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Neurosonology and Neuroimaging of Stroke
José M. Valdueza
Stephan J. Schreiber
Jens-Eric Roehl
Randolf Klingebiel
MediaCenter.thieme.com
plus e-content online
Neurosonology and
Neuroimaging of Stroke
José M. Valdueza, MD
Professor of Neurology
Director Center of Neurology
Segeberger Clinic Group
Bad Segeberg, Germany
Stephan J. Schreiber, MD
Senior Neurologist
Department of Neurology
Charité University Hospital
Berlin, Germany
Jens-Eric Roehl, MD
Neurologist
Department of Neurology
Charité University Hospital
Berlin, Germany
Randolf Klingebiel, MD
Head of Department of Neuroradiology
Charité University Hospital
Berlin, Germany
766 illustrations
Thieme
Stuttgart · New York
Library of Congress Cataloging-in-Publication Data
Neurosonology and neuroimaging of stroke / José M.
Valdueza ... [et al.].
p. ; cm.
Includes bibliographical references and index.
ISBN 978-3-13-141871-5 (alk. paper)
1. Cerebrovascular disease--Ultrasonic imaging--Atlases. 2. Cerebrovascular disease--Ultrasonic imaging--Case studies. I. Valdueza,
José M.
[DNLM: 1. Cerebrovascular Disorders--radiography--Atlases. 2.
Cerebrovascular Disorders--radiography--Case Reports. 3. Cerebrovascular Disorders--ultrasonography--Atlases. 4. Cerebrovascular
Disorders--ultrasonography--Case Reports. 5. Cerebral Angiography--methods--Atlases. 6. Cerebral Angiography--methods--Case
Reports. 7. Cerebrovascular Circulation--Atlases. 8. Cerebrovascular
Circulation--Case Reports. WL 17 N4935 2008]
RC388.5.N4634 2008
616.8'107543--dc22
2008007225
Important note: Medicine is an ever-changing science undergoing
continual development. Research and clinical experience are continually expanding our knowledge, in particular our knowledge of
proper treatment and drug therapy. Insofar as this book mentions
any dosage or application, readers may rest assured that the authors,
editors, and publishers have made every effort to ensure that such
referencesareinaccordancewiththe state of knowledge at the time
of production of the book.
Nevertheless, this does not involve, imply, or express any guarantee or responsibility on the part of the publishers in respect to any
dosage instructions and forms of applications stated in the book.
Every user is requested to examine carefully the manufacturers’ leaf-
lets accompanying each drug and to check, if necessary in consultation with a physician or specialist, whether the dosage schedules
mentioned therein or the contraindications stated by the manufacturers differ from the statements made in the present book. Such
examination is particularly important with drugs that are either
rarely used or have been newly released on the market. Every dosage
schedule or every form of application used is entirely at the user’s
own risk and responsibility. The authors and publishers request
every user to report to the publishers any discrepancies or inaccuracies noticed. If errors in this work are found after publication, errata
will be posted at www.thieme.com on the product description page.
© 2008 Georg Thieme Verlag,
Rüdigerstrasse 14, 70469 Stuttgart, Germany
http://www.thieme.de
Thieme New York, 333 Seventh Avenue,
New York, NY 10001, USA
http://www.thieme.com
Cover design: Thieme Publishing Group
Typesetting by Primustype Hurler, Notzingen, Germany
Printed by Druckerei Grammlich, Pliezhausen, Germany
ISBN 978-3-13-141871-5 123456
Some of the product names, patents, and registered designs referred
to in this book are in fact registered trademarks or proprietary names
even though specific reference to this fact is not always made in the
text. Therefore, the appearance of a name without designation as
proprietary is not to be construed as a representation by the publisher that it is in the public domain.
This book, including all parts thereof, is legally protected by copyright. Anyuse, exploitation, or commercialization outside the narrow
limits set by copyright legislation, without the publisher’sconsent,is
illegal and liable to prosecution. This applies in particular to photostat reproduction, copying, mimeographing, preparation of microfilms, and electronic data processing and storage.
