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Emergency Radiology

, Volume 24, Issue 2, pp 183–193 | Cite as

Neurovascular emergencies: imaging diagnosis and neurointerventional treatment

  • W. Tania Rahman
  • Julius GriauzdeEmail author
  • Neeraj Chaudhary
  • Aditya S. Pandey
  • Joseph J. Gemmete
  • Suzanne T. Chong
Review Article

Abstract

Neurovascular emergencies, consisting of acute ischemic stroke, non-traumatic aneurysmal subarachnoid hemorrhage, arteriovenous malformation, dural arteriovenous fistula, and carotid- cavernous fistula, can have an acute presentation to the emergency department. Radiologists should have an understanding of these processes and their imaging findings in order to provide a prompt and accurate diagnosis. Neurointerventional radiology plays a critical role in providing additional diagnostic information and potentially curative treatment. Understanding the grading scales used to evaluate and prognosticate these neurovascular emergencies can help expedite management for best possible patient outcomes.

Keywords

Emergency department Neurointerventional radiology Neurovascular emergencies 

Notes

Compliance with ethical standards

Conflict of interest

The authors declare that they have no conflict of interest.

Funding source

None.

Financial disclosures

None of the authors have relevant financial disclosures.

Disclaimer

The authors declare that they have no conflict of interest.

