DAVID SUTTON PICTURES VASCULAR IMAGING IN NEURORADIOLOGY ONLY FOR STUDY SHARING

1. 55
DAVID SUTTON

2. DAVID SUTTON PICTURES
DR. Muhammad Bin Zulfiqar
PGR-FCPS III SIMS/SHL

3. • Fig. 55.1 (A) MRA showing all four neck vessels
in AP view. (B) Segmental MRA study of right
carotid and vertebral in lateral view.

4. Fig. 55.2 MRAs. (A) Normal
left carotid and vertebral.
(B) Stenosis of right
common carotid
bifurcation. The stenosed
channel is not outlined
owing to low flow.

5. • Fig. 55.3 MRAs. (A) Right internal carotid
thrombosis. (B) Severe right internal carotid
stenosis. Owing to low flow the proximal segment
does not outline.

6. • Fig. 55.4 MRAs. (A) Normal internal carotid
bifurcation and proximal segments of the
anterior and middle cerebral arteries in lateral
view. Lateral (B) and rotated lateral (C) views of a
posterior communicating aneurysm.

7. • Fig. 55.4 MRAs. (A) Normal internal carotid
bifurcation and proximal segments of the
anterior and middle cerebral arteries in lateral
view. Lateral (B) and rotated lateral (C) views of a
posterior communicating aneurysm.

8. • Fig. 55.5 Spiral CT of the neck vessels showing
sequestrated study of right carotid bifurcation. (A) In
the AP view the stenosis is obscured by a calcified
plaque. (B) The image is computer rotated through
180° to show the stenosed lumen. (C) 3D CT
reconstruction. (Courtesy of Dr A. AI-Kutoubi.)

9. • Fig. 55.6 3D CT
reconstruction of circle
of Willis and adjacent
vessels showing
bilateral aneurysms.
(A) AP view. (B)
Computer-rotated
view. (Courtesy of Dr A.
Al-Kutoubi.)

10. • Fig. 55.7 The neck
vessels shown by
DSA following an
intravenous
injection of contrast
medium. The
internal carotid and
vertebral origins are
normal.

11. • Fig. 55.8 DSA study showing the cortical
veins, sagittal and lateral sinuses. Note large
vein of Trolard and smaller vein of Labbe.

12. • Fig. 55.9 Arch
aortogram in right
posterior oblique
position. There is a
congenital anomaly, in
that the right
subclavian artery arises
distally from the aortic
arch (arrowheads). Its
origin is superimposed
on the left subclavian
origin. Both carotid
bifurcations are well
shown.

13. • Fig. 55.10 Normal blood supply to the spinal
cord as seen (A) in anterior view and (B) in lateral
view. (C) Blood flow currents in the longitudinal
spinal arteries. (After DiChiro & Wener 1973.)

15. • Fig. 55.12 (A) Normal internal carotid arteriogram- AP view. (B) Diagram
to illustrate (A). 1. Anterior cerebral artery; 2. middle cerebral artery and
its branches; 3. posterior cerebral artery; 4. anterior choroidal artery; 5.
lenticulostriate arteries; 6. sylvian point.

17. • Fig. 55.14 Right ophthalmic artery. (A) In
lateral view. (B) In axial view. 1. Supraorbital
branch; 2. main artery with ethmoidal
branches; 3. lacrimal branch; 4. central retinal
branch.

18. Fig. 55.15 Anterior choroidal artery (arrowed).
(A) In AP projection. orbit. (B) In lateral
projection

19. • Fig. 55.16
Lenticulostriate arteries
in AP projection. They are
difficult to identify in
lateral projection because
of the superimposed
middle cerebral vessels.
The anterior temporal
and orbitofrontal
branches are also shown
passing downward.

20. • Fig. 55.17 Relationship of the middle cerebral
artery and its branches to the insula in a
sagittal brain section. (A) Insula. (B) Middle
cerebral artery.

21. • Fig. 55.18 Relationship of
middle cerebral vessels to skull
vault in the AP projection.
Arrow points to the
angiographic sylvian point
which represents the posterior
limit of the insula. Distance A,
from the skull vault to the
lateral aspect of the insula,
varies from 20 to 30 mm.
Distance B, from the sylvian.,
point to the skull vault,
measures 30-40 mm. (After
Taveras 1969.)

