CD B [RADIO]: CEREBROVASCULAR DISEASE, MENINGITIS, ETC.

APRIL 12, 2018

CEREBROVASCULAR DISEASE
STROKE
 Clinical term applied to any abrupt non traumatic brain insult-
literally "'a blow from an unseen hand."
 Infarct (75%)
 Hemorrhage (25%)

ISCHEMIC STROKE
 Caused by a blocked artery to the brain either from the build-up of
plaques within the artery wall or from a clot.
 Etiology:
 2/3 are due to thrombi
 1/3 are due to emboli

HYPERACUTE SIGNS
 Seen within minutes to few hours after occlusion
 CT:
 Hyperdense artery sign – actual thrombus in large intracranial
vessels

ACUTE MCA ISCHEMIA

 CT:
 Within 6 hours of MCA occlusion
 Insular ribbon sign  subtle blurring of the gray-white layers
of the insula due to edema
 Edema may also be seen in the putamen  lentiform nucleus
edema sign
 MRI: DIFFUSION WEIGHTED IMAGE (DWI)
 MR:
 Most sensitive imaging sequence for detection of brain
 Loss of flow void – normal black signal of flowing blood is lost
and may be replaced by abnormal signal representing a clot or ischemia
slow flow  May turn positive minutes after infarction begins, well before
the CT shows subtle signs.
 Hyperintense signal  "light-bulb sign

Page 1 of 8
“Vitanda est improba siren desidia”
CD B: RADIO | CEREBROVASCULAR DISEASE, MENINGITIS, SEIZURES, HEADACHES
APRIL 12, 2018

CHRONIC ISCHEMIA
 Weeks to months after infarction
 Dead tissues are removed leaving a small amount of gliotic scar
 CSF takes the space
 Affected corticospinal tract atrophies (Wallerian degeneration)
seen as shrunken appearance of the ipsilateral cerebral
peduncle
 Widening of adjacent sulci and ex-vacuo dilatation of the
ventricles adjacent to the infarcted area

SUBACUTE ISCHEMIA
 Peak at 3-7 days
 Edema leads to mass effect ranging from sulcal effacement to
marked midline shift with brain herniation

Page 2 of 8
“Vitanda est improba siren desidia”
CD B: RADIO | CEREBROVASCULAR DISEASE, MENINGITIS, SEIZURES, HEADACHES
APRIL 12, 2018

IMAGING OF HEMORRHAGE
CT SCAN
 Hemorrhage are detected because of increased attenuation (white).
 Imaging method of choice for emergency evaluation in acute
setting.

MRI
 Complex signal patterns related to iron oxidation on MR
 Acute blood can sometimes be hard to detect on MR but some
sequences will help in the diagnosis:
 FLAIR for subarachnoid hemorrhage
 Gradient echo T2 for parenchymal bleeding
 MR is better than CT for detection and characterization of
The non-contrast head CT is often negative (normal) with the first 4 subacute or chronic hemorrhage
hours of a stroke. It generally takes 4-6 hours for changes of  MR signal of blood depends on a complex interplay of multiple
ischemia to manifest on CT. In this patient, at 3 hours the head CT factors, mainly the the oxidation state and location of iron species
was normal. 1 day later you start to notice blurring of the gray-white related to hemoglobin
differentiation within the anterior right MCA distribution consistent TIME Hemoglobin state T1 T2
with cytotoxic edema. 3 months later these findings are much more signal signal
obvious, now with areas of encephalomalacia or volume loss Hyperacute < 1day Oxyhemoglobin Iso/dark Bright
Acute 0-2 days Deoxyhemoglobin Iso/dark Dark
Early 2-14 Methemoglobin Bright Dark
subacute days (intracellular)
Late 10-21 Methemoglobin Bright Bright
subacute days (extracellular)
Chronic ≥21 Hemosiderin/ferritin Iso/dark Dark
days

MR is much more sensitive in detecting early infarction than

CT. Specifically the DWI sequence can be positive within minutes of
infarction (not ischemia, but infarction). If MR is more sensitive than
CT to detect infarction why is MRI not performed as the first test in
patients presenting with stroke? Treatment (tPA) decisions are based
on clinical symptoms (stroke scale) and a negative head CT. MRI is
not available everywhere and takes more time to screen patients and
acquire images. Time = brain, so every second counts.