References

  1. 1.
    Larner AJ, Farmer SF (1999) Recent advances. Neurology BMJ 319(7206):362–366PubMedGoogle Scholar
  2. 2.
    Craig J, Patterson V, Rocke L, Jamison J (1997) Accident and emergency neurology: time for a reappraisal? Health Trends 29:89–91Google Scholar
  3. 3.
    Wippold II FJ, Cornelius RS, Aiken AH, Amin-Hanjani S, Berger KL, Broderick DF, Davis PC, Douglas AC, Hoh BL, Mechtler LL, Smirniotopoulos JG (2012) American College of Radiology Appropriateness Criteria: focal neurologic deficit. https://acsearch.acr.org/docs/69480/Narrative/. Accessed Sept. 22 2016
  4. 4.
    Mozaffarian D, Benjamin EJ, Go AS, Arnett DK, Blaha MJ, Cushman M, Das SR, de Ferranti S, Despres JP, Fullerton HJ, Howard VJ, Huffman MD, Isasi CR, Jimenez MC, Judd SE, Kissela BM, Lichtman JH, Lisabeth LD, Liu S, Mackey RH, Magid DJ, McGuire DK, Mohler ER 3rd, Moy CS, Muntner P, Mussolino ME, Nasir K, Neumar RW, Nichol G, Palaniappan L, Pandey DK, Reeves MJ, Rodriguez CJ, Rosamond W, Sorlie PD, Stein J, Towfighi A, Turan TN, Virani SS, Woo D, Yeh RW, Turner MB (2016) Heart disease and stroke statistics—2016 update: a report from the American Heart Association. Circulation 133(4):e38–e360. doi: 10.1161/CIR.0000000000000350 CrossRefPubMedGoogle Scholar
  5. 5.
    Tomandl BF, Klotz E, Handschu R, Stemper B, Reinhardt F, Huk WJ, Eberhardt KE, Fateh-Moghadam S (2003) Comprehensive imaging of ischemic stroke with multisection CT. Radiographics 23(3):565–592. doi: 10.1148/rg.233025036 CrossRefPubMedGoogle Scholar
  6. 6.
    Powers WJ, Derdeyn CP, Biller J, Coffey CS, Hoh BL, Jauch EC, Johnston KC, Johnston SC, Khalessi AA, Kidwell CS, Meschia JF, Ovbiagele B, Yavagal DR, American Heart Association Stroke C (2015) 2015 American Heart Association/American Stroke Association focused update of the 2013 guidelines for the early management of patients with acute ischemic stroke regarding endovascular treatment: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke 46(10):3020–3035. doi: 10.1161/STR.0000000000000074 CrossRefPubMedGoogle Scholar
  7. 7.
    Jauch EC, Saver JL, Adams HP Jr, Bruno A, Connors JJ, Demaerschalk BM, Khatri P, McMullan PW Jr, Qureshi AI, Rosenfield K, Scott PA, Summers DR, Wang DZ, Wintermark M, Yonas H (2013) Guidelines for the early management of patients with acute ischemic stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke 44(3):870–947. doi: 10.1161/STR.0b013e318284056a CrossRefPubMedGoogle Scholar
  8. 8.
    [No authors listed] (1995) Tissue plasminogen activator for acute ischemic stroke. The National Institute of Neurological Disorders and Stroke rt-PA Stroke Study Group. N Engl J Med 333(24):1581–1587. doi: 10.1056/NEJM199512143332401
  9. 9.
    Chalela JA, Kidwell CS, Nentwich LM, Luby M, Butman JA, Demchuk AM, Hill MD, Patronas N, Latour L, Warach S (2007) Magnetic resonance imaging and computed tomography in emergency assessment of patients with suspected acute stroke: a prospective comparison. Lancet 369(9558):293–298. doi: 10.1016/S0140-6736(07)60151-2 CrossRefPubMedPubMedCentralGoogle Scholar
  10. 10.
    von Kummer R, Bourquain H, Bastianello S, Bozzao L, Manelfe C, Meier D, Hacke W (2001) Early prediction of irreversible brain damage after ischemic stroke at CT. Radiology 219(1):95–100. doi: 10.1148/radiology.219.1.r01ap0695 CrossRefGoogle Scholar
  11. 11.
    Goyal M, Demchuk AM, Menon BK, Eesa M, Rempel JL, Thornton J, Roy D, Jovin TG, Willinsky RA, Sapkota BL, Dowlatshahi D, Frei DF, Kamal NR, Montanera WJ, Poppe AY, Ryckborst KJ, Silver FL, Shuaib A, Tampieri D, Williams D, Bang OY, Baxter BW, Burns PA, Choe H, Heo JH, Holmstedt CA, Jankowitz B, Kelly M, Linares G, Mandzia JL, Shankar J, Sohn SI, Swartz RH, Barber PA, Coutts SB, Smith EE, Morrish WF, Weill A, Subramaniam S, Mitha AP, Wong JH, Lowerison MW, Sajobi TT, Hill MD (2015) Randomized assessment of rapid endovascular treatment of ischemic stroke. N Engl J Med 372(11):1019–1030. doi: 10.1056/NEJMoa1414905 CrossRefPubMedGoogle Scholar
  12. 12.
