acute ischemic stroke: imaging and...
TRANSCRIPT
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Acute Ischemic Stroke: Imaging and Intervention
R. Gilberto González, MD, PhD Neuroradiology Division
Massachusetts General Hospital
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38 yo M L Hemiparesis
DWI MTT
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38 yo M L Hemiparesis
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38 yo M L Hemiparesis
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38 yo M L Hemiparesis
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38 yo M s/p IA Thrombolysis
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Acute Ischemic Stroke
• Stroke basics • Stroke imaging: evidence based • Stroke imaging algorithm for therapy • Time versus Physiology
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Ischemic Infarction Types
Lacunar
~35% ~45%
~20%
Major Severe Sxs Large Art. Occl Large Infarct Poor outcome
Minor Mild Sxs No L. Art. Occl Small Infarct Good outcome
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Stroke •~700,000 cases/year in US
•3rd Leading cause of death
•Leading cause of severe disability
•Yearly costs > $55 billion
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Goal of Treatment
Lacunar
150,000- 200,000 Patients/yr
Major Severe Sxs Large Art. Occl Large Infarct Poor outcome
Minor Mild Sxs No L. Art. Occl Small Infarct Good outcome
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Collateral Flow
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Occlusion CTA/MRA Core NCCT Diffusion MRI Perfusion MR/CT Penumbra Perfusion MR/CT
Core+Penumbra Neurological Exam
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Acute Ischemic Stroke
• Stroke basics • Stroke imaging: evidence based • Stroke imaging algorithm for therapy • Time versus Physiology
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Consensus Conference Presentation of Evidence
NCCT Pomerantz CTA Gonzalez DWI Schaefer CTP Lev PWI Copen Perfusion Issues Hunter Stroke Therapy Yoo
Review Panel Gupta, Rapalino, Romero,
Larvie, Chen, Ackerman, Fellows
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Occlusion
Core
Penumbra
Core+Penumbra Neurological Exam Class I
CTA
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BASIS Boston Acute Stroke Imaging Scale
Torres-Mozqueda et al. AJNR 2008 29:1111-7; Epub 2008 May 8.
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Screening Technology and Outcome Project
in Stroke (STOPStroke) Study N = 645 stroke patients MGH and UCSF All underwent CTA/CTP Admission NIHSS 6 month mRS 101 received IV tPA
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Screening Technology and Outcome Project
in Stroke (STOPStroke) Study N = 645 stroke patients
CTA did not hinder management: >15% received IV tPA
Admission NIHSS & BASIS: Independent Predictors of Outcomes
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Patient Outcomes by Classification
**** **** ****
Figure 2
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Occlusion CTA Class I Core NCCT DWI CTP Penumbra
Core+Penumbra Neurological Exam Class I
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Diffusion MRI
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Evidence Based Guideline
Diffusion MRI: Class I Level of Evidence A
Schellinger et al. Neurology 2010; 75(2):177-185
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Prediction of clinical outcome
DWI best predictor of final infarct volume
DWI > 70 cc’s is specific for poor outcome » Sanak et al, Neuroradiology 2006 » Barak et al, International Stroke Conference
2008 » Yoo et al. Stroke 2010; 41:1728-35
Schaefer/ MGH
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Yoo, AJ - MGH
Acute Infarct Volume Threshold
72 cm3
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Occlusion CTA Class I Core NCCT Class I DWI Class I CTP Penumbra
Core+Penumbra Neurological Exam Class I
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CBV CBF MTT
Underperfused, Alive
Underperfused, Dead
WA COPEN
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Examples of ROI Placements
DWI PWI
6x6 pixel placed in center of DWI lesion
6x6 pixel placed in contralateral location
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Time (Hours)
CBV in Center of Diffusion Abnormality
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Occlusion CTA Class I Core NCCT Class I DWI Class I CTP Class IIb Penumbra
Core+Penumbra Neurological Exam Class I
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Acute Ischemic Stroke
• Stroke basics • Stroke imaging: evidence based • Stroke imaging algorithm for therapy • Time versus Physiology
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Acute Ischemic Stroke Recommended Imaging Algorithm
NCCT
CTA
IA Rx
MR Capable? CTP
DWI
MRP
ICA/MCA/Basilar Occlusion+Small DWI?
No
Yes
Yes No
No IA Rx
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Stroke 2009; 40:2046-54
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Yoo, AJ - MGH
p<0.016
Clinical Outcome by DWI & Time to Recanalization by IAT
“Futile DWI”: initial DWI volume > 70 cm3
p<0.008
64%
17%
Yoo AJ, et al. Stroke. 2009; 40: 2046-54.
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Acute Ischemic Stroke
• Stroke basics • Stroke imaging: evidence based • Stroke imaging algorithm for therapy • Time versus Physiology
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Physiology based management
Time based management
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Stroke 2006;37:263-6.
CONCLUSIONS: The typical patient loses 1.9 millon neurons each minute in which stroke is not treated.
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Time after Ictus & DWI
Time
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0 4 8 12 16 20 24 Time after Stroke Onset (hr)
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0 4 8 12 16 20 24 Time after Stroke Onset (hr)
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Acute Ischemic Stroke
• Stroke basics • Stroke imaging: evidence based • Stroke imaging algorithm for therapy • Time versus Physiology
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Acknowledgements
• Neuroradiology – Schaefer, Lev, many others
• Interventional Neuroradiology – Yoo, Hirsch, many others
• Martinos/MGH NMR Center – Rosen, Brady, Sorenson, many others
• Neurology – Koroshetz, Schwamm, Singhal, many others
James Thrall, MD