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Neuroimaging methods in diagnosis of CVI

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Haris Babacic

on 19 September 2014

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Transcript of Neuroimaging methods in diagnosis of CVI

Republic of Macedonia
University "Ss Cyril and Methodius"
Medical Faculty in Skopje
Neuroimaging methods in diagnosis of CVI
37th IMSC
Ohrid, 10-13 May

Lecturers:
Assist. Prof. Arben Taravari
Maja Boshkovska
Elmedina Asani
Haris Babačić

Workshop on:
Introduction
Epidemiology
CT
Angiography
MRI
PET Scan
Definition
Most common causes:
Damage of the blood vessel wall;
Blood vessel occlusion with thrombus or embolus;
Blood vessel rupture;
Blood vessel permeability disorder;
Increased blood viscosity.
CNS Blood Suply:
A. carotis communis
A. carotis externa
A. carotis interna
a. caroticothympanica
a. ophtalmica
a. cerebri anterior
a. cerebri media
a. chorioidea ant.
a. communicans post.
A. vertebralis
rami spinales
a. spinalis post.
a. spinalis ant.
a cerebelli inf. post. (PICA)
A. basilaris
(A, cerebri post.)
Luxury perfusion

Robin Hood phenomenon
15 million suffer every year, worldwide!
5 million deaths + 5 million permanently disabled
Third cause of death;

2/3 are ischemic and 1/3 haemorrhagic;

More frequent in men – the frequency increases with age exponentially, after the 6th decade.
RISK FACTORS
Modifiable
Unmodifiable
Genes
Body weight, obesity
Age, gender, race
Socio-economic factors
Cigars and alcohol
Physical activity
Climate
Geography
Previous disease: DM, HTA, CMP...
TIA and RIND
DM and HTA (with therapy)
TIA and RIND (with therapy)
Blood cholesterol and triglycerides
Sunday, 11.05.2014
16:30-18:00
Definition


Stroke - is the loss of brain function due to a disturbance in the blood supply to the brain.
Ischaemic CVI
Haemorrhagic CVI


Transient ischemic attack
Transient ischemic attack (TIA) is an acute episode of temporary neurologic dysfunction that results from focal cerebral, spinal cord, or retinal ischemia and is not associated with acute tissue infarction with symptoms lasting as long as 24 hours.

Ischemic stroke
Acute ischemic stroke - sudden loss of blood circulation to an area of the brain, typically in a vascular territory, resulting in a corresponding loss of neurologic function.

Patophysiology
Ischemic core and penumbra
Ischemic cascade
Hemorrhagic transformation of ischemic stroke
Poststroke cerebral edema and seizures


Common signs and symptoms
Hemiparesis, monoparesis, or (rarely) quadriparesis
Hemisensory deficits
Monocular or binocular visual loss
Visual field deficits
Diplopia
Dysarthria
Facial droop
Ataxia
Vertigo (rarely in isolation)
Aphasia
Sudden decrease in the level of consciousness

Essential components of physical examination
Ocular fundi (retinopathy, emboli, hemorrhage)
Heart (irregular rhythm, murmur, gallop)
Peripheral vasculature (palpation of carotid, radial, and femoral pulses; auscultation for carotid bruit)


Neurologic examination
Cranial nerves
Motor function
Sensory function
Cerebellar function
Gait
Deep tendon reflexes
Language (expressive and receptive capabilities)
Mental status and level of consciousness

Middle cerebral artery stroke
Anterior cerebral artery stroke
Disinhibition and speech perseveration
Primitive reflexes (eg, grasping, sucking reflexes)
Altered mental status
Impaired judgment
Contralateral weakness (greater in legs than arms)
Contralateral cortical sensory deficits
Gait apraxia
Urinary incontinence

Contralateral hemiparesis
Contralateral hypesthesia
Ipsilateral hemianopsia
Gaze preference toward

Agnosia
Receptive or expressive aphasia, if the lesion occurs in the dominant hemisphere
Neglect, inattention, and extinction of double simultaneous stimulation, with some nondominant hemisphere lesions

the side of the lesion
Posterior cerebral artery stroke
Contralateral homonymous hemianopsia
Cortical blindness
Visual agnosia
Altered mental status
Impaired memory


Vertebrobasilar artery occlusions
Vertigo
Nystagmus
Diplopia
Visual field deficits
Dysphagia
Dysarthria
Facial hypesthesia
Syncope
Ataxia

Lacunar stroke
Lacunar strokes result from occlusion of the small, perforating arteries of the deep subcortical areas of the brain.
pure motor
pure sensory
ataxic hemiparetic strokes
Hemorrhagic Stroke 
It results from a weakened vessel that ruptures and bleeds into the surrounding brain.
intracerebral  hemorrhage
subarachnoid hemorrhage.
Subarachnoid hemorrhage
Sudden onset of severe headache
Signs of meningismus with nuchal rigidity
Photophobia and pain with eye movements
Nausea and vomiting
Syncope - Prolonged or atypical

The goals of stroke identification
Detect extra-cranial causes of stroke symptoms
Distinguish stroke from stroke mimics
Determine and document for future comparison the degree of deficit
Localize the lesion
Identify comorbidities
Identify conditions that may influence treatment decisions (eg, trauma, active bleeding, active infection)

CT Scan
emits a series of narrow beams through the human body as it moves through an arc
X-ray detector which can see hundreds of different levels of density
Bones

Contrast
3D
The tissue density on CT scan is measured in?

Ischemic stroke
Haemorrhagic stroke
DDg:
Ischemic stroke
Haemorrhagic
Ischemic stroke
Haemorrhagic stroke
Uses the body`s natural magnetic properties
Hydrogen nucleus (single proton)
radio wave frequency (RF) NOT X Ray!
Soft tussues


MRI ISCHEMIC STROKE
MRI HAEMORRHAGIC STROKE
detects pairs of gamma rays which are emitted indirectly by a trace

Now, let's practice...
CASES
An 83-year-old woman with a history of hypertension and dyslipidemia developed acute onset of impaired speech and comprehension, and right-sided weakness. Her previous medical history was notable for hyperthyroidism and a curative remote mastectomy for breast cancer. The patient was on two antihypertensive medications and a statin, and she was not receiving any antiplatelet medication. She was taken by ambulance to a primary stroke center. Initial examination showed global aphasia, right homonymous hemianopia, right hemiplegia, and hemisensory loss.
Which artery is probably occluded?

A 52 yo AA hypertensive, diabetic, hypercholesterolemic man awakens and cannot express himself. His entire right side is numb and weak. Neurologic exam shows a right hemiparesis (face, arm and leg are equal). Hemianesthesia is present and there is a Broca aphasia. The patient reports mild left temporal headache.
A 67 year old hypertensive, diabetic, hypercholesterolemic, obese, sedentary man with prior history of coronary artery disease, peripheral vascular disease, and transient ischemic attack develops left facial numbness, vertigo and gait disequilibrium. This develops four days after an episode of emotional stress during which he is accused of causing a labor dispute involving his labor union.
The physical exam reveals BP 200/110, pulse 80. The neurologic exam reveals a broad based gait and a left Horner's syndrome. There is left facial and right body anesthesia, left dysmetria, decreased gag and palatal reflex, and dysarthria.

SCANS
Uh, finally!
CASE 1
CASE 2
CASE 3
Full transcript