Foreword
V
Ultrasound has undoubtedly changed the face of medicine
during the past two decades. Ultrasound testing is safe,
quick, and relatively inexpensive compared with other
imaging modalities. To be able to perform multiple repeat
studies safely has made ultrasound an ideal modality to
monitor various conditions and abnormalities. Echocardiography has revolutionized cardiology, and sonography
of the pregnant uterus has become indispensable for obstetrical care. Compared to ultrasound of the heart and
uterus, ultrasound exploration of the nervous system and
its supply arteries and veins is a relatively new field. The
parts of the nervous system and the cervico-cranial arteries and veins are quite heterogeneous and anatomically
dispersed, making Neurosonology much more complex
and diverse than insonating a single organ. While most
cardiologists and obstetricians have become very familiar
with ultrasound use and images in their specialties,
neurosonology is used extensively by only very few neurologists and neurosurgeons. Cerebrovascular specialists
have become familiar with neck and transcranial ultrasound reports and results, yet very few of these subspecialists actually perform or interpret the examinations. For
these reasons the present monograph fulfills a large void
andwillproveextremelyusefulforneurologists,neurosurgeons, and neuroradiologists and for all physicians caring for patients with cerebrovascular diseases.
This monograph is very systematically organized. The
first part (A) contains the basic principles of neurosonology and of cerebrovascular disease. Ultrasound principles
are described and heavily illustrated with very useful dia-
grams and images. The anatomy, pathology, and pathophysiology of the cervico-cranial arteries are discussed
and illustrated in detail. Other vascular imaging techniques (CT and MR angiography and dye contrast catheter
angiography) are also discussed, compared, and illustrated
in detail in Part A. The quantity, quality, and didactic utility
of the diagrams, cartoons, and illustrations is exceptional
in my experience.
The second part of the monograph (Part B) is unique.
Most individuals learn by example, the case method of
teaching, rather than by general principles alone. Part B
contains 30 case scenarios grouped according to the expected difficulty of the neurosonology exploration and
interpretation. The clinical findings are noted and the
imaging results are shown in detail. The discussions are
thorough and most useful in understanding the techniques
and results. Part B helps clinicians and neuroradiologists
put into practical use the principles enunciated in Part A.
Part B also emphasizes potential difficulties and conun-
drums that are likely to confound even experienced
neurosonologists.
This book will take pride of place on my library shelf and
I anticipate using it often as a reference. It is a superb
addition to the literature on neurosonology and of cerebrovascular diagnosis and management.
Louis R Caplan MD
Professor of Neurology, Harvard University
Boston, Massachusetts, USA
VI
Foreword
Neurovascular disease, in particular stroke, has tremendously contributed to Neurology developing into a therapeutic speciality. Today’s complex treatment strategies of
acute stroke have been established thanks to innumerable
clinical studies. This requires sophisticated pathophysiological and detailed clinical knowledge from the attending
physician, as often the neuroanatomical condition as well
as the functional situation are of therapeutic relevance.
Various diagnostic methods such as magnetic resonance
imaging, computed tomography, angiography as well as
diagnostic ultrasound, which is the only bedside technique, are in continuous development and competition.
This book looks at competing and complementary
methods from the perspective of diagnostic ultrasound.
Oneofthekeyissuesofthisbookistheexplorationof
the advantages and disadvantages of the diagnostic tools
used in cerebrovascular diagnostics, their specificity and
sensitivity as well as their pitfalls. In the first section, the
reader will find detailed and comprehensive text of the
duplex ultrasound technique, including precise and pragmatic instructions, which will help the reader acquire a
fundamental understanding of Neurosonology.
In the second, more extensive part of the book, the
clinical advantages and disadvantages of various vascular
diagnostic methods are demonstrated in relation to ultrasound, by means of 30 case histories. These have been
carefully selected from the wide field of neurovascular
diseases ranging from acute stroke, arteritis and sinus
venous thrombosis to vascular malformations.
Hereby the book offers beginners as well as experienced
practitioners the opportunity to approach ultrasound diagnostics not only from the perspective of a specialized
diagnostician but also from the perspective of a clinician
whoisstrugglingtogaintherelevantinformation.Ittherefore closes a gap in the currently available literature about
the use of neurosonological methods and at the same time
offers extensive opportunities to “train” clinical diagnostic
thoughts in cerebrovascular diseases.
I am particularly proud thatthe work inthe Neurological
Department of the Charité University Teaching Hospital in
Berlin, where I have been Director for 15 years, is honored
with this book. I can highly commend the authors of this
book as they have been outstanding colleagues and companions for many years.
