Neuro Interventional Topics

Interesting NeuroRadiology
cases
Patrick T. Noonan, Jr., M.D.
Director, Interventional Neuroradiology,
SWMH
Or ….. A Survey of What I Do All Day
INR
In a specialty that didn’t exist when this was written ….
….. and that isn’t discussed in these important texts
of diagnostic radiology and neuroradiology
Disclosures
Off label use of some devices will be discussed
I have no financial interests in products discussed
Many of the cases were missed by the reading radiologists;
so if you don’t see the abnormality, don’t worry
60 y/o RH man with onset of right hemiparesis
two weeks after starting ABX for endocarditis.
PTN 1.1.5
The most informative noninvasive study to obtain at this point is
a.
b.
c.
d.
PTN 1.2.5
Contrast head CT
Contrast brain MR
Skull series
CTA
Answer: d. CTA
Dx?
PTN 1.3.5
Mycotic (pseudo) aneurysm
PTN 1.4.5
collateral
Trapping
Post Tx
PTN 1.5.5
44 y/o man with cerebral “angio negative” nontraumatic SAH
and neck pain.
PTN 2.1.5
The next imaging study to recommend is
a.
b.
c.
d.
PTN 2.2.5
A complete brachiocephalic and cerebral angiogram
A CTA
An MRA
A CT myelogram
Answer: a. Perform a complete angiogram
ASA
PTN 2.3.5
AVM
LVA
PTN 2.4.5
L ECA
Cervical Perimedullary AVM
Post ASA Liquid Coil,
Pre NBCA
2 months post Tx
PTN 2.5.5
59 y/o man with rapidly progressive myelopathy
PTN 3.1.4
The consulting neurosurgeon is concerned that the patient has
a.
b.
c.
d.
e.
PTN 3.2.4
MS and calls his neurology associate
Spinal cord tumor and readies the OR
Syringohydromyelia and requests Gado MRI
Perimedullary venous HTN and requests that INR find and fix the problem
Aortic dissection and orders an aortic CTA
Answer: d. Perimedullary venous HTN caused by a dural
arteriovenous fistula (DAVF) will cause ischemic myelopathy
– syndrome of Foix and Alajouanine. Spinal angiography is
the gold standard procedure to find the DAVF. Endovascular
embolizationis the first line treatment.
Dilated perimedullary vessels and
cord edema = DAVF
Charles Foix
PTN 3.3.4
Theophile Alajouanine
Giovanni Di Chiro
John L. Doppman
Spinal dural arteriovenous fistula (SDAVF) in L L2 nerve root sleeve
L L2
L L2
L T10/ASA
Pre @ 18 sec
L T10
ASA Post
L L2 Pre-Embo
PTN 3.4.4
NBCA
L L2 Post
42 y/o man with neck pain
PTN 4.1.5
The next study to recommend is a
a.
b.
c.
d.
PTN 4.2.5
Cervical spine CT
Neck MRA
Head MRA
CT myelogram
Answer: c. MRA
Flow voids
Vermian vein
Another study perhaps?
PTN 4.3.5
PTN 4.4.5
Cerebellar tonsil BAVM
Pre-embo
Post pre-op NBCA embo
PTN 4.5.5
60 y/o barmaid with two weeks of progressive BLE paresis and urinary retention
PTN 5.1.8
The next thing to order is a
a.
b.
c.
d.
PTN 5.2.8
CT myelogram
Gadolinium enhanced total spine MRI
Pelvic CT
Bloody Mary
Answer: b. Gado MR
PTN 5.3.8
At this point you know what has caused her myelopathy
and you can confidently
a.
b.
c.
d.
e.
f.
PTN 5.4.8
Call neurosurgery to remove a spinal tumor
Call neurosurgery to correct a congenital abnormality
Call a neurologist who will promptly ask for an MS LP
Tell the neurologist to stick himself with the needle
Send the case to an interventional neuroradiologist
c. and d.
Answer: e. Enhancing flow voids
and myelopathy = call INR to
treat ……….
