Cerebrovascular disease

summarization
1. definition: diseases come from cerebral vessels
(stroke: rupture or occlusion of cerebral vessels lead to hemorrhage or infarction, at last cause cerebral local blood circulation and dysfunction )

2. pathology: (1) vascular wall disease (2) changes of blood components (3) hemodynamic changes 3. Clinical: (1) incidence: high (2) stroke types: (a) ischemic (b) hemorrhagic (c) mixed 4. imaging: (1) CT (2) MRI

一、 cerebral hemorrhage

1. definition: cerebral parenchymal hemorrhage 2. cause: high blood pressure, aneurysm, vascular malformation, and so on. 3. pathology: atherosclerosis 4. location: basal ganglia, brain lobule, thalamus, pons and cerebellum 5. stages: (1) according to evolution of pathology: (a) acute stage: 1 days ~3 days (b) absorption stage: 3 days ~1 month (c) cystic change stage: >1 month (2) according to time: (a) hyperacute: <24 h (b) acute: 1~2days (c) subacute: 3days ~ 1 month (d) chronic: > 1 month 6. imaging findings: CT and MRI

Imaging findings
CT:
1. acute stage: (1) density: high, CT value=60~90Hu (2) shape: round or oval or irregular (3) border: clear (4) peripheral edema: yes or no (5) mass effect: nearby sulcus or cistern or ventricle
become narrow

2. Absorption stage:
(1) density: slight low and mixed (2) shape: round or oval or irregular (3) border: indistinct (4) peripheral hypodensity: extend (5) mass effect: lighten

(melting ice sign: process of absorption of hematom is from peripheral to center)

2. Cystic change stage:
(1) density: low (2) shape: round or oval (3) border: distinct capsule (4) peripheral hypodensity: disappear (5) negative mass effect: nearby ventricle, sulcus, cistern enlarge

focus of malacia

Evolution of hematoma on MRI
oxyhemoglobin deoxyhemoglobin methemoglobin methemoglobin hemosiderin
(red blood cell complete )

( red blood cell lysis )

oxyhemoglobin
Without effect on T1 and T2

deoxyhemoglobin
T1WI
iso- or slight hypo-

T2WI
hypointensity

(notes: deoxyhemoglobin can shorten time of T2, but cannot effect on T1)

T1WI

T2WI

Methemoglobin
(red blood cell complete)

T1WI
high

T2WI
low

(notes: methemoglobin can shorten T1 and T2 )

Methemoglobin
(red blood cell lysis)

T1WI
high

T2WI
high

(notes: methemoglobin can shorten T1 and prolong T2 )

hemosiderin
T1WI
low

T2WI
low

(notes: methemoglobin can shorten T2, but cannot effect on T1 )

MR:
1. hyperacute stage(<24 hours, oxyhemoglobin) (1) signal: T1: iso- or slight high T2: iso- or slight high or mixed (2) shape: round or oval (3) border: clear (4) peripheral edema: yes or no (5) mass effect: nearby sulcus or cistern or ventricle
become narrow

2. Acute stage: (1~2days , deoxyhemoglobin)
(1) signal: T1: iso- or slight low T2: low (2) shape: round or oval (3) border: clear (4) peripheral edema: yes or no (5) mass effect: nearby sulcus or cistern or ventricle
become narrow

T1WI

T2WI

3. subacute stage: (3 days~1month)
(1) early stage: (methemoglobin in cell, 3~5days, ) T1: high (from peripheral to center) T2: low (2) middle stage: (methemoglobin out cell, 6~10days, ) T1: high T2: high (from peripheral to center) (3) late stage: (methemoglobin out cell, 10days~1month ) T1: high T2: high (low ring-- hemosiderin)

early stage

late stage

4. Chronic stage: (>1 month , hemosiderin )
(1) hemosiderin: T1: low T2: low (2) cyst: T1: low T2: high

cyst

A lot of hematomas have no typical evolution Cause: 1. individual differences 2. time of hematoma is un-definite 3. repeated bleeding 4. difference of size of hematoma 5. different field strength

