Maria Scotti
Outline
1. Stroke Basics
What is stroke?
Stroke facts and figures
Treatment
2. Role of Imaging
Role of the CT Brain Perfusion scan
Dose considerations
Scan protocol
Interpreting CT Perfusion maps
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1. Stroke Basics
What is a Stroke?
www.strokefoundation.com.au
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1. Stroke Basics
Two main causes of stroke:
embolic thrombotic
subarachnoid intracerebral
1. Stroke Basics – Facts & Figures
• Stroke is one of Australia’s biggest killers and a leading cause of disability.
• Stroke kills more women than breast cancer and more men than prostate
cancer.
www.strokefoundation.com.au6
1. Stroke Basics
The FAST test is an easy was to recognise and remember the
signs of stroke:
“Time is brain”
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1. Stroke Basics - Treatment
Thrombolysis
is a clot-busting drug
rt-PA (recombinant tissue
plasminogen activator)
Can reduce the amount of damage & save lives
Must be given within 4.5 hours after symptoms
begin (time is brain)
Complex eligibility criteria, risk of intra cranial
bleeding
Administering is complex and done through an
intravenous line in the arm
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1. Stroke Basics - Treatment
1. Stroke Basics - Intervention
Interventional clot retrieval
Endovascular procedure performed by Interventional Neuroradiologist
Limited access
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ROLE OF IMAGING IN ISCHAEMIC STROKE
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2. Role of Imaging
Infarct Core and Penumbra
Occluded MCA
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2. Role of Imaging
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2. Role of Imaging
The Stroke Team
Enables efficient pt care in the acute setting to expedite:
• Initial pt examination
1 • NIHSS stroke score
• Imaging
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• Diagnosis
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• Treatment
4 • Triage to Treatment < 60min
2. Role of Imaging
Non contrast CT brain
BUT
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2. Role of Imaging
CT Perfusion enhances diagnostic sensitivity
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2. Role of Imaging
Coverage a traditional challenge for stroke imaging
2 - 4cm
• 4slice
• 16slice
• 64row / 128 slice
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2. Role of Imaging
Coverage a traditional challenge for stroke imaging
Up to 16cm
• 320row/ 640slice
• Dynamic Volume CT
• No Table movement
• Isophasic data
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2. Role of Imaging – Dose considerations
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2. Role of Imaging – Dose considerations
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2. Role of Imaging – Perfusion – Scan Protocol
Immobilise pt
Ensure pt is in isocentre
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2. Role of Imaging – Perfusion – Scan Protocol
Perfusion Scan protocol – Variable scan intervals and exposure
Arterial Venous
CT DSA
Mask
2s sampling 5s sampling
CTA
19 scans
mA
Time
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2. Role of Imaging – Perfusion Maps -
Processing
Input Artery Output Vein
Earliest transit time Maximum total density
MCA or ACA Superior sagittal sinus
Vein
2. Role of Imaging – Perfusion Maps
CBV TTP
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2. Role of Imaging – Perfusion Maps
We discuss the maps with reference to an
increase or decrease
Affected
Normal
side
2. Role of Imaging – Perfusion Maps
Area that is not
getting enough
blood
• Measured in seconds
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Infarct Core
0935
Endovascular
Thrombectomy
What a normal LICA angiogram looks like
AP Lateral
CASE STUDY 1 – 82yo male
AP View
before after
1030 0935
Reperfusion Endovascular
achieved Thrombectomy
CASE STUDY 1
DAY 1
DAY 2 DAY 2
DAY 5
Discharged from hospital
CASE STUDY 1 – 82yo male
0615 0715 0756 21 mins 0817
Last seen Found on Pt arrived in ED CT Perfusion
well floor of Stroke Call activated L MCA territory
Stroke Score of 12 threatened
bathroom
R side weakness
Ambulance noted
positive FAST
Conscious but not
responsive
DAY 2 1155
MRI rt-PA infusion
started
CASE STUDY 2 – 75yo male
DAY 2 DAY 1
DAY 4
Discharged from
hospital
CASE STUDY 2 – 75yo male
1100 30 mins
1015 1130
Sudden onset stroke Pt arrived in ED CT Perfusion
symptoms Stroke Call activated R posterior M2
Stroke Score of 9 territory threatened
L sided weakness