PTN 5.5.8
Hen with teeth
PTN 5.6.8
Sacral spinal dural arteriovenous fistula (SDAVF) in association with an
intradural sacral lipoma and a tethered cord
PTN 5.7.8
NBCA cast
Pre-embo
MRI
PTN 5.8.8
1 month post embo
12 y/o boy found down in bathroom by his divorced father during the
father’s weekend to host his son
PTN 6.1.4
You concur with the neurosurgeon’s request for a ______
a.
b.
c.
d.
PTN 6.2.4
Evaluation by child protective services
Head MRI and MRA
Head CTA
Catheter cerebral angiogram
Answer: d. Emergent pre-op cerebral angiogram for definitive Dx and embo.
Ruptured brain arteriovenous fistula
PTN 6.3.4
PA
LAT
Pre AVF embo
Post surgery
Post NBCA pre-op embo of AVF and BAVM
PTN 6.4.4
9 y/o boy and his brother were playing with Dad’s gun
The vascular surgeon can’t locate the source of bleeding so he asks for ….
PTN 7.1.2
R IMA transection
PTN 7.2.2
Post GDC embo
28 y/o multiparous woman was disrespectful of her current boyfriend
when she attempted to drive away during an argument
PTN 8.1.6
Once again the vascular surgeon can’t localize the source of
bleeding and asks for an angiogram. You quickly comply. In
addition to looking for arterial pseudoaneurysms you should
search for
a.
b.
c.
d.
PTN 8.2.6
Traumatic arteriovenous fistulae
Arterial occlusions
Intravascular foreign body emboli
All of the above
Answer: d. all of the above
PTN 8.3.6
Shotgun pellet embolic occlusion of left IMA
and ……
RVA
Shotgun pellet embolus to basilar terminus without occlusion.
PTN 8.4.6
Viabahn (Gore)
repair of LCCA
LCCA
PTN 8.5.6
Viabahn (Gore)
repair of RVA
Pre
Post
PTN 8.6.6
84 y/o woman with headache and change in vision
PTN 9.1.5
You recommend that the next test be
a. Cerebral angiogram because she has a brain AVM (BAVM)
b. A gado brain MR because she has a tumor
c. A GRE brain MR and a gado brain MR because she has a
cavernous malformation and a developmental anomaly of
venous drainage (DVAD)
d. Cerebral angiogram because she has a dural arteriovenous
fistula (DAVF)
PTN 9.2.5
Answer: d. Cerebral angiogram to assess for DAVF
R MCA and PCA
L MCA and PCA
Cortical veins
“Symmetric” normal caliber pial arteries with
enlarged and tortuous cortical veins
PTN 9.3.5
Dural arteriovenous fistula (DAVF) with
cortical venous drainage (Cognard Type IV)
PTN 9.4.5
L MMA Pre Embo
Onyx
L OccA Pre Embo
Post Embo
PTN 9.5.5
NBCA
80 y/o RH woman with increasing headache and vision impairment
that didn’t improve after recent cataract surgery
PTN 18.1.3
PTN 18.2.3
Post placement of coils and
Pipeline Embolization Device
HA resolved and vision normal
by fourth day after procedure
PTN 18.3.3
66 y/o dialysis dependent man with 4 month Hx of progressive BLE weakness,
now wheelchair bound.
PTN 10.1.5
Your next recommendation is a
a.
b.
c.
d.
e.
PTN 10.2.5
Gado cervical and brain MRIs
LP to assess for MBP
Spinal cord biopsy
CTA
Catheter angiography
Answer: e. Catheter angiography
Cord edema + dilated perimedullary vessels = ……………..
PTN 10.3.5
Foramen magnum DAVF with perimedullary venous drainage
Left occipital artery
Left hypoglossal artery with dangerous anastamosis to LVA
PTN 10.4.5
LVA balloon
Pre hypoglossal embo
NBCA
4 month F/U
Walking.
PTN 10.5.5
Post embo
76 y/o RH woman with aphasia admitted after third CVA in past two months
PTN 11.1.5
PTN 11.2.5
The care plan should include
a.
b.
c.
d.
e.
PTN 11.3.5
Risk factor modification
Aggressive antiplatelet therapy
Statins
Interventional revascularization
All of the above
The stroke neurologist picked e.