I give my best wishes to them and their book with its
original concept, and I hope that it will quickly become a
standard text and reference source for many who work
within the speciality, and beyond.
Prof.KarlM.Einhäupl
Professor and Chairman
Department of Neurology
Charité University Hospital
Berlin, Germany
Table of Contents
Part A Principles and Rules
VII
1FlowandUltrasoundBasics.................. 2
Flow Dynamics ............................. 2
Physics of Flow ........................... 2
Flow Pattern and Flow Velocity............. 2
Ultrasound Principles ....................... 3
Doppler Effect............................ 3
Doppler Shift and Flow Velocity ............ 4
Ultrasound Systems......................... 6
Ultrasound Transducer .................... 6
Imaging Modalities, Parameters, and Settings 7
2 Vascular Anatomy and Structure of Ultrasound
Examination
General Arterial Anatomy.................... 13
Extracranial Arterial Anatomy .............. 13
Intracranial Arterial Anatomy .............. 15
General Structure of Arterial Ultrasound
Examination
Special Arterial Anatomy
andUltrasoundAnatomy
Extracranial Arteries ...................... 18
Intracranial Arteries ...................... 24
General Venous Anatomy .................... 40
Intracranial Venous Anatomy............... 41
Extracranial Venous Anatomy .............. 42
General Structure of Venous Ultrasound
Examination
Special Venous Anatomy and Ultrasound
Anatomy
Intracranial Veins and Sinuses.............. 43
Extracranial Veins ........................ 49
3 Intracranial Hemodynamics and Functional
Tes ts
Autoregulation ............................. 55
Testing of Autoregulation .................. 56
Neurovascular Coupling ..................... 56
Testing of Neurovascular Coupling .......... 57
Metabolic Coupling ......................... 57
Other Tests to Assess Differences Between the
Right and Left Sides as Markers of Impaired
Collateral Function
............................... 13
............................... 17
.................... 18
............................... 43
.................................. 43
...................................... 54
........................ 59
Parameters of Cerebral Hemodynamics........ 60
Cerebral Blood Flow Velocity ............... 60
Resistance Indices ........................ 60
Cerebral Blood Flow ...................... 60
Cerebral Circulation Time .................. 61
Cerebral Blood Volume .................... 62
4PathogenesisofStroke...................... 64
Arterial Ischemia ........................... 64
Pathophysiology.......................... 64
Classification of Arterial Stroke ............. 65
Microembolic Signals ....................... 72
Spontaneous Microemboli ................. 72
Detection of Microemboli in Patent Foramen
................................... 74
Ovale
Venous Ischemia ........................... 74
5 Vascular Pathology ......................... 76
VesselWallPathology....................... 76
Elongations .............................. 76
Intima-media Thickness ................... 77
Atherosclerotic Plaques.................... 78
Dissection ............................... 80
Fibromuscular Dysplasia................... 80
Vasculitis ................................ 81
Stenoses and Occlusions ..................... 81
Ultrasound Criteria of Stenoses ............. 81
Ultrasound Criteria of Occlusions ........... 85
Extracranial Pathology ...................... 86
Extracranial Anterior Circulation............ 86
Extracranial Posterior Circulation ........... 91
Intracranial Pathology ....................... 94
Intracranial Anterior Circulation ............ 96
Intracranial Posterior Circulation ........... 99
Collateral Pathways ......................... 101
Intracranial Collateral Pathways ............ 101
Intracranial Collateral Pathways in ICA
Occlusive Processes
Intracranial Collateral Pathways in VA
Occlusive Processes
Extracranial Collateral Pathways............ 108
Clinical Relevance of Collateral Pathways .... 109
....................... 105
....................... 108
VIII Table of Contents
6 Angiographic Techniques in Neuroradiology .... 111
Digital Subtraction Angiography............... 111
Historical Development .................... 111
Technical Aspects ......................... 112
Strengths and Disadvantages ............... 113
Magnetic Resonance Angiography ............. 113
Historical Development .................... 113
Technical Aspects ......................... 114
Strengths and Disadvantages ............... 115
Computed Tomographic Angiography .......... 116
Part B: Case Histories
Case1 ExtracranialInternalCarotidArtery
Stenosis
Clinical Presentation ......................... 128
Initial Neuroradiologic Findings ............... 128
Suspected Diagnosis ......................... 128
