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Neurology advanced hsa jy gauvrit
- 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 ¨
- 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
- 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
- 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
- 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