Should CT angiography of the supra-aortic arteries be performed systematically following attempted suicide by hanging?

PURPOSE: Characterize and determine the frequency of dissections of the supra-aortic arteries (SAA) and injuries to the cervical spine and pharyngolaryngeal cartilages viewed on CT scans after an attempted suicide by hanging. MATERIALS AND METHODS: A retrospective, single-centre study of all patients admitted for attempted suicide by hanging between January 2010 and June 2017 who received CT angiography of the SAA. Search for signs of dissection of the cervical arteries and injuries to the brain, spinal column and pharyngeal and laryngeal cartilages. The results were compared with the initial clinical severity, which was assessed indirectly by whether patients were initially admitted in an intensive care unit (ICU) or in an emergency department (ED). RESULTS: Out of 162 patients included, 4 presented with SAA dissection (2.5%), comprising 3 vertebral arteries and 1 external carotid artery. The cases in question were of 4 men, all in cardiac arrest on arrival and all were treated in ICU. Of the most serious cases, 18/72 (25%) had anoxia-related injuries and one also presented with a C2 fracture. No vascular lesions or signs of cerebral anoxia were observed in the 90 ED patients. Nevertheless, pharyngeal and laryngeal fractures were observed in both groups, with no significant difference. CONCLUSION: In our study, 2.5% of CT angiograms performed after an attempted hanging revealed SAA dissection. Crucially, only most severe patients, who have been immediately admitted to ICU suffered SAA. These results call into question the systematic indication of this exam in cases of hanging attempts.

Standard Diffusion-Weighted Imaging in the Brain Can Detect Cervical Internal Carotid Artery Dissections.

BACKGROUND AND PURPOSE: The ICA is the most common site of cervical artery dissection. Prompt and reliable identification of the mural hematoma is warranted when a dissection is clinically suspected. The purpose of this study was to assess to capacity of a standard DWI sequence acquired routinely on the brain to detect dissecting hematoma related to cervical ICA dissections. MATERIALS AND METHODS: This was a retrospective study of a cohort of 110 patients younger than 55 years of age (40 women; mean age, 46.79 years) admitted at the acute phase of a neurologic deficit, headache, or neck pain and investigated by at least a standard 3T diffusion-weighted sequence of the brain. Among them were 50 patients (14 women; mean age, 46.72 years) with subsequently confirmed ICA dissection. In the whole anonymized cohort, both a senior and junior radiologist separately assessed, on the DWI sequences only, the presence of a crescent-shaped or circular hypersignal projecting on the subpetrosal segment of the ICA arteries, assuming that it would correspond to a mural hematoma related to an ICA dissection. RESULTS: The senior radiologist found 46 subpetrosal hyperintensities in 43/50 patients with ICA dissection and none in patients without dissection (sensitivity, 86%; specificity, 100%). The junior radiologist found 48 subpetrosal hyperintensities in 45/50 patients with dissection and none in patients without dissection (sensitivity, 90%; specificity, 100%). CONCLUSIONS: In our cohort, a standard DWI sequence performed on the brain at the acute phase of a stroke or for a clinical suspicion of dissection detected nearly 90% of cervical ICA dissections.

Acute ischaemic lesions are associated with cortical superficial siderosis in spontaneous intracerebral hemorrhage.

BACKGROUND AND PURPOSE: Diffusion-weighted imaging (DWI) commonly detects acute ischaemic lesions in patients with acute intracerebral hemorrhage (ICH), especially with cerebral amyloid angiopathy (CAA). We investigated the relationship between cortical superficial siderosis (cSS), a neuroimaging marker of CAA, and DWI lesions in patients with acute ICH. METHODS: We conducted a retrospective analysis of prospectively collected data from consecutive patients with acute supratentorial ICH who underwent brain magnetic resonance imaging within 10 days after symptom onset. Magnetic resonance imaging scans were analyzed for DWI lesions, cSS and other markers for small-vessel disease. Univariate and multivariate analyses were performed to assess the association between cSS and DWI lesions. RESULTS: Among 246 ICH survivors (mean age 71.4 ± 12.6 years) who were enrolled, 126 had lobar ICH and 120 had deep ICH. Overall, DWI lesions were observed in 38 (15.4%) patients and were more common in patients with lobar ICH than deep ICH (22.2% vs. 8.3%; P = 0.003). In multivariate logistic regression analysis, the extent of white matter hyperintensities [odds ratio (OR), 1.29; 95% confidence interval (CI), 1.05-1.58; P = 0.02] and cSS severity (focal cSS: OR, 3.54; 95% CI, 1.28-9.84; disseminated cSS: OR, 4.41; 95% CI, 1.78-10.97; P = 0.001) were independently associated with the presence of DWI lesions. CONCLUSIONS: Diffusion-weighted imaging lesions are more frequently observed in patients with acute lobar ICH than in those with deep ICH. cSS severity and white matter hyperintensity extent are independent predictors for the presence of DWI lesions, suggesting that CAA may be involved in the pathogenesis of DWI lesions associated with acute ICH.

Cortical superficial siderosis and acute convexity subarachnoid hemorrhage in cerebral amyloid angiopathy.

BACKGROUND AND PURPOSE: Acute convexity subarachnoid hemorrhage (cSAH) and cortical superficial siderosis (cSS) are neuroimaging markers of cerebral amyloid angiopathy (CAA) that may arise through similar mechanisms. The prevalence of cSS in patients with CAA presenting with acute cSAH versus lobar intracerebral hemorrhage (ICH) was compared and the physiopathology of cSS was explored by examining neuroimaging associations. METHODS: Data from 116 consecutive patients with probable CAA (mean age, 77.4 ± 7.3 years) presenting with acute cSAH (n = 45) or acute lobar ICH (n = 71) were retrospectively analyzed. Magnetic resonance imaging scans were analyzed for cSS and other imaging markers. The two groups' clinical and imaging data were compared and the associations between cSAH and cSS were explored. RESULTS: Patients with cSAH presented mostly with transient focal neurological episodes. The prevalence of cSS was higher amongst cSAH patients than amongst ICH patients (88.9% vs. 57.7%; P < 0.001). In multivariable logistic regression analysis, focal [odds ratio (OR) 6.73; 95% confidence interval (CI) 1.75-25.81; P = 0.005] and disseminated (OR 11.68; 95% CI 3.55-38.35; P < 0.001) cSS were independently associated with acute cSAH, whereas older age (OR 0.93; 95% CI 0.87-0.99; P = 0.025) and chronic lobar ICH count (OR 0.45; 95% CI 0.25-0.80; P = 0.007) were associated with acute lobar ICH. CONCLUSIONS: Amongst patients with CAA, cSS is independently associated with acute cSAH. These findings suggest that cSAH may be involved in the pathogenesis of the cSS observed in CAA. Longitudinal studies are warranted to assess this potential causal relationship.

[Diffusion-weighted imaging of the brain: normal patterns, traps and artifacts]. / IRM de diffusion de l'encéphale: aspect normal, images pièges et artefacts.

Owing to its rapid acquisition time and high sensitivity, diffusion-weighted imaging has turned into a routine sequence for brain imaging. This is the case not only for stroke, but also for various diseases such as abscesses or tumors. Being aware of the artifacts is important for optimal interpretation. After a brief review of the normal patterns, the most frequent artifacts, inherent to the echoplanar imaging technique, are described and we provide suggestions to avoid them. Most current traps are caused by T2-weighting of the diffusion images; the key for avoiding erroneous interpretation relies on the ADC map.