View
132
Download
0
Category
Preview:
Citation preview
ACUTE STROKE: IMAGING AND INTERVENTIONS PERSPECTIVE
Dr. N KHANDELWALPROF AND HEAD
DEPARTMENT OF RADIODIAGNOSIS & IMAGINGPGIMER, Chandigarh
Aims of Imaging• To rule out intracranial hemorrhage.• To rule out stroke mimickers.• To detect early signs of ischemia.• To detect the site of occlusion.• To take a treatment decision.• To prognosticate the patient.
• EVERYTHING TO BE DONE IN 10-15 MINUTES
Aims of Imaging
• To rule out intracranial hemorrhage.
– NCCT – MRI :FLAIR and gradient echo imaging.
Aims of Imaging
• To rule out intracranial hemorrhage.
Aims of Imaging
• To rule out intracranial hemorrhage.• To rule out stroke mimickers.• Seizure• Mass lesion• Hypoglycemia• Migraine• Metabolic
encephalopathy• Multiple Sclerosis• Epidural/subdural
hematoma
Aims of Imaging
• To rule out intracranial hemorrhage.• To rule out stroke mimickers.• To detect early signs of ischemia.
– Dense artery sign– Loss of gray-white differentiation
Dense Artery Sign
NCCT Head Evaluation
Dense Artery Sign
NCCT Head Evaluation
Loss of gray white interface
NCCT Head Evaluation
Loss of insular ribbon
NCCT Head Evaluation
Obscure lentiform nucleus
NCCT Head Evaluation
14 th JULY 11 PM
What we can do to increase the diagnostic confidence ?
NCCT Head Evaluation
Aims of Imaging
• To rule out intracranial hemorrhage.• To rule out stroke mimickers.• To detect early signs of ischemia.• To detect the site of occlusion.
CT Angiography Evaluation
Advanced helical CT application.
High spatial resolution 3d images of the cervical and intracranial vasculature
Permits rapid identification of vessel stenosis/occlusion
CT Angiography Evaluation
CT Angiography Evaluation
CT Angiography Evaluation
CT Angiography Evaluation
• Helpful tip: if no definite occlusion……
CT Angiography Evaluation
Aims of Imaging
• To rule out intracranial hemorrhage.• To rule out stroke mimickers.• To detect early signs of ischemia.• To detect the site of occlusion.• To take a treatment decision.• To prognosticate the patient.
Prognosticating the patient……
• NCCT based approach
• CT angiography based approach
Prognosticating the patient……
• NCCT based approach
• CT angiography based approach
Alberta Stroke Program Early CT Score (ASPECTS)
• Baseline ASPECTS correlated inversely with the NIHSS
• As the ASPECTS decreased, the probability of
dependence, death, and symptomatic hemorrhage increased
TOTAL SCORE =10
SUBTRACT THE NUMBER OF HYPODENSE REGIONS FROM THIS SCORE OF 10.
8-10= GOOD PROGNOSIS
<8= POOR PROGNOSIS
Alberta Stroke Program Early CT Score (ASPECTS)
SCORE : 10-2= 8- GOOD PROGNOSIS
10-5=5. POOR PROGNOSIS
Prognosticating the patient……
• NCCT based approach
• CT angiography based approach
Prognosticating the patient……
• NCCT based approach
• CT angiography based approach
– COLLATERALS IMAGING• SINGLE PHASE CTA• MULTIPHASE CTA
Role of CT Perfusion…
• Limited– wake up strokes– Out of window period strokes
• MR diffusion-perfusion –same status• To decide if treatment would be helpful or
not.
CT Perfusion Parameters
MTT:+++CBF: NormalCBV: Normal
MTT: +++CBF: DecreasedCBV: Normal
Treatment indicated
Treatment may be given
MTT: +++CBF: DecreasedCBV: Decreased Treatment might be
harmful
Aims of Imaging
• To rule out intracranial hemorrhage.• To rule out stroke mimickers.• To detect early signs of ischemia.• To detect the site of occlusion.• To take a treatment decision.