Questions to Answer by Ultrasound Techniques .128
Initial Neurosonologic Findings ............... 128
Conventional Angiography ................... 128
Clinical Course .............................. 128
Final Diagnosis.............................. 130
Discussion ................................. 130
Case 2 Free-floating Thrombus of the
Extracranial Internal Carotid Artery
Clinical Presentation ......................... 133
Initial Neuroradiologic Findings ............... 133
Suspected Diagnosis ......................... 133
Question to Answer by Ultrasound Techniques .. 133
Initial Neurosonologic Findings (Day 1) ........ 133
Clinical Course .............................. 133
Neurosonologic Findings (Day 20) ............. 134
Final Diagnosis.............................. 134
Discussion ................................. 135
Case 3 Common Carotid Artery Occlusion ..... 138
Clinical Presentation ......................... 138
Initial Neuroradiologic Findings ............... 138
Suspected Diagnosis ......................... 138
Questions to Answer by Ultrasound Techniques .138
Initial Neurosonologic Findings ............... 138
Clinical Course .............................. 139
Final Diagnosis.............................. 141
Discussion ................................. 142
Case 4 Temporal Arteriovenous Malformation.. 143
Clinical Presentation ......................... 143
Initial Neuroradiologic Findings ............... 143
Suspected Diagnosis ......................... 143
Questions to Answer by Ultrasound Techniques .143
Initial Neurosonologic Findings ............... 143
............................ 128
.... 133
Historical Development .................... 116
Technical Aspects ......................... 116
Strengths and Disadvantages ............... 117
Current Algorithm at the Charité University
Hospital
Conventional Angiography ................... 143
Clinical Course .............................. 144
Final Diagnosis.............................. 144
Discussion ................................. 146
Case 5 M1 Middle Cerebral Artery Stenosis .... 149
Clinical Presentation ......................... 149
Initial Neuroradiologic Findings ............... 149
Suspected Diagnosis ......................... 149
Questions to Answer by Ultrasound Techniques .149
Initial Neurosonologic Findings (Day 1) ........ 149
Conventional Angiography (Day 2) ............ 149
Final Diagnosis.............................. 150
Discussion ................................. 151
Case 6 P 2 Posterior Cerebral Artery Stenosis... 156
Clinical Presentation ......................... 156
Initial Neuroradiologic Findings ............... 156
Suspected Diagnosis ......................... 156
Questions to Answer by Ultrasound Techniques .156
Initial Neurosonologic Findings (Day 2) ........ 156
Clinical Course .............................. 156
Final Diagnosis.............................. 157
Discussion ................................. 157
Case 7 Cerebral Circulatory Arrest ............ 160
Clinical Presentation ......................... 160
Initial Neuroradiologic Findings ............... 160
Suspected Diagnosis ......................... 160
Clinical Course (1) ........................... 160
Question to Answer by Ultrasound Techniques .. 160
Initial Neurosonologic Findings ............... 160
Cerebral CT ................................. 160
Clinical Course (2) ........................... 160
Final Diagnosis.............................. 162
Discussion ................................. 162
Case 8 Bilateral Intracranial V4 Vertebral
Clinical Presentation ......................... 165
.................................... 119
Stroke ................................... 119
Intracranial Aneurysm ..................... 120
Vasculitis................................. 121
Cerebral Venous Thrombosis................ 123
Peri-therapeutic Imaging ................... 124
Artery Stenosis
...................... 165
IXTable of Co ntents
Initial Neuroradiologic Findings .............. 165
Suspected Diagnosis ........................ 165
Conventional Angiography (Day 1) ............ 165
Clinical Course (1) .......................... 165
Question to Answer by Ultrasound Techniques .. 165
Initial Neurosonologic Findings (Day 42) ....... 165
Neuroradiologic Findings .................... 166
Clinical Course (2) .......................... 168
Final Diagnosis ............................. 168
Discussion ................................. 168
Case 9 Moyamoya Disease with Bilateral
Carotid-T Stenosis
Clinical Presentation ........................ 171
Initial Neuroradiologic Findings .............. 171
Suspected Diagnosis ........................ 171
Questions to Answer by Ultrasound Techniques .171
Initial Neurosonologic Findings (Day 1) ........ 171