22. • Fig. 55.19 (A) Phlebogram showing superficial and
deep veins. (B) Diagram to illustrate (A) 1. Internal
cerebral vein; 2. vein of Galen . 3. striothalamic vein;
4. septal vein; 5. venous angle; 6. inferior sagittal
sinus; 7. straight sinus; 8. superficial cortical veins; 9.
basal vein; 10. lateral sinus.

23. • Fig. 55.20 (A) Deep veins
shown at late
phlebography. (B)
Diagram of late
phlebogram (lateral
view) showing
relationship to the
ventricle. 1. Internal
cerebral vein; 2. vein of
Galen; 3. striothalamic
vein; 4. vein of the
septum pellucidum; 5.
venous angle; 6. atrial
vein; 7. subependymal
veins; 8. straight sinus; 9.
basal vein.

24. • Fig. 55.21 External
carotid artery
branches. 1 . Superior
thyroid artery; 2.
lingual artery; 3. facial
artery; 4. ascending
pharyngeal artery; 5.
occipital artery; 6.
posterior auricular
artery; 7. internal
maxillary artery; 8.
superficial temporal
artery.

25. • Fig. 55.22 (A) Normal vertebral arteriogram-lateral view. (B) Diagram
to illustrate (A). 1. Vertebral artery; 2. posterior inferior cerebellar
artery; 3. basilar artery; 4. superior cerebellar arteries; 5. posterior
cerebellar artery; 6. posterior choroidal arteries; 7. thalamoperforate
arteries; 8. posterior branches and posterior temporal artery; 9. internal
occipital artery.

26. • Fig. 55.23 (A) Vertebral arteriogram-AP view (subtraction print). (B) Diagram to illustrate
(A). 1. Vertebral artery; 2. posterior inferior cerebellar artery (PICA); 3. basilar artery; 4.
superior cerebellar artery; 5. posterior cerebral artery; 8. posterior temporal artery; 9.
internal occipital artery; 10. anterior inferior cerebellar artery (AICA). The right PICA arises
from the surface of the right AICA in this case.

27. • Fig. 55.24 Posterior inferior cerebellar artery. (A) Lateral view. Asterisks mark the
apices of the caudal and cranial loops. The apex of the cranial loop is closely
related to the nodulus (N) and roof of the fourth ventricle (dotted). The upper or
vermis branch runs near the midline around the inferior vermis (including uvula-U,
pyramid-P, tuber-T). The lower or tonsillohemispheric branch runs near the
posterior margin of the tonsil giving off anterior or tonsillar branches and posterior
or hemispheric branches. The tonsil lies between 2 and 3. (B) Anteroposterior
view, in half axial projection. The segments marked in the lateral view are
identified by the same numbers and letters. Segment 3 (the tonsillohemispheric
branch) may be difficult to identify in this view. The apex of the cranial loop (*N)
lies usually within 2 mm of the midline and the terminal portion of the artery (T)
returns to the midline. (Reproduced from Wolf, B.S., et al (1962) American journal
of Roentgenology, 87, 322-337).

28. • Fig. 55.25 Relationship of normal arteries in the posterior
fossa to the brainstem. 1. Posterior inferior cerebellar
artery; 2. superior cerebellar artery; 3. medial posterior
choroidal artery. (After Huang & Wolf 1970.)

29. • Fig. 55.26 Normal veins of the posterior fossa and their relationship to the
normal structures. 1. Inferior vermian vein; 2. precentral cerebellar vein;
3. posterior mesencephalic vein; 4. anterior pontomesencephalic vein; 5.
petrosal vein; 6. lateral mesencephalic vein; 7. brachial vein; 8. vein of the
lateral recess of fourth ventricle; 9. transverse pontine vein; 10. peduncular
vein; 11. retrotonsillar veins. (After Huang & Wolf 1970.)

30. • Fig. 55.27 Anomalies of the aortic arch branches.
(A) Normal. (B) Joint origin of innominate and
left common carotid. (C) Left common carotid
arises from innominate. (D) Left vertebral arises
from arch. (E) Anomalous right subclavian. (From
Sutton, D., Davies, E.R. (1966) Clinical Radiology,
17, 330-345.)

