CT perfusion and

CT angiography before thrombolysis in acute

strokeKinga Pozsár , Géza Szilágyi PhD*, Gábor Forrai PhD National Health Center, Radiology Department*Neurology Department, BudapestHungary

CLINICAL PROTOCOL2007- 110 patients with intravenous thrombolysis, 2007 AHA, 2009 ESO guidelines

CT positive(hemorrhage, tumour, stb.)

Admission to neurology

department or other department

yes

CTA, CTP

no

MCA or T occlusion or BA occlusion

MCA or T occlusion or BA occlusion

within 3 (4.5) hours

over3 (4.5)hours

IVTIVT-IAT bridgingIAT

Admission to neurology

department or other department

yesyes

nono

PATIENT Emergency Department: physical, neurological examination, laboratory tests

NECT examination

RADIOLOGICAL PROTOCOLUnenhanced CT examination -exlusion of hemorrhage Perfusion CT examination -stroke radiological diagnosis -therapeutic plan (perfusion damaged area’s size and viable area’s

proportion)CT angiography -site of the occlusion -evaluation of the carotid system ( intraarterial lysis)Contrast enhanced CT examination - Contraindication of thrombolysis (luxusperfusion, other pathological

enhanced areas-tumours)Follow up CT examination (24, 48 hours) - hemorrhagic complications - size of finally damaged area

DATABASE 30 patients 17 females, 13 males Age 69.8±12.9 years Time (CT) 107.2±25,1 minutes Time (thrombolysis) 153.8±32,1 minutes Risk factors

Hypertension 82% Ischaemic heart disease 45% Atrial fibrillation 36% Stroke 22% DM 18%

Groups based on CTA Main artery occlusion ICA or T occlusion MCA primary branch occlusion MCA secondary-third- branch occlusion

AIMS• We examined the perfusion damage, penumbra and supposedly

damaged area’s size and proportion furthermore on follow up CT we examined saved and finally damaged area’s size and proportion in each group

• Penumbra – perfusion mismatch (MTT-CBV) MTT:7-8 sec, CBV:3ml/100g brain tissue• Supposedly finally damaged area – CBV • Finally damaged area-follow up CT hypodensity• Cooperating with neurologists we compared the CT study results with clinical improvement -NIHSS (National Institutes of Health Stroke Scale) -mRankin scale• Efficiency of intravenous thrombolysis from clinical and radiological

point of view

ICA OCCLUSION

MTT CBF

CBV CTA

Follow up CT

SECONDARY BRANCH OCCLUSION

MTT CBF

CBV CTA

Follow up CT

PERFUSION CT- RESULTS

ICA, T occlusion

MCA primary branch occlusion

Secondary branch occlusion

CBV MTT Penumbra InfarctIn the relevant slices

Saved area

PERFUSION CT- RESULTS

Damaged areaSaved area

CBVPenumbra

ICA, T occlusion

MCA primary branch occlusion

MCA secondary branch occlusion

ICA, T occlusion

CBV

CBV

Saved area

Saved area

Damaged area

Damaged area

Penumbra

Penumbra

MCA primary branch occlusion

MCA secondary branch occlusion

NEUROLOGICAL OUTCOME

ICA, T occlusion

MCA primary branch occlusion

Secondary branch occlusion

All patients with secondary branch occlusion went home,8 patinets got to the rehabilitation center,9 patient got to the chronic center,3 patients died

NHISS before

NHISS 7 days later

mRankin 7 days later

CT PERFUSION-DIAGNOSTIC ROLE

Young patient with mild hemisymptomsPerfusion damaged area in basal ganglions in PCA territory Small partial basilar thrombosisTherapeutic plan IA lysis

MTT CBV CTA

CTA

SUMMARYCTP and CTA studies are useful for several reasons quick and easily availableDiagnostic role (stroke radiological diagnosis- differential diagnosis)Therapeutic role (setting up therapeutic plan and foreseeing the therapeutic

efficiency)

Considerations

- Patients arriving within 2 hours at the hospital have remarkable penumbra- A major part of penumbra can be saved performing intravenous lysis- In case of main artery occlusion nearly the whole penumbra can be saved

within 3 hours- In case of secondary branch occlusion the intravenous lysis results in

optimal functional outcome, however the whole penumbra is not saved

IF THE CT PROTOCOL IS NOT ACCURATE FOR ANY REASON MRI EXAMINATION IS NECESSARY

THANK YOU FOR YOUR ATTENTION