Updated in Diagnosis of Acute Ischemic Stroke CTMRI and advances

VIETNAM NATIONAL CONGRESS OF CARDIOLOGY 15th Meeting, Ninh Binh Updated in Diagnosis of Acute Ischemic Stroke: CT/MRI and advances Nguyen Quang Anh, MD Introduction • Ischemic: 80% of stroke • 3rd leading cause of dead in United States • 2025: prediction of 1.2 millions patients/year • In Viet Nam, stroke is top cause of Death (account for 18% - 2008) • Cardiovascular disease, diabetes… Diagnostic Tools • Multi-choices in diagnosis • CT Scanner -> MRI (3 steps) • Perfusion -> Multiphase CT Scanner protocol • CT non-contrast: rule out hemorrhage + identify ischemic stroke area • CT Angiography: arterial occlusion • PW: if possible (double dose of contrast) MRI protocol • T2*: rule out hemorrhage + identify cerebral microbleeding • DWI: core of infarction • FLAIR: parenchymal lesion/ absence of “flow voids” in the occluded artery • TOF 3D: arterial occlusion site • PW: if possible Non-contrast • “Emergency imaging of the brain is recommended before any specific treatment for AIS Non-enhanced CT will provide the necessary information for initial treatment of IV r-tPA (Class I; level of Evidence A - same as 2013)*” *AHA/ASA-stroke guide line 2015 CT Non-contrast • Rule out the hemorrhage • Identify ischemic lesion • Tips: • Change the window level –C: –W: 32 Protocol • Non contrast first then multiphase • Phase 1: • Evaluate the carotid and brain circulation • Double scan with contrast, then subtraction algorithm • Phase 2: • Just only the brain • Time for moving table+scan • Total 8sec • Phase • Similar to phase Menon et al., (2015) Neuroradiology, 000 (0) Evaluation Menon et al., (2015) Neuroradiology, 000 (0) Evaluation scale Điểm Đánh giá (khi so sánh với bán cầu bên bệnh với bên lành) Không quan sát thất bất kỳ nhánh mạch máu nào vào vùng nhồi máu tại bất kỳ phase nào Có một vài nhánh mạch máu nhỏ vào vùng nhồi máu tại bất kỳ phase nào Chậm phase hiện hình mạch máu vùng ngoại vi VÀ giảm đậm độ-tốc độ ngấm thuốc, HOẶC chậm phase có vùng không có mạch máu Chậm phase hiện hình mạch máu vùng ngoại vi, HOẶC chậm phase số lượng mạch máu vùng nhồi máu giảm Chậm phase hiện hình mạch máu vùng ngoại vi, đậm độ và tốc độ ngấm thuốc thì tương tự Không có chậm phase, quan sát thấy các nhánh mạch máu bàng hệ vào bình thường hoặc nhiều vùng nhồi máu • 0-3: nghèo bàng hệ (poor)̣, 4: vừa (moderate), 5: tốt (good) Case 2a • Male, 75 years old, history of cardiac coronary disease • Stroke during hospitalizing time (17h30’) due to chest pain • Right hemiplegia, unconscious, G~13pt, NIHSS = 19 • Left M1 occlusion (19h00’ ASPECTS ~ point) Multiphase PHASE PHASE PHASE • Multiphase score ~ point (good collateral) Perfusion TTP (Time to Peak) • Mismatch > 35% CBF (Cerebral Blood Flow) CBV (Cerebral Blood Volume) DSA (19h50’ – 20h10’) • Solitaire 6/20: times • TICI Follow up • G ~ 15pt • NIHSS ~ 6pt • mRS ~ after days Case 2b • Female, 57 years old; Atrial fibrillation, still using anticoagulant • Administered to BM hospital in 2nd hours (13h15’->14h30’) • Left hemiplegia, NIHSS = 18 • Right ICA occlusion (14h45’ ASPECTS ~ point) Multiphase PHASE PHASE PHASE • Multiphase score ~ point (poor collateral) DSA (15h15’ – 15h57’) • Solitaire 6/30: times • TICI MRI follow up • G 15pt • NIHSS ~ 9pt • mRS ~ after wks Conclusion • CT Scanner noncontrast and MSCT is very important and always/strongly recommended in AIS (in new guideline 2015) before any treatment – easy and accessible in all hospital • MRI only in big hospital, very useful especially in unknown time stroke patients/ same function as CT • DWI/PW: good information but need more trial to prove its evidence and cut-off volume in prognosis • CT Multiphase: new choice and simple, also need more trials and time THANK YOU FOR YOUR ATTENTION [...]... cerebral microbleeding -> risk factor of bleeding after treatment Kidwell Stroke 2002; Nighoghossian Stroke 2002; Derex Cerebrovasc Dis 2004 T2* Identify occlusion site Acute stage < 6h Acute stage (6-24h) Early sub -acute stage: 48hrs - 3 weeks Late sub -acute stage Chronic stage ASPECTS • ≥ 6: favorable clinical outcome* *Stroke, 2008 39(8): p 2388-2391 ASPECTS L • ≥ 6: favorable clinical outcome* Pc-ASPECTS... time of initial imaging, r-tPA should done first then try vascular imaging as quickly as possible (Class I, level A - New)” *AHA/ASA -stroke guide line 2015 CT Angiography MIP (Single phase) VRT MRI TOF 3D Perfusion CT Perfusion • “The benefit of CT perfusion, DWI/perfusion-weighted imaging for selecting patients (ASPECTS36cm3: bad result (*) Stroke, 2009 40: p 2046-2054 (** )Stroke, 2011 42(5): p 1251-4 Correlation between Volume of infarction and clinical recovery in our study V30cm3 N mRS ≤ 2 69 4 73 mRS > 2 21 37 58 Volume p < 0.05 • V 100cm3 -> no indication of treatment (>1/3 territory of MCA) • >70cm3: poor prognosis even rapid recanalization* • no penumbra -> no indication of treatment Mismatch PW/DW -> good indication for treatment Case Before DWI After PWI DWI PWI DWI/PW • Sn of PW ~[74-84%], Sp of PW ~[96-100%] • Mismatch... treatment Case Before DWI After PWI DWI PWI DWI/PW • Sn of PW ~[74-84%], Sp of PW ~[96-100%] • Mismatch DW/PW = penumbra area • (PW – DW)/ DW x 100% > 20% -> significant difference* (*) EPITHET study -Stroke, 2009 40: p 2046-2054