Stroke Imaging FINAL - Copy

7/25/2019 Stroke Imaging FINAL - Copy

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IMAGING INACUTE

ISCHEMIC

STROKEDr.J S K ChaitanyaDr.Vijayan K


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Imaging in acute stroke is mainly targetedtowards assessment of 4 Ps

Parenchy

ma

Pi!es

Perfusion

Penum"r

a

P


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Parenchyma

C# $%I

Pi!es

&S' C#( $%( DS(

Perfusion andPenum"ra

SP)C# *)+,+ C# C#

P)%-&SI,

+ $%

P)%-&SI,+


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PARENCHYMA


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Parenchyma

rain tissue.

/hat has to "e seen0

Change in density 1 intensity of "rain tissue.

/hat are the modalties0

C# 1 $%I

/hy to assess !arenchyma0

)2clude hemorrhage.

Detection of ischemic tissue.

)2clude mimics


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)2clusion of haemorrhage

C# is the gold standard fordiagnosing haemorrhage.

$% '%) se3uence a!!eared to "e atleast as accurate as C# for thedetection of acute IC.

-5(I% se3uences are useful inidentifying S( and SD on $%I.


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FLAIR


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SWI


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Doesthe !resence of tiny amounts of hemorrhage seenon $% "ut not C# contraindicate the use of a throm"olytic

agent0

(lthough the !resence of old micro"leedsmay !redict recurrent disa"ling and fatalstrokes6 there was no statistically

signi7cant increase in the risk ofsym!tomatic IC when !atients with asmall num"er of microhemorrhages 89 :;on $% were treated with intra


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Detection of cere"ral ischemia ande2clusion of mimics

C#

$%I

C#( > Source images


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C# 8!lain;

Sulcal e?acement

5oss of insular ri""on

lurring of grey > white matterjunction

,"scuration of lentiform nucleus

y!erdense artery sign 6 indicati


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HYPERDENSEMCA SIGN


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SULCAL EFFACEMENT


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OBSCURATION OFLENTIFORM NUCLEUS


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I+S&5(%%I,+SI'+


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5oss ofdi?erentiation among"asal

ganglionnuclei


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@uanti7cationA(SP)C#SSC,%)

#he (l"erta Stroke Program )arly C#Score 8(SP)C#S; was !ro!osed inB as a means of 3uantitati


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(SP)C#S SC,%)

#he normal $C( territory is assigned a totalscore of . -or each area in


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$

$B

$E

C

IC

5I

$4

$:

$F

SPECTS Sc!re ' () * M+ ' ,


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$%I

#Aweighted s!inAecho 8#/;

#BA weighted fast s!inAecho8#B/;

-luid attenuated in


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Princi!les of $%I

#o ac3uire images %- !ulses are a!!lied at5armor fre3uency of hydrogen 8 resonants!in fre3uency;.

#he energy from these !ulses is a"sor"ed andthen released until the tissue has remitted theenergy a"sor"ed and undergone rela2ation.

#he energy released occurs o


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)C, #I$) 8 #) ;

#he time the machine waits after a!!lied%- !ulse to recei


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Con /I#)CS- > 5(CK(%#)%I)S > 5(CK

8-5,/ V,IDS;

'%) $(##)% >'%)/I#) $(##)% > '%)CS- > /I#)(%#)%I)S > 5(CK

8-5,/ V,IDS;

'%) $(##)% >'%)/I#) $(##)% >'%)CS- > 5(CK

(%#)%I)S > 5(CK-5,/ V,IDS


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(d


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FLAIR

DWI. ' )

DWI.'())

)

ADC


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FLAIRDWI.')

DWI. '())) ADC


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Susce!ti"ility /eighted Imaging 8S/I; ere the contrast "etween tissues

de!ends on the magnetic susce!ti"ility

di?erences. S/I imaging hel!s in detection of acute

hemorrhage 6 chronic micro "leeds andcere"ral


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C# SWI


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&sual 7ndings noted on $% L

y!er intense signal in white matter6

8 #B 6#BG6D/I 6-5(I% ; 5oss of gray matter> white matter

di?erentiation.

Sulcal e?acement and mass e?ect

5oss of the arterial Mow


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BLOOMING


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C#( > Source images

C#(ASI a!!ears to "e as good as D/Iat detecting acute ischemia6 with thee2ce!tion of small foci and those in

the !osterior fossa. 8 5)V)5 ;


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PIPES


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&S' C(%,#ID D,PP5)%

#CD

C#(

$%(

DS(


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#CD > #ranscranial Do!!ler

#ranscranial Do!!ler 8#CD; wasintroduced "y Rne Aas(id in NOBto non)invasive(*assess cere"ral

hemodynamics.

