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diff --git a/docs_md/articles/fusiform-arterial-enlargement_31d50b93-b057-4da3-86b5-4cc8fb0bc806.md b/docs_md/articles/fusiform-arterial-enlargement_31d50b93-b057-4da3-86b5-4cc8fb0bc806.md
index 3e3302d..d6583dc 100644
--- a/docs_md/articles/fusiform-arterial-enlargement_31d50b93-b057-4da3-86b5-4cc8fb0bc806.md
+++ b/docs_md/articles/fusiform-arterial-enlargement_31d50b93-b057-4da3-86b5-4cc8fb0bc806.md
@@ -119,23 +119,19 @@ breadcrumbs:
### Selected Images
-
in an octogenarian related to dolichoectasia. Fusiform dolichoectasia is a common finding in the vertebrobasilar arteries in older patients.](images/app.statdx.com_image_38e1497f-31e3-49db-8b46-4ab561bf1eac_fb437f8b_20251018T080401Z.jpg)
+
**Dolichoectasia**
*Axial CT shows fusiform dilatation and tortuosity of the basilar artery in an octogenarian related to dolichoectasia. Fusiform dolichoectasia is a common finding in the vertebrobasilar arteries in older patients.*
-
+
**Dolichoectasia**
*Axial CT shows fusiform dilatation and tortuosity of the basilar artery in an octogenarian related to dolichoectasia. Fusiform dolichoectasia is a common finding in the vertebrobasilar arteries in older patients.*
-
-**Dolichoectasia**
-*Axial CT shows fusiform dilatation and tortuosity of the basilar artery in an octogenarian related to dolichoectasia. Fusiform dolichoectasia is a common finding in the vertebrobasilar arteries in older patients.*
-
-
. No significant mural thrombus was noted in this fusiform aneurysm.](images/app.statdx.com_image_thumbnail_f63a9221-71c6-4320-af66-1ed581202eb9_size_168_quality_85_8a3ae196_20251018T080328Z.jpg)
+
**Atherosclerotic Fusiform Aneurysm**
*Coronal CTA shows fusiform dilatation of the right supraclinoid internal carotid artery (ICA). Irregularity from atherosclerotic disease can be seen of the M1 segment of the middle cerebral artery . No significant mural thrombus was noted in this fusiform aneurysm.*
-
, T2 
, and T1 pre- and post DANTE VWI sequences shows peripheral enhancement, suggestive of instability.](images/app.statdx.com_image_thumbnail_68b41ae0-9f3a-4484-8b02-69d6772626db_size_168_quality_85_8d79e53e_20251018T080328Z.jpg)
+
**Dissecting Aneurysm/Pseudoaneurysm**
*Dissecting pseudoaneurysm in the V4 segment of the right vertebral artery seen on 3D TOF MRA , T2 , and T1 pre- and post DANTE VWI sequences shows peripheral enhancement, suggestive of instability.*
@@ -143,7 +139,7 @@ breadcrumbs:
**Ehlers-Danlos**
*3D MIP MRA of the vertebrobasilar arteries in a teenage female with a history of type 4 Ehlers-Danlos shows fusiform dilatation of the vertebral artery . The affected gene is COL3A1, and this specific type of Ehlers-Danlos has a higher risk of aneurysm and vascular rupture.*
-
+
**Marfan Syndrome**
*Axial MIP from CT arteriography shows fusiform dilatation of the left middle cerebral artery bifurcation in this child with a history of Marfan syndrome.*
@@ -151,34 +147,34 @@ breadcrumbs:
**Familial Thoracic Aneurysm &/or Dissection**
*Coronal MIP reformat from CT arteriography shows bilateral fusiform aneurysms of supraclinoid ICAs . This patient also had thoracic aortic aneurysm, which is consistent with familial thoracic aortic aneurysm and dissection and is associated with a mutation of ACTA2. This gene is responsible for a component of vascular smooth muscle.*
-
+
**HIV Infection**
*Axial T2WI MR shows strikingly enlarged middle cerebral arteries in this child with congenital HIV/AIDS (an uncommon but well-recognized cause of pediatric fusiform arteriopathy). The stroke-like presentations of HIV infection may relate to vasculopathies, including large-vessel aneurysmal vasculopathy.*
-
with associated mural thrombus 
seen on sagittal CTA.](images/app.statdx.com_image_thumbnail_8fb2594c-2abc-43d9-84bc-b8b67664090e_size_168_quality_85_e273dd7e_20251018T080329Z.jpg)
+
**Giant Serpentine Aneurysm**
*Axial NECT demonstrates a giant serpentine aneurysm in the basilar artery with associated mural thrombus seen on sagittal CTA.*
### Additional Images
-
.](images/app.statdx.com_image_thumbnail_5a50f257-ef7f-4680-94e0-670c586154aa_size_168_quality_85_75bc027c_20251018T080401Z.jpg)
+
**Dolichoectasia**
*Sagittal T1WI MR shows an elongated basilar artery with a slow-flow, thickened wall . The apex of the tortuous basilar artery indents the hypothalamus, 3rd ventricle .*
-
+
**Dolichoectasia**
*Axial T2WI MR shows an elongated, tortuous basilar artery with a thickened arterial wall , typical for atherosclerosis-associated fusiform ectasia.*
-
. This is an unusual example because of the location (ICA, middle cerebral artery).](5b2eae83-b875-4f2c-9903-07a167a394a0)
+
**Atherosclerotic Fusiform Aneurysm**
*Lateral angiography shows a large fusiform middle cerebral artery aneurysm that extends into smaller, more distal branches . This is an unusual example because of the location (ICA, middle cerebral artery).*
-
+
**Nonaneurysmal Dissection**
*Axial T1WI MR shows an enlarged right vertebral artery with high signal intensity as well as an absent flow void of the left vertebral artery .*
-
+
**Ehlers-Danlos Syndrome**
*Anteroposterior oblique view of the left vertebral angiogram shows focal elongations and widening of the basilar artery in a 6-year-old child with Ehlers-Danlos type 4.*
@@ -186,7 +182,7 @@ breadcrumbs:
**Giant Serpentine Aneurysm**
*Axial MRA submentovertex view shows an unusual nonatherosclerotic giant serpentine fusiform aneurysm. The patent channel lies within the clot in the partially thrombosed lumen.*
-
+
**Atypical Saccular Aneurysm**
*Lateral angiography in 30-year-old man with a subarachnoid hemorrhage shows an elongated, bizarre-appearing, multilobulated aneurysm with long aspect ratio, tit-like projections.*
diff --git a/docs_md/articles/hyperattenuating-dense-artery_70b5e153-27a5-4871-aaf3-0942c49f02e0.md b/docs_md/articles/hyperattenuating-dense-artery_70b5e153-27a5-4871-aaf3-0942c49f02e0.md
new file mode 100644
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+++ b/docs_md/articles/hyperattenuating-dense-artery_70b5e153-27a5-4871-aaf3-0942c49f02e0.md
@@ -0,0 +1,201 @@
+---
+title: "Hyperattenuating (\"Dense\") Artery"
+docid: "70b5e153-27a5-4871-aaf3-0942c49f02e0"
+authors:
+ - key: "2bca6b86-1eca-4e93-b997-4e18913686a7"
+ value: "Hediyeh Baradaran, MD, MS"
+ - key: "7cc3ba75-2642-4233-b9f6-0ce69ffe28f3"
+ value: "Sheri L. Harder, MD, FRCPC"
+ - key: "8d5254e9-8dda-478b-8f08-bdee97a32c79"
+ value: "Karen L. Salzman, MD, FACR"
+breadcrumbs:
+ -
+ name: "Brain"
+ slug: "brain"
+ treeNodeId: "6d8829f1-14d7-45af-8675-255189aa526a"
+ -
+ name: "Differential Diagnosis"
+ slug: "differential-diagnosis"
+ treeNodeId: "a7fdd139-664e-4bb8-8d18-400e4733ff60"
+ -
+ name: "Arteries"
+ slug: "arteries"
+ treeNodeId: "f5fee8ee-062f-41f2-b449-efcca9fb78f9"
+ -
+ name: "Modality-Specific Imaging Findings"
+ slug: "modality-specific-imaging-findings"
+ treeNodeId: "369f11e2-7476-4e44-89b6-0a28c866b3e9"
+ -
+ name: "Hyperattenuating (\"Dense\") Artery"
+ slug: "hyperattenuating-dense-artery"
+ treeNodeId: null
+category: "Brain"
+documentVersionId: "26d80075-82d0-4b92-b0c7-f1b0e5fbf5da"
+imageCount: 19
+lastUpdated: "02/07/23"
+pageDescription: "Hyperattenuating (\"Dense\") Artery"
+pageKeywords: "Brain, Differential Diagnosis, Arteries, Modality-Specific Imaging Findings, Hyperattenuating (\"Dense\") Artery"
+pageTitle: "Hyperattenuating (\"Dense\") Artery | STATdx"
+enhancedTitle: "Hyperattenuating ("Dense") Artery"
+type: "DDX"
+references: true
+breadcrumbs:
+ - "Brain"
+ - "Differential Diagnosis"
+ - "Arteries"
+ - "Modality-Specific Imaging Findings"
+ - "Hyperattenuating (\"Dense\") Artery"
+---
+# ESSENTIAL INFORMATION
+
+- ## Key Differential Diagnosis Issues
+
+
+ - Presence, localization of focal neurologic findings important
+ - High hematocrit/hemoconcentration can mimic dense middle cerebral artery (MCA) sign
+ - Compare to other intracranial vessels!
