IMAGING IN STROKE

ACUTE ONSET OF CNS INJURY WITH

AN ABRUPT ONSET.

80% ACUTE ISCHAEMIA.

IMPORTANT CAUSE OF MORTALITY

AND MORBIDITY
 TRADITIONALLY CT TO EXCULDE
HAEMORRHAGE.
STROKE MIMICS.-INFECTION &NEOPLASMS
RECENT ADVANCES IN TREATEMENT
DEVELOPMENT OF NEW TECHINIQUES-
FURTHER EVOLUTION OF IMAGING
TECHNIQUES
IN ACUTE STROKE-EVALUATION ONLY BY
SCT I CLEARLY NOT ADEQUATE .
 NATIONAL INSTITUTE OF
NEUROLOGICAL DISORDERS AND
STROKE TRIAL
INTRAVENOUS AND INTRA ARTERIAL
THROMBOLYTIC THERAPY.
CONECPT OF SALVAGEABLE BRAIN
TISSUE.-PENUMBRA
 SUBSEQUENT MULTIPLE CLINICAL
TRIALS HAVE DOCUMENTED THE
BENEFITS OF THROMBOLYTIC
THERAPY IN ACUTE STROKE
CAREFUL SELECTION OF PATIENTS
BASED ON CLEARCUT IMAGING
FINDINGS IS ESSENTIAL.
 CONCEPT OF SALVAGABLE BRAIN TISSUE-
PENUMBRA-HAS DRIVEN THE
DEVELOPMENT OF FUNCTIONAL IMAGING-
BRAIN PEFUSION IMAGING
AIM OF IMAGING IN ACUTE STROKE-
IDENTIFY THE PATIENTS WHO WILL BENEFIT
FROM THROMBOLYTIC THERAPY-VERY
ESSENTIAL AS THROMBOLTIC THERAPY IS
ASSOCIATED WITH POTENTIAL LEFT
THREATENING COMPLICATIONS.
 IMAGING -4 P S
PARENCHYMA.

PIPES

PENUMBRA

PERFUSION
 BRAIN VERY SENSITIVE TO ISCHEAMIA-NO
NEURONAL ENERGY STORE IRREVERSIBLE
TISSUE DAMAGE-2 TO 3MTS OF COMPLETE
ABSENCE OF BLOOD FLOW.
IRREVERSIBLE CELL DEATH-CEREBRAL
BLOOD FLOW LESS THAN 10ML/100G /MIN
ISCHAEMIA INCOMPLETE
LEPTOMENINGEAL COLLATERRALS.

CENTRAL PART-IRREVERSIBLE
PERIPHERAL PART -SALVAGEABLE
 ACUTE CEREBRAL ISCHAEMIA
CENTRAL IRREVERSIBLY INFARCTED
TISSUE CORE
SURROUNDED BY PERIPHERAL REGION OF
STUNNED CELLS-PENUMBRA-CELLS IN THIS
REGION HAVE CEASED TO FUNCTION WITH
ABNORMAL EVOKED POTENTIALS ,BUT THIS
THIS REGION IS POTENTIALLY
SALVAGEABLE WITH EARLY
REVASCULARIZATION
 PENUMBRA CAN BE EVALUATED BOTH
BY CT AND MRI
CT-DISCREPENCY IN PERFUSION
PARAMETERS
MRI-DIFFUSION PERFUSION
MISMATCH
 TRADITIONALLY NO IV THROMBOLYSIS- IF
PRESENTAION IS 3 HOURS BEYOND THE
ONSET OF STROKE
IF PRESENTATION IS WITH 3 HOURS-IV
THROMBOLYSIS WITHOUT ANY EXTENSIVE
IMAGING TO DOCUMENT THE PENUMBRA
RECENT STUDIES-3 HOURS PERIOD FOR IV
THROMBOLYSIS CAN BE EXTENDED IN
CAREFULLY SELECTED PATIENT
SUBGROUP.
 POSTERIOR CIRCULATION STROKE
MORE WINDOW TIME
THROMBOLYSIS CAN BE DONE UPTO
12 TO 24 HOURS
 ROLE OF CT IN ACUTE STROKE

UNENHANCED SCAN
CTA
PERFUSION
ALL THESE TECHIQUES CAN BE USED
IN COMBINATION DEPENDING ON
CLINICAL NEED
 UNENHNCED SCAN-QUICK ,READILY
AVAILABLE 24X7 IN MOST CERTRES
EASY TO PERFORM
NO CONTRAST ADMINISTRATION.
RULES OUT HAEMORRHAGE
CAN DOCUMENT SIGNS OF
ISCHAEMIA.
 SIGNS OF EARLY INFARCT
HYPREDENSE VESSEL SIGN.
OBSCURATION OF LENTIFORM
NUCLEUS.
INSULAR RIBBON SIGN.

