Anterior Cerebral Artery Angiographic Anatomy

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  • ACA segments: A1, A2, A3, A4
  • Deep perforators from A1
  • Artery of Heubner (double arrow)
  • Medullary arteries (M, short and long branches) from cortical branches
  • Leptomeningeal anastomosis with MCA (——–)

Reference:

Bradač, G. B. Cerebral Angiography. Berlin: Springer, 2011. Print.

 

ASCOD Phenotyping for Stroke

ASCO Criteria:

  • A: atherosclerosis
  • S: small-vessel disease
  • C: cardiac pathology
  • O: other causes

Assigns a degree of likelihood of causal relationship to every potential disease commonly encountered in ischemic stroke describing all underlying diseases in every patient

  • 1 for potentially causal
  • 2 for causality is uncertain
  • 3 for unlikely causal but the disease is present
  • 0 for absence of disease
  • 9 for insufficient workup to rule out the disease

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ASCOD Criteria

  • D: dissection
  • ‘levels of diagnostic evidence’integrated into grades 9 and 0 were left out
  • cutoff for significant carotid or intracranial stenosis changed from 70% to more commonly used 50% luminal stenosis
  • cardiogenic stroke pattern using neuroimaging added

Reference:

Amarenco, P. et al. “The ASCOD Phenotyping Of Ischemic Stroke (Updated ASCO Phenotyping)”.Cerebrovasc Dis 36.1 (2013): 1-5.

 

Angiogram of the Internal Carotid Artery

Common carotid angiogram, lateral view (a) and AP view (b)

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  • arrows indicate the ECA

 

Axial cut through dotted line in figure (b) above

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  • CS = carotid space (inside is ICA and JV, jugular vein and CN 9, 10, 11, 12)
  • PS = parotid space (inside ECA is posterior and retromandibular vein anterior)
  • PPS = parapharyngeal space
  • RPS = retropharyngeal space
  • PVS = perivertebral space
  • MS = masticator space

 

Petrous and cavernous portion of the ICA, lateral carotid angiogram.

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  • Petrous portion (red)
  • Cavernous portion (green)
  • Dural ring proximal to the origin of the ophthalmic artery
  • C5, C4, C3 = parts of cavernous ICA
  • C2, C1 = supraclinoid and subarachnoid ICA

 

Lateral carotid angiogram:

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  • arrow with dot = PComA
  • arrow = anterior choroidal artery
  • arrowhead = ophthalmic artery

 

The ophthalmic artery

Lateral ICA angiogram

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  • OA = ophthalmic artery
  • large arrow = bend around the optic nerve
  • small arrow = ocular complex (retina and cilial arteries)
  • arrowhead = choroid plexus
  • L = lachrymal artery
  • arrow with dot = anterior falx artery

 

Reference:

Bradač, G. B. Cerebral Angiography. Berlin: Springer, 2011. Print.

External Carotid Artery Branches on Angiogram

Common carotid angiogram, lateral view, showing the anterior course of the external carotid artery related to the internal carotid artery.

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  • superior thyroid artery (Th)
  • lingual artery (LA)
  • facial artery (FA)
  • occipital artery (large arrow)
  • ascending pharyngeal artery (small arrow)
  • internal maxillary artery (IMA)
  • middle meningeal artery (MMA)
  • middle deep temporal artery (DT)
  • superficial temporal artery (STA)

Reference:

Bradač, G. B. Cerebral Angiography. Berlin: Springer, 2011. Print.

Algorithm for Treatment of ICP and PbtO2 from BOOST Trial

  • Algorithm for treatment of monitoring parameters in the BOOST trial.
  • Treatment options for each ICP and PbtO2 scenario

 

Scenario Type B:  decreased PbtO2, normal ICP

123

 

Scenario Type C:  increased ICP, normal PbtO2

456

Scenario Type D:  increased ICP, decreased PbtO2

7890

 

 

Reference:

Frontera, Jennifer et al. “Regional Brain Monitoring In The Neurocritical Care Unit”. Neurocritical Care 22.3 (2015): 348-359.

SAH Management Algorithm

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Notes: 

  • In our practice, we prefer to start seizure prophylaxis in the setting of an unsecured aneurysm to abate potential deleterious effects of seizures on an already dysregulated brain. (N.B. We prefer agents other than phenytoin.)
  • The 2012 American Stroke Association guidelines suggest that a decrease in systolic blood pressure to <160mm Hg is reasonable, but in our clinical practice,  we keep the systolic blood pressure <140mm hg to further lower the risk of aneurysmal rerupture, as long as the patient is alert and CPP is adequate.

pdf file: nrneurol.2013.246-pf1

Reference:

Macdonald, R. Loch. “Delayed Neurological Deterioration After Subarachnoid Haemorrhage”. Nature Reviews Neurology 10.1 (2013): 44-58.

 

Checklist: Predictors of DCI

  • SAH Blood clot:  Volume, location, persistence over time and density
  • Poor clinical condition on admission and loss of consciousness at ictus
  • smoking (strong)
  • diabetes (mod)
  • systemic inflammatory response syndrome (mod)
  • hyperglycaemia (mod)
  • hydrocephalus (mod)
  • hex?
  • history of hypertension?
  • age (inconsistent)

CSF molecules that are possible markers of DCI

  • endothelin-1
  • IL-6
  • some markers of thrombin activation

Serum biomarkers (association, but not validated)

  • TNF
  • IL-6
  • S100β
  • ubiquitin C-terminal hydroxylase 1
  • phosphorylated axonal neurofilament heavy chain
  • matrix metalloproteinases
  • von Willebrand factor
  • endothelin-1
  • vascular endothelial growth factor
  • selectins
  • adhesion molecules

 

Reference

Macdonald, R. Loch. “Delayed Neurological Deterioration After Subarachnoid Haemorrhage”. Nature Reviews Neurology 10.1 (2013): 44-58.