1

CT Angiography and
CT Perfusion in the
Management of Acute
Stroke
Stroke past
good outcome with IV good outcome with IV tPA(mRS tPA(mRS 0 0- -1): 1): 39% 39% vs. vs. 26% 26%
1 1
most patients arrive too late most patients arrive too late (>3 hrs for NINDS) (>3 hrs for NINDS)
currently, only currently, only 0.6 0.6- -1.8% 1.8% of strokes get IV tPA of strokes get IV tPA
2,3 2,3
NINDS NEJM 1995
1
,
Katzan JAMA 2000 Katzan JAMA 2000
2
, ,
Qureshi NRS 2005 Qureshi NRS 2005
3
Stroke present
Odds Ratio for Favorable Outcome Odds Ratio for Favorable Outcome
IV IV tPA tPA exclusions / contraindications exclusions / contraindications
Stroke present
1. > 3 hrs from stroke onset
2. 80 > age > 18
3. pregnancy (up to 10 days postpartum)
4. symptoms suggestive of SAH despite negative CT
5. rapidly improving or minor symptoms
6. seizure at onset of stroke
7. ever: history of intracranial hemorrhage
8. within 3 mo: stroke, serious head trauma, intracranial surgery
9. within 21d: GI/urinary/pulmonary hemorrhage
10. within 14d: major surgery
11. within 7d: arterial puncture at a non-compressible site
12. SBP > 185 mmHg or DBP > 110 mmHg
13. aggressive treatment required to reduce BP to specified limits
14. current use of anticoagulants (or recent, with PT > 15s)
15. use of heparin within 48hrs and elevated PTT
16. platelets < 100,000
17. glucose < 50 or > 400 mg per deciliter
18. brain tumour, abscess, aneurysm, AVM
19. bacterial endocarditis
20. known bleeding diathesis includes renal, hepatic insufficiency
21. etc
IV IV tPA tPA is less effective for severe strokes is less effective for severe strokes
1 1
NIHSS NIHSS 10: 75% decreased chance of good outcome 10: 75% decreased chance of good outcome
NIHSS > 20: only 8% will attain NIHSS=1 after IV NIHSS > 20: only 8% will attain NIHSS=1 after IV tPA tPA
IV IV tPA tPA is less effective for large vessel occlusions is less effective for large vessel occlusions
2,3 2,3
ICA recanalization rate is 1/3 that of MCA ICA recanalization rate is 1/3 that of MCA
tandem ICA/MCA has poor recanalization & bad prognosis tandem ICA/MCA has poor recanalization & bad prognosis
IV IV tPA tPA is relatively slow is relatively slow- -acting acting
4,5 4,5
TCD over 6hrs TCD over 6hrs 30% 30% recan recan (of which (of which are within 1hr are within 1hr tpa tpa) )
angio 1hr after angio 1hr after tPA tPA 1/10 ICA/proximal MCA, 1/3 distal MCA 1/10 ICA/proximal MCA, 1/3 distal MCA
1: NINDS Stroke 1997; 28:21192125
2: LInfante Stroke 2002; 33:2066 2: LInfante Stroke 2002; 33:2066- -2071 2071
3: 3: Rubiera Rubiera Stroke 2006; 37:2301 Stroke 2006; 37:2301- -2305 2305
4: 4: Christou Christou Stroke 2000; 31:1812 Stroke 2000; 31:1812- -1816 1816
5: Lee 5: Lee Stroke 2007; 38:192-3
Stroke present Time is brain Time is brain
typical supratentorial large vessel stroke: ~54ml brain is typical supratentorial large vessel stroke: ~54ml brain is
lost over ~10 hrs lost over ~10 hrs
per hour: per hour: 830 billion synapses, 120 million neurons, 447 830 billion synapses, 120 million neurons, 447
miles of myelinated miles of myelinated fibre fibre lost lost
each each hour hour, brain effectively ages 3.6 , brain effectively ages 3.6 years years
Saver, Stroke 2006; 37:263
2
1987
IV tPA
1996
IV tPA
2000
Stent
2003
Cypher
1993
PTCA
2004
MERCI Retriever
1999
PROACT II
Treatment of Acute Stroke
Treatment of Acute MI
???
Multimodal
Revascularization
Stroke future? now.
today
Thrombolytics: Thrombolytics: Alteplase, Retavase Alteplase, Retavase
GIIb/IIIa inhibitors: GIIb/IIIa inhibitors: Reopro, Integrilin Reopro, Integrilin
Mechanical disruption: Mechanical disruption: microwire / snare microwire / snare
Clot retrieval: Clot retrieval: MERCI, Penumbra MERCI, Penumbra
Ultrasound Catheter: Ultrasound Catheter: EKOS EKOS
Angioplasty / Stenting Angioplasty / Stenting Gateway / Wingspan Gateway / Wingspan
Stroke new tools
Case example:
45 yo male
acute LMCA stroke
R paretic, R hemianopic, R facial droop, dysphasic, dysarthric.