Conventional Angiography (Day 2) ............ 171
Clinical Course ............................. 173
Final Diagnosis ............................. 173
Discussion ................................. 173
Case 10 Thrombolysis of M1 Middle Cerebral
Artery Occlusion
Clinical Presentation ........................ 176
Initial Neuroradiologic Findings .............. 176
Suspected Diagnosis ........................ 176
Clinical Course (1) .......................... 176
Questions to Answer by Ultrasound Techniques .176
Initial Neurosonologic Findings ............... 176
Clinical Course (2) .......................... 176
Follow-up Neurosonologic Findings (1 Hour) ... 176
Clinical Course (3) .......................... 177
Final Diagnosis ............................. 177
Discussion ................................. 178
Case11 SecondaryOcclusioninInternalCarotid
Artery Dissection
Clinical Presentation ........................ 183
Initial Neuroradiologic Findings .............. 183
Suspected Diagnosis ........................ 183
Questions to Answer by Ultrasound Techniques .183
Initial Neurosonologic Findings (Day 1) ........ 183
Clinical Course (1) .......................... 183
Questions to Answer by Ultrasound Techniques .184
Follow-up Neurosonologic Findings (Day 2) .... 184
Clinical Course (2) .......................... 184
Follow-up Neurosonologic Findings (Day 7) .... 184
Clinical Course (3) .......................... 184
Follow-up Neurosonologic Findings (6 Months).184
Final Diagnosis ............................. 185
Discussion ................................. 190
Case12 BilateralProximalExtracranialInternal
Carotid Artery Occlusion and Highgrade V1 Vertebral Artery Stenosis
................... 171
................... 176
..................... 183
... 194
Clinical Presentation ........................ 194
Initial Neuroradiologic Findings .............. 194
Suspected Diagnosis ........................ 194
Questions to Answer by Ultrasound Techniques .194
Initial Neurosonologic Findings ............... 194
Conventional Angiography ................... 195
Clinical Course ............................. 195
Final Diagnosis ............................. 196
Discussion ................................. 200
Case 13 Internal Carotid Artery Stenosis in
Fibromuscular Dysplasia and
Wegener Granulomatosis
Clinical Presentation ........................ 204
Initial Neuroradiologic Findings .............. 204
Suspected Diagnosis ........................ 204
Question to Answer by Ultrasound Techniques .. 204
Initial Neurosonologic Findings (Day 1) ........ 204
Clinical Course (1) .......................... 204
Conventional Angiography (Day 5) ............ 205
Clinical Course (2) .......................... 205
Follow-up Neurosonologic Findings (5 Years)... 205
Final Diagnosis ............................. 206
Discussion ................................. 207
Case 14 Isolated Carotid Siphon Stenosis ..... 210
Clinical Presentation ........................ 210
Initial Neuroradiologic Findings .............. 210
Suspected Diagnosis ........................ 210
Questions to Answer by Ultrasound Techniques .210
Initial Neurosonologic Findings ............... 210
Clinical Course ............................. 210
Final Diagnosis ............................. 211
Discussion ................................. 213
Case 15 Near Occlusion of the Extracranial
Internal Carotid Artery
Clinical Presentation ........................ 215
Initial Neuroradiologic Findings .............. 215
Suspected Diagnosis ........................ 215
Questions to Answer by Ultrasound Techniques .215
Initial Neurosonologic Findings ............... 215
Conventional Angiography ................... 216
Clinical Course (1) .......................... 216
Follow-up Neurosonologic Findings (2 Months).216
Clinical Course (2) .......................... 216
Follow-up Neurosonologic Findings (5 Months).216
Final Diagnosis ............................. 216
Discussion ................................. 222
Case 16 Giant-cell Arteritis with Bilateral
Intracranial V4 Vertebral Artery
Stenosis
Clinical Presentation ........................ 225
Initial Neuroradiologic Findings .............. 225
Suspected Diagnosis ........................ 225
Questions to Answer by Ultrasound Techniques .225
.......................... 225
........... 204
.............. 215
XTableofContents
Initial Neurosonologic Findings (Day 1) ........ 225
Clinical Course (1) ........................... 225
Follow-up Neurosonologic Findings (6 weeks)... 226
Clinical Course (2) ........................... 226
Final Diagnosis.............................. 226
Discussion ................................. 228
Case 17 Ascending Middle Cerebral Artery
Occlusion
Clinical Presentation ......................... 231
