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Blunt Cerebrovascular Trauma.pptx

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					Blunt Cerebrovascular
       Trauma
            James M. Provenzale, M.D.
             prove001@mc.duke.edu
                   Department of Radiology
               Duke University Medical Center
Departments of Radiology, Oncology and Biomedical Engineering
             Emory University School of Medicine




                   Introduction

  This presentation will:

  •  Explain mechanisms of arterial injury
  •  Review common imaging findings
   •  Compare imaging techniques
   •  Show some common imaging pitfalls
            Mechanisms of Injury
 •  Superficial location of the carotid arteries -
 injury by impact from an external object

 •  Many forms of trauma involve twisting
 and turning motions of head and neck

 •  Carotid and vertebral arteries injury can
 result even without direct trauma




Indications for Vascular Imaging

1. Cervical spine fracture with
     A. Foramen transversarium involvement, or
      B. 30% or more subluxation, or
      C. Significant rotation or distraction mechanism

2. Basilar skull fracture crossing carotid canal,
     foramen lacerum, or cavernous sinus

C. Sliker, S. Mirvis. European Journal of Radiology 2007; 64: 3–14
Indications for Vascular Imaging

  3. Severe facial fractures (e.g., LeFort II or III)

  4. Carotid or vertebral artery perivascular hematoma
     on imaging

  5. New-onset Horner’s syndrome


C. Sliker, S. Mirvis. European Journal of Radiology 2007; 64: 3–14




Indications for Vascular Imaging

  6. Glasgow Coma Score≤6 at 24 h after initial assessment


  7. Neurologic examination incongruent with brain
     imaging studies

  8. Stroke or transient ischemic attack



C. Sliker, S. Mirvis. European Journal of Radiology 2007; 64: 3–14
           	






Carotid-Cavernous Fistula
Carotid-Cavernous Fistula




 Convex, instead of concave, shape




Carotid-Cavernous Fistula
Dissection: Luminal Occlusion




   Pseudoaneurysms
         Dissection: MR Imaging


Hyperintense
   Rim =
 Intramural
 Hematoma




           Unenhanced T1-Weighted Image




       Hyperintense Rim Sign




   T1-weighted Image        MR Angiography
         A Canine Analogy




Feddersen B, et al. J Neurol Neurosurg Psychiatry 2007; 78:1055




   Dissection: MR Angiography




T2-weighted Image MR Angiography
 Vertebral Dissection




 Basilar Artery Dissection




T2WI             MR Angiography
CT Angiography: Arterial Narrowing




     CTA: Luminal Narrowing
  Dissection: CT Angiography




“flame-shaped” tapering   pseudoaneurysm




   Dissecting Aneurysm
     CTA Compared with MRA




Retrospective MRA Studies
   Authors       Dissection Type   Sensitivity   Specificity   PPV    NPV


 Kitanaka 1994         NS               -             -        100%    -
      (n=5)
  Zuber 1994           NS            100%             -         -      -
    (n=19)
 Ozduba 1996           NS               -             -        80%     -
   (n=12)
   Stringaris          NS            100%          100%         -      -
  1996 (n=12)
   Yoshimoto           S              73%             -         -      -
  1997 (n=13)
   Mascalchi     10 spontaneous,     100%             -         -      -
  1997 (n=12)      4 traumatic
   Auer 1998     7 spontaneous,       95%           29%         -      -
    (n=17)        10 traumatic
Retrospective CTA Studies
     Author           Dissection Type       Sensitivity    Specificity   PPV       NPV

   Leclerc 1996                NS              100%           85%         -         -
     (n=16)

Chen 2004 (n=17)      15 spontaneous;          100%           98%        95        100
                         2 traumatic

 Bub 2005 (n=32)               T               76%            93%        68        95


Utter 2006 (n=372)             T                 -              -         -        92


  Malhotra 2007                T               74%            86%        65        90
    (n=119)

  Pugliese 2007       12 spontaneous;          100%           95%        94        100
     (n=15)             3 traumatic

   Sliker 2008                 T               69%            82%         -         -
    (n=108)
   Whole Body




Prospective MRA Studies
  Author           Imaging         Dissection Sensitivity Specificity     PPV           NPV
                    Method            Type
                 (100% DSA)

Müllges 1992         MRI               S              -             -     100            -
    (n=5)

 Levy 1994           MRI              NS             79%       99%            -          -
  (n=180)            MRA

 Biffl 2002      MRA (n=16)            T             75%       67%            43        89


                  CTA (n=46)                         68%       67%            65        70


 Miller 2002   CTA (n=143)             T             51%       99%            -          -


                 MRA (n=21)                          50%       98%            -          -
Prospective CTA Studies
   Author       Dissection   Sensitivity   Specificity   PPV    NPV
                   Type



Múnera 2000         T           90%          100%        100%   98%
  (n=60)

Schneidereit        T             -             -        65%     -
2006 (n=170)



Malhotra 2007       T           74%           86%        65%    90%
  (n=119)




        False-Positive MR




Hypoplastic Artery
False-Positive MR




Cervical Carotid Stenosis




False-Positive CTA




    Pulsation Artifact
            False-negative CTA
                                Final
                             Diagnosis:
     Initial                  Carotid
  Diagnosis:                 Dissection
Fibromuscular
   Dysplasia




            False-negative MRA

                                 CTA,
                                 day 13




       Fat saturation
  T1-weighted image, day 1
       False-negative MRA




 Expected delay in           Day 7
  development of
hyperintense signal




                 Summary
•  We have reviewed classical findings
of blunt cerebrovascular injury


•  In general, MR and CT-based
techniques seem relatively
equivalent with regard to detection
and accuracy

				
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posted:8/20/2012
language:English
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