+ - Diffuse low-density brain (anoxia, etc.) makes all vessels appear hyperdense, mimics thrombus or subarachnoid hemorrhage
+- ## Helpful Clues for Common Diagnoses
+
+
+ - **Physiologic****H****yperdensity**
+ - Circulating blood in arteries normally slightly hyperdense to brain: Especially prominent in newborns with unmyelinated, hypodense brain
+ - Diffuse cerebral edema makes vessels appear hyperdense (false dense MCA sign)
+ - **Cerebral****I****schemia-Infarction, Acute**
+ - Acute thrombus in affected vessel (e.g., true dense MCA sign)
+ - Acute clot undergoes time-dependent decrease in density within first 5 hours after stroke onset
+ - **Recent IV Contrast Administration**
+ - History of prior imaging exam; more common and longer lasting in patients with renal clearance impairment
+- ## Helpful Clues for Less Common Diagnoses
+
+
+ - **Atherosclerosis, Intracranial**
+ - ASVD with microcalcifications can mimic "dense" MCA
+ - **Polycythemia**
+ - All vessels (arteries, veins, dural sinuses) become hyperdense in polycythemia
+ - Can be physiologic (elevated hematocrit in newborns, high altitude, etc.)
+ - Numerous pathologic causes (cyanotic congenital heart disease, COPD, etc.)
+ - **Fusiform Aneurysm (ASVD, Non-ASVD)**
+ - Vertebrobasilar > anterior circulation
+ - Thickened walls may appear hyperdense
+ - Non-ASVD: Younger; inherited vasculopathy, immune disorder
+ - **Dissection**
+ - Most posterior circulation
+ - Trauma most common etiology
+ - **Pseudoaneurysm**
+ - Trauma most common etiology
+- ## Helpful Clues for Rare Diagnoses
+
+
+ - **Devices and Complications**
+ - Coils, balloons, stents, methacrylate, etc.
+ - Embolized foreign bodies, calcified atheromata can cause hyperattenuating vessel sign
+
+## References
+
+# Selected References
+
+1. [Figurelle ME et al: Viz.ai Implementation of stroke augmented intelligence and communications platform to improve indicators and outcomes for a comprehensive stroke center and network. AJNR Am J Neuroradiol. 44(1):47-53, 2023](http://www.ncbi.nlm.nih.gov/pubmed/?term=36574318%5Bpmid%5D)
+1. [Legrand L et al: FLAIR vascular hyperintensities as a surrogate of collaterals in acute stroke: DWI matters. AJNR Am J Neuroradiol. 44(1):26-32, 2023](http://www.ncbi.nlm.nih.gov/pubmed/?term=36521962%5Bpmid%5D)
+1. [Lu SS et al: Automated estimation of quantitative lesion water uptake as a prognostic biomarker for patients with ischemic stroke and large-vessel occlusion. AJNR Am J Neuroradiol. 44(1):33-9, 2023](http://www.ncbi.nlm.nih.gov/pubmed/?term=36549850%5Bpmid%5D)
+1. [Derraz I et al: Impact of white matter hyperintensity burden on outcome in large-vessel occlusion stroke. Radiology. 304(1):145-52, 2022](http://www.ncbi.nlm.nih.gov/pubmed/?term=35348382%5Bpmid%5D)
+1. [DiBella EVR et al: Beyond diffusion tensor MRI methods for improved characterization of the brain after ischemic stroke: a review. AJNR Am J Neuroradiol. 43(5):661-9, 2022](http://www.ncbi.nlm.nih.gov/pubmed/?term=35272983%5Bpmid%5D)
+1. [Fukutomi H et al: Location-weighted versus volume-weighted mismatch at MRI for response to mechanical thrombectomy in acute stroke. Radiology. ePub, 2022](http://www.ncbi.nlm.nih.gov/pubmed/?term=36194114%5Bpmid%5D)
+1. [Grand T et al: Benefit of mechanical thrombectomy in acute ischemic stroke related to calcified cerebral embolus. J Neuroradiol. 49(4):317-23, 2022](http://www.ncbi.nlm.nih.gov/pubmed/?term=35183595%5Bpmid%5D)
+1. [Regenhardt RW et al: Symmetric CTA Collaterals Identify Patients With Slow-progressing Stroke Likely To Benefit From Late Thrombectomy. Radiology. 302(2):400-7, 2022](http://www.ncbi.nlm.nih.gov/pubmed/?term=34726532%5Bpmid%5D)
+1. [Zhou Y et al: CT hyperdense artery sign and the effect of alteplase in endovascular thrombectomy after acute stroke. Radiology. 305(2):410-8, 2022](http://www.ncbi.nlm.nih.gov/pubmed/?term=35819327%5Bpmid%5D)
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+
+
+## Images
+
+
+### Selected Images
+
+
+**Physiologic Hyperdensity**
+*Axial NECT shows a hyperdense middle cerebral artery (MCA) and basilar arteries in this patient with dehydration. Typically, the circle of Willis arteries are mildly hyperdense compared with normal brain parenchyma. Vessels become prominent in normal newborns with unmyelinated, hypodense brain.*
+
+
+**Physiologic Hyperdensity**
+*Axial NECT shows a hyperdense middle cerebral artery (MCA) and basilar arteries in this patient with dehydration. Typically, the circle of Willis arteries are mildly hyperdense compared with normal brain parenchyma. Vessels become prominent in normal newborns with unmyelinated, hypodense brain.*
+
+
+**Physiologic Hyperdensity**
+*Axial NECT shows bilateral dense MCA signs and ↑ density in venous structures in an anoxic patient with diffuse cerebral edema. Low-density brain makes the normal vascular structures appear hyperdense.*
+
+
+**Cerebral Ischemia-Infarction, Acute**
+*Axial NECT shows ↑ density in the left MCA (dense MCA sign) in a patient with acute right-sided symptoms. The density is from acute thrombus within the vessel. Note the associated loss of gray-white differentiation in the MCA territory .*
+
+
+**Cerebral Ischemia-Infarction, Acute**
+*Axial NECT in the same patient 48 hours later shows a large left MCA distribution infarct with hemorrhagic transformation . Infarct in the basal ganglia indicates involvement of lenticulostriate arteries, which typically arise from the proximal MCA.*
+
+
+**Cerebral Ischemia-Infarction, Acute**
+*Axial NECT shows ↑ density related to a dot sign in a distal left MCA branch , representing acute thrombus. Hypodensity related to early infarct is seen in the adjacent brain parenchyma.*
+
+
+**Atherosclerosis, Intracranial**
+*Axial NECT shows calcification in the supraclinoid internal carotid arteries , a common location for intracranial atherosclerosis. Intracranial atherosclerosis is associated with atherosclerosis of the carotids, coronaries, aorta, renal arteries, and iliofemoral system.*
+
+
+**Fusiform Aneurysm (ASVD, Non-ASVD)**
+*Axial NECT shows a large, hyperdense basilar artery related to a fusiform aneurysm. Atherosclerotic calcification and hyperdensity is also present in the proximal left MCA .*
+
+
+**Devices and Complications**
+*Axial NECT shows embolized hyperdense material in the left MCA in an IV drug abuser, possibly secondary to talc powder. Adjacent hypodense parenchyma is related to a subacute infarct.*
+
+
+### Additional Images
+
+
+**Physiologic Hyperdensity**
+*Axial NECT demonstrates relatively hyperdense internal carotid arteries in this neonate. Note the corresponding ↑ density of the transverse sinuses .*
+
+
+**Physiologic Hyperdensity**
+*Axial NECT shows false dense MCA sign in a patient with diffuse cerebral edema. Low-density brain makes normal MCA and cerebellum appear hyperdense.*
+
+
+**Cerebral Ischemia-Infarction, Acute**
+*Axial NECT suggests increased linear density in the left sylvian branches , more evident when compared to the normal appearing right-sided branches .*
+
+
+**Fusiform Aneurysm (ASVD, Non-ASVD)**
