ischemic stroke imaging › backup-nna › pdf_file › academic7 › 12-sy… · ischemic stroke...
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ISCHEMIC STROKE IMAGING
ผศผศ..พญพญ..จุรีรัตนจุรีรัตน ธรรมโรจนธรรมโรจนภาควิชารังสีวิทยาภาควิชารังสีวิทยา คณะแพทยศาสตรคณะแพทยศาสตรมหาวทิยาลยัขอนแกนมหาวทิยาลยัขอนแกน
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A case of acute hemiplegia
Which side is the abnormality ,right or left ?
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Early Right MCA infarction - CTRight hemisphere low density
Loss of Insular ribbon sign
( loss of right insular corticomedullary junction distinction)
NB; normal left side
Well defined insular cortex
Well defined lentiform nucleus
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Early Right ACA+ MCA infarctionLow density at right frontal and temporal lobe
Effacement sylvian fissure
Hyperdense arterial sign
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Hyperdense artery sign
Cord sign
temporal lobe low density with mass effect
Right MCA thrombosis , infarction- CT
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Posterior cerebral a. infarction(occipital lobe &inferior aspect of temporal lobe )Balance blood supply between PCA/ MCA
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Basilar artery occlusion
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Small areas of low density in right basal ganglia ( lacuna )
Deep seated or small vessels infarction ( DDX ,thrombosis ,emboli,
Co2 poisoning
Lacunar infarction
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Follow up 3 weeks later
Subacute infarction
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Decrease mass effect ,Gyral enhancement
Luxury perfusion / collateral circulation
DDX . Cerebritis / inflammation
Subacute infarction
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Water shed infarction
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Looking for pathology of ICA
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A case of left hemiplegia for 3 days
then progression of conscious
change and neurological deficit
Massive right cerebral infarctionwith hemorrhagic transformation
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case of female with headache conscious change and convulsion
Empty delta sign in SSS
in post contrast CT
Left cerebral hemisphere edema
SSS thrombosis - CT
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Venous infarction , sagittal sinus thrombosis
Hypodensity area within the white matter
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A case of coma
Low density in bilateral thalami and basal ganglia edema
small hemorrhage
thrombosis in deep venous system
( internal cerebral V)
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A case of coma
From hypoxia, brain death
Generalize low density of the whole brain.
Relative small ventricle, cisterns and sulci
Poor gray-white differentiation
Diffuse cerebral edema
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Hemorrhagic stroke Hypertensive
Non hypertensive
Rupture vascular structure , AVM / aneurysmBleeding tumor
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Hypertensive hemorrhage ,ICHBasal ganglia ,external capsule , thalamus ,pons ,cerebellar hemisphere
Pt. With underlying HT
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A case of headache, hypertension
and seizure
Underlying HT ,renal
Posterior Reversible Encephalopathy Syndrome (PRES) - CT
Low density in bilateral occipital lobe
at cortex or subcortical along PCA
Disappear after treatment of HT / underlying dz.
DDX; PCA infarction
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Rupture AVM , multi-compartmental bleeding Uncommon location for HT
ICH and IVH
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Rupture AVM ( continue )
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Pial ( parenchyma) AVM
No mass effect , minimal surrounding brain atrophy
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Multiple Carvernoma ,unbleed ,no mass effect
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A case of severe sudden headache
High density lesion in the cisterns
Sylvian fissures
Interhemispheric fissures
basal cistern
Obstructive hydrocephalus
SAH ---rupture aneurysm trauma
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Localized SAH , located site of aneurysm
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Rupture MCA aneurym with large ICH
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Unruptured thrombosed RT.PCA aneurysm
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Bleeding tumor ( high grade astrocytoma)
Established evidence of surrounding brain edema on T2W
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Hemorrhagic strokeHypertensive Non hypertensive ( vascular rupture )Bleeding tumorAterial infarction with hemorrhageic tranformationVenous infarction with parenchymal he.
Ischemic -InfarctionThrombosis / emboliArterial or venousLarge or small vessel.Hypotensive infarction
Border-zone (water –shed )Hypertensive encephalopathy
posterior reversible encephalopathy
Conclusion
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Vascular territory
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Signs of infarction- NECT
Hyperdense vessel ; MCA
Loss of gray-white distinction
Obscuration of deep nuclei
Loss of insular ribbon
Parenchymal hypodensity
Gyral swelling , sulcal effacement
+hemorrhagic transformation ( 24-48 hrs)
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Signs of infarction- CECT
Absent vessel = occlusion
Enhanced cortical vessels
= slow flow or ollateral
DDx cerebritis, vasculitis
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Brain edema & mass effectVasogenic edema
tumor
Cytotoxic edema
metabolic
Interstitial edema
Ischemia = cytotoxic + vasogenic
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Anne G. Osborn .Diagnostic imaging ;brain 2004
Peter Reimer . Clinical MR imaging.Springer 1999
Kenneth W. Linsay . Neurology and neurosurgery 1997.
Wolfgang Dahnert. Radiology review manual . Williams & Wilkins 1993.
REFERENCES
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