    Pexman JH, Barber PA, Hill MD, Sevick RJ, Demchuk AM, Hudon ME, Hu WY, Buchan AM (2001) Use of the Alberta Stroke Program Early CT Score (ASPECTS) for assessing CT scans in patients with acute stroke. AJNR Am J Neuroradiol 22(8):1534–1542PubMedGoogle Scholar
  13. 13.
    Hill MD, Demchuk AM, Goyal M, Jovin TG, Foster LD, Tomsick TA, von Kummer R, Yeatts SD, Palesch YY, Broderick JP, I.M.S. Investigators (2014) Alberta stroke program early computed tomography score to select patients for endovascular treatment: interventional management of stroke (IMS)-III trial. Stroke 45(2):444–449. doi: 10.1161/STROKEAHA.113.003580 CrossRefPubMedGoogle Scholar
  14. 14.
    Allen LM, Hasso AN, Handwerker J, Farid H (2012) Sequence-specific MR imaging findings that are useful in dating ischemic stroke. Radiographics 32(5):1285–1299. doi: 10.1148/rg.325115760 CrossRefPubMedGoogle Scholar
  15. 15.
    Verro P, Tanenbaum LN, Borden NM, Sen S, Eshkar N (2002) CT angiography in acute ischemic stroke: preliminary results. Stroke 33(1):276–278CrossRefPubMedGoogle Scholar
  16. 16.
    Schaefer PW, Souza L, Kamalian S, Hirsch JA, Yoo AJ, Kamalian S, Gonzalez RG, Lev MH (2015) Limited reliability of computed tomographic perfusion acute infarct volume measurements compared with diffusion-weighted imaging in anterior circulation stroke. Stroke 46(2):419–424CrossRefPubMedGoogle Scholar
  17. 17.
    Lui YW, Tang ER, Allmendinger AM, Spektor V (2010) Evaluation of CT perfusion in the setting of cerebral ischemia: patterns and pitfalls. AJNR Am J Neuroradiol 31(9):1552–1563. doi: 10.3174/ajnr.A2026 CrossRefPubMedGoogle Scholar
  18. 18.
    Murphy BD, Fox AJ, Lee DH, Sahlas DJ, Black SE, Hogan MJ, Coutts SB, Demchuk AM, Goyal M, Aviv RI, Symons S, Gulka IB, Beletsky V, Pelz D, Hachinski V, Chan R, Lee TY (2006) Identification of penumbra and infarct in acute ischemic stroke using computed tomography perfusion-derived blood flow and blood volume measurements. Stroke 37(7):1771–1777. doi: 10.1161/01.STR.0000227243.96808.53 CrossRefPubMedGoogle Scholar
  19. 19.
    Copen WA, Schaefer PW, Wu O (2011) MR perfusion imaging in acute ischemic stroke. Neuroimaging Clin N Am 21(2):259–283. doi: 10.1016/j.nic.2011.02.007 CrossRefPubMedPubMedCentralGoogle Scholar
  20. 20.
    Marder CP, Narla V, Fink JR, Tozer Fink KR (2014) Subarachnoid hemorrhage: beyond aneurysms. AJR Am J Roentgenol 202(1):25–37. doi: 10.2214/AJR.12.9749 CrossRefPubMedGoogle Scholar
  21. 21.
    Suarez JI, Tarr RW, Selman WR (2006) Aneurysmal subarachnoid hemorrhage. N Engl J Med 354(4):387–396. doi: 10.1056/NEJMra052732 CrossRefPubMedGoogle Scholar
  22. 22.
    Zacharia BE, Hickman ZL, Grobelny BT, DeRosa P, Kotchetkov I, Ducruet AF, Connolly ES Jr (2010) Epidemiology of aneurysmal subarachnoid hemorrhage. Neurosurg Clin N Am 21(2):221–233. doi: 10.1016/j.nec.2009.10.002 CrossRefPubMedGoogle Scholar
  23. 23.
    Graff-Radford NR, Torner J, Adams HP Jr, Kassell NF (1989) Factors associated with hydrocephalus after subarachnoid hemorrhage. A report of the cooperative aneurysm study. Arch Neurol 46(7):744–752CrossRefPubMedGoogle Scholar
  24. 24.
    van Gijn J, Hijdra A, Wijdicks EF, Vermeulen M, van Crevel H (1985) Acute hydrocephalus after aneurysmal subarachnoid hemorrhage. J Neurosurg 63(3):355–362. doi: 10.3171/jns.1985.63.3.0355 CrossRefPubMedGoogle Scholar
  25. 25.
    Meyers PM, Schumacher HC, Higashida RT, Derdeyn CP, Nesbit GM, Sacks D, Wechsler LR, Bederson JB, Lavine SD, Rasmussen P, American Society of Interventional N, Society of Interventional R (2009) Reporting standards for endovascular repair of saccular intracranial cerebral aneurysms. J Vasc Interv Radiol 20(7 Suppl):S435–S450. doi: 10.1016/j.jvir.2009.03.004 CrossRefPubMedGoogle Scholar
  26. 26.
    Fisher CM, Kistler JP, Davis JM (1980) Relation of cerebral vasospasm to subarachnoid hemorrhage visualized by computerized tomographic scanning. Neurosurgery 6(1):1–9CrossRefPubMedGoogle Scholar
  27. 27.
    Griauzde J, Dickerson E, Gemmete JJ (2016) Hemorrhagic stroke. In: Saba L, Raz E (eds) Neurovascular imaging: from basics to advanced concepts. Springer, New York, pp. 383–412. doi: 10.1007/978-1-4614-9029-6_46 CrossRefGoogle Scholar