二、 cerebral infarction

1. definition: necrosis of cerebral tissue owing to blood barrier 2. cause: (1) atherosclerosis: 90% (2) embolic embolism (3) blood disease (4) vasculitis 3. location: basal ganglia, brain lobule, thalamus, brain stem,cerebellum 4. stages: according to time: (a) hyperacute: <6 h (b) acute: <3 days (c) subacute: 4day ~ 2 weeks (d) chronic: > 2 weeks 5. types: (1) ischemic (2) hemorrhagic (3) lacunar

6. clinical: (1) age: >40 years old (2) symptom and sign: (dependent on size, location and time of infarction)
(a) headache, dizzy, vomit, coma (b) damage of cerebral function: hemiplegia, aphasia, hemianopsia

7. imaging findings: CT and MRI

1. ischemic cerebral infarction
1. definition: cerebral necrosis owing to lack of blood 2. cause: artery stenosis, occlusion 3. imaging: (a) CT (b) MR

CT: 1. hyperacute stage: (< 6h) (1) some of cases: normal (2) some of cases: dense artery sign (3) some of cases: gray-white borer obscure

?

>24h

dense artery sign

< 12h

> 12h

2. Acute stage: (<3 days) (1) density: low (2) shape : patchy or irregular (3) border: unclear (4) mass effect: slight

3. subacute stage: (4 days ~ 2 weeks) (1) density: low (2) shape : patchy or irregular (3) border: un-clear (4) mass effect: peak within 2~5 days

4. chronic stage: (> 2 weeks) (1) density: low (2) shape : patchy or irregular (3) border: clear or unclear (4) mass effect: disappear gradually (5) fogging effect:
(a) time: 2~3 weeks (b) cause: capillary proliferation, reperfusion, macrophage activity (c) isodensity on CT

fogging effect

MR: 1. hyperacute stage: (< 6h)
(1) T1WI: (a) gyrus slight swelling (b) sulcus obscure (c) gray-white border unclear (2) T2WI: normal (3) DWI: hyperintensity (within 30 minutes DWI can get diagnosis)

DWI

DWI

2. acute stage: (< 3 days)
(1) T1WI: low (2) T2WI: high (3) DWI: high

flair

DWI

3. subacute stage: (4 days ~2 weeks )
(1) T1WI: low > acute (2) T2WI: high> acute (3) enhancement: gyrus-like

4. chronic stage: (>2 weeks )
(1) T1WI: low (2) T2WI: high

focus of malacia

2. Hemorrhagic cerebral infarction
1. definition: secondary hemorrhage after infarction 2. cause: (a) embolus embolism: common (b) thrombosis 3. incidence: 18~42% 4. age: (a) embolism: all ages (b) thrombosis: > 40 years old 5. imaging: (a) CT (b) MR

CT: (1) density: mixed (2) shape: irregular (3) border: unclear

MR: T1 and T2: mixed signal

3. lacunar cerebral infarction
1. definition: small infarction in deep brain, D<15~20mm 2. cause: small branch of the artery blockage 3. incidence: 20% 4. location: basal ganglia, internal capsule, thalamus, corona radiata, brain stem 5. imaging: (a) CT (b) MR

CT: (1) density: low (2) shape: dot-like, similar round (3) border: unclear

MR: T1: low T2: high

三、 aneurysm

1. cause: (1) atherosclerosis
(2) trauma (3) congenital development 2. types: according to the shape: (1) berry: the most common (2) fusiform (3) dissecting aneurysm 3. location: (1) berry: furcation of MCA (2) fusiform: vertebral-basilar artery (3) dissecting: vertebral-basilar artery 4. clinical: subarachnoid hemorrhage

anterior cerebral artery

anterior communicating artery

middle cerebral artery posterior communicating artery

basilar artery

vertebral artery

posterior cerebral artery

CT: (1) un-enhancement: (a) shape: round or similar round mass (b) density: high, mixed when thrombosis (c) subarachnoid hemorrhage (2) enhancement: obvously (3) CTA

Aneurysm in cavernous portion of internal carotid

CTA

Aneurysm in MCA

MR:
(1) un-enhancement: (a) shape: round or similar round mass (b) signal: T1: low T2: low, mixed when thrombosis (c) subarachnoid hemorrhage (2) enhancement: obvously (3) MRA