Initial Neuroradiologic Findings ............... 231
Suspected Diagnosis ......................... 231
Questions to Answer by Ultrasound Techniques .231
Initial Neurosonologic Findings (Day 1) ........ 231
Conventional Angiography (Day 3) ............ 231
Clinical Course .............................. 232
Final Diagnosis.............................. 234
Discussion ................................. 235
Case 18 Bilateral Internal Carotid Artery
Dissection
Clinical Presentation ......................... 238
Initial Neuroradiologic Findings ............... 238
Suspected Diagnosis ......................... 238
Questions to Answer by Ultrasound Techniques .238
Initial Neurosonologic Findings ............... 238
Conventional Angiography ................... 238
Clinical Course (1) ........................... 239
Follow-up Neurosonologic Findings (3 Months) .239
Clinical Course (2) ........................... 239
Final Diagnosis.............................. 239
Discussion ................................. 243
Case 19 Vertebral Artery Dissection with
Distal Occlusion
Clinical Presentation ......................... 245
Initial Neuroradiologic Findings ............... 245
Suspected Diagnosis ......................... 245
Questions to Answer by Ultrasound Techniques .245
Initial Neurosonologic Findings ............... 245
Conventional Angiography ................... 245
Clinical Course .............................. 246
Final Diagnosis.............................. 246
Discussion ................................. 248
Case 20 Internal Carotid Artery Dissection
with Fast Recanalization
Clinical Presentation ......................... 251
Initial Neuroradiologic Findings ............... 251
Suspected Diagnosis ......................... 251
Questions to Answer by Ultrasound Techniques .251
Initial Neurosonologic Findings (Day 1) ........ 251
Evaluation of Collateral Function .............. 251
Conventional Angiography ................... 252
Clinical Course (1) ........................... 252
Follow-up Neurosonologic Findings (Day 20) ... 252
Clinical Course (2) ........................... 253
.......................... 231
......................... 238
.................... 245
............. 251
Final Diagnosis.............................. 253
Discussion ................................. 259
Case 21 Mid-basilar Artery Occlusion ......... 261
Clinical Presentation ......................... 261
Initial Neuroradiologic Findings ............... 261
Suspected Diagnosis ......................... 261
Clinical Course (1) ........................... 261
Follow-up Neuroradiologic Findings (Day 3) .... 261
Questions to Answer by Ultrasound Techniques .261
Initial Neurosonologic Findings (Day 3) ........ 261
Conventional Angiography (Day 4) ............ 262
Clinical Course (2) ........................... 262
Final Diagnosis.............................. 262
Discussion ................................. 266
Case 22 M1 Middle Cerebral Artery Occlusion
with Prominent Early Temporal
Branch
............................ 269
Clinical Presentation ......................... 269
Initial Neuroradiologic Findings ............... 269
Suspected Diagnosis ......................... 269
Questions to Answer by Ultrasound Techniques .269
Initial Neurosonologic Findings (Day 1) ........ 269
Clinical Course (1) ........................... 269
Questions to Answer by Ultrasound Techniques .270
Neurosonologic Findings (Day 10) ............. 270
Neuroradiologic Findings (Day 11) ............. 270
Clinical Course (2) ........................... 271
Final Diagnosis.............................. 271
Discussion ................................. 275
Case 23 Takayasu Arteritis with Subclavian
Artery and Vertebral Artery Stenoses
Clinical Presentation ......................... 279
Initial Neuroradiologic Findings ............... 279
Suspected Diagnosis ......................... 279
Questions to Answer by Ultrasound Techniques .279
Initial Neurosonologic Findings ............... 279
Conventional Angiography ................... 279
Clinical Course (1) ........................... 280
Question to Answer by Ultrasound Techniques
(6 Months)
Neurosonologic Findings (6 Months) ........... 280
Clinical Course (2) ........................... 280
Questions to Answer by Ultrasound Techniques
(8 Months)
Neurosonologic Findings (8 Months) ........... 280
Final Diagnosis.............................. 281
Discussion ................................. 284
Case 24 Dissection of the Extracranial Internal
Clinical Presentation ......................... 287
Initial Neuroradiologic Findings ............... 287
Suspected Diagnosis ......................... 287
................................. 280
................................. 280
Carotid Artery and Contralateral M1
Middle Cerebral Artery Stenosis
.. 279
...... 287