  28. 28.
    Rogg JM, Smeaton S, Doberstein C, Goldstein JH, Tung GA, Haas RA (1999) Assessment of the value of MR imaging for examining patients with angiographically negative subarachnoid hemorrhage. AJR Am J Roentgenol 172(1):201–206. doi: 10.2214/ajr.172.1.9888768 CrossRefPubMedGoogle Scholar
  29. 29.
    Brown RD Jr, Broderick JP (2014) Unruptured intracranial aneurysms: epidemiology, natural history, management options, and familial screening. Lancet Neurol 13(4):393–404. doi: 10.1016/S1474-4422(14)70015-8 CrossRefPubMedGoogle Scholar
  30. 30.
    Etminan N, Brown RD Jr, Beseoglu K, Juvela S, Raymond J, Morita A, Torner JC, Derdeyn CP, Raabe A, Mocco J, Korja M, Abdulazim A, Amin-Hanjani S, Al-Shahi Salman R, Barrow DL, Bederson J, Bonafe A, Dumont AS, Fiorella DJ, Gruber A, Hankey GJ, Hasan DM, Hoh BL, Jabbour P, Kasuya H, Kelly ME, Kirkpatrick PJ, Knuckey N, Koivisto T, Krings T, Lawton MT, Marotta TR, Mayer SA, Mee E, Pereira VM, Molyneux A, Morgan MK, Mori K, Murayama Y, Nagahiro S, Nakayama N, Niemela M, Ogilvy CS, Pierot L, Rabinstein AA, Roos YB, Rinne J, Rosenwasser RH, Ronkainen A, Schaller K, Seifert V, Solomon RA, Spears J, Steiger HJ, Vergouwen MD, Wanke I, Wermer MJ, Wong GK, Wong JH, Zipfel GJ, Connolly ES Jr, Steinmetz H, Lanzino G, Pasqualin A, Rufenacht D, Vajkoczy P, McDougall C, Hanggi D, LeRoux P, Rinkel GJ, Macdonald RL (2015) The unruptured intracranial aneurysm treatment score: a multidisciplinary consensus. Neurology 85(10):881–889. doi: 10.1212/WNL.0000000000001891 CrossRefPubMedPubMedCentralGoogle Scholar
  31. 31.
    [No authors listed] (1998) Unruptured intracranial aneurysms—risk of rupture and risks of surgical intervention. International Study of Unruptured Intracranial Aneurysms Investigators. N Engl J Med 339(24):1725–1733. doi: 10.1056/NEJM199812103392401
  32. 32.
    Matsukawa H, Fujii M, Akaike G, Uemura A, Takahashi O, Niimi Y, Shinoda M (2014) Morphological and clinical risk factors for posterior communicating artery aneurysm rupture. J Neurosurg 120(1):104–110. doi: 10.3171/2013.9.JNS13921 CrossRefPubMedGoogle Scholar
  33. 33.
    Molyneux AJ, Kerr RS, Yu LM, Clarke M, Sneade M, Yarnold JA, Sandercock P, International Subarachnoid Aneurysm Trial Collaborative Group (2005) International subarachnoid aneurysm trial (ISAT) of neurosurgical clipping versus endovascular coiling in 2143 patients with ruptured intracranial aneurysms: a randomised comparison of effects on survival, dependency, seizures, rebleeding, subgroups, and aneurysm occlusion. Lancet 366(9488):809–817. doi: 10.1016/S0140-6736(05)67214-5 CrossRefPubMedGoogle Scholar
  34. 34.
    Spetzler RF, McDougall CG, Zabramski JM, Albuquerque FC, Hills NK, Russin JJ, Partovi S, Nakaji P, Wallace RC (2015) The barrow ruptured aneurysm trial: 6-year results. J Neurosurg 123(3):609–617. doi: 10.3171/2014.9.JNS141749 CrossRefPubMedGoogle Scholar
  35. 35.
    Geibprasert S, Pongpech S, Jiarakongmun P, Shroff MM, Armstrong DC, Krings T (2010) Radiologic assessment of brain arteriovenous malformations: what clinicians need to know. Radiographics 30(2):483–501. doi: 10.1148/rg.302095728 CrossRefPubMedGoogle Scholar
  36. 36.
    Mohr JP, Parides MK, Stapf C, Moquete E, Moy CS, Overbey JR, Al-Shahi Salman R, Vicaut E, Young WL, Houdart E, Cordonnier C, Stefani MA, Hartmann A, von Kummer R, Biondi A, Berkefeld J, Klijn CJ, Harkness K, Libman R, Barreau X, Moskowitz AJ (2014) Medical management with or without interventional therapy for unruptured brain arteriovenous malformations (ARUBA): a multicentre, non-blinded, randomised trial. Lancet 383(9917):614–621. doi: 10.1016/S0140-6736(13)62302-8 CrossRefPubMedGoogle Scholar
  37. 37.
    Spetzler RF, Martin NA (1986) A proposed grading system for arteriovenous malformations. J Neurosurg 65(4):476–483. doi: 10.3171/jns.1986.65.4.0476 CrossRefPubMedGoogle Scholar
  38. 38.