MRA

Aneurysm in MCA

DSA: (1) the golden standard (2) filling contrast mass

SAH,
aneurysm in anterior communicating artery

Fusiform aneurysm in MCA

四、 cerebral vascular malformation

summarization
1. cause: congenital development 2. types: (a) arteriovenous malformation (b) cerebral venous malformation (c) cavernous angioma (d) capillary malformation (e) occult cerebral vascular malformation

1. Arteriovenous malformation
1. definition: consist of a mass of arteries and venouses, directly connected 2. age: 11~40 years old, 80% 3. location: (a) system of MCA: the most common (b) system of PCA 4. clinical: (a) cerebral hemorrhage (b) epilepsy 5. imaging findings: (a) CT and CTA (b) MR and MRA>> CT (c) DSA

CT: 1. density: high or mixed 2. shape: irregular 3.calcification: common 4. hemorrhage: common 5. mass effect: no, but yes with hemorrhage 6. enhancement: obviously (feeding artery and draining vein)

AVM with hemorrhage

MR: 1. signal: low tortuous vessel mass 2. shape: irregular 3.calcification: common 4. hemorrhage: common 5. mass effect: no , but yes with hemorrhage 6. enhancement: obviously (feeding artery and draining vein)

AVM with hemorrhage

DSA: (1) the golden standard (2) filling contrast mass

2. Cavernous angioma
1. definition: consist of a mass of cavernous vessel sinus
without muscular layer and elastic layer

2. age: 3. location:

20~60 years old common (a) supratentorial: common, 75% (b) infratentorial: rare, 25% 4. clinical: (a) cerebral hemorrhage (b) epilepsy (c) headache 5. imaging findings: (a) CT and CTA (b) MR and MRA>> CT (c) DSA

CT: 1. density: high or mixed 2. shape: similar round 3.calcification: common 4. hemorrhage: common 5. mass effect: no, but yes with hemorrhage 6. enhancement: un-homogeneous

MR: 1. signal:

(a) well-defined mixed signal (b) hoop sign: center high signal and
peripheral low signal on T1 and T2

2. shape: similar round 3.calcification: common 4. hemorrhage: common 5. mass effect: no , but yes with hemorrhage 6. enhancement: un-homogeneous

Un-enhancement

enhancement

DSA: Most of cases show normal Cause: 1. thrombosis 2. blood stasis 3. smaller lesion 4. hematoma or edema oppression 5. technology

Cerebral infectious diseases

1. pathogen: germ, virus, fungus, parasite, and so on 2. types: according to site (1) meningitis (2) ependymitis (3) encephalitis (4) empyema 3. clinical: fever, headache, vomit

1. Pyogenic meningitis
1. definition: meningococcus or other germs cause the meninges 2. type: (1) epidemic meningitis (2) non-epidemic meningitis 3. pathology: (1) early: meninges congestive (2) late: thickening of meningies 4. clinical: (1) symptom and sign: acute fever, headache, meningeal irritation (2) lumbar puncture: (a) increased pressure (b) WBC and protein content increased (c) pathogen 5. imaging findings:(a) CT (b) MR

CT:
1. early stage: normal 2. advanced stage:
(a) hyperdensity: sulcus, cistern of bottom of brain, hemisphere fissure and choroid
plexus

(b) ventricle:

① enlargement: circulation of CSF blocked ② narrow: diffuse brain swelling

3. enhancement: thread-like, gyrus-like

Cisterna of lateral sulcus

Suprasellar cistren

Cisterna ambiens

MR:
1. early stage: normal 2. advanced stage:
T1: low (higher than CSF) T2: high

3. enhancement:

obviously, thread-like, gyrus-like

2. encephalitis
1. definition: inflammation of parenchama 2. pathogen: (1) virus: the most common (2) others: germ, fungus, parasite, and so on. 3. viral types: (1) herpes simplex virus : the most common (2) Japanese encephalitis virus 4. herpes simplex encephalitis types: (1) Ⅰtype: adolescent or adults (2) Ⅱtype: newborns 5. clinical: fever, headache, vomit 6. imaging findings:(a) CT (b) MR

