Issues in Imaging for Stroke Shawn Halpin MRCP FRCR LLM University Hospital of Wales, Cardiff.
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Transcript of Issues in Imaging for Stroke Shawn Halpin MRCP FRCR LLM University Hospital of Wales, Cardiff.
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Issues in Imaging for Stroke
Shawn Halpin MRCP FRCR LLM
University Hospital of Wales, Cardiff
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National Intercollegiate WP for Stroke 2004
Hospital care
specialist teams
weekly MDT
SITS MOST
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contd...
“initial assessment by experienced clinician”
“non specialist care costs lives, increases dependancy, less cost effective”
brain imaging within 24 hours
MRI if CT delayed for 10 days
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Audit data:
How many patients imaged within 24 hours?
Wales criticised for worst UK performance
But 97% patients scanned within 24 hours of request
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New report
Immediate imaging for certain stroke subgroups - thrombolysis, unconscious, warfarin
Immediate review by an expert in stroke
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Immediate (1hr) scan?
Trivial to provide
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Immediate clinical diagnosis
Very difficult
large/small vessel; TIA; migraine; SAH; dissection, watershed, global etc etc
3 patient with limb fractures referred as acute stroke patients
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Plain scan in early stroke:
Usually normal
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Rush to treat:
Undoubtedly some non-stroke patients will be treated with rTPA
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Early CT signs:
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Add specialist neuroradiological
advice
Non Trivial
Network?
Interested DGH radiologists?
Every DGH radiologist?
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Alternative?
Perfusion scanning
CT or MR
Make decisions based on physiology
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Reichenbach et al AJNR 20 1999
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45 yr old, large ophthalmic aneurysm
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Perfusion during occlusion
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Tissue Classification
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Advantages of Physiology
No false positives
Treat only those with viable tissue
Use as triage: a tool to spare the expert in stroke?
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Radiology will enthusiastically
support acute stroke
Give us the tools to do it
Help us with the out of hours reporting
Bear in mind we have other responsibilities too:
Most radiologists cover all emergencies, not just neuro
And there are not many of us!
BUT
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1. Plain scan only
Who reports?
Fear of onerous on call duty
Consultant radiologists ideal
In each hospital?
Network in Wales, or wider UK -
local/extended?
Network outside Wales?
Radiographer or stroke team report??
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2. ASPECT scoreMore radiologist experience needed
Greater physician input
Give drug or not?
No longer a yes/no, now a maybe
Further need for experienced clinician
Use of the Alberta Stroke Program Early CT Score (ASPECTS) for Assessing CT Scans in Patients with Acute Stroke
AJNR Am J Neuroradiol 22:1534 ミ 1542, September 2001 . Alternatively, what percentage of the MCA territory is low density?
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2. ASPECTS score reporting
Need consultant radiologist
In house
local
network
outsource
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3.Assess other pathology
Need consultant radiologist
As before
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4. Perfusion data
Need Neuroradiologist
or highly specialised other person
this may change in the future, but not yet
Similar issues with location
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Suggestion:
All hospitals support IST3
Start slowly, learn where the problems are
Build resources based on local experience
Radiologist, radiographer, stroke team
Look to develop perfusion scanning, 24/7 services over time