+*Axial NECT shows extensive calcification in the internal carotid and MCS and a dilated hyperdense basilar artery with peripheral calcification .*
+
+
+**Fusiform Aneurysm (ASVD, Non-ASVD)**
+*Axial NECT shows a nonatherosclerotic fusiform aneurysm of the MCA with a lobulated hyperdense mass seen in the left sylvian fissure .*
+
+
+**Pseudoaneurysm**
+*Axial NECT shows a hyperdense lesion in the region of the cavernous sinus representing a large pseudoaneurysm in this 31-year-old man with a remote history of skull base fracture.*
+
+
+**Pseudoaneurysm**
+*Axial CTA in the same patient reveals communication with the right internal carotid artery .*
+
+
+**Devices and Complications**
+*Axial NECT shows a coil in the left internal carotid artery.*
+
+
+**Polycythemia**
+*Axial NECT shows hyperdense arteries as well as veins and dural sinuses in a patient with markedly elevated hematocrit. Polycythemia can mimic a CECT scan but vessels are usually not as dense.*
+
+
+**Dissection**
+*Axial NECT shows high-density thrombus in the internal carotid artery related to dissection of the left internal carotid artery just above the carotid bulb (not shown).*
+
+
+**Physiologic Hyperdensity**
+*Coronal NECT shows ↑ density in the vascular structures compatible with physiologic hyperdensity.*
+
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+---
+title: "Multifocal Arterial Narrowing"
+docid: "761665cd-65e1-48e7-a539-1a5d7c148a6b"
+authors:
+ - key: "2bca6b86-1eca-4e93-b997-4e18913686a7"
+ value: "Hediyeh Baradaran, MD, MS"
+ - key: "f6dcad15-b660-4243-a242-a9845c929101"
+ value: "J. Scott McNally, MD, PhD"
+breadcrumbs:
+ -
+ name: "Brain"
+ slug: "brain"
+ treeNodeId: "6d8829f1-14d7-45af-8675-255189aa526a"
+ -
+ name: "Differential Diagnosis"
+ slug: "differential-diagnosis"
+ treeNodeId: "a7fdd139-664e-4bb8-8d18-400e4733ff60"
+ -
+ name: "Arteries"
+ slug: "arteries"
+ treeNodeId: "f5fee8ee-062f-41f2-b449-efcca9fb78f9"
+ -
+ name: "Anatomically Based Differentials"
+ slug: "anatomically-based-differentials"
+ treeNodeId: "9955b05e-9840-401a-b3da-4039f8b22a35"
+ -
+ name: "Multifocal Arterial Narrowing"
+ slug: "multifocal-arterial-narrowing"
+ treeNodeId: null
+category: "Brain"
+documentVersionId: "c67290b9-b36e-40c7-8b42-406b9bfad39e"
+imageCount: 25
+lastUpdated: "02/22/23"
+pageDescription: "Multifocal Arterial Narrowing"
+pageKeywords: "Brain, Differential Diagnosis, Arteries, Anatomically Based Differentials, Multifocal Arterial Narrowing"
+pageTitle: "Multifocal Arterial Narrowing | STATdx"
+enhancedTitle: "Multifocal Arterial Narrowing"
+type: "DDX"
+references: true
+breadcrumbs:
+ - "Brain"
+ - "Differential Diagnosis"
+ - "Arteries"
+ - "Anatomically Based Differentials"
+ - "Multifocal Arterial Narrowing"
+---
+# ESSENTIAL INFORMATION
+
+- ## Key Differential Diagnosis Issues
+
+
+ - **Clinical history major determinant of DDx (if available)**
+ - **Arteriosclerotic vascular disease**(ASVD): Clinical history of uncontrolled diabetes, hypertension, hyperlipidemia, smoking
+ - **Reversible cerebral vasoconstriction syndrome**(RCVS): Thunderclap headache and vasoactive drug use (cannabis, SSRI)
+ - **Vasospasm**: Recent subarachnoid hemorrhage (SAH)
+ - **Vasculitis**: Smoldering headache and CSF/systemic inflammatory markers
+ - **Intravascular large B-cell lymphoma (IVL):** DDx excluded, progression despite treatment
+ - **Effect of patient age on DDx**
+ - **Middle-aged or older adults**
+ - ASVD, vasculitis, RCVS
+ - **Child or young adult**
+ - Transient arteriopathy of young, moyamoya, inherited vasculopathy (e.g., Ehlers-Danlos), congenital infection (e.g., HIV vasculopathy)
+ - **Is there hemorrhage?**
+ - **Subarachnoid**→ RCVS, vasospasm, dissection, or pseudoaneurysm
+ - **Parenchymal**→ vasculitis, RCVS, moyamoya, IVL
+- ## Helpful Clues for Common Diagnoses
+
+
+ - **Atherosclerosis****, Intracranial**
+ - **Location**
+ - ASVD occurs in areas of flow reversal and oscillatory shear stress (e.g., bifurcations)
+ - Proximal circle of Willis branches, vertebrobasilar, internal carotid arteries (ICAs)
+ - **Lumen imaging of intracranial atherosclerosis**
+ - Focal stenoses, lumen irregularities, elongation/ectasia
+ - Stenosis measured by WASID criteria
+ - CTA vs. 3D time-of-flight (TOF) MRA
+ - CTA has slightly higher resolution than 3D TOF
+ - 3D TOF can be limited in tortuous vessels with signal loss in inferiorly directed branches
+ - 3D TOF MRA at 3T outperforms CTA in distal branches due to venous contamination
+ - 3D TOF MIPs outperform CTA MIPs
+ - **MR + CT**
+ - High T2 signal → lipid/necrotic core (ASVD)
+ - High T1 signal → intraplaque hemorrhage (less common)
+ - Enhancement → unstable/active ASVD
+ - Highly associated with acute territorial stroke; can persist for months
+ - High repeat stroke risk despite medical therapy (15-30% per year)
+ - Positive remodeling → outward bulging of vessel wall as compensatory response to plaque; may have little vessel narrowing on angiographic imaging
+ - Calcification on CT/CTA → atherosclerosis
+ - Most common cause of vessel narrowing ASVD, **not**vasculitis
+- ## Helpful Clues for Less Common Diagnoses
+
+
+ - **Reversible Cerebral Vasoconstriction Syndrome**
+ - **Etiology**
+ - Spontaneous, related to vasoactive substances, postpartum state
+ - **Lumen imaging**
+ - Multifocal segmental narrowing, ± dilatations
+ - **Vessel wall imaging**
+ - No T2 signal, no or mild enhancement
+ - **Vasospasm**
+ - **Etiology**
+ - Most common: Aneurysmal SAH
+ - Less common: Trauma
+ - **Lumen imaging**
+ - Multifocal narrowing
+ - **Vessel wall imaging**
+ - No T2 signal, no or mild enhancement
+ - **Vasculitis**
+ - **Etiology**
+ - Primary arteritis of CNS
+ - Secondary vasculitis
+ - Infectious
+ - Autoimmune
+ - **Lumen imaging**
+ - Multifocal alternating stenoses, dilatations
+ - **Vessel wall imaging**
+ - T2 signal: None or mild
+ - Wall enhancement: Positive, concentric
+ - **Vasculopathy, Non-ASVD**
+ - **Lumen imaging**
+ - Fusiform or alternating areas of stenosis and dilatation, "beading"
+ - Long, nonbranching vessel segments
+ - **Vessel wall imaging**
+ - Not well studied, likely active and inactive stages similar to ASVD
+ - Younger patients
+ - Vertebrobasilar > carotid
+ - Inherited (e.g., Ehlers-Danlos) or acquired (e.g., viral)
+ - **Dissection**
+ - **Pathophysiology**
+ - Can be traumatic or spontaneous, ± SAH
+ - Often combined with pseudoaneurysm (dissecting pseudoaneurysm)
+ - **Location**
+ - Vertebral > > ICA
+ - **Lumen imaging**
+ - Lumen irregularity, ± dilation (pseudoaneurysm)
+ - Reimage if dilation, risk of growth/rupture
+ - **Vessel wall imaging**
+ - T2 signal: Variable high signal, depends on age
+ - T1 signal: High signal if subacute (~ 2-8 weeks old)
+ - Wall enhancement: Avid if acute
+ - **Pseudoaneurysm**
+ - **Pathophysiology**
+ - Lacks normal arterial wall layers, contained by adventitia or cavitated clot
+ - Trauma, infection = common causes
+ - Rapidly changes within hours or days, easily ruptures
+ - **Location**
+ - Can be peripheral location (distal to circle of Willis)
+ - Often adjacent to skull base fractures or dura
+ - e.g., dorsal variant ICA blister aneurysm
+ - **Lumen imaging**
+ - Often adjacent vessel segment irregular