    van Beijnum J, van der Worp HB, Buis DR, Al-Shahi Salman R, Kappelle LJ, Rinkel GJ, van der Sprenkel JW, Vandertop WP, Algra A, Klijn CJ (2011) Treatment of brain arteriovenous malformations: a systematic review and meta-analysis. JAMA 306(18):2011–2019. doi: 10.1001/jama.2011.1632 CrossRefPubMedGoogle Scholar
  39. 39.
    Redekop G, TerBrugge K, Montanera W, Willinsky R (1998) Arterial aneurysms associated with cerebral arteriovenous malformations: classification, incidence, and risk of hemorrhage. J Neurosurg 89(4):539–546. doi: 10.3171/jns.1998.89.4.0539 CrossRefPubMedGoogle Scholar
  40. 40.
    Kiyosue H, Hori Y, Okahara M, Tanoue S, Sagara Y, Matsumoto S, Nagatomi H, Mori H (2004) Treatment of intracranial dural arteriovenous fistulas: current strategies based on location and hemodynamics, and alternative techniques of transcatheter embolization. Radiographics 24(6):1637–1653. doi: 10.1148/rg.246045026 CrossRefPubMedGoogle Scholar
  41. 41.
    Gemmete JJ, Chaudhary N, Pandey A, Ansari S (2010) Treatment of carotid cavernous fistulas. Curr Treat Options Neurol 12(1):43–53. doi: 10.1007/s11940-009-0051-3 CrossRefPubMedGoogle Scholar
  42. 42.
    Chaudhary N, Griauzde J, Gemmete JJ, Pandey AS, Trobe JD (2014) Issues in the diagnosis and management of the papilledema shunt. J Neuroophthalmol 34(3):259–263. doi: 10.1097/WNO.0000000000000118 CrossRefPubMedGoogle Scholar
  43. 43.
    Barrow DL, Spector RH, Braun IF, Landman JA, Tindall SC, Tindall GT (1985) Classification and treatment of spontaneous carotid-cavernous sinus fistulas. J Neurosurg 62(2):248–256. doi: 10.3171/jns.1985.62.2.0248 CrossRefPubMedGoogle Scholar
  44. 44.
    Ikawa F, Uozumi T, Kiya K, Kurisu K, Arita K, Sumida M (1996) Diagnosis of carotid-cavernous fistulas with magnetic resonance angiography—demonstrating the draining veins utilizing 3-D time-of-flight and 3-D phase-contrast techniques. Neurosurg Rev 19(1):7–12CrossRefPubMedGoogle Scholar
  45. 45.
    Saposnik G, Barinagarrementeria F, Brown RD Jr, Bushnell CD, Cucchiara B, Cushman M, deVeber G, Ferro JM, Tsai FY (2011) Diagnosis and management of cerebral venous thrombosis: a statement for healthcare professionals from the American Heart Association/American Stroke Association. Stroke 42(4):1158–1192CrossRefPubMedGoogle Scholar
  46. 46.
    Brott TG, Halperin JL, Abbara S, Bacharach JM, Barr JD, Bush RL, Cates CU, Creager MA, Fowler SB, Friday G, Hertzberg VS, McIff EB, WS M, Panagos PD, Riles TS, Rosenwasser RH, Taylor AJ (2011) 2011 ASA/ACCF/AHA/AANN/AANS/ACR/ASNR/CNS/SAIP/SCAI/SIR/SNIS/SVM/SVS guideline on the management of patients with extracranial carotid and vertebral artery disease. A report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines, and the American Stroke Association, American Association of Neuroscience Nurses, American Association of Neurological Surgeons, American College of Radiology, American Society of Neuroradiology, Congress of Neurological Surgeons, Society of Atherosclerosis Imaging and Prevention, Society for Cardiovascular Angiography and Interventions, Society of Interventional Radiology, Society of NeuroInterventional Surgery, Society for Vascular Medicine, and Society for Vascular Surgery. Circulation 124(4):31CrossRefGoogle Scholar
  47. 47.
    Rodallec MH, Marteau V, Gerber S, Desmottes L, Zins M (2008) Craniocervical arterial dissection: spectrum of imaging findings and differential diagnosis. Radiographics 28(6):1711–1728CrossRefPubMedGoogle Scholar

Copyright information

© American Society of Emergency Radiology 2016

Authors and Affiliations

  • W. Tania Rahman
    • 1
  • Julius Griauzde
    • 1
    • 2
    Email author
  • Neeraj Chaudhary
    • 2
    • 3
  • Aditya S. Pandey
    • 2
    • 3
  • Joseph J. Gemmete
    • 2
    • 3
  • Suzanne T. Chong
    • 4
  1. 1.Department of RadiologyUniversity of MichiganAnn ArborUSA
  2. 2.Division of Neurointerventional Radiology, Department of RadiologyUniversity of MichiganAnn ArborUSA
  3. 3.Department of NeurosurgeryUniversity of MichiganAnn ArborUSA
  4. 4.Division of Emergency Radiology, Department of RadiologyUniversity of MichiganAnn ArborUSA

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