Imagen Cerebral Nejm

Review Article
Medical Progress

812

March 19, 1998

The New Engl and Journal of Medi ci ne

I

MAGING

THE

B

RAIN

First of Two Parts

S

ID

G

ILMAN

, M.D.

From the Department of Neurology, University of Michigan, Ann Arbor.
Address reprint requests to Dr. Gilman at the Department of Neurology,
University of Michigan Medical Center, 1500 E. Medical Center Dr., TC
1914, Ann Arbor, MI 48109-0316.
1998, Massachusetts Medical Society.

XCITING advances in anatomical imaging
have greatly improved our capacity to detect
pathologic processes in the nervous system,
localize these processes precisely, and predict the
type of disease more accurately than ever before
(Table 1). These advances, coupled with new and
emerging therapies for previously untreatable diseas-
es, have expedited the evaluation of patients with
neurologic disorders and permitted the rapid initia-
tion of therapy. In acute ischemic stroke, for exam-
ple, brain imaging is required before the administra-
tion of recombinant tissue plasminogen activator,
and treatment within three hours of onset greatly
improves the outcome.

1

The rapid evolution of techniques of anatomical
imaging has occurred in parallel with developments
in physiologic imaging. Physiologic imaging permits
evaluation of changes in metabolic processes, either
within focal regions or diffusely in the brain, includ-
ing cerebral blood flow, blood volume, tissue oxy-
genation, metabolic rate for glucose, and biochemi-
cal changes within brain cells, including changes in
structures such as neurotransmitter receptors.
During the early phases of development and re-
finement of current imaging methods, the view
arose that imaging would obviate the need for neu-
rologists and neurosurgeons. Subsequent events dem-
onstrated that imaging does not replace, but rather
supplements, their work. Imaging is costly and time-
consuming, and physicians do their patients a disserv-
ice if they order these tests before taking a history,
conducting a thorough physical and neurologic ex-
E

amination, and determining the location and type of
pathologic process responsible for the symptoms.
This article provides a succinct guide to the cur-
rently available techniques for imaging the brain, a
brief description of their methods, a list of the prin-
cipal neurologic disorders requiring imaging, and
recommendations concerning the most useful imag-
ing technique for each disorder. Several textbooks
provide additional information.

2-11

IMAGING TECHNIQUES

The central nervous system can be imaged with
anatomical and physiologic techniques. Anatomical
imaging provides information about the structure of
the skull, the brain, the vascular supply of the nerv-
ous system, and the cerebrospinal fluid spaces. Phys-
iologic imaging provides information about the func-
tional state of brain tissues, including water content,
blood flow, blood volume, metabolism, and bio-
chemistry.

X-Ray Techniques

Passage of x-radiation through tissue attenuates
the radiation, and the intensity of the exiting radia-
tion can be measured with sensitive film or detec-
tors. X-ray computed tomography (CT) permits the
examination of tissue by the same principle as con-
ventional x-ray imaging, except that radiation passes
successively through tissue from multiple different
directions, detectors measure the degree of attenua-
tion of the exiting radiation relative to the incident
radiation, and computers integrate the information
and construct the images in cross section. Adminis-
tration of contrast material increases x-ray attenua-
tion owing to the high atomic number and electron
density of the iodinated compounds used. The use
of intravenous contrast medium with CT allows ex-
amination of the integrity of the bloodbrain barri-
er, which consists of the tight junctions between the
endothelial cells of blood vessels and astrocytes. Dis-
ruption of the bloodbrain barrier occurs in many
neurologic disorders, including acute stroke, brain
tumors, inflammatory and some infectious cerebral
diseases, and some stages of multiple sclerosis.
CT has the advantages of widespread availability,
short study time, sensitivity for detection of calcifi-
cations and acute hemorrhage, and excellent visual-
ization of the anatomy of bone, such as the skull
base and vertebrae. It is useful when magnetic reso-
nance imaging (MRI) cannot be used, as in people
with ferromagnetic aneurysm clips,

12,13

foreign ob-
jects in the eye, pacemakers, and other metal pros-
theses.

14

CT images are less degraded by motion ar-
Downloaded from www.nejm.org on August 29, 2007 . Copyright 1998 Massachusetts Medical Society. All rights reserved.