+ - Suspect pseudoaneurysm if broad-based bulge without neck
+ - Look carefully for pseudoaneurysms in "angiogram-negative" SAH
+- ## Helpful Clues for Rare Diagnoses
+
+
+ - **Intravascular Large B-Cell Lymphoma**
+ - Consider after excluding other diagnoses
+ - Often initial response with steroids with recrudescence of symptoms and progression of infarcts and hemorrhages
+ - **Moyamoya**
+ - Characteristic "puff of smoke" on DSA
+ - Most often seen in children and young adults
+ - **Radiation Vasculopathy**
+ - Consider radiation vasculopathy if age-accelerated vessel narrowing/ASVD
+ - History of prior radiation key
+- ## Other Essential Information
+
+
+ - **Clinical management of intracranial atherosclerosis**
+ - SAMPRIS trial: Intensive medical therapy superior to stenting
+ - Recommended by SAMPRIS for symptomatic intracranial ASVD
+ - Life coach, smoking cessation, dual antiplatelets, antihypertensive therapy, statins
+ - Still had ~ 15% annual stroke risk
+ - **Artifacts and limitations**
+ - Motion degrades CTA, MRA, and vessel wall MR
+ - Motion affects studies with longer acquisition times: Vessel wall MR > MRA > CTA
+ - Motion degrades black blood vessel wall MR due to misregistration artifact ("ghosting" can mimic wall enhancement)
+ - Pulsation artifact
+ - Can obscure vessel narrowing on 3D TOF
+ - Occurs in phase-encoding direction
+ - Occluded vessels difficult to detect on CTA/MRA
+ - T2 MR to troubleshoot (e.g., T2 SPACE)
+ - CSF pulsation artifact may cause spin dephasing and mimic pathology (especially around distal basilar artery)
+ - DANTE prepulse eliminates CSF pulsation artifact
+ - Incomplete suppression of flowing contrast in black blood imaging
+ - DANTE prepulse eliminates flowing contrast
+ - DANTE T1 SPACE much higher signal:noise ratio and contrast:noise ratio than T1 SPACE alone
+ - Slow-flow and entry slice phenomenon → T1 shortening may mimic thrombus
+ - Venous contrast on CTA limits distal branch evaluation (3rd and 4th order)
+ - 3D TOF MRA at 3T outperforms CTA in these areas
+
+## References
+
+# Selected References
+
+1. [Culleton S et al: MRI detection of carotid intraplaque hemorrhage and postintervention cognition. AJNR Am J Neuroradiol. 43(12):1762-9, 2022](http://www.ncbi.nlm.nih.gov/pubmed/?term=36357151%5Bpmid%5D)
+1. [Larson AS et al: Nonstenotic carotid plaques and embolic stroke of undetermined source: a multimodality review. AJNR Am J Neuroradiol. ePub, 2022](http://www.ncbi.nlm.nih.gov/pubmed/?term=36549844%5Bpmid%5D)
+1. [McCarty JL et al: Ischemic infarction in young adults: a review for radiologists. Radiographics. 39(6):1629-48, 2019](http://www.ncbi.nlm.nih.gov/pubmed/?term=31589580%5Bpmid%5D)
+1. [Schaafsma JD et al: Diagnostic Impact of intracranial vessel wall MRI in 205 patients with ischemic stroke or TIA. AJNR Am J Neuroradiol. 40(10):1701-6, 2019](http://www.ncbi.nlm.nih.gov/pubmed/?term=31488500%5Bpmid%5D)
+1. [Mandell DM et al: Intracranial vessel wall MRI: principles and expert consensus recommendations of the American Society of Neuroradiology. AJNR Am J Neuroradiol. 38(2):218-29, 2017](http://www.ncbi.nlm.nih.gov/pubmed/?term=27469212%5Bpmid%5D)
+1. [Alexander MD et al: High-resolution intracranial vessel wall imaging: imaging beyond the lumen. J Neurol Neurosurg Psychiatry. 87(6):589-97, 2016](http://www.ncbi.nlm.nih.gov/pubmed/?term=26746187%5Bpmid%5D)
+1. [Lehman VT et al: Clinical interpretation of high-resolution vessel wall MRI of intracranial arterial diseases. Br J Radiol. 89(1067):20160496, 2016](http://www.ncbi.nlm.nih.gov/pubmed/?term=27585640%5Bpmid%5D)
+1. [Mossa-Basha M et al: Added value of vessel wall magnetic resonance imaging in the differentiation of moyamoya vasculopathies in a non-Asian Cohort. Stroke. 47(7):1782-8, 2016](http://www.ncbi.nlm.nih.gov/pubmed/?term=27272486%5Bpmid%5D)
+1. [Miller TR et al: Reversible cerebral vasoconstriction syndrome, part 1: epidemiology, pathogenesis, and clinical course. AJNR Am J Neuroradiol. 36(8):1392-9, 2015](http://www.ncbi.nlm.nih.gov/pubmed/?term=25593203%5Bpmid%5D)
+1. [Miller TR et al: Reversible cerebral vasoconstriction syndrome, part 2: diagnostic work-up, imaging evaluation, and differential diagnosis. AJNR Am J Neuroradiol. 36(9):1580-8, 2015](http://www.ncbi.nlm.nih.gov/pubmed/?term=25614476%5Bpmid%5D)
+1. [Mossa-Basha M et al: Multicontrast high-resolution vessel wall magnetic resonance imaging and its value in differentiating intracranial vasculopathic processes. Stroke. 46(6):1567-73, 2015](http://www.ncbi.nlm.nih.gov/pubmed/?term=25953365%5Bpmid%5D)
+
+
+## Images
+
+
+### Selected Images
+
+
+**Atherosclerosis, Intracranial**
+*MIP MRA shows multifocal stenoses , characteristic for intracranial atherosclerosis, the most common cause of alternating stenoses and dilatations. Risk factors include diabetes, hypertension, hyperlipidemia, and smoking.*
+
+
+**Atherosclerosis, Intracranial**
+*MIP MRA shows multifocal stenoses , characteristic for intracranial atherosclerosis, the most common cause of alternating stenoses and dilatations. Risk factors include diabetes, hypertension, hyperlipidemia, and smoking.*
+
+
+**Atherosclerosis, Intracranial**
+*CTA in the right middle cerebral artery (MCA) shows focal severe stenosis with associated avid enhancement on postcontrast vessel wall MR as well as T2 hyperintensity in the vessel wall, consistent with active atherosclerotic plaque.*
+
+
+**Reversible Cerebral Vasoconstriction Syndrome**
+*NECT in a patient with RCVS shows vertex subarachnoid hemorrhage (SAH) . There is no associated enhancement on MR T1 DANTE SPACE pre- or post- contrast. Typical presentation includes a thunderclap headache; history of vasoactive drug use is also common.*
+
+
+**Reversible Cerebral Vasoconstriction Syndrome**
+*DSA in the same patient shows multifocal narrowing on the initial ICA injection. Following Verapamil injection, there is reversal of the multifocal narrowing with a more normal caliber of the intracranial vasculature, compatible with RCVS.*
+
+
+**Vasospasm**
+*Lateral DSA shows a saccular aneurysm and narrowed cortical vessels , indicating a vasospasm caused by an aneurysmal SAH (aSAH).*
+
+
+**Vasospasm**
+*DWI MR in a traumatic brain injury patient shows SAH and right MCA vasospasm with acute infarct . The right MCA proximal M2 is narrowed on 3D TOF MR . No intrinsic MR T1 signal is seen on precontrast image, and there is no enhancement on postcontrast DANTE T1 SPACE, consistent with posttraumatic SAH-induced vasospasm.*
+
+
+**Vasculitis**
+*3D TOF MRA in a young patient with vasculitis and MCA stroke shows lumen irregularity of the right anterior circulation . DSA confirms lumen findings and more subtle right M2 MCA narrowing . Avid wall enhancement is on DANTE T1 SPACE comparing pre- (magnified ), vs. postcontrast (magnified ).*
+
+
+**Vasculopathy, Non-ASVD**
+*MIP MRA in a drug user shows multifocal narrowing in the right MCA and anterior cerebral artery branches , confirmed on DSA , compatible with drug-induced vasculopathy.*
+
+
+**Dissection**