NIHSS = 15
CT: early left caudate head, basal ganglia infarct
CTP:
MTT, CBF, CBV
Interpretation:
small caudate and
frontopolar infarcts,
surrounded by large
(but salvageable)
ischemic penumbra
Flow
Volume
Transit Time
3
CTA: LM1 occlusion (w/distal collateral) CTA: LCCA/inominate stenosis
AP:
Sag:
LCCA origin severe stenosis, 5F sim2 finally pops in but is occlusive (static dye column) T-occlusion equivalent: proximal LA1, LM1 occluded, poor collateralization
All-star 0.014 wire maintains access to LCCA, pigtail arch run shows severe origin stenosis
1. Aviator 6x30mm over
All-star wire, LCCA
origin angioplastied
2. Sim2 back over All-
star wire into distal
LECA
3. All-star wire then
exchanged for 0.035
stiff exchange
glidewire
4. Sim2 swapped out for
7F concentric balloon
guide over stiff
exchange wire, parked
in LCCA
5. Concentric guide
catheter taken to distal
cervical LICA
6. LMCA occlusion
crossed with 18L
Concentric
microcatheter over
Transend microwire
Cross LM1 occlusion with MERIC 18L microcatheter over transend
AP Lateral
4
Deploy MERCI L5 retriever
AP Lateral
Clot retreived, flow restored
AP Lateral
AP
Pre
Post
AP Lateral
Post Arch MRA: LCCA stenosis better, inominate as before, will need tx later
Thrombolytics: Alteplase, Retavase Thrombolytics: Alteplase, Retavase
GIIb/IIIa GIIb/IIIa inhibitors: inhibitors: Reopro Reopro, , Integrilin Integrilin
Mechanical disruption: microwire/snare Mechanical disruption: microwire/snare
Clot retrieval: MERCI (X6, L5, variants) Clot retrieval: MERCI (X6, L5, variants)
Ultrasound assisted Catheter: EKOS Ultrasound assisted Catheter: EKOS
Balloon Angioplasty Balloon Angioplasty
Primary Stenting Primary Stenting
IA Thrombolysis: New Tools
5
To select out To select out
patients with patients with viable viable
brain tissue at risk brain tissue at risk
that can be treated that can be treated
with the with the optimal optimal
tool for tool for
revascularisation revascularisation
GOAL:
HOW?
New-generation CTA/CTP = anatomy+physiology
1. faster: <5 min total acquisition time
2. less motion artifact
3. less dye (CTA+CTP <120ml) <50ml with 320-slice!
4. CTA (arch to vertex) :
lesion presence/absence/location
lesion accessibility
a priori knowledge = no guessing!
5. CTP:
absolute numbers for CBF, CBV
4-8 slices, + post-fossa coverage full coverage with 320-slice!
CBF penumbra+core; CBV collateral supply
CBF/CBV mismatch = salvageable penumbra!
Imaging for stroke intervention
13.33.75
1.120.37
threshold=31.3
sensitivity=97.0%
specificity=97.2%
accuracy=97.1%
for CBFxCBV and
subsequent stroke
25.03.82 37.35.01
2.150.43 1.780.30
FLOW VOLUME
CBFxCBV
Murphy, B. D. et al. Radiology 2008;247:818-825 Murphy, B. D. et al. Radiology 2008;247:818-825
6
Figure 3: Scatterplot shows mean CBV versus mean CBF in penumbra and infarct regions in patients with acute stroke and
confirmed recanalization at 24 hours (dashed line represents CBFCBV = 8.14)
Murphy, B. D. et al. Radiology 2008;247:818-825
- 40 patients, median NIHSS=16, 19 received iv-tpa
- compared initial CTP/CTA and day #3 postop MRI/MRP
- reperfusion defined as normalization of 80% area with increased MTT
Regions with infarction (based upon DWI+ADC) at day #3 compared with CBV maps
on initial CTP in hypoperfused areas ( CBF, MTT), does CBV predict
eventual infarction?
94%(go on to
infarct)
63%(go on to
infarct)
94%(go on to
infarct)
No reperfusion
3%(go on to
infarct)
41%(go on to
infarct)
97%(go on to
infarct)
With reperfusion
High Normal Low CBV
rCBF prediction of symptomatic ICH
following IA treatment for MCA occlusion
Gupta 2006 Stroke 37:2526
~ 13 ml
per 100g/min
~ 1/3 MCA
territory
CTP parameters can predict hemorrhage
CTP in posterior circulation!