31. • Fig. 55.28 Some rare anomalies of the great
vessels (see text).

32. • Fig. 55.29 Anomalies of the circle of Willis. The posterior
communicating artery is most frequently involved and
combined lesions are common. (a) Hypoplastic anterior
communicating (3%); (b) hypoplastic proximal segment of
anterior cerebral (2%); (c) hypoplastic posterior
communicating (22%); (d) carotid origin of posterior
cerebral (15%). (After Alpers et al 1959.)

33. • Fig. 55.31 Anomalous communications
between the carotid and vertebrobasilar
systems. (a) Trigeminal artery; (b) acoustic
artery; (c) hypoglossal artery; (d) proatlantal
intersegmental artery.

34. • Fig. 30: Anomalous carotid-basilar anastomosis
(arrow). This is an example of the trigeminal
artery. Lateral view.

35. • Fig. 55.32 Acoustic artery (arrow) connecting basilar
artery to internal carotid. This had been ligated in the
neck for an aneurysm arising from its suprasellar
segment. A vertebral arteriogram shows it still filling
from the basilar (intra-arterial DSA study).

36. • Fig. 55.33 Hypoglossal artery connecting
carotid and basilar arteries. Lateral view.

37. • Fig. 55.34 Origin of the vertebral artery from the
carotid in the neck. This is an example of the
proatlantal intersegmental artery. Lateral view.

38. • Fig. 55.35 Vertebral arteriogram showing
dissecting aneurysm of a posterior interior
cerebellar artery (MR study).

39. • Fig. 55.36 Multiple
aneurysms. MR
angiography without
contrast injection. (A) MIP
projection (contrast
reversal); (B) a 3D shaded
surface display; (C) direct
left carotid angiogram
shows anterior
communicating aneurysm
and posterior
communicating aneurysm.

40. • Fig. 55.37 (A) CT scan showing blood in
subarachnoid space and large haematoma in left
temporal lobe, indicating ruptured aneurysm at
middle cerebral bifurcation. (B) Lateral view
showing displacement of middle cerebral vessels
by large haematoma in the left temporal lobe
from ruptured irregular aneurysm at left middle
cerebral bifurcation (arrows).

41. • Fig. 55.37 (A) CT scan showing blood in subarachnoid
space and large haematoma in left temporal lobe,
indicating ruptured aneurysm at middle cerebral
bifurcation. (B) Lateral view showing displacement of
middle cerebral vessels by large haematoma in the left
temporal lobe from ruptured irregular aneurysm at left
middle cerebral bifurcation (arrows).

42. • Fig. 55.38 Posterior communicating aneurysm
shown in lateral view by arterial DSA study.

43. • Fig. 55.39 Posterior communicating aneurysm
shown in lateral view (MR study).

44. • Fig. 55.41 Bilateral intracavernous
aneurysms. MR angiography. (A) MIP
projection. (B) 3D shaded surface display. This
study was made after intravenous contrast
injection: contrast-enhanced 3D MR
angiography.

45. • Fig. 55.40 Large left intracavernous aneurysm
projecting medially and laterally. There is a
smaller right intracavernous aneurysm
(intravenous DSA study).

46. • Fig. 55.42 Huge intra- and suprasellar aneurysm
of right internal carotid. (A) Lateral view. (B,C)
CT cuts through anterior clinoids and suprasellar
cisterns, respectively, show bony erosions (arrow)
and rounded mass of aneurysm (arrow). (D) Post-
enhancement CT shows the aneurysm clearly.

47. • Fig. 55.42 Huge intra- and suprasellar aneurysm
of right internal carotid. (A) Lateral view. (B,C)
CT cuts through anterior clinoids and suprasellar
cisterns, respectively, show bony erosions (arrow)
and rounded mass of aneurysm (arrow). (D) Post-
enhancement CT shows the aneurysm clearly.

48. • Fig. 55.43 Giant terminal
right-internal carotid
aneurysm. (A) Coronal MRI
(B,C) Contrast-enhanced 3D
angiogram B is a source
image showing the neck of
the aneurysm C is a shaded
surface display.

49. • Fig. 55.44 Large basilar aneurysm presenting
as a suspected pontine tumour. (A) Lateral and
(B) axial MR. (C,D) Large terminal basilar
aneurysm partially thrombosed; AP and lateral
vertebral arteriogram.

