imaging in pediatric stroke - mgh child … issues: infarct 1.exclude hemorrhage 2.confirm clinical...
TRANSCRIPT
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Imaging in Pediatric Stroke
Paul Caruso, MD, Director of Pediatric Neuroimaging, Mass General Hospital for
Children
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indicationdifferential diagnosis andmanagement issues
protocolinterpretive strategy
impression
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differential diagnosis:infarct
CNS malformationneoplasm
metabolic disorder
focal neurologic deficit: hemiparesishypotoniaseizurepremature sidednessvisual deficits
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management issues:infarct
1.exclude hemorrhage2.confirm clinical diagnosis
3. determine extent, location4.determine vessel patency
5.cerebral perfusion
focal neurologic deficit: hemiparesishypotoniaseizurepremature sidednessvisual deficits
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PROTOCOL
US
CT
MRI
focal neurologic deficit: hemiparesishypotoniaseizurepremature sidednessvisual deficits
management issues:infarct
1.exclude hemorrhage2.confirm clinical diagnosis
3. determine extent, location4.determine vessel patency
5.cerebral perfusion
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hemorrhage: important triage tool in thrombolysisconfirm dgx: may detect infarct in first 6-8 hours extent, may underestimate c/w DWICTACT perfusiongold standard for venographyde facto modality of choice for herniation, edema: ER, ICU
low specificity, good sensitivity, limited by age, doppler
PROTOCOL
US
CT
MRI
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CT
ICRP, 1991 analysisBrenner DJ. Pedatr Radiol 2002 32: 228-231
CT at 300 mA is 60 mSvbackgroud radiation is 3.6 mSv
10 CTs to a 10 yo ~ 10% life time risk, 1 Sv to 10 yo, 10% life time cancer risk 1/10,000 cancer morality risk for 10 year olds foreach CT
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PROTOCOL
US
CT
MRI
susceptibility: hemorrhage
DWI: confirm diagnosis, extent
MRA: patency
MR perfusion: mismatch, territory at risk
T1
T2
FLAIR
consider:
MRV
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venous thomboses and infarcts
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venous sinus thrombosis, venous infarct6 yo girl, seizure
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venous sinus thrombosis, venous infarct6 yo girl, seizure
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venous sinus thrombosis, venous infarct6 yo girl, seizure
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venous sinus thrombosis, venous infarct6 yo girl, seizure
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venous sinus thrombosis, venous infarct6 yo girl, seizure, 8 months later
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deep venous thrombosis10 day old girl, former 36 weeker
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deep venous thrombosis10 day old girl, former 36 weeker
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deep venous thrombosis10 day old girl, former 36 weeker
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deep venous thrombosis10 day old girl, former 36 weeker
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arterial infarcts
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R MCA infarct6 yo girl, left hemiparesis
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R MCA infarct6 yo girl, left hemiparesis
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R MCA infarct6 yo girl, left hemiparesis
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left MCA infarct and MCA stenosis14 yo girl, right hemiparesis
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left MCA infarct and MCA stenosis14 yo girl, right hemiparesis
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left MCA infarct and MCA stenosis14 yo girl, right hemiparesis
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left MCA infarct and MCA stenosis14 yo girl, right hemiparesis
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left MCA infarct and MCA stenosis14 yo girl, right hemiparesis
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L MCA infarct3 yo boy, seizure
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L MCA infarct, likely in utero3 yo boy, seizure
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left thalamocapsular infarct14 yo boy, R hemiplegia and hemihypesthesia sudden onset
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left thalamocapsular infarct14 yo boy, R hemiplegia and hemihypesthesia sudden onset
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left thalamocapsular infarct14 yo boy, R hemiplegia and hemihypesthesia sudden onset
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left thalamocapsular infarct14 yo boy, R hemiplegia and hemihypesthesia sudden onset
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left thalamocapsular infarct14 yo boy, R hemiplegia and hemihypesthesia sudden onset
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R thalamic infarcts16 year old new onset gait instability
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hemorrhages and hemorrhagic infarcts
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cerebellar hemorrhage16 yo boy, hemophilia
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cerebellar hemorrhage16 yo boy, hemophilia, 2 months later
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infarct mimics
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infarct?5 year old girl, seizure
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infarct?5 year old girl, seizure
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infarct?5 year old girl, seizure
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infarct?5 year old girl, seizure
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infarct?5 year old girl, seizure
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infarct?5 year old girl, seizure
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infarct?5 year old girl, seizure
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ecitotoxic unilateral cortical necrosis hypoglycemia, AEFCSE
5 year old girl, seizure
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? stroke3 year old girl, L sided weakness
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? stroke3 year old girl, L sided weakness
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? stroke3 year old girl, L sided weakness
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? stroke3 year old girl, L sided weakness
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complex I deficiency 3 year old girl, L sided weakness
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imaging in pediatric stroke
• GOALS OF NEUROIMAGING– hemorrhage: CT, susceptibility– confirmation of diagnosis: infarct mimics– extent and location– vessel patency: CTA, MRA– regional perfusion: MR perfusion, CTP
• CT: important modality in the imaging of stroke– gold standard for venography
• MRI– DWI/ADC detects stroke within hours of ictus
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DWI
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http://hsc.uwe.ac.uk/radscience/MRI/MRI_Physics.pdf
http://www.tbrhsc.com/patient_information/media_releases/new_MRI_scanners.asp
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http://hsc.uwe.ac.uk/radscience/MRI/MRI_Physics.pdf
RF pulse applied
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• What is diffusion weighted imaging?
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• What is diffusion weighted imaging?
t= 0
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• What is diffusion weighted imaging?
t= 5 millisec
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• What is diffusion weighted imaging?
t= 10 millisec
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• What is diffusion weighted imaging?
t= 20 millisec
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• What is diffusion weighted imaging?
t= 30 millisec
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• What is diffusion weighted imaging?
t= 30 millisec
d
d2 = 6Dt
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ECHO90 180y
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ECHO90 180
d2 = 6Dt
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ECHO90 180
d2 = 6Dt
signal loss α d
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b = n (γδG)2 (Δ-δ/3)
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Background
RF
Gx
Gz
Gy
diffusion sensitization gradients, n = 3
b = n (γδG)2 (Δ-δ/3)
δ
G
Δ
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applications
• classic application: stroke
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applications
• classic Application to Stroke
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MR spectroscopy
Water
LipidsFat
Proton MR signal of the in the human brain. We are able to see the waterpeak and the fat/lipid peak, because these molecules are most abundantin the human body. However, we are interested in the peaks between fatand water.
Dr. Eva Rata, Guidline for reading MR spectroscopy, MGH, 2006
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MR spectroscopy
Dr. Eva Rata, Guidline for reading MR spectroscopy, MGH, 2006
PPM
Metabolites
5 4 3 2 1PPM
Cr2
Cho
Cr
NAA
Water suppressed
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MRS
• NAA: 2 ppm, neuronal density and viability, necrosis
• Creatine: 3 ppm, metabolic marker, ATP reservoir• Choline: 3.2 ppm, cell membranes, myelin, marker
for membrane turnover, leukodystrophies, hypercellularity/tumor
• Lactate: 1.3 ppm, marker of anearobic metabolism, hypoxia, infarct, mitochondrial disease, tumor
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• things to do next time
• US physics slide
• CT physics slide