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