50. • Fig. 55.44 Large basilar aneurysm presenting as a
suspected pontine tumour. (A) Lateral and (B) axial MR.
(C,D) Large terminal basilar aneurysm partially
thrombosed; AP and lateral vertebral arteriogram.

51. • Fig. 55.45 Parasagittal angioma shown by
intravenous DSA.

52. • Fig. 55.46 Cerebellar arteriovenous
malformation. (A,B) MR angiography without
contrast injection. A 3D shaded surface
display.

53. • Fig. 55.47 (A) Large angiomatous
malformation in the region of the anterior
end of the corpus callosum. (B) Drainage is
mainly by a hypertrophied internal cerebral
vein to the vein of Galen and straight sinus.

54. • Fig. 55.48 Vertebral angiography
demonstrates a vein of Galen aneurysm,
secondary to an angioma.

55. • Fig. 55.49 AV fistula in the cavernous sinus (caroticocavernous
fistula). (A) Lateral view showing contrast entering cavernous and
superior petrosal sinus (arrow). (B) AP view showing contrast
medium entering left cavernous sinus (arrow) and crossing over to
fill the right cavernous sinus (arrow). The right carotid siphon
appears as a defect in the opacified sinus.

56. • Fig. 55.50 (A) Dural AV fistula supplied by
meningohypophyseal trunk (arrow). (B) The
drainage is into the superior ophthalmic vein
(arrows). Subtraction prints.

58. • Fig. 55.52 Dural AV fistula supplied by the occipital
artery and draining into the lateral sinus and internal
jugular vein. Superselective occipital artery injection
(subtraction print). This case was successfully treated
by percutaneous embolisation.

59. • Fig. 55.53 (A) Stenosis of the internal carotid
arteries. (B) Thrombosis of the internal carotid
artery in the neck.

60. Fig. 55.54 Bilateral stenosis of the internal carotid artery sinuses. (A) MR angiography using the neurovascular coil
(3D contrast-enhanced MIP projection) showing the extensive coverage achieved. (B) Higher resolution 3D
contrast- enhanced image of the left carotid artery shown as a shaded surface display. The other arteries have
been excluded from the image. (C) Left carotid and vertebral arteries. MR angiography contrast- enhanced 3D
shaded surface display. Mild smooth narrowing of the left carotid sinus is shown. Neurovascular coil, other
arteries are excluded from the display.

61. • Fig. 55.55 Arch
aortogram showing
occlusion of right
common carotid
artery and left internal
carotid artery and
severe stenosis of the
left subclavian artery.
The right vertebral is
also occluded.
(Subtraction print.)

62. • Fig. 55.57 Possible collateral pathways in
cerebrovascular insufficiency. (A,B)
Posterior communicating and anterior
communicating arteries of the circle of
Willis. (C) Communication between
maxillary and ophthalmic artery. (D)
Communication between muscular
branches of the vertebral and the occipital
artery. (E) Communication between the
vertebral and ascending cervical arteries.
(F) Communications between the inferior
thyroid and superior thyroid arteries of the
same and opposite sides. (G) The vertebral
artery providing retrograde flow to the
subclavian (subclavian steal). (H) Pial
anastomosis between terminal branches of
the anterior cerebral, middle cerebral and
posterior cerebral arteries. (J) Pial
anastomosis in the posterior fossa. (K)
Meningeal anastomosis and rete mirabile.
(From Sutton, D., Davies, E.R. (1966)
Clinical Radiology, 17, 330-345.)

63. • Fig. 55.56 Four-vessel neck studies by intravenous
DSA in three different patients. (A) Left carotid
stenosis. (B) Bilateral carotid stenosis. (C.) Right
common carotid thrombosis.

64. • Fig. 55.56 Four-vessel neck studies by
intravenous DSA in three different patients. (A)
Left carotid stenosis. (B) Bilateral carotid
stenosis. (C.) Right common carotid thrombosis.

65. • Fig. 55.58 (A)
Fibromuscular
hyperplasia
producing beaded
appearance of the
internal carotid. (B)
Dissecting aneurysm
of internal carotid
artery. The channel
is narrowed and
irregular.

66. • Fig. 55.59 Middle cerebral artery thrombosis
(arrow).