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CT Neuroangiography: A Glance at the Common Pitfalls and Their Prevention

¹ Department of Radiology, Johns Hopkins School of Medicine, B100G Phipps Basement, 600 N. Wolfe St., Baltimore, MD 21287.

View larger version (106K): [in a new window]   Fig. 1A —Right arm versus left arm injection. Right arm injection. Contrast material in brachiocephalic vein steers clear of origin of major arteries.

View larger version (131K): [in a new window]   Fig. 1B —Right arm versus left arm injection. Contrast material is in left brachiocephalic vein arching over major arteries, which can produce streak artifacts and obscure origin of major vessels.

View larger version (139K): [in a new window]   Fig. 2A —Effect of reconstruction slice thickness. Volume-rendered image with 2-mm slice reconstruction. Arrow = pseudostenosis.

View larger version (121K): [in a new window]   Fig. 2B —Effect of reconstruction slice thickness. 1-mm reconstruction from same raw data set. Note pseudostenosis and diffusely attenuated arteries in A, which improve in this image.

View larger version (131K): [in a new window]   Fig. 3A —Stair-step or zebra-stripe artifact. 3D volume-rendered image from 1-mm slices with 1.5-mm gap reconstruction parameters shows zebralike appearance of bone and some attenuation of middle cerebral artery branches (arrow).

View larger version (135K): [in a new window]   Fig. 3B —Stair-step or zebra-stripe artifact. Image was created with 1-mm slices and 0.5-mm overlap from same raw data, and provides better delineation of smaller vessels, smooth bone background, and better visualization of distal vessels. Incidental note is made of right vertebral artery stenosis (arrow).

View larger version (102K): [in a new window]   Fig. 4A —Partially thrombosed aneurysm in a 52-year-old man. Actual size of aneurysm is larger on source image (A) than appreciated on 3D reconstructed images (B).

View larger version (56K): [in a new window]   Fig. 4B —Partially thrombosed aneurysm in a 52-year-old man. Actual size of aneurysm is larger on source image (A) than appreciated on 3D reconstructed images (B).

View larger version (97K): [in a new window]   Fig. 5A —Presumed schwannoma likely to be misinterpreted as aneurysm in a 6-year-old girl. Maximum-intensity-projection image shows an aneurysm-like structure in relation to posterior cerebral artery (arrow).

View larger version (49K): [in a new window]   Fig. 5B —Presumed schwannoma likely to be misinterpreted as aneurysm in a 6-year-old girl. Volume-rendered image shows suspected aneurysm at right P1 and P2 junction (arrow).

View larger version (91K): [in a new window]   Fig. 5C —Presumed schwannoma likely to be misinterpreted as aneurysm in a 6-year-old girl. Source image clearly separates lesion (arrow) from vessel and rules out aneurysm. Conventional catheter angiogram was negative.

View larger version (19K): [in a new window]   Fig. 6A —Vertebral artery dissection in a 67-year-old woman. Limitation of volume-rendered technique. Volume-rendered picture of vertebral artery (A) shows alternate areas of narrowing and dilatation but fails to show intimal flap (arrow, B-D) seen on curved multiplanar reconstruction (B) and source image (C). Angiogram done later confirms finding (D).

View larger version (93K): [in a new window]   Fig. 6B —Vertebral artery dissection in a 67-year-old woman. Limitation of volume-rendered technique. Volume-rendered picture of vertebral artery (A) shows alternate areas of narrowing and dilatation but fails to show intimal flap (arrow, B-D) seen on curved multiplanar reconstruction (B) and source image (C). Angiogram done later confirms finding (D).

View larger version (101K): [in a new window]   Fig. 6C —Vertebral artery dissection in a 67-year-old woman. Limitation of volume-rendered technique. Volume-rendered picture of vertebral artery (A) shows alternate areas of narrowing and dilatation but fails to show intimal flap (arrow, B-D) seen on curved multiplanar reconstruction (B) and source image (C). Angiogram done later confirms finding (D).

View larger version (76K): [in a new window]   Fig. 6D —Vertebral artery dissection in a 67-year-old woman. Limitation of volume-rendered technique. Volume-rendered picture of vertebral artery (A) shows alternate areas of narrowing and dilatation but fails to show intimal flap (arrow, B-D) seen on curved multiplanar reconstruction (B) and source image (C). Angiogram done later confirms finding (D).

View larger version (142K): [in a new window]   Fig. 7A —Follow-up in 54-year-old man with stents placed in the transverse and sigmoid sinuses for the thrombosis. Volume rendering versus curved multiplanar reformations. 3D volume-rendered image of right transverse and sigmoid sinuses does not reveal information about its lumen or wall.

View larger version (108K): [in a new window]   Fig. 7B —Follow-up in 54-year-old man with stents placed in the transverse and sigmoid sinuses for the thrombosis. Volume rendering versus curved multiplanar reformations. Curved multiplanar reconstruction through same shows stent and areas of thrombus formation (arrow) in transverse and sigmoid venous sinuses.

View larger version (86K): [in a new window]   Fig. 8A —Maximum intensity projection (MIP) of circle of Willis. MIP with 10-mm slab in axial plane (A) suggests that middle (arrow) and posterior cerebral arteries (arrowhead) are occluded; however, 40-mm MIP slab reformation (B) shows full extent of arteries. Veins are also visualized. Internal cerebral veins are seen (arrow).

