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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Ferne brain illness and injury course

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 and Injury Course


4 th mediterranean emergency medicine congress sorrento italy september 17 2007

4th MediterraneanEmergency MedicineCongressSorrento, Italy September 17, 2007


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


Hyperdense mca sign

Hyperdense MCA Sign


Obscuration of the lentiform nucleus and basal ganglia

Obscuration of the Lentiform Nucleus and Basal Ganglia


Effacement of the subinsular cortex

Effacement of the Subinsular Cortex


Subtle crowding of sulci from early edema

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 patient presenting within 3 hour window2

Case: Patient presentingwithin 3 hour window


Case patient presenting within 3 hour window3

Case: Patient presentingwithin 3 hour window

Initial

BF

BV

TTP


Case wake up stroke

Case:“Wake up” Stroke

0735 at outside hospital


Case wake up stroke1

Case: “Wake up” Stroke


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


Good collateral flow will buy you some time and brain

Good Collateral Flow will Buy you Some Time and Brain


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


Definitions

Definitions


Changes in cerebral vascular physiology with worsening circulatory impairment

Changes in Cerebral Vascular Physiology with Worsening Circulatory Impairment


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


Example of the progression of advanced images

Example of the Progression of Advanced Images


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

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10/1/2014 5:04 AM


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