Uncommon Neurovascular Problems with a Common Presentation - PowerPoint Presentation

1. Uncommon Neurovascular Problems with a Common PresentationEwen Nicol 7/23/2021

2. ObjectivesRecall uncommon neurovascular conditions that present with epistaxis, nasal congestion, pulsatile tinnitus, visual field abnormalities cranial nerve palsies and proptosis. Appreciate anatomy that can lead to these neurovascular conditions.Comfortably discuss neurovascular conditions with patients.Compose a suitable work up and differential diagnosis that will account for neurovascular conditions in your patients.Recognize the complex treatment teams involved for successful patient outcomes.Disclaimer: Neuroradiology was a former area of my practice as a PA, and I have no financial or ethical considerations in presenting this talk. I just really enjoy neuradiology and its’ complexity and encourage PA’s to consider this area of practice.

3. Epistaxis“Epistaxis has a prevalence of approximately 60% in the adult population and is the commonest acute disorder seen in ear-nose and throat clinical practice.”“According to Small et al. [1], only 6% of cases of epistaxis require medical treatment although some may be fatal without treatment.”Hereditary Hemorrhagic Telangiectasiae (Rendu-Osler disease)

4. Diagnostic and Interventional ImagingVolume 96, Issues 7–8, July–August 2015, Pages 757-773https://www.sciencedirect.com/science/article/pii/S22115684150021321: lingual artery; 2: facial artery; 3: occipital artery; 4: superficial temporal artery; 5: internal maxillary artery; 6: ascending pharyngeal artery.https://www.juniordentist.com/what-is-littles-area-or-kiesselbachs-area-and-the-arteries-in-it.htmlFigure 2. Dividing branches of the external carotid artery after selective catheterization. Selective arteriography of the external carotid artery (a), and flat panel CT angiography (b).

5. Left common carotid arteriography (a) shows vascularization of the posterior nasal fossa mostly through branches of the internal maxillary artery but also from branches of the ophthalmic artery (a: ethmoidal) and to a lesser extent by branches of the facial artery. Hyperselective arteriography of the internal maxillary artery (b) shows modal anatomy and no anastomoses seen in the internal carotid artery territory, particularly the ophthalmic region. A repeat view after ipsilateral embolization of the internal maxillary artery with 700 μm microparticlesEmbolization of essential refractory epistaxis. Eighty-two-year-old female patient with left refractory essential epistaxis despite correct medical treatment.Endonasal electrocoagulation (endoscopic) of the sphenopalatine artery for refractory epistaxis: the sphenopalatine artery is coagulated by bipolar diathermy forceps (arrow).

6. Juvenile Nasal AngiofibromaA benign neoplasm of the nasopharynx, sphenopalatine or posterior nasopharynx, that accounts for 0.5% of head and neck tumors, or approximately 1 in 150,000. Predominately affecting male adolescents or young adults between 14 and 25 years.1st recorded as a tumor by Hippocrates around 5th century BC. Friedberg first used the term angiofibroma in 1940.Typically presents with a classical triad of epistaxis, unilateral nasal obstruction and a mass in the nasopharynx.Treatment usually requires a multi-disciplinary team with ENT, neuroradiology, radiation oncology and neurosurgery specialties.Contemp Clin Dent. 2015 Jan-Mar; 6(1): 98–102.doi: 10.4103/0976-237X.149301PMCID: PMC4319355PMID: 25684921Juvenile Nasopharyngeal Angiofibroma: Case report with review on role of imaging in diagnosisShikha Gupta, Sunita Gupta, Sujoy Ghosh, and Poonam Narang1

7. Case courtesy of Dr Bruno Di Muzio, Radiopaedia.org, rID: 31874Case courtesy of Dr Micheál Breen, Radiopaedia.org, rID: 25926MRI Sagittal T1 imaging showing tumor extension into orbital and intrancranial compartments. Axial CTA image showing tumor extension into orbital and intracranial areas with bone remodeling and contrast enhancement reflecting vascularity.

8. Case courtesy of Assoc Prof Frank Gaillard, Radiopaedia.org, rID: 5022

9. JNA Treatment – tumor embolization followed by surgical excision.

10. Tinnitus – perception of sound in absence of external stimulus, commonly referred to as ringing in the ears. When persistent or bothersome, tinnitus can cause functional impairment in thought processing, emotions, hearing, sleep, and concentration.Prevalence ranges from 8% to 25.3% of the US population.Associated with noise exposures at work or in leisure activities.Most common service-related disability among veterans.https://jamanetwork.com/journals/jamaotolaryngology/fullarticle/2533660

