Vascular capstone course

Welcome to the Emory vascular capstone course. In this course, we are going to learn about vascular imaging of the head and neck. We’ll start with some general principles, such as the types of imaging that are used and when you might want to perform them. Then, you’ll have some interactive cases you can use to follow along and learn how to read vascular imaging on your own.

The following links will help you get access to the cases you need to scroll through the course and give you some additional information.

Before you start with the cases on your own, watch this video to learn some general principles of vascular imaging, including what types of studies we normally do and when you might want to do them.

Normal case

This is a case of a 30-year-old woman with a cervical spine fracture after trauma. Because of the extent of injuries, she underwent a CT angiogram to assess her vascular structures. In this case, the vasculature of her neck is normal. Use this case to practice your search through the vessels of the head and neck for injury.

Images

Top left – axial images from a CT angiogram

Top right – 3D volume rendering of the circle of Willis

Bottom left – oblique images through the right carotid artery

Bottom right – oblique images through the left carotid artery

Video explanation

Now that you know general concepts about imaging of the head and neck, you should learn about different types of pathology that you might encounter. Aneurysms, vascular malformations, dissections, and other abnormalities can all be seen on vascular imaging. Watch the following video before you proceed to the cases for independent learning.

Case A

80 year-old woman with altered mental status

Images

Top left – axial images from a CT head

Top right – 3D volume rendering of the circle of Willis

Bottom left -axial images from a CT angiogram

Questions

1. On the non-contrast head CT (top left panel), what is the bright material and where is it located?
   Answer 1

   Blood products; right temporal parenchyma and subarachnoid space
2. What is the appropriate recommendation for the next imaging test after noncontrast CT?
   Answer 2

   CT Angiogram
3. What are the abnormalities on CTA? Which vessels are affected?
   Answer 3

   Multiple aneurysms (right MCA, anterior communicating artery, left MCA)
   Given the location of the hemorrhage, the right MCA is most likely the bleeding source

Video explanation – Case A

Before you move on to the next case, check out the video explanation here.

Case B 

47 year-old woman with new neurologic symptoms

Images

Top left – diffusion weighted images from an MRI.

Top right – axial images from a CT angiogram

Bottom left – oblique images through the right carotid artery

Bottom right – oblique images through the left carotid artery

Questions

1. Where is the vascular abnormality on the CTA?
   Answer 1

   The left internal carotid artery in the neck is severely narrowed starting at the bifurcation. It smoothly tapers with some thrombus in the vessel distally. The right ICA is also tortuous and irregular
2. What is the abnormality?
   Answer 2

   Left carotid dissection in a person with vasculitis (in this case fibromuscular dysplasia – FMD)
3. What are the risks/complications if this is not treated?
   Answer 3

   Continued infarctions and chronic occlusion.

Case  C 

43 year old woman with seizure

Images

Top left – axial images from a CT head

Top right – 3D volume rendering of the circle of Willis

Bottom left – axial images from a CT angiogram

Bottom right – coronal images from a CT angiogram

Questions

1. What is the bright stuff on the noncontrast CT?
   Answer 1

   Calcium. The high density material in the right frontal lobe is too bright to simply be blood.
2. What is the appropriate recommendation for the next imaging test after CT?
   Answer 2

   Vascular imaging, such as CT angiogram
3. What is the abnormality on CTA? What is the major risk if this is not treated?
   Answer 3

   Abnormal tangle of vessels (nidus) in the right frontal lobe. This is an arteriovenous malformation (AVM).
4. Bonus: What’s the next exam you should recommend?
   Answer 4

   Conventional angiogram. This can be used to find the source of the abnormal vessels and potentially embolize (treat) portions of the arterial supply or aneurysms before definitive treatment with surgery or radiation.

Case D 

41 year-old man after trauma from motor vehicle collision

Images

Top left – axial images from CT angiogram

Bottom left – coronal images from CT angiogram

Right – 3D volume rendering of left carotid artery

Questions

1. Where is the abnormality located?
   Answer 1

   The left internal carotid artery (ICA). Just beyond the bifurcation, the vessel is irregular and has a rounded outpouching, or aneurysm.
2. What is the likely cause of the abnormality?
   Answer 2

   Traumatic disruption of the wall of the artery.
3. Is this abnormality considered a “true” or “pseudo” version?
   Answer 3

   Pseudo. This is a pseudoaneurysm, which is a tear in the wall of the vessel with blood extending beyond the wall. A true aneurysm (like those in the brain), is smooth stretching of all the layers of the vessel wall.