+*Axial T1 C+ FS MR in a patient with posterior circulation ischemic symptoms after severe deceleration injury shows both vertebral arteries markedly enlarged by subacute clot . The right vertebral artery is completely thrombosed, while small residual lumen is seen on the left .*
+
+
+**Pseudoaneurysm**
+*Right V4 vertebral artery pseudoaneurysm in a trauma patient with initial and follow-up 3D TOF MRA shows growth with 2 areas of dilation , confirmed on angiography (DSA and 3D ).*
+
+
+**Pseudoaneurysm**
+*Dorsal variant ICA pseudoaneurysm is shown on 3D TOF MRA and DSA with wall enhancement on MR T1 SPACE and magnified views in bottom right.*
+
+
+**Intravascular Large B-Cell Lymphoma**
+*Biopsy-proven intravascular lymphoma with multifocal hemorrhages, infarcts, and surrounding edema is shown on FLAIR, DTI, and SWI. DSA shows multifocal distal vessel lumen irregularity . Vessel wall MR was negative. Intravascular large B-cell lymphoma is often a diagnosis of exclusion. Skin biopsy or brain biopsy is typically needed to make the diagnosis.*
+
+
+**Moyamoya**
+*Lateral DSA angiography shows tapered occlusion of supraclinoid ICA with a tangle of "puff of smoke" lenticulostriate , characteristic of moyamoya.*
+
+
+**Radiation Vasculopathy**
+*Axial DWI shows a recent infarct superimposed on a FLAIR hyperintense , remote right posterior cerebral artery (PCA) infarct with delayed MTT in a patient with radiation vasculopathy. DSA shows severe right PCA narrowing with near occlusion and contralateral PCA narrowing .*
+
+
+### Additional Images
+
+
+**Vasculopathy, Non-ASVD**
+*Lateral angiography shows a posterior communicating ICA aneurysm with multiple lobulations and an unusually long "aspect ratio." This atypical aneurysm is likely related to a vasculopathy.*
+
+
, a potential source for embolic stroke.](c3f8dab2-11da-438c-a0f1-3a09017ef9ec)
+**Pseudoaneurysm**
+*Lateral angiography in a patient with a skull base fracture and stroke shows a pseudoaneurysm at the junction of the ascending/horizontal cavernous carotid artery. Note narrowing and intimal irregularity , a potential source for embolic stroke.*
+
+
+**Pseudoaneurysm**
+*Axial T2 MR in a 30-year-old man with headache, a history of a motor vehicle accident and basilar skull fracture 10 years earlier shows a cavernous pseudoaneurysm .*
+
+
+**Pseudoaneurysm**
+*Anteroposterior angiography in a patient who decompensated clinically 24 hours after admission for a closed head injury shows traumatic pseudoaneurysm caused by impingement of ACA against falx.*
+
+
+**Atherosclerosis, Intracranial**
+*3D TOF MPR and axial TOF show ~ 50% narrowing of the left V4 vertebral artery. T2 SPACE shows a lipid/necrotic core . MPRAGE is positive for IPH . DANTE T1 SPACE pre- and post- contrast images demonstrate avid wall enhancement (active plaque).*
+
+
+**Vasculopathy, Non-ASVD**
+*HIV vasculopathy with bilateral fusiform aneurysms of the terminal ICAs is shown. A T2-hyperintense clot is present in the right ICA terminus aneurysm , and there is a preserved flow void in the aneurysmal left ICA terminus . CTA shows an occluded right terminal ICA aneurysm and patent left terminal ICA fusiform aneurysm . DSA confirms these findings with a fusiform aneurysm of the left ICA terminus .*
+
+
+**Reversible Cerebral Vasoconstriction Syndrome**
+*Postpartum RCVS shows slow flow/vertex SAH on FLAIR , multivessel narrowing on 3D TOF , and absent enhancement on DANTE T1 SPACE pre- or post- contrast.*
+
+
+**Atherosclerosis, Intracranial**
+*Anteroposterior angiography shows multifocal stenoses characteristic for atherosclerosis, the most common cause of alternating stenoses and dilatations.*
+
+
+**Atherosclerosis, Intracranial**
+*DSA shows multifocal stenoses characteristic for atherosclerosis, the most common cause of alternating stenoses and dilatations.*
+
+
+**Vasculopathy, Non-ASVD**
+*DSA shows fusiform elongation of an MCA branch . The patient later admitted to using street drugs.*
+
+
+**Pseudoaneurysm**
+*Lateral angiography shows a classic blood, blister-like aneurysm along the greater curvature of the supraclinoid ICA. A hemispherical bulge with a broad orifice is typical for blood blister aneurysms. (Courtesy D. Phillips, MD).*
+
diff --git a/docs_md/articles/vessel-wall-abnormalities_850dc563-30b3-4627-87bc-fd858bccf896.md b/docs_md/articles/vessel-wall-abnormalities_850dc563-30b3-4627-87bc-fd858bccf896.md
new file mode 100644
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--- /dev/null
+++ b/docs_md/articles/vessel-wall-abnormalities_850dc563-30b3-4627-87bc-fd858bccf896.md
@@ -0,0 +1,290 @@
+---
+title: "Vessel Wall Abnormalities"
+docid: "850dc563-30b3-4627-87bc-fd858bccf896"
+authors:
+ - key: "2bca6b86-1eca-4e93-b997-4e18913686a7"
+ value: "Hediyeh Baradaran, MD, MS"
+ - key: "f6dcad15-b660-4243-a242-a9845c929101"
+ value: "J. Scott McNally, MD, PhD"
+breadcrumbs:
+ -
+ name: "Brain"
+ slug: "brain"
+ treeNodeId: "6d8829f1-14d7-45af-8675-255189aa526a"
+ -
+ name: "Differential Diagnosis"
+ slug: "differential-diagnosis"
+ treeNodeId: "a7fdd139-664e-4bb8-8d18-400e4733ff60"
+ -
+ name: "Arteries"
+ slug: "arteries"
+ treeNodeId: "f5fee8ee-062f-41f2-b449-efcca9fb78f9"
+ -
+ name: "Anatomically Based Differentials"
+ slug: "anatomically-based-differentials"
+ treeNodeId: "9955b05e-9840-401a-b3da-4039f8b22a35"
+ -
+ name: "Vessel Wall Abnormalities"
+ slug: "vessel-wall-abnormalities"
+ treeNodeId: null
+category: "Brain"
+documentVersionId: "9cf47507-a8f6-447a-8848-ac23bd794e2d"
+imageCount: 18
+lastUpdated: "02/22/23"
+pageDescription: "Vessel Wall Abnormalities"
+pageKeywords: "Brain, Differential Diagnosis, Arteries, Anatomically Based Differentials, Vessel Wall Abnormalities"
+pageTitle: "Vessel Wall Abnormalities | STATdx"
+enhancedTitle: "Vessel Wall Abnormalities"
+type: "DDX"
+references: true
+breadcrumbs:
+ - "Brain"
+ - "Differential Diagnosis"
+ - "Arteries"
+ - "Anatomically Based Differentials"
+ - "Vessel Wall Abnormalities"
+---
+# ESSENTIAL INFORMATION
+
+- ## Key Differential Diagnosis Issues
+
+
+ - **Clinical history**
+ - History can narrow DDx, but it is often absent initially
+ - **Stroke**
+ - DDx includes extra/intracranial atherosclerosis, dissection, vasospasm, reversible cerebral vasoconstriction syndrome (RCVS)
+ - **Subarachnoid hemorrhage (SAH)**
+ - DDx includes aneurysm (or other vascular lesion/arteriovenous malformation) vs. RCVS vs. vasculitis
+ - Imaging can narrow differential, guide treatment
+ - Vessel wall MR (vwMR) protocol
+ - 3T MR, sub mm, 3D volumetric images
+ - Precontrast: Time of flight (TOF), T2 SPACE, DANTE T1 SPACE, MPRAGE
+ - Postcontrast: DANTE T1 SPACE, TOF
+- ## Helpful Clues for Common Diagnoses
+
+
+ - **Atherosclerosis, Extracranial**
+ - **Location**
+ - Usually at branch points (e.g., carotid bifurcations)
+ - Oscillatory shear stress at branch points predisposes to endothelial dysfunction and atrioventricular septal defect (ASVD)
+ - **Lumen imaging (CTA or MRA)**
+ - Plaque thickness
+ - Positive remodeling occurs prior to stenosis
+ - Increased soft plaque → lipid → necrosis → intraplaque hemorrhage
+ - Stenosis
+ - Carotid stenosis is measured by North American Symptomatic Carotid Endarterectomy Trial (NASCET) (a-b)/a: "a" = diameter of downstream ICA, and "b" = diameter at level of stenosis
