Head CT Interpretation and Advanced Neuroimaging in ED Stroke Patients
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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


Ferne brain illness and injury course

FERNE Brain Illness Stroke Patientsand Injury Course


4 th mediterranean emergency medicine congress sorrento italy september 17 2007

4 Stroke Patientsth MediterraneanEmergency MedicineCongressSorrento, Italy September 17, 2007


Disclosures
Disclosures Stroke Patients

  • NovoNordisk, Boehringer Ingelheim Advisory Boards

  • Research support from Boehringer Ingelheim


Session objectives
Session Objectives Stroke Patients

  • 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 Stroke Patients

  • 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 presenting Stroke Patientswithin 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 Stroke Patients

  • 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 Stroke Patients

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


Evolution of an infarct on ct
Evolution of an Infarct on CT Stroke Patients

6hrs

24hrs

48hrs

72hrs

96hrs


Hyperacute stroke subtle signs on non contrast ct
Hyperacute Stroke: Subtle Signs on Non-contrast CT Stroke Patients

  • Hyperdense MCA sign

  • Obscuration of the lentiform nucleus and basal ganglia

  • Effacement of the subinsular cortex

  • Subtle crowding of sulci from early edema


Hyperdense mca sign
Hyperdense MCA Sign Stroke Patients





Case patient presenting within 3 hour window1
Case: Patient presenting Stroke Patientswithin 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 patient presenting within 3 hour window2
Case: Patient presenting Stroke Patientswithin 3 hour window


Case patient presenting within 3 hour window3
Case: Patient presenting Stroke Patientswithin 3 hour window

Initial

BF

BV

TTP


Case wake up stroke
Case: Stroke Patients“Wake up” Stroke

0735 at outside hospital


Case wake up stroke1
Case: Stroke Patients “Wake up” Stroke


Case wake up stroke2
Case: Stroke Patients “Wake up” Stroke

1030 at stroke center


Therapeutic window
Therapeutic Window Stroke Patients

  • 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 Stroke Patients

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


Ct perfusion terminology
CT Perfusion Terminology Stroke Patients

Blood Flow

Blood Volume

Mean Transit Time

or

Time to Peak


Definitions
Definitions Stroke Patients



Relationship between cbv cbf and mtt
Relationship between CBV, CBF, and MTT Circulatory Impairment

Blood Flow

Blood Volume

Mean Transit Time

or

Time to Peak

MTT= CBV/CBF



Conclusions
Conclusions Circulatory Impairment

  • 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 Circulatory ImpairmentCTP 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? Circulatory Impairment

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704 355 4212

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10/1/2014 5:04 AM


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