Hyperacute Arterial Stroke: CTA/MRA Neck

History

Acute change in neurologic status; rule out stroke.

Exam

CTA of the Neck
This part of the CTA is performed after the second bolus of contrast, and therefore has dense contrast in both the arteries and the veins related to recirculation plus twice the contrast load. The CTA neck is performed in conjunction with the delayed post contrast head CTA for assessment of the CT-density in the parenchymal venocapillary pool.

**MRA of the neck was performed in Case 9 rather than CTA. The introductory video addresses the imaging differences between MRA of the neck versus CTA of the neck.

Purpose

1. Define sites of any and all arterial thromboses or flow-limiting, high-grade stenosis, or tandem stenoses with of lesser degrees luminal narrowing but are included in the same arterial circuit;

2. Characterize the features of each stenotic/occluded arterial segment (NASCET, assess length of stenosis/occlusion, intimal dehiscence, atherosclerotic vs inflammatory basis, etc.)

3. Determine whether there is any persistent antegrade flow past the stenosis, but if not, is there effective collateral around any occluded segment;

4. Assess the presence of effective EC-IC collateral in cases of extradural ICA occlusion;

Prior Study

CT Head

CT Perfusion

Findings

Low Neck Evaluation (Aorta, Brachiocephalic, Proximal Common Carotid (CCA) & Proximal Vertebral Arteries)

There is evidence of aortic arch dissection or other abnormality. [Yes/No]

There is evidence of occlusion of brachiocephalic arteries. [Yes/No]

There is evidence of stenosis of brachiocephalic arteries. [Yes/No]

There is evidence of occlusion at the origin of a carotid artery. [Yes/No]

If there evidence of stenosis at the origin or the cervical segment of either common carotid artery. [Yes/No]

Given a CCA is occluded, are the vertebral to occipital branch of the external carotid artery (EAC) collateral arcades functional. [Yes/No]

There is evidence of occlusion in the proximal segment of a vertebral artery. [Yes/No]

There is evidence of stenosis in the cervical segment of either vertebral artery. [Yes/No]

Upper Cervical Neck & Intracranial/Extradural Evaluation for Carotid & Vertebral Arteries

There is evidence of occlusion at the carotid bifurcation including proximal ICA or ECA or both. [Yes/No]

There is evidence of some degree of stenoses within either the carotid or the vertebral arteries, but these are in the range of 50% or less by NASCET standards. [Yes/No]

There is carotid bifurcation of carotid origin (ICA or ECA) stenosis exceeding 60% by NASCET and physiologic criteria. [Yes/No]

There is carotid bifurcation or carotid origin (ICA or ECA) stenosis exceeding 70% by NASCET and physiologic (post stenotic dilatation and/or partial luminal collapse beyond the stenosis) criteria. [Yes/No]

There is intimal stenotic web within an area of carotid stenosis. [Yes/No]

There is intimal ulceration or intimal dehiscence in the area of carotid plaque. [Yes/No]

There is intraluminal soft clot in the area of carotid plaque. [Yes/No]

There is evidence of occlusion/high grade stenosis of high cervical ICA or vertebral arteries. [Yes/No]

Given there is an ICA occluded are there functional EC-IC collateral? [Yes/No]

There is dissection of high cervical ICA. [Yes/No]

There is dissection of mid or high cervical vertebral artery. [Yes/No]

There is FMD (fibromuscular dysplasia) of high cervical ICA. [Yes/No]

There is FMD of the high cervical vertebral artery & its’ dural penetration. [Yes/No]

There is pseudoaneurysm of high cervical ICA. [Yes/No]

There is stenosis/occlusion of the ICA in its intracranial-extradural segment. [Yes/No]

There is stenosis/occlusion of the high cervical carotid or vertebral artery at the skull base. [Yes/No]

There is focal occlusion of the ICA or the vertebral at the dural ring. [Yes/No]

There is thrombosis of internal jugular or other large neck veins. [Yes/No]

Other

Other findings are present more consistent with a diagnosis other than stroke. [Yes/No]

Impression

Hyperacute Stroke - Arterial, Diagnostic: CTA Neck

There is no evidence of acute stroke.
There is evidence of acute stroke.
There is an abnormality, but it is related to a process other than stroke.