1. Neuroradiology presents…..

2. Cerebrovascular Disease David M. Pelz, MD, FRCPC Neuroradiology, LHSC

3. Cerebrovascular Disease Normal Anatomy Stroke Hemorrhage - Aneurysms, AVMs External Carotid

4. Normal Anatomy Historical Angiography Duplex Ultrasound (DUS) MR Angiography (MRA) CT Angiography (CTA)

5. Origins Roentgen - 1896

7. Egas Moniz - 1934

8. Moniz - 1934

9. Direct Puncture Carotid Vertebral APLateralAP Lateral

10. Sven Seldinger - 1953

11. Modern Angiography - DSA Digital Subtraction Angiography

12. Risks of Angiography Stroke - 1:1000 Contrast reaction - 1:1,000,000 Groin hematoma - 1:500 Vasovagal reactions, etc.

13. Auto Angiography

14. Normal Anatomy -DSA

15. Normal Anatomy - Carotid APLateral

16. Normal Anatomy - Vertebral APLateral

17. 3D-CRA

18. Duplex Ultrasound (DUS)

19. MR Angiography - MRA TOF -Circle of Willis CEMRA - Contrast-enhanced

20. CT Angiography - CTA Circle of Willis Carotid bifurcation

21. Stroke Normal

22. NASCET North American Symptomatic Endarterectomy Trial

23. KFC

26. John Hunter (1728-1793) “Blood goes where it is needed”

27. Collateral supply to the brain Circle of Willis EC-IC

28. Duplex Ultrasound

29. DUS and CTA - ? Good enough for surgery

30. MRA of carotid disease ? Good enough for surgery

31. Carotid Angioplasty/Stenting (CAS)

32. Pre- Post-

33. Endarterectomy vs CAS Over 12,000 worldwide, symptomatic and asymptomatic pts, anecdotal evidence CAVATAS - 10% risk for both CREST - 5 yrs, 2500 pts, RCT

34. Pre- Post- Intracranial Disease

35. Thrombolysis for acute stroke

36. 1 2 3 4

37. Basilar artery occlusion Pre- Post-

38. Thrombolysis in Acute Stroke “Time is brain” IV r-TPA within 3 hrs, most practical IA - large vessel occlusions (MCA or basilar), up to 6 hrs Still no conclusive evidence favouring IA or IV

39. Cerebral Aneurysms

44. Endovascular Therapy of Cerebral Aneurysms

45. Coiling of Cerebral Aneurysms LateralAP

46. Post- GDC Coiling

47. Stents and Coils AP lateral

49. Clipping vs.. Coiling

50. International Subarachnoid Aneurysm Trial (ISAT)

51. Cerebral Arteriovenous Malformations (AVMs)

55. Endovascular Therapy of Brain AVMs NBCA

56. Pre-Post-

57. MRA

58. External Carotid Artery

59. External Carotid Artery - Lat

60. External Carotid Artery - AP

61. Epistaxis

62. Juvenile Nasal Angiofibroma

63. Tumours

64. Chemodectomas Carotid body tumour Glomus Vagale Glomus jugulare Glomus tympanicum

66. “ Mother - in - Law”

67. The End