+ - Watch for near occlusion [e.g., downstream ICA < 3 mm or < external carotid artery (ECA)]
+ - Millimeter stenosis measurement can also be used
+ - Ulceration
+ - CTA has high accuracy for detecting ulcerations measuring > 2 mm
+ - Intraluminal thrombus
+ - Rare, but if present, highly associated with acute infarction (positive predictive value: ~ 1)
+ - Identified by donut sign on CTA or MRA
+ - Calcification
+ - Indicates atherosclerosis
+ - Calcification itself may be stable but often adjacent to unstable components
+ - Calcification pattern can indicate unstable plaque (e.g., spotty calcification)
+ - Thin, adventitial calcification (< 2 mm) coupled with thick, soft plaque (> 2 mm) (rim sign) is associated with intraplaque hemorrhage
+ - **vwMR**
+ - Carotid intraplaque hemorrhage
+ - American Heart Association (AHA) type VIb plaque (intraplaque rupture)
+ - Highly associated with acute ipsilateral infarcts
+ - High annual stroke risk (15-45%) despite medication
+ - Best detected by heavily T1-weighted sequences; MPRAGE has ↑↑ signal-to-noise, spatial resolution, and accuracy compared to T1 FS or 3D TOF
+ - MPRAGE-positive plaque: > 2x signal intensity of adjacent muscle, validated by histology
+ - Lipid-rich necrotic core (LRNC)
+ - Nonenhancing on DANTE T1 SPACE post contrast
+ - Can also be detected as T2-hyperintense plaque
+ - LRNC decreases after 1-2 years of statins
+ - Fibrous cap (FC)
+ - FC thinning (< 100 μm) or rupture indicates instability
+ - FC (collagen-rich tissue) enhances on delayed T1 postcontrast black blood images, but detection of rupture can be difficult
+ - **Atherosclerosis, Intracranial**
+ - **Location**
+ - Branch points predisposed
+ - Proximal > distal branches
+ - **Lumen imaging**
+ - Focal stenosis, multifocal stenoses, lumen irregularities, ectasia
+ - Stenosis measured by warfarin-aspirin symptomatic intracranial disease (WASID) criteria
+ - **vwMR**
+ - High T2 signal → lipid/necrotic core
+ - High T1 signal → intraplaque hemorrhage (not as common as in extracranial plaque)
+ - Enhancement → unstable/active atherosclerotic plaque
+ - Highly associated with acute territorial stroke
+ - High repeat stroke risk despite medical therapy (15-30% per year)
+ - Calcification on CT/CTA → atherosclerosis
+ - **Dissection**
+ - **Location**
+ - Extracranial > > intracranial
+ - Vertebral > carotid arteries
+ - Carotid arteries: Distal cervical ICAs > common carotid arteries (CCAs)
+ - Vertebral arteries: V1/V3 > V2/V4 segments
+ - **Lumen imaging**
+ - Biffl grading system
+ - Grade I: Mild irregularity with < 25% narrowing
+ - Grade II: > 25% narrowing, dissection flap, intramural hematoma, or intraluminal thrombus
+ - Grade III: Pseudoaneurysm
+ - Grade IV: Occlusion
+ - Grade V: Transection
+ - **vwMR**
+ - Intramural hematoma
+ - Often, intramural hematoma is not present or detectable in dissection
+ - T1-hyperintense signal indicates subacute dissection (methemoglobin)
+ - Acute trauma: No T1-hyperintense signal and rarely hyperdense on CT
+ - **Vasospasm**
+ - Location
+ - Usually, it is worst closest to source of SAH
+ - Lumen imaging: Multifocal narrowing
+ - vwMR: Negative = no T2 signal, no or mild enhancement
+ - **Aneurysm**
+ - Location
+ - Occurs most often at branch points
+ - If linear vessel segment, think pseudoaneurysm
+ - Lumen imaging
+ - Most often saccular
+ - Irregularities and focal outpouchings more associated with instability
+ - Rupture risk increases with size
+ - vwMR
+ - Wall enhancement associated with unstable aneurysm
+ - Can identify SAH source if multiple aneurysms
+ - **Pseudoaneurysm**
+ - Location
+ - Not often at branch points
+ - Often adjacent to skull base fracture or dura
+ - Common type is dorsal variant ICA blister aneurysm
+ - Lumen imaging
+ - Broad-based bulge, no neck, fusiform, irregular
+ - Rapidly change in size over hours or days
+ - vwMR
+ - Avid wall enhancement at site of wall breakdown
+- ## Helpful Clues for Less Common Diagnoses
+
+
+ - **Reversible Cerebral Vasoconstriction Syndrome**
+ - Location: Multifocal, diffuse
+ - Lumen imaging: Multiple alternating stenoses
+ - vwMR: Negative = no T2 signal, no or mild enhancement
+ - **Vasculitis**
+ - Location: Multifocal, diffuse
+ - Lumen imaging: Multiple alternating stenoses
+ - vwMR: Avid wall enhancement, no/mild T2 signal
+ - **Carotid Web**
+ - Location: Posterolateral carotid bifurcation
+ - Lumen imaging: Linear filling defect
+- ## Helpful Clues for Rare Diagnoses
+
+
+ - **Perivascular Infection**
+ - Location
+ - Often direct spread from sinuses or mastoid air cells
+ - Lumen imaging
+ - Smooth or irregular stenosis
+ - ± pseudoaneurysm, intraluminal thrombus
+ - May require DSA for full delineation
+ - vwMR: Wall enhancement with invasion
+ - **Perivascular Tumor**
+ - Location: Direct spread from adjacent tumor
+ - Lumen imaging: Vessel narrowing, ± pseudoaneurysm, thrombus
+ - vwMR: Thick, irregular wall enhancement
+
+## References
+
+# Selected References
+
+1. [El-Masri S et al: Systematic review and meta-analysis of ipsilateral and contralateral carotid web prevalence in embolic supratentorial strokes of undetermined source. J Clin Neurosci. 107:118-23, 2023](http://www.ncbi.nlm.nih.gov/pubmed/?term=36535218%5Bpmid%5D)
+1. [Chung CY et al: Imaging intracranial aneurysms in the endovascular era: surveillance and posttreatment follow-up. Radiographics. 42(3):789-805, 2022](http://www.ncbi.nlm.nih.gov/pubmed/?term=35333634%5Bpmid%5D)
+1. [Culleton S et al: MRI detection of carotid intraplaque hemorrhage and postintervention cognition. AJNR Am J Neuroradiol. 43(12):1762-9, 2022](http://www.ncbi.nlm.nih.gov/pubmed/?term=36357151%5Bpmid%5D)
+1. [Fanning NF et al: Thromboembolism from carotid web. Radiology. 221504, 2022](http://www.ncbi.nlm.nih.gov/pubmed/?term=36378034%5Bpmid%5D)
+1. [Larson AS et al: Nonstenotic carotid plaques and embolic stroke of undetermined source: a multimodality review. AJNR Am J Neuroradiol. ePub, 2022](http://www.ncbi.nlm.nih.gov/pubmed/?term=36549844%5Bpmid%5D)
+1. [Lehman VT et al: Conventional and high-resolution vessel wall MRI of intracranial aneurysms: current concepts and new horizons. J Neurosurg. 1-13, 2017](http://www.ncbi.nlm.nih.gov/pubmed/?term=28598273%5Bpmid%5D)
+1. [McNally JS et al: Magnetic resonance imaging detection of intraplaque hemorrhage. Magn Reson Insights. 10:1-8, 2017](http://www.ncbi.nlm.nih.gov/pubmed/?term=28469441%5Bpmid%5D)
+1. [Eisenmenger LB et al: Prediction of carotid intraplaque hemorrhage using adventitial calcification and plaque thickness on CTA. AJNR Am J Neuroradiol. 37(8):1496-503, 2016](http://www.ncbi.nlm.nih.gov/pubmed/?term=27102316%5Bpmid%5D)
+1. [McNally JS et al: Intraluminal thrombus, intraplaque hemorrhage, plaque thickness, and current smoking optimally predict carotid stroke. Stroke. 46(1):84-90, 2015](http://www.ncbi.nlm.nih.gov/pubmed/?term=25406146%5Bpmid%5D)
+1. [Mossa-Basha M et al: Multicontrast high-resolution vessel wall magnetic resonance imaging and its value in differentiating intracranial vasculopathic processes. Stroke. 46(6):1567-73, 2015](http://www.ncbi.nlm.nih.gov/pubmed/?term=25953365%5Bpmid%5D)