MEDI CAL PROGRESS

Vol ume 338 Number 12

813

tifacts than MRI scans. CT is preferred in rapidly
evolving neurologic disorders, when direct observa-
tion of the patient and life-support equipment are
required during scanning. Indeed, many hospitals
maintain CT scanners in their emergency rooms to
facilitate rapid imaging with constant observation of
patients in unstable condition. Although CT is the
preferred imaging technique for patients who re-
quire monitoring, MRI can be performed when vir-
tually any monitoring device is in use. Both MRI
and CT with iohexol for myelography have replaced
myelography with oil-based contrast agents, greatly
improving patients comfort and reducing the chance
of subsequent arachnoiditis.
The principal disadvantages of CT are the adverse
effects of ionizing radiation and the insensitivity of
the test, as compared with MRI, for many common
neurologic diseases. CT is also less sensitive than
MRI in patients with disorders in the posterior fossa
(brain stem and cerebellum) and the floor of the
middle fossa (temporal lobes) because of beam-
hardening artifacts, which result from computer er-
rors generated by the sudden change in tissue den-
sity in these locations from a relatively low level in
brain to a high level in bone. The costs of imaging
vary with the type and complexity of the study
required. However, CT on average costs about 50
percent less than MRI; MRI, on average, costs about
50 percent less than positron-emission tomography
(PET).

Ultrasonography

Ultrasound devices use a piezoelectric element in
a transducer that converts electrical energy into
sound energy. These devices operate on the princi-
ple that movement of the source of a reflected sound
relative to the receiver alters the sound frequency.
Ultrasound devices are widely used to measure
blood-flow velocity, permitting assessment of the
carotid and vertebral arteries in the neck and, with
transcranial Doppler ultrasonography, the intracra-
nial vessels. Performing ultrasound studies requires
skill and experience. Currently a major use of ultra-
sonography is for ischemic cerebrovascular disease.
This use has assumed great importance, because
treatment of high-grade carotid stenosis with endar-
terectomy and medical therapy, as compared with
medical therapy alone, improves the outcome.

15

Ul-

*CT denotes x-ray computed tomography, MRI magnetic resonance imaging, PET positron-emission tomography,
SPECT single-photon-emission computed tomography, and TCD transcranial Doppler ultrasonography.

T

ABLE

1.

P

REFERRED

I

MAGING

P

ROCEDURES

IN

N

EUROLOGIC

D

ISEASES

.*

N

EUROLOGIC

D

ISEASE

I

MAGING

P

ROCEDURE

Cerebral or cerebellar ischemic infarction CT in the first 1224 hr; MRI after 1224 hr (diffusion-weighted and per-
fusion-weighted MRI augments the findings, especially in the first 24 hr,
and even before 8 hr)
Cerebral or cerebellar hemorrhage CT in the first 24 hr; MRI after 24 hr; MRI and endovascular angiography
for suspected arteriovenous malformation
Transient ischemic attack MRI to identify lacunar or other small lesions; ultrasound studies of the ca-
rotid arteries; magnetic resonance angiography
Arteriovenous malformation CT for acute hemorrhage; MRI and endovascular angiography as early as
possible
Cerebral aneurysm CT for acute subarachnoid hemorrhage; CT angiography or endovascular
angiography to identify the aneurysm; TCD to detect vasospasm
Brain tumor MRI without and with injection of contrast material
Craniocerebral trauma CT initially; MRI after initial assessment and treatment
Multiple sclerosis MRI without and with injection of contrast material
Meningitis or encephalitis CT without and with injection of contrast material initially; MRI after initial
assessment and treatment
Cerebral or cerebellar abscess CT without and with injection of contrast material for initial diagnosis or,
if stable, MRI instead of CT; MRI without and with injection of contrast
material subsequently
Granuloma MRI without and with injection of contrast material
Dementia MRI; PET; SPECT
Movement disorders MRI; PET
Neonatal and development disorders Ultrasound in unstable premature neonates; otherwise MRI
Epilepsy MRI; PET; SPECT
Headache CT in patients suspected of having structural disorders

814

March 19, 1998


trasonography is an important tool for real-time
monitoring of brain structure during surgical proce-
dures on the brain, for detecting vasospasm after
subarachnoid hemorrhage, and for detecting hydro-
cephalus, germinal-matrix hemorrhage, and periven-
tricular leukomalacia in neonates.