Site of Occlusion
Proximal
Distal
• ICA bifurcation• M1-MCA• MCA bifurcation• A1-ACA• Vertebral-Basilar
artery• P1-PCA
• M2-M4 MCA• A2-A4-ACA• P2-P4 PCA
Mechanical thrombectomy
Thrombolysis
INTERVENTIONS IN ACUTE STROKE
CHOICE OF INTERVENTIONS
– IV THROMBOLYSIS
– IA THROMBOLYSIS
– MECHANICAL THROMBECTOMY
– MECHANICAL ASPIRATION
• Intravenous Thrombolysis (t-PA)
– Treatment of choice in small vessel acute stroke
(<4.5hrs).
– Treatment of choice in large vessel stroke but in
combination with mechanical thrombectomy
INTERVENTIONS IN ACUTE STROKE
INTERVENTIONS IN ACUTE STROKE
iv thrombolysis work….
Why do we need alternative form of treatment ?
INTERVENTIONS IN ACUTE STROKE
Limitations of iv-tPA
– Moderate to poor efficacy in large strokes
– Window period too short
– Risk of bleed
INTERVENTIONS IN ACUTE STROKE
Available Techniques:
•Intra-arterial thrombolysis
•Mechanical clot removal– MERCI– PENUMBRA – STENTRIEVERS– DIRECT ASPIRATION
INTERVENTIONS IN ACUTE STROKE
ESCAPEEXTEND-IASWIFT PRIME
MR-CLEAN
Mechanical Thrombectomy
Stent retrievers
INTERVENTIONS IN ACUTE STROKE
Mechanical ThrombectomyINTERVENTIONS IN ACUTE STROKE
• Ability to restore blood flow immediately,
administer medical therapy and retrieve clot.
• Basically a dedicated, low profile retrievable stent
system which catches the clot and retrieves it.
INTERVENTIONS IN ACUTE STROKE
67y/M
• Weakness over left side of the body• deviation of face towards left side• inability to speak• Duration 4hrs
• Known case of Type 2 DM since 20 years, on medication
Post procedure NCCT
60Y/F
CLINICAL DETAILS:
• Known hypertensive and DM on treatment.• c/o unresponsiveness at 8:20pm with left facial deviation.• h/o vomiting – 2episodes.
O/E:• E1V1M3 status with non reacting pupils ? Posterior
circulation stroke.• NCCT HEAD WITH CT ANGIO.• IV THROMBOLYSIS
Mr.VA; 26 M
• Left facial weakness and right lower limb paresis of 16 hours duration.
• Upper limb paresis 4hrs.
Follow up
• Patient improved in the DSA room.
• Discharge with mRS of 4
• Mechanical Thrombectomy leads to good
outcomes
• Limitation is still the time of intervention
• Puncture to reperfusion time should be
minimized
INTERVENTIONS IN ACUTE STROKE
Disadvantages:
•Blind negotiation of the occluded segment.
•Distal migration of clot fragments
•Complication rate 3-5%.
INTERVENTIONS IN ACUTE STROKE
• Direct Catheter Aspiration– Attractive concept– No handling of thrombus– Minimally invasive– No blind progression of microcatheter
• Problems:– Larger bore catheters usually too stiff– No dedicated systems
INTERVENTIONS IN ACUTE STROKE
INTERVENTIONS IN ACUTE STROKE
Turk AS, et al. J NeuroIntervent Surg 2014;0:1–5. doi:10.1136/neurintsurg-2014-011125
INTERVENTIONS IN ACUTE STROKE
INTERVENTIONS IN ACUTE STROKE
INTERVENTIONS IN ACUTE STROKE
AHA GUIDELINES:
Towards end……
• NCCT– Rule out hemorrhage– Early signs of
ischemia– Prognostication
(ASPECTS scoring)
• CT angiography– Site of blockage– Collateral mapping
• CT Perfusion– Wake up strokes.
• INTERVENTIONS– iv t-PA– Stentrievers– Direct aspiration technique
Time is the key.NCCT and CT angiography mainstay of imaging.
November 11-13, 2016Venue: Lecture theatre complex, PGIMER, Chandigarh
In collaboration with Society of Breast Imaging (SBI), USA
Thank You
Recommended