11. Vascular structures associated with auditory perception.

12. Dural Arteriovenous FistulaA broad term referring to aberrant arterial to venous connections typically involving venous blood vessels of the dura mater.1Predominately affects older adults equally and believed to be result of a stenosis or occlusion of venous vessels with resultant blood pressure changes causing a breakthrough connection. No known genetic predisposition.Symptoms of an urgent/emergent dural AVF include those for cerebral hemorrhage as well as non-hemorrhagic neurological deficits. However, a more benign onset is associated with a notable pulsatile tinnitus.Treatment is more commonly endovascular but also can be neurosurgical and involves obliteration of the aberrant connection.Japanese prevalence 0.29/100,000 and US prevalence thought to be similar.2 https://www.mayoclinic.org/diseases-conditions/dural-arteriovenous-fistulas/symptoms-causes/syc-20364280https://pubmed.ncbi.nlm.nih.gov/18717191/#:~:text=The%20detection%20rate%20of%20DAVF,year%20is%200.29%20for%20DAVF.

13. Case courtesy of Assoc Prof Frank Gaillard, Radiopaedia.org, rID: 4227Case courtesy of Assoc Prof Frank Gaillard, Radiopaedia.org, rID: 9971DSA Dural AV Fistula

14. Case courtesy of Dr Chris O'Donnell, Radiopaedia.org, rID: 38000Corronal MRA of Dural AVF with pulsatile tinnitusAxial MRA of Dural AVF with pulsatile tinnitus

15. Visual Field DefectICD-10 Diagnosis Codes:H53.411–Central scotoma, right eyeH53.412–Central scotoma, left eyeH53.413–Central scotoma, bilateralH53.421–Enlarged blind spot, right eyeH53.422–Enlarged blind spot, left eyeH53.423–Enlarged blind spot, bilateralH53.431–Sector or arcuate defects, right eyeH53.432–Sector or arcuate defects, left eyeH53.433–Sector or arcuate defects, bilateralH53.531–Other localized visual field defect, right eyeH53.532–Other localized visual field defect, left eyeH53.533–Other localized visual field defect, bilateralH53.461–Homonymous bilateral defects, right sideH53.462–Homonymous bilateral defects, left sideH53.47–Heteronymous bilateral field defectH53.481–Generalized contraction, right eyeH53.482–Generalized contraction, left eyeH53.483–Generalized contraction, bilateralhttps://decisionmakerplus.net/dg-post/h53-413-visual-field-defect/https://jamanetwork.com/journals/jamaophthalmology/article-abstract/638285Variety of causes including trauma to the brain or visual pathway, diseases and disorders of the eye, optic nerve or the brain and systemic vascular disease.National projections indicate that greater than 3 million persons are visually impaired, 890 000 of whom are bilaterally blind by US definitions.Treatment options – see an ophthalmologist.

16. Case courtesy of Assoc Prof Craig Hacking, Radiopaedia.org, rID: 81780Vascular Opthalmic Structures

17. Case courtesy of Assoc Prof Frank Gaillard, Radiopaedia.org, rID: 36101, 36388Opthalmic artery berry aneurysm

18. Case courtesy of Dr Bruno Di Muzio, Radiopaedia.org, rID: 42916Case courtesy of Assoc Prof Frank Gaillard, Radiopaedia.org, rID: 25989Axial CTA carotico-ophthalmic aneurysmDSA Cavernous Sinus Aneurysm

19. Case courtesy of Dr Ian Bickle, Radiopaedia.org, rID: 50362Clipped AneurysmCase courtesy of Assoc Prof Frank Gaillard, Radiopaedia.org, rID: 4371DSA Giant ICA aneurysm

20. Proptosishttps://loyolamedicine.org/ophthalmology/proptosis-bulging-eyehttps://medlineplus.gov/genetics/condition/graves-disease/#frequencyBulging or protrusion of the eyeball from its’ socket. Most common cause - Graves’ disease (1 in 200) where 25 -50% develop the condition but can be present many years prior to diagnosis. Autoimmune reaction can also lead to enlargement of the eye muscles and fat surrounding the eye which may push the eyeball forward.Other causes of proptosis include:TraumaThrombosisTumorPeri-orbital cellulitisBrain abnormalitiesCarotid Cavernous Fistulahttps://www.merckmanuals.com/home/eye-disorders/symptoms-of-eye-disorders/eyes-bulgingTreatment dependent on underlying condition.