-rom that #CD has e


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#his techni3ue can detect Intracranial Mow


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TCD4TIBI

Demchuk et al. de


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#CD

B $ !ro"e

/indows #em!oral

,r"ital

Su" occi!ital

%etro mastoid


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'%(D) > no Mow

'%(D) > minimal Mow

'%(D) B >"lunted Mow

'%(D) E > dam!ened

'%(D) 4 > stenotic

'%(D) : > normal Mow


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5t.$C( grade B Mow


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Post lysis 5t.$C(


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POST THROMBOLYSIS

PRE THROMBOLYSIS


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$%(

BAD #,- 8 #ime of Might ;

EAD #,-

C) > $%(


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$% (ngiogra!hy

#he


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In diagnosis of arterial dissection 6-i"romuscular dys!lasia6


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C# (+'I,'%(P

C#( has twice the s!atial resolution of $%(.

( study "y erg et al found that CTA wascom#arab(e to !SA for diagnosing signi7cantcarotid disease.

-or an acute stroke !atient6 5e< et al ha


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C5,# &%D)+ SC,%)

#o detect the intra


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C5,# &%D)+ SC,%) > distal $C(8B; >$C( cortical "ranches8B; F


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PERFUSION 7 PENUMBRA


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P)+&$%(

(cute cere"ral ischemia may result in a centralirreversib(* in,arcted tisse core surrounded"y a !eri!heral region of stunned cells that iscalled a#enmbra"ut this region is#otentia((*

sa(va$eab(e with early recanaliation. It is a dynamic entity


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%ole of !erfusion imaging

Identi7cation of "rain regions with e2tremely lowcere"ral "lood Mow 8C-;6 i.e core

Identi7cation of !atients with atArisk "rain regions i.e#enmbrawhich is sal


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SP)C#

*enon C#

C# !erfusion

$% !erfusion


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C# P)%-&SI,+

Im!ortant information o"tained "y!erfusion imaging Cere"ral "lood


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C#(ASI6 can s!eci7cally detect infarctcore and can therefore "e used tode7ne a worstAcase lower limit to

-na( in,arct si.e /"I01' In !atients with major re!erfusion6

mean CB0 and C#PASI infarct sie

closely !redicted 7nal infarct sie 6indicating its accrac*in identifyingthe e2tent of re


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#hresholds 2334 redction in CB" ,ornonviab(e #enmbra and 5674 redctionin CB" ,or beni$n o(i$emiaRmay !redictthe u!!er and lower limits of 7nal infarct sie.

Visual threshold for identi7cation of the CVcore corres#onded to a 864 redction inCB"'

( relati


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: yr $ 6 !resenting within E hrs of%t hemi!legia with grade B !owerand a!hasia.

+ISS > O (SP)C# Score A N

,+ #) D( E %S -%,$ S$P#,$S


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,+ #) D( E %S -%,$ S$P#,$S


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C)%)%(5 5,,D V,5&$)


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MEAN TRANSIT TIME


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CEREBRAL BLOOD

FLOW

CEREBRAL BLOOD VOLUME


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-


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MEAN TRANSIT TIME-


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CEREBRAL BLOOD FLOW

-



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+


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MEAN TRANSIT TIME

+


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CEREBRAL BLOOD

FLOW+

(-#)% B4 %S


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(-#)% B4 %S


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$% Perfusion

B techni3ues olus tracking with contrast

(rterial s!in la"elling 8 without contrast ; A newer

(mount of signal loss is !ro!ortional tocerebra( b(ood vo(me 8CV ;

#ime taken to !eak 8##P; change is!ro!ortional to Mean transit time /MTT1of

"lood Cerebra( b(ood :ow /CB"; e3uals the

ratio of CV L $##


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PRE THROMBOLYSIS


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POSTTHROMBOLYSIS

PRE THROMBOLYSIS


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TA8E HOME POINTS


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CT $ore readily a


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Techni9"e se&eci!n $!r e:a&"ai!n !$ac"e sr!;e #ih CT and MRI

C# $%I

Parench6

5a

C# P5(I+ -5(I% 6 D/I 6

Pipes C# (+'I,'%(P $% (+'I,'%(P

Per$"si!n C# P)%-&SI,+I$('I+'

P)%-&SI,+/)I')D I$('I+'

Pen"5.ra Cere"ral "lood Mowand cere"ral "loodCV ; mismatch

D/I > P/Imismatch

$ lti d l C# i i


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$ulti modal C# imaging

Sulcal e?acement 5oss of insular ri""on

lurring of grey > white matter junction

,"scuration of lentiform nucleus

y!erdense artery sign 6 indicati


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$%I

H*#erintensit* on !%I with minimal or no changes on #B/Ior -5(I%.

H*#ointensit* on A!C

y!ointense artery sign on 'radient recalled echo 8 '%) ;se3uences6 suggesti


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(SP)C#S


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(SP)C#S score

Cl t " d


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Clot "urden score


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DWI. '

)

DWI.'()))

D/I" :


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Stroke Imaging FINAL - Copy

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