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Neurology advanced hsa jy gauvrit
Neurology advanced hsa jy gauvrit
Neurology advanced hsa jy gauvrit
Neurology advanced hsa jy gauvrit
Neurology advanced hsa jy gauvrit
Neurology advanced hsa jy gauvrit
Neurology advanced hsa jy gauvrit
Neurology advanced hsa jy gauvrit
Neurology advanced hsa jy gauvrit
Neurology advanced hsa jy gauvrit
Neurology advanced hsa jy gauvrit
Neurology advanced hsa jy gauvrit
Neurology advanced hsa jy gauvrit
Neurology advanced hsa jy gauvrit
Neurology advanced hsa jy gauvrit
Neurology advanced hsa jy gauvrit
Neurology advanced hsa jy gauvrit
Neurology advanced hsa jy gauvrit
Neurology advanced hsa jy gauvrit
Neurology advanced hsa jy gauvrit
Neurology advanced hsa jy gauvrit
Neurology advanced hsa jy gauvrit
Neurology advanced hsa jy gauvrit
Neurology advanced hsa jy gauvrit
Neurology advanced hsa jy gauvrit
Neurology advanced hsa jy gauvrit
Neurology advanced hsa jy gauvrit
Neurology advanced hsa jy gauvrit
Neurology advanced hsa jy gauvrit
Neurology advanced hsa jy gauvrit
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Neurology advanced hsa jy gauvrit

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  • 1. Imaging of subarachnoid hemorrhage Jean-Yves Gauvrit University hospital of Rennes, Department of radiology and medical imaging
  • 2. SAH: reminders Where? Subarachnoid spaces Dura mater Arachnoid mater Subarachnoid spaces Pia mater Frequent? 100/1 000 000 inhabitants/year 5% of strokes Rare before the age of 20 years Age? Serious? Frequent between 40 and 60 years Mortality rate: ~ 50% Disabling deficits: 30%
  • 3. SAH: clinical reminders ANAMNESIS When? •  Sudden and painful “thunderclap” headaches (10% of SAHs) • Persistent headaches CLINICAL EXAMINATION •  Meningeal syndrome, neck stiffness •  2/3 impaired consciousness (1/2 coma) •  No fever initially •  No prior trauma III •  Neurological signs without localizing value VI with localizing value cranial nerve III paralysis Nerve compression via carotid siphon aneurysm
  • 4. SAH: reminders n  Intracranial aneurysm: 80% of cases PComA Cause? 20% 40% AComA 30% MCA Multiple aneurysms 20% 10% PCA BA PICA n  n  n  n  n  n  n  Arteriovenous malformations Intracranial dissections Angiopathies Hemopathies Venous thrombosis Traumas Medullary vascular malformations
  • 5. Objectives of imaging 1) Emergency 2) Diagnosis of SAH Ø  Presence of blood in the subarachnoid spaces Ø  Localization of rupture site Ø  Early and late complications 3) Etiologies a) Aneurysm Radio-anatomical examination Ø Aneurysm neck Ø Dimensions Ø Aneurysm-carrying artery b) Others Therapeutic decision
  • 6. Confirming SAH n  Brain ¨  scan 95% Presence of blood Hyperdensity in the subarachnoid cisterns and cerebral sulci ¨  Localizing value Associated signs Hydrocephalus Hematoma ¨ 
  • 7. Confirming SAH
  • 8. HSA : sensibilité du scanner Confirming SAH Normal scan 5% Emergency brain MRI Boesiger, B. M.J Emerg Med 2005 FLAIR T2* Da Rocha AJ. J Comput Assist Tomogr 2006
  • 9. HSA : sensibilité du scanner Confirming SAH Normal scan 5% Normal MRI LP Red, uncoagulated, xanthochromic FLAIR T2* Mohamed M. AJNR 2004
  • 10. Complications n  Acute hydrocephalus n  Ventricular dilatation n  Obstruction by blood clots n  Intracranial pressure elevation n  Diagnosis with scan or MRI
  • 11. Complications n  Vasospasm ¨  Due to the presence of blood around the arteries n  n  maximum from D3 to D12 Artery diameter reduction ¨  Daily transcranial echo-color Doppler at patient bedside n  Narrowing, acceleration of flow velocities ¨  Asymptomatic ¨  Symptomatic n  Delayed ischemia cerebral