MRI

Placement of tissue in a strong magnetic field
causes certain naturally occurring isotopes (atoms)
within the tissue to line up within the field, orient-
ing the net tissue magnetization in the longitudinal
direction. Many isotopes are affected, but current
MRI uses signals derived from

1

H, the most plentiful
endogenous isotope. When in a magnetic field, these
atoms do not orient precisely with the axis of the
field, but wobble a few degrees off center. Transient
application of a radio-frequency pulse perpendicular
to the applied magnetic field reorients the net tissue
magnetization from the longitudinal to the trans-
verse plane, thereby increasing the tissue energy lev-
el. When the radio-frequency pulse is turned off, the
net tissue magnetization returns to its previous ori-
entation, resulting in a magnetic resonance signal
that receiver coils can detect. Application of differ-
ential-gradient magnetic fields to the tissue under
study permits reconstruction of the signal from indi-
vidual volume units in space. The result is a clear im-
age of the tissue studied. Particular sequences such
as T

1

-, T

2

-, proton-density-, and spinecho-weighted
images enhance the utility of MRI. Use of the intra-
vascular contrast material gadoliniumdiethylenetri-
amine pentaacetic acid (gadoliniumDTPA) with
MRI alters the magnetic susceptibility of adjacent
tissue, thereby providing information about the in-
tegrity of the bloodbrain barrier.
The advantages of MRI are the absence of ioniz-
ing radiation, exquisite sensitivity to blood flow, the
capacity to produce images in planes with any orien-
tation, sensitivity to the accumulation of iron in tissue,
high soft-tissue contrast resolution, high sensitivity
to tissue edema, and absence of beam-hardening ar-
tifacts. MRI is the imaging procedure of choice for
most neurologic diseases and is more sensitive than
CT for demyelinating and other white-matter diseas-
es, primary and metastatic intracerebral neoplasms,
degenerative diseases, nonacute hemorrhage, and cer-
ebral infarction. Conventional MRI is not as effec-
tive as CT for detecting abnormal calcification, dis-
orders of cranial and vertebral bones and joints, and
acute subarachnoid hemorrhage. In the past, the rel-
atively long time needed for scanning limited the
use of MRI in acute craniocerebral trauma and in
unstable, rapidly evolving, or life-threatening disor-
ders. Advances such as ultrafast and echoplanar im-
aging have made MRI as fast as CT. However, the
value of echoplanar images for routine brain imag-
ing is not equal to that of standard fast spinecho
images, because of the lack of versatility and exces-
sive sensitivity to magnetic-gradient artifacts. MRI
provides excellent visualization of the spinal cord, al-
though myelography with CT and iohexol remains
an important procedure.
MRI is superior to CT in demonstrating most
central nervous system lesions, except for acute sub-
arachnoid hemorrhage, calcified lesions, skull frac-
tures, and various craniofacial and sinus-related ab-
normalities. Nevertheless, the choice between MRI
and CT for the initial evaluation of patients with
neurologic disorders is not clear-cut, for several rea-
sons. First, the relative advantage of MRI over CT
ranges from minimal to substantial, depending on
the type of pathologic change. Second, the severity
of symptoms, urgency of the problem, and prior
probability of underlying structural disease vary and
are part of the challenge of clinical medicine. Third,
as already noted, the average difference in cost be-
tween CT and MRI is substantial. CT has remained
an effective technique for the initial neuroimaging
examination for these reasons, and also because CT
examinations of the head that are of reasonable
quality can be performed quickly, even in uncooper-
ative patients.
Many developments have improved the usefulness
of MRI. They include fluid-attenuated inversion re-
covery, which gives a high signal for parenchymal le-
sions and a low signal for cerebrospinal fluid

16

; dif-
fusion-weighted imaging, which can detect cytotoxic
edema and is sensitive to early ischemic changes

17

;
echoplanar imaging, which uses improved gradient
design to acquire ultrafast images, a requirement for
functional MRI

18

; and combinations of these tech-
niques.

19

Magnetic resonance angiography allows
noninvasive visualization of the cerebral and extra-
cerebral vasculature. Magnetic resonance spectrosco-
py provides a noninvasive means of studying cerebral
metabolites, brain pH, and some neurotransmitters
without the use of ionizing radiation.

20,21

Functional
MRI is a method of imaging the oxygenation status
of hemoglobin in order to visualize local changes in
cerebral blood flow that reflect changing neuronal
activity in response to a specific sensory stimulus or
motor task.

22

Although the technique gives better
temporal resolution than current radionuclide tech-
niques and is used widely, interpretation of the re-
sults is complex and actively debated.