21. An abnormal connection between vessels of the carotid circulation and cavernous sinus.Other symptoms of carotid cavernous fistulas may include:Pulsatile exopthalmosVisual field deficitsCranial nerve palsiesExtra-ocular movement disordersRinging in the earsEpistaxisHeadachePulsatile tinnitusBruitTreatment options include surgical and endovascular techniques for severing the abnormal connection/s.Carotid Cavernous Fistulahttps://www.upmc.com/services/neurosurgery/brain/conditions/neurovascular-conditions/conditions/carotid-cavernous-sinus-fistulahttps://radiopaedia.org/articles/caroticocavernous-fistula-1?lang=usClassificationFlow characteristics: high flow vs low flowEtiology: spontaneous vs traumaticVascular anatomyDirect: direct communication between intracavernous ICA and cavernous sinusIndirect: communication exists via branches of the carotid circulation (ICA or ECA)Barrow classificationType A: direct connection between the intracavernous internal carotid artery and cavernous sinusType B: dural shunt between intracavernous branches of the internal carotid and cavernous sinusType C: dural shunts between meningeal branches of the external carotid artery and cavernous sinusType D: type B + type C

22. Case courtesy of Dr Charlie Chia-Tsong Hsu, Radiopaedia.org, rID: 35379CTA reconstruction CCFCase courtesy of Dr Alexandra Stanislavsky, Radiopaedia.org, rID: 14617Conventional axial CTA imaging CCF

23. Case courtesy of Dr Abhinav Ranwaka, Radiopaedia.org, rID: 28599MR angiography axial T2 imaging CCFMR sagittal T2 imaging CCF

24. Case courtesy of Assoc Prof Frank Gaillard, Radiopaedia.org, rID: 4017DSA “direct” frontal view CCFDSA “direct” lateral view CCF

25. Case courtesy of Dr Katia Kaplan-List, Radiopaedia.org, rID: 42346DSA imaging frontal view post coil embolizationhttps://www.uofmhealth.org/radiology-and-imaging/neurointerventional-radiology/carotid-cavernous-fistulaDSA imaging stent and coil embolization

26. Neck PainCase courtesy of Assoc Prof Craig Hacking, Radiopaedia.org, rID: 81779Case courtesy of Dr Jeffrey Hocking, Radiopaedia.org, rID: 43811Case courtesy of Mr Gray's Illustrations, Radiopaedia.org, rID: 36266Case courtesy of Assoc Prof Craig Hacking, Radiopaedia.org, rID: 82814

27. Case courtesy of Dr. Tabby A. Kennedy, Radiopaedia.org, rID: 74853Annotated CTA coronal imageAnnotated CTA Axial image Sagittal CTA imageCase courtesy of Assoc Prof Frank Gaillard, Radiopaedia.org, rID: 35881MRA Aortic Root

28. Case courtesy of Dr Sachintha Hapugoda, Radiopaedia.org, rID: 51777

29. Case courtesy of Dr Jeremy Jones, Radiopaedia.org, rID: 32907CTA Reconstruction vertebral artery

30. Blood enters the wall of the artery through a tear of the intima and dissecting along the intima-media plane. As the blood expands the wall, it compromises the lumen resulting in stenosis or occlusion.Dissections are mostly located in the pars transversaria segment (V2) ~35% or in the atlas loop segment (V3) ~34% 2-3,11. It is important to note whether a dissection involves the intradural portion of the vertebral artery (V4), and origin of the Posterior Inferior Cerebellar Artery. It is also important to differentiate an extracranial dissection(with or without intracranial extension) versus intracranial dissection.In intracranial dissection, there is a high risk of subarachnoid hemorrhage secondary to decreased thickness of tunica media and tunica adventitia layers when compared to extracranial vessels.Etiologyblunt trauma (most common)antecedent neck manipulation or other sudden movementsspontaneousfibromuscular dysplasia (FMD)connective tissue diseasesEhlers-Danlos diseaseMarfan's diseasepseudoxanthoma elasticumCTA, MRI and DSA can all be used to detect vertebral artery dissection, with pros and cons. Vertebral artery dissectionhttps://www.researchgate.net/figure/Anatomical-segmentation-of-the-PICA-Lateral-view-of-the-PICA-showing-its-5-segments_fig1_284712367https://radiopaedia.org/articles/vertebral-artery-dissection?lang=us

31. Case courtesy of Dr Henry Knipe, Radiopaedia.org, rID: 48493CTA reconstruction traumatic right vertebral artery dissectionCase courtesy of Dr Roberto Schubert, Radiopaedia.org, rID: 17474Case courtesy of Dr Derek Smith, Radiopaedia.org, rID: 57166CTA right vertebral artery dissectionMRA right vertebral artery dissection

32. Case courtesy of Dr Dalia Ibrahim, Radiopaedia.org, rID: 38724MRA Hypoplastic left vertebral arteryTreatment options are dependent on symptoms and damage: Options are allowing collateral circulation to develop and making use of the Circle of Willis, vertebral artery repair surgical or endovascular.https://els-jbs-prod-cdn.jbs.elsevierhealth.com/cms/attachment/716bbbbc-9e21-4aca-a6b3-b23f1b5969d4/gr1_lrg.jpg

33. Questions ??