IMPORTANT TO ESTABLISH DIAGNOSIS

WITH IN 3HOURS OF STROKE.
EARLY SCAN AFTER 24 HOURS
LOSS OF INSULAR RIBBON
 IDEALLY INTERPRETATION ON WORK
STATION VARIABLE WINDOW SETTING.
STANDARD WINDOW SETTINH-80- 40
SENSITIVITY 57%
VARIABLE WINDOW SETTING WITH
WINDOW SETTING AT 8HU AND 32 HU-
1005 SENSITIVITY.
WINDOW WIDTH 80 CENTRE 35
WINDOW 10-28
QUANTIFICATION OF ISCHAEMIA.

1/3 EXCLUSION RULE

EUROPEAN CO OPERATIVE ACUTE

STROKE STUDY TRIAL.

SOME LIMITATION
 ASPECTS
ALBERTA STROKE PROGRAM EARLY
CT SCORE -2001
MCA TERRITORY DIVIDED IN 10
ZONES.
NORMAL SCORE -10
WITH DECREASE IN ASPECTS
INCREASE IN MORTALITY AND
MORBIDITY
 ASPECTS-ROBUST ,SYSTEMIC AND
PRACTICAL METHOD FOR
QUANTIFICATION OF CEREBRAL
ISCHAEMIA.
ROUTINELY FOLLOWED IN ALL
CENTRES DEALING WITH ACUTE
STROKE.
ASPECTS 6
ASPECTS-7
 CT ANGIO
AORTIC ARCH TO CIRCLE OF WILLIS
100 TO 120 ML OF IV CONTRAST
4ML/SECOND

SIGNIFICANT THROMBUS BURDEN-

INTRA ARTERIAL THROMBOLYSIS OR
MECHANICAL THROMBOLYSIS
 IF THROMBUS BURBEN IS
SIGNIFICANT INTRA ARTERIAL
THROMBOLYSIS IS MORE EFFECTIVE
THAN INTRAVENOUS THROMBOLYSIS.
STSTUS CAROTIDS CAN BE
ASSESSED AT THE SAME SITTING AND
CAROTID INTERVENTIONS CAB BE
PLANNED
 CT PERFUSION
DYNAMIC SCAN.

CONTINUOUS SCANNING IN 4
PRESELECTED SECTIONS FOR 45
SECONDS.
50ML OF CONTRAST -5ML/SEC
 CBV-VOLUME OF BLOOD/UNIT BRAIN
TISSUE.-4 TO 5 ML/100G
CBF-VOLUME OF BLOOD FLOW/UNIT
BRAIN TISSUE /SEC
50 TO 60 ML/SEC/100G.
MTT-MEAN TRANSIT TIME-TIME
DIFFERENCE-ARTERIAL AND VENOUS
TIME TO PEAK ENHANCEMENT.
 PENUMBRA-
MODERATE DECREASED CEREBRAL
BLOOD FLOW-,60%
NORMAL OR INCREASED CEREBRAL
BLOOD VOLUME-AUTOREGULATORY
MECHANSIM
INCREASED MTT
 INFARCTED TISSUE
SEVERELY DECREASED CEREBRAL
BLOOD FLOW-LESS THAN 30%
SEVERELY REDUCED BLOOD
VOLUME-LESS THA 40%
INCREASED MTT
CORE AND PENUMBRA
CBV CBF
MTT
 ROLE OF MRI
CONEVENTIONA SPIN ECHO
SEQUENCES.
GRADIENT AND SUSCEPTIBILITY
WEIGHTED SEQUENCES.
DIFFUSION IMAGING VERY
SENSITIVE FOR EARLY INFARCT
CHRONIC SDH
SECONDARY DEPOSITS
 IMAGING TECHNOLOGY HAS RAPIDLY
ADVANCED IN PAST 2 DECADES
CT AND MR ARE COMPLIMENTARY-
COMPREHENSIVE EVALUATION IS
POSSIBLE IN ACUTE STROKE
CORRECTLY IDENTIFIES THE PATIENTS
WHO WILL BENEFIT FROM INTRA ARTERIAL
THROMBOLYSIS.
IMAGING PROVIDES IMPORTANT AND
NECESSARY INFORMATION FOR CORRECT
THERAPY PLANNING