Radionuclide Scanning

Highly versatile methods of studying cerebral
function have emerged from the development of
PET and single-photon-emission computed tomog-
raphy (SPECT). These techniques use a radiolabeled
biologically active compound (radioligand tracer)
and a kinetic model describing the fate of the tracer
as it participates in a biologic process. PET imaging
requires the intravenous injection or inhalation of a

MEDI CAL PROGRESS


815

radioligand labeled with a positron-emitting isotope,
accumulation of the ligand in the brain, and subse-
quent emission of positrons from the ligand into the
adjacent tissue during radioactive decay. Positrons
are the antimatter equivalent of electrons. The colli-
sion of an electron and a positron annihilates both
particles, converting their masses to energy in the
form of two photons (gamma rays) that leave the
brain at an angle of 180 degrees to each other and
can be detected.
The radioligands most frequently used are [

18

F]flu-
orodeoxyglucose for measuring cerebral metabolic
rates for glucose

23

and [

15

O]water for determining
cerebral blood flow.

24

Carbon-11 is used to label
many biologic compounds that can quantify bio-
chemical changes in the brain, such as striatal mono-
amine deficiency in Parkinsons disease

25

and multiple-
system atrophy,

26

and changes in benzodiazepine

27

and opiate

28

receptors. The use of PET is limited by
its high cost, the need for a cyclotron nearby to pro-
duce radioisotopes with short half-lives, and its re-
stricted spatial and temporal resolution.
SPECT uses principles similar to those of PET,
but the radioligands decay to emit only a single pho-
ton. Many tracers have been used in SPECT studies
of the brain, notably xenon-133 and technetium-
99mhexamethyl-propylamine-oxime for investiga-
tion of blood flow in patients with ischemic stroke,
subarachnoid hemorrhage, migraine, Alzheimers dis-
ease and other neurodegenerative diseases, and com-
plex partial epilepsy.

29

SPECT has the shortcomings
of restricted resolution and quantitation and limited
versatility for studying cerebral biochemistry and
metabolism.

IMAGING IN NEUROLOGIC DISORDERS

Cerebrovascular Disease

Cerebral Infarction

The sudden onset of focal sensory loss, weakness,
or speech disorder raises the possibility of cerebral
ischemia or infarction, particularly in older people
with hypertension, diabetes, hypercholesterolemia,
heart disease, or a history of cigarette smoking. Rap-
id and accurate assessment is crucial for treatment,
since recombinant tissue plasminogen activator pro-
vides effective treatment for acute ischemic infarc-
tion in the absence of cerebral hemorrhage if given
within three hours after onset.

1,30

Accordingly, the
current management of suspected ischemic infarc-
tion requires rapid transfer of the patient to the hos-
pital, expeditious history taking and physical and
neurologic examination, laboratory testing of hema-
tologic and metabolic status, and an imaging study
to detect an ischemic lesion and determine whether
hemorrhage has occurred. If the diagnosis of ische-
mic stroke without hemorrhage can be made and all
inclusion and exclusion criteria are met, treatment
with recombinant tissue plasminogen activator may
be indicated. The value of this activator adminis-
tered more than three hours after the onset of symp-
toms is not known.
Currently, CT is the brain-imaging method of
choice for the assessment of acute ischemic injury to
determine whether hemorrhage is present, because
it is highly sensitive to hemorrhage, rapid, widely
available, relatively low in cost, and noninvasive.

31

CT will not detect an infarction in the first three
hours after the onset of symptoms and may show an
abnormality only many hours or days after the event
(Fig. 1A). Hyperdensity of a major cerebral vessel is
an important sign that can be detected by CT within
minutes of vessel thrombosis and hours before pa-
renchymal changes occur.

32

The finding of a hyper-
dense vessel can be used in the appropriate clinical
setting to consider a patient for aggressive endovas-
cular lytic therapy. Mineralized vessels can be mis-
taken for hyperdense vessels, however, giving a false
positive result. CT has several disadvantages: it pro-
vides limited information about the nature and age
of an ischemic stroke during the crucial first three
hours, and it has limited capacity to show vascular
lesions in the brain stem and cerebellum and small
ischemic infarctions deep within the cerebral hemi-
spheres.
MRI, particularly diffusion-weighted and perfu-
sion-weighted MRI, is more sensitive than CT to the
early pathologic changes of ischemic infarction be-
cause it is superior in detecting brain edema.

