CTA Head
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This CME activity consists of the student reviewing the video of the professor reviewing the case as well as the associated DICOM image set related to the case in question.
Learning Objectives
As a result of participation in this activity, participants should be able to:
- Provide improved patient care.
- Greater knowledge of the imaging characteristics of the patient's disease.
- Understand a better approach to interpretation of studies.
Faculty Disclosure
Mehmet Albayram, MD, Ivan Davis, MD, Mariam Hanna, MD, Anthony Mancuso, MD, Ronald Quisling, MD, Dhanashree Rajderkar, MD, Priya Sharma, MD, Roberta Slater, MD and Joann Stamm, MBA have disclosed that they have no relevant financial relationships. No one else is a position to control content have any financial relationship to disclose.
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Conflict of interest information for the CME Advisory Committee members can be found on the following website: https://cme.ufl.edu/disclosure/.
Continuing Medical Education Credit
Accreditation: The University of Florida College of Medicine is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians.
Credit: The University of Florida College of Medicine designates this enduring material for a maximum of 0.5 AMA PRA Category 1 Credits. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
CA0457-CTA Head
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CA0457-CTA Head
Case ReportHistory
Exam
Prior Study
1. Acute thrombus in Lt. intracranial primary and secondary stem components of the Lt. ICA
2. Early cytogenic edema in both Lt. ACA & MCA territories, likely stroke-age is in the 3-6 hour range.
CT Perfusion
CT perfusion was not obtained.
CTA of the Neck
There were no flow limiting stenoses in the lower and mid cervical major afferent arteries.
There is unexplained reduced lumen size of the upper Lt. cervical ICA likely secondary to downstream obstruction. However, the neck CTA did not include any of the intracranial/extradural parts of the left ICA.
No venous egress obstruction was evident.
Findings
CTA of the head
The precise level of the left ICA occlusion is difficult to see, particularly in the skull base, because subtracted images were not obtained in this case. However, the upper part of the left cervical ICA demonstrates a reduced lumen size consistent to a downstream arterial block. There is no contrast in the intrapetrous carotid nor cavernous carotid and no EC-IC collateralization. Arterial block is likely at beginning at the vertical intrapetrous artery segment. The absence of proximal arterial atherosclerotic or inflammatory changes makes intrapetrous ICA dissection very likely when the occlusion originates at the start of the intrapetrous carotid canal (a fixation point).
CTA of the head demonstrates virtually no contrast in any of the intracranial/extradural segment, nor is there any contrast opacification of the Lt. intradural ICA nor it’s secondary divisions or distal branches; there is no evidence or afferent arterial circulation to the left carotid circuit.
There is evidence of pial collateral arising from the left PCA at least to the ventral brain surface. There is no circle of Willis nor ACA collateralization to the left cerebrum.
The right side of the circle of Willis is intact. The left P-com fills but stops in the suprasellar space. This abrupt cut off in the context of cytogenic edema, is indicative of a pathological compression related incisural herniation and is an ominous sign.
The left orbital arteries are present but reduced in size compared to the right. These ophthalmic branches are filling via collateral pathways.
There is no filling of superficial or deep Lt. hemispheric veins
Impression
2. There is complete thrombosis of both the intracranial/extradural and intradural Lt. ICA with no filling of the primary or secondary intracranial stem branches, plus there is little distal pial artery retrograde filling from pial collaterals. In essence there is no arterial circulation to the left ICA at all.
3. There is no filling of the left cortical or deep central veins. These same veins are all well seen on the normal right side. This is consistent with the venous collapse and advanced hemispheric dense ischemic core possibly to the level of acute sequestered infarction.
4. Cut-off of the opacified left P-com is indicative of incisural brain herniation on the left.