  • 12. Complications MTT At patient bedside
  • 13. Complications n  Re-bleeding New rupture of untreated aneurysm ¨ Sudden ¨ 35% ¨ More and unpredictable at 1 month severe than initial SAH ¨ Diagnosis with scan or MRI
  • 14. Etiological diagnosis of SAH n  Non-invasive angiography ¨ CT angiography ++ ¨ MR angiography n  Invasive angiography ¨ Conventional arteriography 3D
  • 15. Etiological diagnosis of SAH CT angiography n  n  n  Acquisition 10 sec IV inj. of contrast agent Slices <1mm n  n  n  Morphology of aneurysm sac Sac-to-neck ratio Aneurysm-carrying artery Goddard AJ. Clin Radiol 2005 Therapeutic decision
  • 16. CT angiography Etiological diagnosis of SAH VRT MIP Angiography Aneurysm of the right PICA
  • 17. CT angiography Etiological diagnosis of SAH Dissection Dural fistula
  • 18. CT angiography Etiological diagnosis of SAH VRT False positive: normal vein TOF T2 CT angiography
  • 19. MR angiography Etiological diagnosis of SAH MR angiography ¨ Acquisition 3 min ¨ Without injection, TOF ¨ Slices 1mm 2D n  n  n  Morphology of aneurysm sac Sac-to-neck ratio Aneurysm-carrying artery 3D
  • 20. MR angiography Etiological diagnosis of SAH VRT TOF FLAIR MIP
  • 21. Etiological diagnosis of SAH n  Cerebral angiography ¨ 40 minutes ¨ IA injection of contrast agent ¨ Slices <0.5mm ¨ 3D reconstructions n  78% patients with negative arteriography had an aneurysm (<2 mm) visible with 3D angiography n  n  n  Morphology of aneurysm sac Sac-to-neck ratio Adjacent branches Van Rooij WJ. AJNR Am 2008
  • 22. Diffuse SAH without aneurysm ¬  Technical Scan-CT angiography Causes? Angiography (1) ¬  Thrombosis ¬  Vasospasm ¬  Compression ¬  Anatomy-localization Angiography (2) 10-15% of aneurysms visible with 2nd angiography Bradac et al. Neuroradiology 1997
  • 23. Perimesencephalic SAH Scan FLAIR
  • 24. Perimesencephalic SAH Ø  Preserved general state Ø  Limited SAH Scan-CT angiography Ø  Normal angiography Ø  Hypothesis: vein rupture? Ø  No usual complications (vasospasm) Ø  No recurrence Ruigrok YM, Stroke 2000 Greebe P, Stroke 2007 Angiography MRI-MR angiography
  • 25. Cortical SAH FLAIR Diffusion Angiitis
  • 26. Cortical SAH DP Venous thrombosis T2* Oppenheim, C.AJNR 2005 T2* E Aufray-Calvier
  • 27. Cortical SAH Ø Anamnesis, clinical examination Vascular malformations Reversible cerebral vasoconstriction syndrome Vasculitis Septic aneurysm Scan-CT angiography Ø Causes Ø Venous thrombosis Ø Angiitis Ø Trauma Ø Remote ruptured aneurysm Ø Malformations… - Cerebral venous thrombosis PRES Neoplasia Abscess Endocarditis MRI-MR angiography - Cerebral venous thrombosis Amyloid angiopathy Cavernoma Angiography Bonneville F AJNR 2010 Geraldes R J Stroke Cerebrovasc Dis 2013
  • 28. Cortical SAH AngioCTA Angio CTV FLAIR DWI T2* SWI Vascular malformations Reversible cerebral vasoconstriction syndrome Vasculitis Septic aneurysm Cerebral venous thrombosis PRES Neoplasia Abscess Endocarditis Cerebral venous thrombosis Amyloid angiopathy Cavernoma T1+Gd MRVein MRA DSA Bonneville F AJNR 2010
  • 29. Fortuitously discovered aneurysm: risk factors for hemorrhage INDEPENDENT - SIZE >7mm - LOBULATION, GIRLS -  LOCALIZATION: anterior and posterior communicating arteries -  WOMEN, AHT (p ∼0.05) Multiple aneurysms: no increased risk/aneurysm, but cumulated risk of different locations Calcified or thrombosed aneurysm: trend to increased hemorrhagic risk 29
  • 30. Subarachnoid hemorrhage Emergency imaging Aneurysm 80% Triple diagnosis: • Positive • Etiologies • Complications Scan-CT angiography in 1st intention MRI-MR angiography: localized SAH Angiography: alternative examination option

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