33,34

MRI is superior to CT in detecting small lacunar
lesions, particularly those located deep within the
cerebral hemispheres and in the brain stem and cere-
bellum (Fig. 1B). In the future, as echoplanar imag-
ing and diffusion-weighted imaging become widely
available, these techniques may supplant CT because
they can be performed in 6 seconds to 1.5 minutes.
Nevertheless, at present CT is the procedure of
choice in evaluating patients for tissue plasminogen
activator therapy because of the longer time current-
ly needed to perform MRI in most institutions and
because patients cannot be monitored easily during
scanning. After the initial CT scan, MRI is often
used to determine the precise location and size of
the infarction and to follow the lesion over time.

35

However, CT can detect most infarctions within two
to four days after onset and can be used more cost
effectively than MRI to follow the course of the in-
farction over time.

Cerebral Hemorrhage

Cerebral hemorrhage can result from the transfor-
mation of an ischemic infarction

36

(Fig. 1C) or from
a primary hemorrhage into the brain. The risk fac-
tors include hypertension, a source of emboli in the
heart or major arteries supplying the brain, antico-
agulant therapy, coagulation defects, vascular mal-

816

March 19, 1998


A C
B
D

MEDI CAL PROGRESS


817

formations, infections, tumors, trauma, and, in eld-
erly patients, amyloid angiopathy. The onset of
cerebral hemorrhage is often sudden but it can be
slow, and severe neurologic impairment is common.
After a hemorrhage into brain tissue, clot formation
occurs within one to two hours. The clot causes
focal attenuation of x-rays, and thus CT is highly
sensitive in detecting cerebral hemorrhage. MRI is
relatively insensitive to acute subarachnoid hemor-
rhage, but it is sensitive to acute intraparenchymal
bleeding, particularly with gradient-echo MRI pulse
sequences. As the oxyhemoglobin in a hematoma
becomes deoxygenated with time, its magnetic sus-
ceptibility changes, making the lesion more conspic-
uous on MRI. CT is the procedure of choice in the
first hours after cerebral hemorrhage, because of its
speed and availability, but MRI is more sensitive af-
ter the first hours.

Cerebellar Hemorrhage

The risk factors for cerebellar hemorrhage are sim-
ilar to those for cerebral hemorrhage. Cerebellar
hemorrhage commonly begins with an occipital head-
ache followed by nausea, vomiting, lightheadedness
or vertigo, and ataxia of gait. A large hemorrhage of-
ten causes progressive lethargy followed by coma
from compression of the brain stem. CT is the pro-
cedure of choice (Fig. 1D) and should be performed
immediately, since patients are at risk for compres-
sion of the brain stem and subsequent death.

37

Sur-
gical evacuation can be lifesaving after large hemor-
rhages, but with small collections of blood, surgery
may not be needed. CT or MRI can be used for
monitoring over subsequent days. If a vascular mal-
formation or an aneurysm is suspected as the cause
of hemorrhage, endovascular angiography can be
used to identify the bleeding site after the patient
becomes medically stable.

Transient Ischemic Attacks

Transient ischemic attacks are episodes of im-
paired focal neurologic function resulting from vas-
cular disease. The symptoms resolve completely
within 24 hours, and most episodes last less than
1 hour. Transient ischemic attacks often result from
ischemic cerebrovascular disease affecting either prox-
imal or distal cerebral vessels, but cerebral emboli
occasionally are responsible. Although transient is-
chemic attacks may cause no pathologic changes, la-
cunar infarction may occur. In a patient with an
acute ischemic attack whose initial neurologic deficit
shows no change during the first three hours, the
CT scan commonly shows no abnormality, and the
patient should be evaluated for treatment with tissue
plasminogen activator.
A patient with a history of transient ischemic at-
tacks should be evaluated for risk factors that can be
treated and have an evaluation of the cerebral arte-
rial tree with ultrasound studies of the neck and, if
indicated, an evaluation of the intracranial circu-
lation with transcranial Doppler ultrasonography.
Transesophageal echocardiography may be needed if
the patient has an abnormal electrocardiogram or
symptoms or signs of heart disease, or if there are
other reasons to suspect a cardiac source. MRI
should be performed to look for lacunar infarc-
tions,

38

and magnetic resonance angiography can be
used to visualize the large and medium-sized extra-
cranial and intracranial vessels noninvasively.
The possibility of a dissection in the carotid or ver-
tebral artery should be considered if a patient with a
transient (or permanent) ischemic disorder has pain
in the anterior (with carotid dissection) or posterior
(with vertebral dissection) aspect of the neck, which
occasionally may radiate into the head.

