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 (red blood cell complete )

methemoglobin （ red blood cell lysis ）

hemosiderin
 oxyhemoglobin
Without effect on T1 and T2
 deoxyhemoglobin
T1WI T2WI

iso- or slight hypo- hypointensity

(notes: deoxyhemoglobin can shorten time of T2,

but cannot effect on T1)
T1WI T2WI
 Methemoglobin
(red blood cell complete)

T1WI T2WI

high low

(notes: methemoglobin can shorten T1 and T2 )

 Methemoglobin
(red blood cell lysis)
T1WI T2WI

high high

(notes: methemoglobin can shorten T1 and prolong T2 )

 hemosiderin
T1WI T2WI

low 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: 20~60 years old common
3. location: (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 T2: high
2. shape: patchy
3. border: un-clear
4. peripheral edema: no
5. mass effect: mild
6. enhancement: no
(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