+1. [Bartlett ES et al: Quantification of carotid stenosis on CT angiography. AJNR Am J Neuroradiol. 27(1):13-9, 2006](http://www.ncbi.nlm.nih.gov/pubmed/?term=16418349%5Bpmid%5D)
+
+
+## Images
+
+
+### Selected Images
+
+![CTA shows a left carotid bifurcation/proximal ICA plaque. NASCET stenosis [(a-b)/a] is calculated by subtracting the maximal stenosis (b ) from the downstream normal-caliber ICA (a ) and normalizing to the downstream normal ICA (a). A single mm stenosis measurement (b) can alternatively be used. Maximum plaque thickness can also be measured on CTA .](images/app.statdx.com_image_thumbnail_f989d945-abad-41d9-b68c-275ef656c54c_annotated_true_size_900_quality_90_679e427c9a49899cecad73baec4cb8abd5628178.jpg)
+**Atherosclerosis, Extracranial**
+*CTA shows a left carotid bifurcation/proximal ICA plaque. NASCET stenosis [(a-b)/a] is calculated by subtracting the maximal stenosis (b ) from the downstream normal-caliber ICA (a ) and normalizing to the downstream normal ICA (a). A single mm stenosis measurement (b) can alternatively be used. Maximum plaque thickness can also be measured on CTA .*
+
+![CTA shows a left carotid bifurcation/proximal ICA plaque. NASCET stenosis [(a-b)/a] is calculated by subtracting the maximal stenosis (b ) from the downstream normal-caliber ICA (a ) and normalizing to the downstream normal ICA (a). A single mm stenosis measurement (b) can alternatively be used. Maximum plaque thickness can also be measured on CTA .](images/app.statdx.com_image_thumbnail_f989d945-abad-41d9-b68c-275ef656c54c_size_174_quality_85_ff3ccf1c1fb72983384b6b81e4d8e7e242cdc5ad.jpg)
+**Atherosclerosis, Extracranial**
+*CTA shows a left carotid bifurcation/proximal ICA plaque. NASCET stenosis [(a-b)/a] is calculated by subtracting the maximal stenosis (b ) from the downstream normal-caliber ICA (a ) and normalizing to the downstream normal ICA (a). A single mm stenosis measurement (b) can alternatively be used. Maximum plaque thickness can also be measured on CTA .*
+
+
+**Atherosclerosis, Extracranial**
+*CTA (and MRA) can also detect ulceration (sagittal and axial ) and intraluminal thrombus (sagittal and axial ).*
+
+
+**Atherosclerosis, Extracranial**
+*Intraplaque hemorrhage (IPH) can be detected on MRA. 3D TOF can detect IPH (sagittal and axial ), but TOF and conventional T1 FS MR are less accurate than MPRAGE when compared to histology.*
+
+
+**Atherosclerosis, Extracranial**
+*While IPH is best detected with MR and heavily T1-weighted sequences, such as MPRAGE , IPH can be inferred on CTA with a rim sign , which consists of a thin, < 2-mm rim of calcification with ≥ 2-mm central soft plaque. Likelihood of IPH increases with soft plaque thickness.*
+
+
+**Atherosclerosis, Intracranial**
+*DSA shows ~ 50% narrowing of the midbasilar artery in a patient with a pontine infarct. T2-hyperintense plaque on vwMR, IPH on MPRAGE , and wall enhancement on DANTE T1 SPACE indicate active plaque.*
+
+
+**Dissection**
+*CTA shows traumatic dissection of the ICA with narrowing and associated intramural hematoma on MR . Intramural hematoma can be detected on MR using T1 FS MR or MPRAGE. Methemoglobin within intramural hematoma is T1 hyperintense.*
+
+
+**Aneurysm**
+*MRA 3D TOF source image shows an anterior communicating artery saccular aneurysm . Vessel wall MR (vwMR) images show areas of wall enhancement comparing pre- and postcontrast DANTE T1 SPACE, thought to be linked to growth and rupture risk.*
+
+
+**Pseudoaneurysm**
+*Dorsal variant ICA blister aneurysm, or pseudoaneurysm, is shown on DSA . Initial CTA shows mild lumen outpouching . vwMR shows that avid wall enhancement is present comparing pre- and postcontrast DANTE T1 SPACE.*
+
+
+**Reversible Cerebral Vasoconstriction Syndrome**
+*Multifocal areas of narrowing are shown on DSA in a patient with thunderclap headache. Multifocal anterior circulation narrowing was also present (not shown). vwMR was negative. The patient improved with calcium channel blockers. Imaging appearance is typical of RCVS.*
+
+
+**Reversible Cerebral Vasoconstriction Syndrome**
+*In the same patient, CT shows left-sided SAH , and DWI MR shows a single punctate recent infarct . There was no T2 signal or vessel wall enhancement on DANTE T1 SPACE . Diagnosis was RCVS.*
+
+
+**Vasculitis**
+*DSA in a 40-year-old patient with recurrent strokes and eventual diagnosis of vasculitis shows subtle right middle cerebral artery (MCA) narrowing . Avid wall enhancement is present on vwMR DANTE T1 SPACE without T2 signal .*
+
+
+**Carotid Web**
+*CTA images show linear filling defects in the posterolateral carotid bifurcation in 3 different patients , consistent with carotid webs. Carotid webs are associated with increased risk of ipsilateral ischemic infarct.*
+
+
+**Perivascular Infection**
+*3D TOF C+ MR in a 62-year-old man with left CNVI palsy and Horner syndrome shows left cavernous sinus thrombophlebitis and intraluminal clot in the left ICA . DSA confirms perivascular infection along the left ICA with intraluminal clot .*
+
+
+**Perivascular Tumor**
+*A 59-year-old woman presented with left MCA infarcts on DTI but elevated CBV along the left insula . MR spectroscopy reveals elevated choline . Vessel wall enhancement is present on DANTE T1 SPACE . This was biopsy-proven GBM with MCA invasion.*
+
+
+### Additional Images
+
+
+**Vasospasm**
+*In a patient with a ruptured pseudoaneurysm , DSA shows multifocal areas of vessel narrowing, consistent with vasospasm . vwMR was negative in the areas of narrowing (not shown).*
+
+
+**Aneurysm**
+*Right ICA ophthalmic segment saccular aneurysm is shown on DSA and 3D TOF MRA . Note areas of wall enhancement comparing pre- and postcontrast DANTE T1 SPACE, thought to be linked to growth and rupture risk.*
+
+
+**Reversible Cerebral Vasoconstriction Syndrome**
+*DSA shows multifocal areas of narrowing in a patient with thunderclap headache. Multifocal posterior circulation narrowing was also present, and vwMR was negative (not shown). The patient improved with calcium channel blockers. This was RCVS.*
+
+
+**Vasculitis**
+*DSA in a 40-year-old patient with recurrent strokes and eventual diagnosis of vasculitis shows severe right subclavian artery narrowing . Wall enhancement is present on DANTE T1 SPACE without T2 signal .*
+
diff --git a/docs_md/articles/visual-network_404625d9-3125-4923-9f9d-53d0f81c3542.md b/docs_md/articles/visual-network_404625d9-3125-4923-9f9d-53d0f81c3542.md
new file mode 100644
index 0000000..488d4e0
--- /dev/null
+++ b/docs_md/articles/visual-network_404625d9-3125-4923-9f9d-53d0f81c3542.md
@@ -0,0 +1,132 @@
+---
+title: "Visual Network"
+docid: "404625d9-3125-4923-9f9d-53d0f81c3542"
+authors:
+ - key: "15a1b74a-5576-4e3a-a193-2d84e315fbd0"
+ value: "Jeffrey S. Anderson, MD, PhD"
+breadcrumbs:
+ -
+ name: "Brain"
+ slug: "brain"
+ treeNodeId: "6d8829f1-14d7-45af-8675-255189aa526a"
+ -
+ name: "Anatomy"
+ slug: "anatomy"
+ treeNodeId: "45a4cfd4-910b-4f11-8eba-c887895fdbf8"
+ -
+ name: "Brain Network Anatomy"
+ slug: "brain-network-anatomy"
+ treeNodeId: "95c502bb-ba84-4fbc-be46-f1f2600ce4dd"
+ -