39,40

Carotid
dissection may cause atypical facial pain and a partial
or complete ipsilateral Horners syndrome (ptosis,
miosis, enophthalmos, and lack of sweating on the
ipsilateral side of the face) because of injury to sym-
pathetic fibers in the carotid sheath. In these pa-
tients, ultrasonography coupled with MRI of the
neck provides excellent visualization of dissections,
particularly with fat-suppressed, T

1

-weighted axial
MRI scans to visualize subintimal hematomas. How-
ever, endovascular angiography should be performed
if a dissection is not identified but is clinically sus-
pected.

Arteriovenous Malformations

Arteriovenous malformations are congenital dis-
orders consisting of tangled collections of vessels,
often with a feeder artery and tortuous assort-
ments of veins

41

(Fig. 2A and 2B). Arteriovenous
malformations are an important cause of intracere-
bral hemorrhage and can also result in recurrent
headaches, seizures, ischemic or hemorrhagic infarc-
tions, or subarachnoid hemorrhage. At times pro-

Figure 1.

Images of Ischemic and Hemorrhagic Cerebrovascu-
lar Disorders.
Panel A is a CT scan showing a large, subacute, nonhemor-
rhagic infarction in the territory of the left middle cerebral ar-
tery (arrowheads) in a 39-year-old woman with a two-day his-
tory of weakness of the right upper and lower extremities.
Panel B is an axial T

2

-weighted MRI showing a 1-cm lacunar in-
farction (arrow) in the region of the left internal capsule in a 30-
year-old man with a one-month history of right hemiparesis.
Panel C is a CT scan showing a large hemorrhagic infarction in
the territory of the left middle cerebral artery (arrowheads) in
a 61-year-old man with sudden onset of right-sided weakness
three hours earlier. Panel D is a contrast-enhanced CT scan
showing a 1.5-cm cerebellar hemorrhage (arrow) and an en-
hancing vein (arrowheads), findings consistent with the pres-
ence of a venous angioma, which was subsequently identified
by catheter angiography, in a 22-year-old woman with sudden
onset of headache several hours earlier. The hemorrhage, but
not the vein, was seen before the administration of contrast
material.

818

March 19, 1998


A C
B
D

MEDI CAL PROGRESS


819

gressive cerebral dysfunction occurs, leading to the
suspicion of a tumor. CT is the procedure of choice
to detect hemorrhage resulting from a previously
undetected arteriovenous malformation, but MRI is
preferable for optimal visualization, and subsequent
endovascular angiography is essential to detect the
vascular pattern of feeding and draining vessels and
thereby determine the best therapy, usually endovas-
cular techniques coupled with surgery.

Cerebral Aneurysms

Most cerebral aneurysms are acquired malforma-
tions of cerebral arteries at their bifurcations.

42

An-
eurysms are the most frequent cause of sudden
subarachnoid hemorrhage unrelated to trauma, re-
sulting in the rapid onset of severe headache fol-
lowed by stiff neck and photophobia.

43

With its sen-
sitivity to fresh intracranial hemorrhage, CT is the
imaging procedure of choice (Fig. 2C). Because of
the danger of transtentorial herniation, CT should
be performed before lumbar puncture. Subsequent
endovascular angiography is the next procedure
needed to visualize the aneurysm

44

(Fig. 2D) and
determine the therapeutic options. Magnetic reso-
nance angiography can be used to identify and char-
acterize intracranial aneurysms, provided they are
more than 3 mm in diameter.

45,46

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Figure 2.

Images of an Arteriovenous Malformation, a Sub-
arachnoid Hemorrhage, and an Aneurysm.
Panel A is an axial T

1

-weighted MRI showing multiple flow
voids replacing almost the entire left occipital lobe (arrow-
heads) in a 16-year-old boy with a six-month history of head-
aches without visual deficits, findings consistent with the pres-
ence of an arteriovenous malformation, which was confirmed
by a catheter arteriogram (Panel B) shown in lateral projection.
To facilitate comparison, the arteriogram is shown in the same
orientation as the MRI in Panel A. Arrowheads indicate the area
of the malformation. Panel C is a CT scan showing a subarach-
noid hemorrhage filling the basal cisterns diffusely, most
prominently on the left (arrow), secondary to a large aneurysm
(Panel D, arrowheads) arising in the supraclinoid portion of the
left internal carotid artery at the origin of the left posterior com-
municating artery in a 69-year-old woman with sudden onset
of headache followed by loss of consciousness. Panel D is a lat-
eral view from a left internal carotid arteriogram in this patient.

820

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