CBF CBV MTT DWI
Acute Stroke
CTA / CTP
large vessel occl. (ICA, M1/M2, A1, VA/BA)
large ischemic penumbra > infarct
large stroke (NIHSS10)
0-3 hr
IV tPA IA Tx IA Tx bridging IV tPA no acute thrombolysis,
later medical or surgical
stroke prophylaxis
>3 hr
large vessel occl. (ICA, M1/M2, A1,VA/BA)
large ischemic penumbra > infarct
large stroke (NIHSS10)
yes no yes no
Stroke Algorithm
7
SUMMARY
CTP is available and powerful:
Transit time = very sensitive (but not specific)
Flow = penumbra plus core
Volume = penumbra vs core (collateral supply)
preserved penumbra (still salvageable)
decreased core (dead)
CBF/CBV = crude risk/reward ratio
onset often unclear CT perfusion = more accurate
physiological data
perfusion beats onset
POD#1 DWI: frontopolar, caudate, basal ganglia infarcts (predicted by CTP), but
large LMCA territory salvaged
POD#1 FLAIR: small
caudate head, basal
ganglia, frontopolar
infarcts
POD#2 CT
Case example:
83 yo male
acute right hemisphere stroke
left plegic, R gaze preference, L facial droop, dysarthric
NIHSS > 10
last normal > 14hrs ago
past medical history = paroxysmal atrial fibrillation
(discovered on this admission)
8
preop CBF preop CBV
Emergency
CT perfusion:
Low CBF but preserved
CBV stroke is still
salvageable.
residual
clot
thrombectomy and lytics inferior division open, residual clot in superior division
balloon angioplasty superior division now also open
Post Pre
preop CBF preop CBV
Case example:
33 yo female
acute right carotid stroke
left hemiplegia, facial droop, dysarthria, hemianopia,
neglect, decreased left body sensation, drowsy, fixed gaze
deviation to right.
NIHSS = 16
onset > 4 hrs
past medical history = smoker, oral contraceptive pills
CBF CBV TTP
INITIAL CTP:
-Very low blood flow
-Very slow blood flow
-Preserved blood volume
-BUT: > 4hrs onset
9
Complete right internal carotid artery occlusion no intracranial blood flow microcatheter run shows distal blood vessels remains patent
MERCI thrombectomy opens distal carotid and proximal middle cerebral artery,
balloon angioplasty opens distal middle cerebral artery
MRI
few
days
later
Case example:
76 year old female
Found 2:30 am at outside institution with stroke, onset
unknown
Rapidly transferred to tertiary-care institution.
When seen, unable to move anything except eyes
rapidly loosing consciousness crash intubated in ED
NIHSS = 30
Mid-BA occlusion
10
Big Problem
Bigger Problem?
Access is going to be tough!!!
a
r
m
a
rm
Pooled NASCET, ECST, VA309 results Lancet 2003,361(9352):107
Case example #1:
70 yo male
acute LMCA stroke
driving swerved off road min. responsive on scene
right plegic, aphasic, fixed gaze to left in ED
NIHSS = 22
onset <1.5 hrs
PMH = HTN, NIDDM, dyslipidemia, atrial flutter, on ASA
hyperdense sign
11
CBF CBV TTP
13.6 x 0.9 = 12.2
CBV reduction matches
reduction in CBF no
collateral reserve, no
penumbra, infarct already
well established.
Case example #5:
70 yo male
acute RMCA stroke
initial NIHSS=12 in ED, worsened to > 18 intubated
onset > 6 hrs
PMH = MI, CABG, PVD, HTN, NIDDM, previous L parietal
subcortical stroke
CT (pre)
CBF CBV TTP
CTP (pre)
12
Treatment:
Angio = RMCA bifurcation occlusion, ant. temporal open
Retavase 2mg M1
Retavase 1mg M2
inf
wire both M2s
Merci M2
sup
x2 Pre Post
CT (POD#1)
Outcome:
TIMI-3 M1/M2s
distal branch of inferior M2 remained occluded
R basal ganglia ICH, R parietal infarct
rest of MCA territory spared
discharged 17 days later to rehab, NIHSS=16
return w/urosepsis one month later no sig improvement
CT 44 days laterNIHSS still 16.
CTP keypoints:
1. TTP/MTT is very sensitive but not specific
2. CBV distinguishes infarction vs. ischemic penumbra (dead vs. salvageable brain)
3. Areas at risk for hemorrhage post-thrombolysis can be predicted
4. Crude risk/benefit ratio = CBV / CBF deficit
Bottom line = physiological imaging is real and powerfulCTP does not lie!
13
SUMMARY
CTP is available and powerful:
Transit time = very sensitive (but not specific)
Flow = penumbra plus core
Volume = penumbra vs core (collateral supply)
preserved penumbra (still salvageable)
decreased core (dead)
CBF/CBV = crude risk/reward ratio
onset often unclear CT perfusion = more accurate
physiological data
perfusion beats onset