COMPUTED TOMOGRAPHY, COMPUTED TOMOGRAPHY

ANGIOGRAPHY, AND PERFUSION COMPUTED TOMOGRAPHY

EVALUATION OF ACUTE ISCHEMIC STROKE

Carlos Leiva-Salinas & Max Wintermark

PRESEPTOR :
dr. Noflih Sulistia, Sp.Rad

OLEH:
Firdha Yossi Chani
Iffat Taqiyyah
Siti Zahnia

KEPANITERAAN KLINIK RADIOLOGI

FAKULTAS KEDOKTERAN UNIVERSITAS LAMPUNG
RSUD Dr. H. ABDUL MOELOEK PROVINSI LAMPUNG
2019
2
Stroke is the leading cause
of disability and fifth cause
of death in the United
States
More than 80% of strokes are
ischemic in origin.
Each year, approximately
800,000 people in the United
States and more than 15 Neuroimaging is essential for
million people worldwide stroke assessment. Given its
experience a stroke. wider availability, computed
tomography (CT) is the most
commonly used imaging
modality used for acute stroke.
MAPS

3
COMPONENTS
OF MULTIMODAL
COMPUTED
TOMOGRAPHY
 ▸ Multimodal CT in acute stroke,
including noncontrast CT (NCCT) of
the brain, CTA of the head and neck,
and PCT

▸ intracranial hemorrhage or other stroke

mimics,
▸ early ischemic changes,
▸ underlying thrombus location and
characteristics,
▸ collateral circulation, and e
▸ evaluation of potential ischemic penumbra
based on mismatch profile.
5
NON CONTRAST
COMPUTED
TOMOGRAPHY
 NCCT of the head remains the
first line of imaging for patients
with suspected acute ischemia

Brain NCCT is used not only to exclude intracranial

hemorrhage but also toassess for early ischemic
changes. In the early phases after symptom onset,
NCCTrelies on the identification of subtle
hypoattenuation as a predictor of infarction

7
CT ANGIO-
GRAPHY
8
COMPUTED TOMOGRAPHIC
ANGIOGRAPHY (CTA)

CTA is increasingly used in the evaluation of patients with suspect

9
EVALUATION OF COLLATERAL FLOW

•Good collateral circulation on baseline CTA is

associated with smaller final infarct volume and better
functional outcome.

•Collateral status on CTA not only is a prognostic

biomarker but also can be used to select patients for
endovascular therapy.

• Recent trials have shown how patients with good

collaterals at pretreatment CTA have better functional
outcome after endovascular therapy when compared with
IV rtPA, whereas patients with poor collaterals did not
show a differential effect of successful recanalization
10
EVALUATION OF ISCHEMIC CHANGES

CTA images are usually acquired in the steady-

state phase of the contrast bolus injection and
are cerebral blood volume (CBV) weighted.
Hypoattenuation on CTA has greater sensitivity
to detect ischemia than NCCT.

11
A 79-year-old male
patient with acute
stroke. Baseline
multimodal CT (A–
G), posttherapy
CTA (H), and follow-
up axial DWI MR
imaging (I)
performed 1.5
hours, 26.5 hours,
and 5 days after
symptom onset.

12
A 90-year-old
female patient with
acute stroke.
Baseline
multimodal CT (A–
G), posttherapy
CTA (H), and follow-
up axial DWI MR
imaging (I)
performed 1.5
hours, 26 hours,
and 9 days after
symptom onset.

13
PERFUSION
COMPUTED
TOMOGRAPHY
(PCT)
14
 PERFUSION COMPUTED TOMOGRAPHY
(PCT)

• PCT is increasingly used in acute stroke for

the evaluation of hemodynamic physiology of
the brain parenchyma in an attempt to
determine the volume of infarct core and
ischemic penumbra

• The quantitative perfusion data are displayed in color-coded

parametric maps, most frequently including cerebral blood
flow (CBF), mean transit time (MTT), and CBV. Brain regions
with significant decreased CBV or CBF correspond to the
infarct core, and areas with prolonged MTT represent the
overall area of low perfusion pressure
15
PERFUSION COMPUTED TOMOGRAPHY
(PCT)

• PCT has been available for years, but there

is still no clear consensus regarding the role of
perfu- sion biomarkers for the selection of
patients for revascularization treatment.

• Indeed, the penumbra could be seen as a

dual-edged sword, in the sense that it can
predict good or bad outcome depend- ing on
recanalization status
16
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▸ Multimodal CT in acute stroke,
including noncontrast CT (NCCT) of
the brain, CTA of the head and neck,
and PCT

▸ intracranial hemorrhage or other stroke

mimics,
▸ early ischemic changes,
▸ underlying thrombus location and
characteristics,
▸ collateral circulation, and e
▸ evaluation of potential ischemic penumbra
based on mismatch profile.
19
NON CONTRAST
COMPUTED
TOMOGRAPHY
20
NCCT of the head remains the
first line of imaging for patients
with suspected acute ischemia

Brain NCCT is used not only to exclude intracranial

hemorrhage but also toassess for early ischemic
changes. In the early phases after symptom onset,
NCCTrelies on the identification of subtle
hypoattenuation as a predictor of infarction

21
 A 79-year-old male
patient with acute
stroke. Baseline
multimodal CT (A–
G), posttherapy
THIS IS A SLIDE TITLE
CTA (H), and follow-
up axial DWI MR
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22
A 90-year-old
female patient with
acute stroke.
Baseline
multimodal CT (A–
G), posttherapy
CTA (H), and follow-
up axial DWI MR
imaging (I)
performed 1.5
hours, 26 hours,
and 9 days after
symptom onset.

23
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“
▸ NCCT of the head remains the
first line of imaging for
patients with suspected acute
ischemia

25
A 79-year-old male patient with ac
multimodal CT (A–G), posttherapy
follow-up axial DWI MR imaging (
hours, 26.5 hours, and 5 days afte

26
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