Pre
Post
L MCA PTA without stent
PTN 11.4.5
INITIAL
7 MONTHS
11 MONTHS
PTN 11.5.5
No recurrence of Sx
23 y/o RH woman develops R hemiparesis 2 hours after motorcycle accident
Dx: Traumatic intracranial LICA dissection.
PTN 19.1.3
5 hours after CTA, I was called
PTN19.2.3
RICA and LVA collaterals
LICA Pre treatment
Crossing the dissection
Neuroform stent placement
Perfusion re-established by 9 hours after CTA.
Unfortunately, left hemispheric infarct established.
Time is brain!
PTN 19.3.3
86 y/o RH woman with sudden onset of HA and AD hearing loss
PTN 12.1.5
PTN 12.2.5
The Dx is
a.
b.
c.
d.
e.
PTN 12.3.5
Ruptured
Ruptured
Ruptured
Ruptured
Ruptured
distal PICA aneurysm
distal AICA aneurysm
DAVF
spinal cord AVM
BAVM
Answer: b. Ruptured AICA (variant) aneurysm
Ruptured AICA/RVA fenestration aneurysm
PTN 12.4.5
Lateral Post
PTN 12.5.5
PA Post
48 y/o RH man with right neck pain and AD pulsatile tinnitus
PTN 13.1.9
PTN 13.2.9
DX is
a.
b.
c.
d.
PTN 13.3.9
Paraganglioma
Aberrant vessel
Persistant hyoid artery
DAVF of the hypoglossal canal
Photo: Matthew Harris, Ph.D., University of Wisconsin
Normal chicken embryo on left. Mutant chicken embryo on right.
PTN 13.4.9
Answer: d. DAVF of the hypoglossal canal
Asymmetrically larger arterial flowvoid-containing R hypoglossal canal
PTN 13.5.9
Tanoue S, et al, AJNR 26:1955–1959, 2005
PTN 13.6.9
Liu JK, et al, J Neurosurg 109:335–340, 2008
L APA
R APA
RVA
R Occip
PTN 13.7.9
DX: R hypoglossal canal DAVF
R IJV
Pre R IPS embo
PA
LAT
IPS embo
NBCA
Post
Tx of hypoglossal canal DAVF
PTN 13.8.9
Pre hypoglossal a. embo
Immediate post
3 month post
PTN 13.9.9
No recurrence of Sx
55 y/o RH man with HA and new L hemiparesis has distant Hx of XRT for pineal tumor
PTN 16.1.7
Because of concern for ____________ he received a cerebral angiogram
a.
b.
c.
d.
PTN 16.2.7
BAVM
Aneurysm
Cerebral vasculitis
DAVF
Answer: c. Cerebral
vasculitis may present
with hemorrhage.
MCA stenoses
PTN 16.3.7
Lateral displacement of MCA
Angiographic DX: Intra-axial mass with AV shunt = GBM = Path Dx
PTN 16.4.7
Different patient
Medial displacement of MCA
16.5.7
Extra-axial mass displaces
pial vessels towards brain.
Vessels are seen between
brain cortex and mass.
PTN 16.6.7
Angiographic DX: extra-axial mass with pial invasion, e.g., meningioma
PTN 16.7.7
51 y/o RH man with tonsillar SCCA and significant bleed necessitating a
tracheostomy one week prior to this neck CT
PTN 17.1.6
One month later he returns c/o oropharyngeal bleeding after a coughing fit.
You are concerned that he may have impending _______________.
Regardless, he leaves the hospital after counseling.
a. Carotid blowout
b. Pharyngeal obstruction
c. a. and b.
PTN 17.2.6
Answer: c.
Ill defined submucosal
vessels
Airway narrowing
PTN 17.3.6
He returns in shock 10 days after leaving hospital (40 days post CT)
L ECA blowout
PTN 17.4.6
L ECA embo
Post
PTN 17.5.6
Post LECA embo
LICA sacrifice
PTN 17.6.6
Summary
For complex and seemingly insoluble neurologic disease and
anything else in the head, neck, and spine that may have a vascular
basis, consider consultation with interventional neuroradiology. I
will be glad to help you.
Addendum:
Attention to detail is everything.
PT Noonan, ENS, USNR, DCA
USS Farragut DDG-37. Underway, 06 July 1982