ISCHEMIC STROKE IMAGING
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1 ISCHEMIC STROKE IMAGING ผศ.พญ พญ.จ ร ร ตน ธรรมโรจน ภาคว ชาร งส ว ทยา คณะแพทยศาสตร มหาว ทยาล ยขอนแก น
2 A case of acute hemiplegia Which side is the abnormality, right or left?
3 Early Right MCA infarction - CT Right hemisphere low density Loss of Insular ribbon sign ( loss of right insular corticomedullary junction distinction) NB; normal left side Well defined insular cortex Well defined lentiform nucleus
4 Early Right ACA+ MCA infarction Low density at right frontal and temporal lobe Effacement sylvian fissure Hyperdense arterial sign
5 Right MCA thrombosis, infarction- CT Hyperdense artery sign Cord sign temporal lobe low density with mass effect
6 Posterior cerebral a. infarction (occipital lobe &inferior aspect of temporal lobe ) Balance blood supply between PCA/ MCA
7 Basilar artery occlusion
8 Lacunar infarction Small areas of low density in right basal ganglia ( lacuna ) Deep seated or small vessels infarction ( DDX,thrombosis,emboli, Co2 poisoning
9 Subacute infarction Follow up 3 weeks later
10 Subacute infarction Decrease mass effect,gyral enhancement Luxury perfusion / collateral circulation DDX. Cerebritis / inflammation
11 Water shed infarction
12 Looking for pathology of ICA
13 Massive right cerebral infarction with hemorrhagic transformation A case of left hemiplegia for 3 days then progression of conscious change and neurological deficit
14 SSS thrombosis - CT case of female with headache conscious change and convulsion Empty delta sign in SSS in post contrast CT Left cerebral hemisphere edema
15 Venous infarction, sagittal sinus thrombosis Hypodensity area within the white matter
16 A case of coma thrombosis in deep venous system ( internal cerebral V) Low density in bilateral thalami and basal ganglia edema small hemorrhage
17 A case of coma From hypoxia, brain death Generalize low density of the whole brain. Relative small ventricle, cisterns and sulci Poor gray-white differentiation Diffuse cerebral edema
18 Hemorrhagic stroke Hypertensive Non hypertensive Rupture vascular structure, AVM / aneurysm Bleeding tumor
19 Hypertensive hemorrhage,ich Basal ganglia,external capsule, thalamus,pons, cerebellar hemisphere Pt. With underlying HT
20 A case of headache, hypertension and seizure Underlying HT,renal Low density in bilateral occipital lobe at cortex or subcortical along PCA Disappear after treatment of HT / underlying dz. DDX; PCA infarction Posterior Reversible Encephalopathy Syndrome (PRES) - CT
21 Rupture AVM, multi-compartmental bleeding Uncommon location for HT ICH and IVH
22 Rupture AVM ( continue )
23 Pial ( parenchyma) AVM No mass effect, minimal surrounding brain atrophy
24 Multiple Carvernoma,unbleed,no mass effect
25 A case of severe sudden headache High density lesion in the cisterns Sylvian fissures Interhemispheric fissures basal cistern Obstructive hydrocephalus SAH ---rupture aneurysm trauma
26 Localized SAH, located site of aneurysm
27 Rupture MCA aneurym with large ICH
28 Unruptured thrombosed RT.PCA aneurysm
29 Bleeding tumor ( high grade astrocytoma) Established evidence of surrounding brain edema on T2W
30 Conclusion Hemorrhagic stroke Hypertensive Non hypertensive ( vascular rupture ) Bleeding tumor Aterial infarction with hemorrhageic tranformation Venous infarction with parenchymal he. Ischemic -Infarction Thrombosis / emboli Arterial or venous Large or small vessel. Hypotensive infarction Border-zone (water shed ) Hypertensive encephalopathy posterior reversible encephalopathy
31 Vascular territory
32 Signs of infarction- NECT Hyperdense vessel ; MCA Loss of gray-white distinction Obscuration of deep nuclei Loss of insular ribbon Parenchymal hypodensity Gyral swelling, sulcal effacement +hemorrhagic transformation ( hrs)
33 Signs of infarction- CECT Absent vessel = occlusion Enhanced cortical vessels = slow flow or ollateral DDx cerebritis, vasculitis
34 Brain edema & mass effect Vasogenic edema tumor Cytotoxic edema metabolic Interstitial edema Ischemia = cytotoxic + vasogenic
35 REFERENCES Anne G. Osborn.Diagnostic imaging ;brain 2004 Peter Reimer. Clinical MR imaging.springer 1999 Kenneth W. Linsay. Neurology and neurosurgery Wolfgang Dahnert. Radiology review manual. Williams & Wilkins กล บส เมน หล ก
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