HEMORRHAGE
 Occurs when an artery or vein ruptures
 Divided into:
 Subarachnoid
 Parenchymal

Page 3 of 8
“Vitanda est improba siren desidia”
CD B: RADIO | CEREBROVASCULAR DISEASE, MENINGITIS, SEIZURES, HEADACHES
APRIL 12, 2018

SUBARACHNOID HEMORRHAGE (SAH)

 Most commonly due to aneurysm rupture
 Other causes: drugs, trauma, dissection, coagulopathies
 Most common presentation of aneurysm rupture: sudden, severe
headache, sometimes described as the worst headache of their life
 Aneurysms greater than 3 to 5mm are at increased risk for rupture
 Usually berry aneurysms
 Common locations include near branch points of the Circle of Willis
 Nearly 85% sprout from the anterior part of the circle of Willis,
whereas 15% from the vertebrobasilar territory.
 33% - anterior communicating artery
 30% - middle cerebral artery  MRI (GRE sequence)
 25% - posterior communicating artery  (+) Susceptibility in GRE MRI sequence (black)
 10% - basilar artery  Can diagnose microbleeds early
 Use of FLAIR sequences on MR can improve conspicuity of acute
blood, but CT is still considered the imaging method of choice when
clinical finding suggest the possibility of SAH.

MENINGITIS
 Can be caused by bacteria, mycobacteria, fungi, parasites, or viruses.
PARENCHYMAL HEMORRHAGE  Bacteria most commonly enter the meninges during systemic
 Bleeding directly into the brain substance bacteremia but can spread directly from infected sinuses or after
 Causes: surgery or trauma.
 Hypertensive hemorrhage is the most common cause of  Patients present with a relatively acute onset of fever, neck stiffness,
spontaneous intraparenchymal bleed. irritability, and headache, followed by a decline in the mental status.
 5 most common location of hypertensive bleed:
 Putamen (35 to 50%) IMAGING OF MENINGITIS
 Subcortical white matter (30%)  CT scan performed in the emergency setting are frequently
 Cerebellum (15%) normal.
 Thalamus (10-15%)  The inflammatory exudate caused by the meningitis may produce
 Pons (5 to 10%) high density on CT scan and hyperintensity on FLAIR sequence
 CT SCAN within the subarachnoid spaces and ventricles.
 Increased attenuation on CT  Contrast enhanced imaging  meningeal enhancement can range
 Plain CT scan from being absent or subtle to very thick and extensive.
 test of choice for emergency evaluation of suspected  Neuroimaging is perhaps used more importantly later in the course
hemorrhage of meningitis when there are suspected complications such as

Page 4 of 8
“Vitanda est improba siren desidia”
CD B: RADIO | CEREBROVASCULAR DISEASE, MENINGITIS, SEIZURES, HEADACHES
APRIL 12, 2018

hydrocephalus, cerebritis or abscess, arterial or venous infarction,  What imaging do you request?
subdural effusion or empyema, and herniation.  Detailed MR examination (high-resolution coronal
images of the medial temporal lobes and other clinically
ENHANCEMENT PATTERNS suspected abnormal brain structures, is performed.

MESIAL TEMPORAL SCLEROSIS

 Hippocampal sclerosis, is the most common association with
intractable temporal lobe epilepsy (TLE).
 MRI is the modality of choice to evaluate the hippocampus.
 Findings include:
 Reduced hippocampal volume: hippocampal atrophy
 Increased T2 signal
 Abnormal morphology: loss of internal architecture
(interdigitations of hippocampus): stratum radiata, a thin layer
of white matter separates the dentate nucleus and Ammon
horn.

