3 monts. Then it fades.

Accumilation of dead cells/protein creates T1 hyperintensity. No blood.

Question 18

What do Brain MRI sequences look like in peds patients.

Answer 18

On T1, you don’t look like you’re an adult until you’re 1

On T2, you don’t look like an adult unti you’re 2. (before that, your white matter is still bright on T2, cause it hasn’t yet myelinated)

Question 19

2 types of watershed territories

Answer 19

External watersheds

• between cortical branches
• isolated infarcts, hemodynamic compromise, decreased distal perfusion pressures with less embolism washout
• better prognosis

Internal watersheds

• between cortical branches and perforators.
• systemic hypodynamic compromise
• Poorer prognosis (deep perforators have less collaterals)

Question 20

ICA stenosis with puff of smoke appearance on angiographyl in a Sickle cell patient.

Difference in how this can present for kids vs. adults.

Answer 20

MoyaMoya

Stenosis of supraclinoid ICA - develops lots of collaterals

In a kid - watershed stroke

in Adult - bleed

Question 21

What is classic association with DVA

Answer 21

Cavernoma

Question 22

Low flow lesion with a dilated capillary bed. Name, classic imaging, classic association.

Answer 22

Cavernoma

Can be single or familial

“popcorn-like” with peripheral rim of hemosidern

typically do not have catastrophic bleeds

a/w nearby DVA

Question 23

Venous malformation in the PONS.

Classic pattern

What is an iatrogenic way they can develop

Answer 23

Capillary telengiectasia

has intervening normal brain tissue

Incidental findings

Brush-like or stipple pattern

can develop as a complication of radiation therapy.

Question 24

Middle age person with bad white matter disease centeredon temporal lobes

Answer 24

CADASIL

Temporal lobes heavily involved

Normal vasculature.

Classic hx is 40 year old w/ migraine headaches and eventual dementia. There will be severe white matter disease with multiple vascular territories. Temporals involved, occipitals usually spared.