CT:
1. density: low 2. shape: patchy 3. border: un-clear 4. mass effect: vary from mild to moderate dependent on size of lesions 5. enhancement: (a) no (b) thread-like or gyrus-like (dependent on severity and course of lesion)

MR:
1. signal: T1: low T2: high (no involved lentiform nucleus) 2. shape: patchy 3. border: un-clear 4. mass effect: vary from mild to moderate dependent on size of lesions 5. enhancement: (a) no (b) thread-like or gyrus-like (dependent on severity and course of lesion)

3.Cerebral abscess
1. definition: parenchama local pyogenic inflammation and vomica come into being 2. pathogen: (1) pyogenic germ: staphylococcus aureus (2) others: anaerobe, colon bacillus etc. 3. infectious way: (1) direct spread: 65% , otogenic and nose-derived (2) blood-borne: 25% (3) direct infection: 10%, open head injury 4. stages: (1) acute encephalitis stage (2) purulent stage (3) capsule formation stage 5. clinical: (1) infectious symptoms: fever, WBC increased (2) increased intracranial pressure: headache, vomit (3) focal symptoms of brain location: hemiplegia, aphasia, hemianopsia 6. imaging findings: (a) CT (b) MR

CT: (1) acute encephalitis stage:
1. density: low 2. shape: patchy 3. border: un-clear 4. mass effect: obviously 5. enhancement: (a) no (b) thread-like or gyrus-like

(2) Purulent and capsule formation stage:
1. density: low 2. shape: round or similar round 3. border: clear 4. mass effect: obviously 5. enhancement: ring

MR: (1) acute encephalitis stage:
1. signal: T1: low T2: high 2. shape: patchy 3. border: un-clear 4. mass effect: obviously 5. enhancement: (a) no (b) thread-like or gyrus-like

(2) Purulent and capsule formation stage:
1. signal: T1: low T2:high, wall: low 2. shape: round or similar round 3. border: clear 4. mass effect: obviously 5. enhancement: ring

4. Cysticercosis of brain
1. definition: parasite infecton 2. pathogen: cysticercus of pork tapeworm 3. infectious way: digestive canal 4. stages: (1) early stage (2) medium stage (3) late stage (degeneration or death phase ) 5. types: (1) parenchama type (2) ventricle type (3) meninges type (4) mixed type 5. clinical: (1) epilepsy: usual the first or only symptom (2) headache 6. imaging findings: (a) CT (b) MR

CT: (1) early stage:
1. density: low 2. shape: patchy 3. border: un-clear 4. peripheral edema: no 5. mass effect: mild 6. enhancement: no

(2) Medium stage:
1. density: low 2. shape: round or similar round or lobulated 3. border: clear 4. peripheral edema: no or slight 5. mass effect: mild or moderate 6. enhancement: no

(3) late stage (degeneration or death phase ) 1. density: low 2. shape: patchy 3. border: unclear 4. peripheral edema: obviously 5. mass effect: mild or moderate 6. enhancement: ring or nodular

At last calcification:
1. density: high 2. shape: nodular or pathcy 3. border: clear 4. peripheral edema: disappear 5. mass effect: disappear 6. enhancement: no

degeneration phase

enhancement

calcification

MR: (1) early stage:
1. signal: T1: low 2. shape: patchy 3. border: un-clear 4. peripheral edema: no 5. mass effect: mild 6. enhancement: no T2: high

(2) Medium stage:
1. signal: T1: low T2: high 2. shape: round 3. border: clear 4. peripheral edema: no or slight 5. mass effect: mild or moderate 6. enhancement: no

notable feature: scolex
(a) location: side-wall (b) size: 1~2mm (c) signal: similar to parenchama

(3) late stage (degeneration or death phase ) 1. signal: T1: low T2: high 2. shape: patchy 3. border: unclear 4. peripheral edema: obviously 5. mass effect: mild or moderate 6. enhancement: ring or nodular

At last calcification:
1. signal: T1: low T2: low 2. shape: nodular or pathcy 3. border: clear 4. peripheral edema: disappear 5. mass effect: disappear 6. enhancement: no

calcification

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