SEIZURE HEADACHE
 First episode of seizure:  Frequent indication for imaging of the brain.
 What to rule out?  Patients with "thunderclap" headaches or with complain of
 Intracranial tumor “worst headache of his life”.
 Infection  What do you request?
 Other acute process must be excluded  Non-contrast head CT scan
 What imaging modality do you request?  What to rule out?
 Contrast-enhanced MR or contrast enhanced CT?  Subarachnoid haemorrhage
 If the patient is in the immediate postictal state, or if  Acute hydrocephalus
a residual neurologic deficit is present at the time of  Enlarging intracranial mass
imaging  non-contrast CT scan should be  Chronic headache
obtained as the first study to exclude acute surgical  What imaging do you request?
pathology.  If not accompanied by focal neurologic symptoms 
 If the seizure disorder is chronic, and particularly if it is Non-contrast MR scan
refractory to medical therapy.  If the headache is associated with focal neurologic
complaints  gadolinium-enhanced MR

Page 5 of 8
“Vitanda est improba siren desidia”
CD B: RADIO | CEREBROVASCULAR DISEASE, MENINGITIS, SEIZURES, HEADACHES
APRIL 12, 2018
 When chronic headache is the sole presenting complaint, the
yield of imaging is low.
 Typical uncomplicated migraine may not require imaging.
REVIEW
A 59 year old woman develops sudden onset left-sided weakness. A
stat non-contrast head CT is ordered which reveals what etiology for
her symptoms?
 This is a classic location for a hypertensive hemorrhagic stroke in a
nontraumatic patient.
 Incidental hyperdensities in the basal ganglia and pineal gland (blue
arrows) are benign calcifications, not to be confused with additional
foci of hemorrhage
An unidentified male is brought to the ED by EMS after suffering a
blow to the head. A non-contrast head CT is performed. What is the
principal abnormality and how many associated findings can be
identified?
54 year old male. Known hypertensive and diabetic. 3 hours history
of right sided body weakness and slurring of speech. What pertinent
CT scan finding do you see?
A patient with a known intracranial aneurysm develops a sudden
onset headache and a non-contrast head CT is performed. What is
the principal abnormality?
 The CT scan demonstrates an extensive subarachnoid hemorrhage
(red arrows) filling the basilar cisterns.
 Subarachnoid hemorrhage will replace the normally hypodense
cerebrospinal fluid with hyperdense acute blood.
 This can be found within the cisterns or around the sulci, typically
the largest subarachnoid spaces, such as the suprasellar cistern and
the Sylvian fissures.
 Trauma and rupture of an intracranial aneurysm are the most
common etiologies.
An inpatient develops sudden onset right-sided weakness. A stroke
code is called and a non-contrast CT scan is obtained emergently.
What findings are present?
 The CT scan shows an acute left middle cerebral artery territory
ischemic stroke.
 There is obscuration of the lentiform nucleus, loss of the gray-white
matter differentiation (yellow arrow), and sulcal asymmetry (green
arrow).
 Acute ischemic strokes may be difficult to detect before edema or
mass effect develops.
 Another classic early sign is a hyperdense vessel from intraluminal
thrombus.
Page 6 of 8
“Vitanda est improba siren desidia”
CD B: RADIO | CEREBROVASCULAR DISEASE, MENINGITIS, SEIZURES, HEADACHES
APRIL 12, 2018

A patient is brought in by EMS after rear-ending another motor

vehicle. A stat non-contrast head CT is performed. What is the cause
of the abnormalities identified by the arrows?

 The arrows are pointing to multiple petechial hemorrhages in a

patient with diffuse axonal injury (DAI).
 DAI is frequently caused by a sudden deceleration and is responsible
for about half of all intra-axial traumatic lesions. The hemorrhages
are classically small, multiple, and located at the gray-white matter
interface, as in this example. They may not be apparent on CT and
MRI is the preferred imaging modality.

64 year old patient, smoker, known diabetic and hypertensive. 5

hours prior to consult left sided hemiparesis. What important
subtle finding do you see? What is your diagnosis?

Source: Powerpoint only!!

Page 7 of 8
“Vitanda est improba siren desidia”