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FERNE Brain Illness and Injury Course

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Head CT Interpretation and Advanced Neuroimaging in ED Stroke Patients Andrew Asimos, MD Director of Emergency Stroke Care Carolinas Medical Center Charlotte, NC Adjunct Associate Professor, Department of Emergency Medicine University of North Carolina School of Medicine at Chapel Hill.

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Head CT Interpretation and Advanced Neuroimaging in ED Stroke PatientsAndrew Asimos, MDDirector of Emergency Stroke CareCarolinas Medical CenterCharlotte, NCAdjunct Associate Professor, Department of Emergency MedicineUniversity of North Carolina School of Medicine at Chapel Hill

disclosures
Disclosures
  • NovoNordisk, Boehringer Ingelheim Advisory Boards
  • Research support from Boehringer Ingelheim
session objectives
Session Objectives
  • Review findings consistent with early ischemic changes on non-contrast CT
  • Understand the basis for the clinical application of CTA and CTP imaging in acute stroke
  • Understand the images that comprise a CTA/CTP series
  • Understand the limitations of CTP imaging
key learning points
Key Learning Points
  • Non-contrast CT features of early ischemic stroke are subtle, with considerable inter-reader variability
  • CTP more accurate than unenhanced CT for detecting stroke and determining the extent of stroke
  • CTA excellent at detecting large vessel occlusion
  • CTA and CTP will likely replace non-contrast CT as the imaging standard within the next few years
case patient presenting within 3 hour window
Case: Patient presentingwithin 3 hour window
  • 50 yo male
  • CT less than 2 hours within symptom onset
  • Awake, alert, dysarthric
  • Fixed right sided gaze
  • Left sided weakness
essential imaging questions
Essential Imaging Questions
  • Is there hemorrhage?
  • Are findings consistent with acute ischemic stroke?
  • Can this imaging modality’s results add to my risk/benefit analysis?
    • Is there large vessel occlusion?
    • Is there “irreversibly” infarcted core?
    • Is there “salvageable” penumbra?
    • Are other findings present that should be considered
      • Microbleeds
      • Leukoaraiosis
the four p s of acute stroke imaging
The Four P’s of Acute Stroke Imaging

Rowley HA et al. Am J Neuroradiol 2001;22:599-601.

evolution of an infarct on ct
Evolution of an Infarct on CT

6hrs

24hrs

48hrs

72hrs

96hrs

hyperacute stroke subtle signs on non contrast ct
Hyperacute Stroke: Subtle Signs on Non-contrast CT
  • Hyperdense MCA sign
  • Obscuration of the lentiform nucleus and basal ganglia
  • Effacement of the subinsular cortex
  • Subtle crowding of sulci from early edema
case patient presenting within 3 hour window1
Case: Patient presentingwithin 3 hour window
  • 50 yo male
  • CT less than 2 hours within symptom onset
  • Awake, alert, dysarthric
  • Fixed right sided gaze
  • Left sided weakness
case wake up stroke
Case:“Wake up” Stroke

0735 at outside hospital

case wake up stroke2
Case: “Wake up” Stroke

1030 at stroke center

therapeutic window
Therapeutic Window
  • Time from symptom onset used for theoretical and practical reasons
  • Increasingly will rely on imaging studies to determine tissue salvageability and clot burden
advanced ct imaging for acute stroke ctp versus mri
Advanced CT Imaging for Acute Stroke: CTP versus MRI

Muir KW et al. Lancet Neurology 2006; 5:755-768

ct perfusion terminology
CT Perfusion Terminology

Blood Flow

Blood Volume

Mean Transit Time

or

Time to Peak

relationship between cbv cbf and mtt
Relationship between CBV, CBF, and MTT

Blood Flow

Blood Volume

Mean Transit Time

or

Time to Peak

MTT= CBV/CBF

conclusions
Conclusions
  • CTP more accurate than unenhanced CT for detecting stroke and determining the extent of stroke
  • Possible to distinguish penumbra from infarcted tissue
  • Correlation between PCT/CTA and MRI is excellent
  • Already used in DIAS and DEDAS

Wintermark M et al. Am J Neuroradiol 2005;26(1):104-12.

Wintermark M et al. Stroke 2006;37:979-985.

Wintermark M et al. Neurology 2007;68(9):694-697.

important remaining ctp questions
Important Remaining CTP Questions
  • What is the interrater reliability of visual estimation of lesion volumes?
    • Is that variability clinically important?
  • Can computerization automate measurement of absolute perfusion thresholds and lesion volume in a clinically meaningful way?
  • Will the current perfusion thresholds for penumbra and infarct be maintained with rigorous future testing?
questions
Questions?

www.FERNE.org

[email protected]

704 355 4212

ferne_memc_2007_braincourse_asimos_neuroimaging_091707_finalcd

10/1/2014 5:04 AM

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