+ name: "Visual Network"
+ slug: "visual-network"
+ treeNodeId: null
+category: "Brain"
+documentVersionId: "6e469918-0145-4a20-93a5-2cc5da2e3cac"
+imageCount: 1
+lastUpdated: "02/23/21"
+pageDescription: "Visual Network"
+pageKeywords: "Brain, Anatomy, Brain Network Anatomy, Visual Network"
+pageTitle: "Visual Network | STATdx"
+enhancedTitle: "Visual Network"
+type: "ANATOMY"
+references: true
+breadcrumbs:
+ - "Brain"
+ - "Anatomy"
+ - "Brain Network Anatomy"
+ - "Visual Network"
+---
+# IMAGING ANATOMY
+
+- ## Overview
+
+
+ - Visual cortex consumes virtually all of the occipital lobe, from primary sensory areas along the calcarine sulcus and occipital pole through the posterior parietal and temporal lobes
+ - 2 primary sensory processing streams
+ - Dorsal pathway ("where" pathway) extends from V1/V2 to V3 and into medial posterior parietal lobe
+ - Processes localization of stimuli in space, visual attention, spatial awareness, coordination of reaching and grasping
+ - Ventral pathway ("what" pathway) extends from V1/V2 to V4, V5/MT, and anterior inferior temporal lobe (AIT)
+ - Processes complex feature detection in visual stimuli, motion perception
+ - Multiple bilateral visual processing areas, each with a complete retinotopic map of visual space (V1, V2, V3, V4, V5/MT, V6, IPS regions)
+- ## Primary (Striate) Visual Cortex (V1)
+
+
+ - 1st visual area receiving sensory input in the cortex
+ - Located along margins of the calcarine sulcus
+ - Foveal vision near occipital pole, with more peripheral vision extending anteriorly
+- ## Extrastriate Visual Cortex (V2, V3, V4, V5/MT)
+
+
+ - V2 (Brodmann area 18): Immediately borders V1, with inverted retinotopic maps
+ - V3 (Brodmann area 19): Superior and anterior area V2, part of dorsal stream
+ - Processes progressively more abstract feature extraction
+ - V3A and V3B retinotopic maps
+ - V4 (Brodmann area 19 ): Anterior to V2 in lateral occipital cortex, part of ventral stream
+ - Lateral occipital: LO-1, LO-2 retinotopic maps along lateral occipital cortex anterior to V3
+ - Ventral occipital, human V4: VO-1, VO-2, hV4 retinotopic maps along inferomedial occipital cortex anterior to V3
+ - V5 (Brodmann area 19): Middle temporal gyrus at temporooccipital junction; processes motion, color, and attention perception; part of ventral stream
+ - V6 (Brodmann area 19): Along parietooccipital sulcus (medial motion area, analogue to primate mediodorsal area), part of dorsal stream
+- ## Lateral Geniculate Nuclei of Thalamus
+
+
+ - Visualized on axial slice through superior colliculus at posterior lateral margin of the thalamus
+ - Endpoint of optic tracts
+ - Postsynaptic fibers extend anteromedial along Meyer loop, then posteriorly along optic radiations through visual cortex
+ - Additional fibers likely extend through lingual gyrus of occipital lobe to reach primary visual cortex layer 4
+- ## Intraparietal Sulcus (IPS0/V7, IPS1, IPS2, IPS3, IPS4)
+
+
+ - Posterior parietal regions processing stimulus attention
+ - Visual attentional regions along medial aspect of intraparietal sulcus
+ - Multiple areas with complete retinotopic map of visual space (IPS0, IPS1, IPS2, IPS3, IPS4)
+
+# ANATOMY IMAGING ISSUES
+
+- ## Imaging Recommendations
+
+
+ - Expanding ring, rotating hemifield tasks for visual field mapping
+- ## Imaging Pitfalls
+
+
+ - Should check visual acuity prior to fMRI visual field mapping
+
+# CLINICAL IMPLICATIONS
+
+- ## Clinical Importance
+
+
+ - Vascular loops (P1 segment) can compress optic tracts and result in otherwise unexplained quadrantanopsia
+ - Presurgical visual field mapping usually focused on preserving V1/V2 retinotopic maps and foveal vision, optic radiations
+ - DTI best for imaging course of optic radiations for presurgical mapping
+
+ 906ccf1c-1128-4cd5-bfeb-c469e993ee01
+
+## References
+
+# Selected References
+
+1. [Ko H et al: The emergence of functional microcircuits in visual cortex. Nature. 496(7443):96-100, 2013](http://www.ncbi.nlm.nih.gov/pubmed/?term=23552948%5Bpmid%5D)
+1. [Baldassarre A et al: Individual variability in functional connectivity predicts performance of a perceptual task. Proc Natl Acad Sci U S A. 109(9):3516-21, 2012](http://www.ncbi.nlm.nih.gov/pubmed/?term=22315406%5Bpmid%5D)
+1. [Gaglianese A et al: Evidence of a direct influence between the thalamus and hMT+ independent of V1 in the human brain as measured by fMRI. Neuroimage. 60(2):1440-7, 2012](http://www.ncbi.nlm.nih.gov/pubmed/?term=22300813%5Bpmid%5D)
+1. [Chadick JZ et al: Differential coupling of visual cortex with default or frontal-parietal network based on goals. Nat Neurosci. 14(7):830-2, 2011](http://www.ncbi.nlm.nih.gov/pubmed/?term=21623362%5Bpmid%5D)
+1. [Wandell BA et al: Imaging retinotopic maps in the human brain. Vision Res. 51(7):718-37, 2011](http://www.ncbi.nlm.nih.gov/pubmed/?term=20692278%5Bpmid%5D)
+1. [Wendt J et al: The functional connectivity between amygdala and extrastriate visual cortex activity during emotional picture processing depends on stimulus novelty. Biol Psychol. 86(3):203-9, 2011](http://www.ncbi.nlm.nih.gov/pubmed/?term=21130141%5Bpmid%5D)
+1. [Yeo BT et al: The organization of the human cerebral cortex estimated by intrinsic functional connectivity. J Neurophysiol. 106(3):1125-65, 2011](http://www.ncbi.nlm.nih.gov/pubmed/?term=21653723%5Bpmid%5D)
+1. [Zou Q et al: Functional connectivity between the thalamus and visual cortex under eyes closed and eyes open conditions: a resting-state fMRI study. Hum Brain Mapp. 30(9):3066-78, 2009](http://www.ncbi.nlm.nih.gov/pubmed/?term=19172624%5Bpmid%5D)
+1. [Shmuel A et al: Neuronal correlates of spontaneous fluctuations in fMRI signals in monkey visual cortex: Implications for functional connectivity at rest. Hum Brain Mapp. 29(7):751-61, 2008](http://www.ncbi.nlm.nih.gov/pubmed/?term=18465799%5Bpmid%5D)
+1. [Wandell BA et al: Visual field maps in human cortex. Neuron. 56(2):366-83, 2007](http://www.ncbi.nlm.nih.gov/pubmed/?term=17964252%5Bpmid%5D)
+1. [Nir Y et al: Widespread functional connectivity and fMRI fluctuations in human visual cortex in the absence of visual stimulation. Neuroimage. 30(4):1313-24, 2006](http://www.ncbi.nlm.nih.gov/pubmed/?term=16413791%5Bpmid%5D)
+1. [Hampson M et al: Changes in functional connectivity of human MT/V5 with visual motion input. Neuroreport. 15(8):1315-9, 2004](http://www.ncbi.nlm.nih.gov/pubmed/?term=15167557%5Bpmid%5D)
+1. [Sereno MI et al: Borders of multiple visual areas in humans revealed by functional magnetic resonance imaging. Science. 268(5212):889-93, 1995](http://www.ncbi.nlm.nih.gov/pubmed/?term=7754376%5Bpmid%5D)
+
+
+## Images
+
+
+### Visual Network
+
+
+*The visual network cluster is shown from a 6-network parcellation of the brain based on whole-brain functional connectivity in 1,353 subjects. Regions within this cluster include striate and extrastriate visual cortex, medial parietal visual attentional regions, and lateral geniculate nuclei of the thalamus.*
+
diff --git a/results.json b/results.json
index 09b592b..f1251d7 100644
--- a/results.json
+++ b/results.json
@@ -1,25 +1,112 @@
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