View larger version (104K): [in a new window]   Fig. 8B —Maximum intensity projection (MIP) of circle of Willis. MIP with 10-mm slab in axial plane (A) suggests that middle (arrow) and posterior cerebral arteries (arrowhead) are occluded; however, 40-mm MIP slab reformation (B) shows full extent of arteries. Veins are also visualized. Internal cerebral veins are seen (arrow).

View larger version (94K): [in a new window]   Fig. 9A —73-year-old woman with history of transient ischemic attack. Curved multiplanar reconstruction image of carotid shows true lumen of internal carotid with calcific plaques in arterial wall.

View larger version (51K): [in a new window]   Fig. 9B —73-year-old woman with history of transient ischemic attack. Volume-rendered 3D image fails to shows extent of stenosis, as it incorporates calcified plaques in image and surface of artery appears blistered (arrow).

View larger version (69K): [in a new window]   Fig. 10A —57-year-old man with headaches. Calcific plaque on source image (arrow) (A) masquerades as aneurysm (arrow) on volume-rendered 3D image (B).

View larger version (147K): [in a new window]   Fig. 10B —57-year-old man with headaches. Calcific plaque on source image (arrow) (A) masquerades as aneurysm (arrow) on volume-rendered 3D image (B).

View larger version (144K): [in a new window]   Fig. 11A —75-year-old man with transient ischemic attack. Images show importance of appropriate windowing. 3D volume-rendered image on right with width and center of 200/180 H shows diffusely attenuated vessels.

View larger version (146K): [in a new window]   Fig. 11B —75-year-old man with transient ischemic attack. Images show importance of appropriate windowing. Width/center of 200/140 H shows many more peripheral branches and no significant stenosis.

View larger version (117K): [in a new window]   Fig. 12A —47-year-old man with subarachnoid hemorrhage.Venous confluence masks an aneurysm. Veins obscure aneurysm (arrow) in proximal left A1 segment.

View larger version (109K): [in a new window]   Fig. 12B —47-year-old man with subarachnoid hemorrhage.Venous confluence masks an aneurysm. After clearing overlying venous branches, aneurysm (arrow) is clearly visualized.

View larger version (107K): [in a new window]   Fig. 12C —47-year-old man with subarachnoid hemorrhage.Venous confluence masks an aneurysm. Aneurysm (arrow) was confirmed on angiogram.

View larger version (84K): [in a new window]   Fig. 13A —53-year-old woman with headaches. Venous confluence at internal carotid artery (ICA) terminus. Confluence of veins at ICA terminus (arrow) on source image (A) gives appearance of aneurysm (arrow) on volume-rendered image (B).

View larger version (111K): [in a new window]   Fig. 13B —53-year-old woman with headaches. Venous confluence at internal carotid artery (ICA) terminus. Confluence of veins at ICA terminus (arrow) on source image (A) gives appearance of aneurysm (arrow) on volume-rendered image (B).

View larger version (93K): [in a new window]   Fig. 13C —53-year-old woman with headaches. Venous confluence at internal carotid artery (ICA) terminus. MR angiogram is normal.

View larger version (98K): [in a new window]   Fig. 14A —Pseudofenestration in 76-year-old woman with history of right-sided weakness. 3D time-of-flight MR angiography shows stenosis of right M1 segment (arrow).

View larger version (48K): [in a new window]   Fig. 14B —Pseudofenestration in 76-year-old woman with history of right-sided weakness. Volume-rendered image on CT angiography shows pseudofenestration due to deep middle cerebral vein (curved arrow) running parallel to stenosed middle cerebral artery (straight arrow). Basal vein of Rosenthal and posterior communicating artery are superimposed (arrowhead).

View larger version (115K): [in a new window]   Fig. 14C —Pseudofenestration in 76-year-old woman with history of right-sided weakness. Maximum-intensity-projection image shows same finding. Mild difference in density of contrast between vein (curved arrow) and artery (straight arrow) is evident.

View larger version (100K): [in a new window]   Fig. 15A —70-year-old man with ataxia. Basilar artery stenosis is hidden by pontomesencephalic vein. Normal variant vein (arrow) obscures basilar artery stenosis.

View larger version (154K): [in a new window]   Fig. 15B —70-year-old man with ataxia. Basilar artery stenosis is hidden by pontomesencephalic vein. Rotation of image shows relationship of vein (small arrow) and stenosis in basilar artery (thick arrow).

View larger version (89K): [in a new window]   Fig. 16 —51-year-old woman with headaches. Source axial image shows small aneurysm (thin arrow) by side of posterior communicating artery (thick arrow).

View larger version (93K): [in a new window]   Fig. 17A —CT angiography on 81-year-old man for evaluation of carotid stenosis. Pseudothrombus in jugular veins. Reflux of contrast into jugular veins mimics thrombi.

View larger version (86K): [in a new window]   Fig. 17B —CT angiography on 81-year-old man for evaluation of carotid stenosis. Pseudothrombus in jugular veins. Sagittal reformation and axial images show contrast material localized in dependent posterior aspect of veins. Sagittal reformation (B) also shows continuous column of contrast material extending from brachiocephalic to jugular vein.

View larger version (69K): [in a new window]   Fig. 17C —CT angiography on 81-year-old man for evaluation of carotid stenosis. Pseudothrombus in jugular veins. Sagittal reformation and axial images show contrast material localized in dependent posterior aspect of veins. Sagittal reformation (B) also shows continuous column of contrast material extending from brachiocephalic to jugular vein.

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