pham minh thong advances in diagnosis of acute ischemic stroke jfim hanoi 2015
TRANSCRIPT
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Advances in Diagnosis of Acute Ischemic Stroke
Prof. Pham Minh Thong Bach Mai University Hospital
Hanoi-Viet Nam
Journées Francophones d’Imagerie Médicale 14th Annual Meeting, Hanoi, nov 2015
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Introduction
• Ischemic: 80% of stroke
• 3rd leading cause of dead in United States
• 2025: prediction of 1.2 millions patients/year • In Viet Nam, stroke is top cause of Death (account
for 18% - 2008)
• Cardiovascular disease, diabetes… 2
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Diagnostic Tools
• Multi choices in diagnosis
• CT Scanner -> MRI • Perfusion -> Multiphase
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CT SCANNER
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• “Emergency imaging of the brain is recommended before any specific treatment for AIS. Non-enhanced CT will provide the necessary information for initial treatment of IV r-tPA (Class I; level of Evidence A - same as 2013)*”
*AHA/ASA-stroke guide line 2015 5
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CT Non-contrast 6
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• Rule out the hemorrhage • Identify ischemic lesion
• Tips: • Change the window level
– C: 8 – W: 32
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ASPECTS
• ≥ 6: favorable clinical outcome* *Stroke, 2008. 39(8): p. 2388-2391 9
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CT Angiography (MSCT)
• “A non-invasive intracranial vascular study is strongly recommended. If not possible at the time of initial imaging, r-tPA should done first then try vascular imaging as quickly as possible (Class I, level A - New)”
*AHA/ASA-stroke guide line 2015 10
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CT Angiography
MIP (Single phase) VRT 11
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CT Perfusion • “The benefit of CT perfusion, DWI/perfusion-weighted
imaging for selecting patients (ASPECTS<6…) for endovascular therapy are unknown (Class IIb; level C - New). Further randomized, controlled trials should be done*”
*AHA/ASA-stroke guide line 2015
Lesions = Core (irreversible )+ penumbra (reversible)
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CT Perfusion
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MRI
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MRI protocol
• T2*: rule out hemorrhage + identify cerebral microbleeding
• DWI: core of infarction • FLAIR: parenchymal lesion/ absence of “flow voids” in
the occluded artery
• TOF 3D: arterial occlusion site
• PW: if possible
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- Rule out hemorrhage
- Identify cerebral microbleeding
-> risk factor of bleeding after treatment
T2*
Kidwell Stroke 2002; Nighoghossian Stroke 2002; Derex Cerebrovasc Dis 2004 16
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Identify occlusion site
T2*
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MRI TOF 3D
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• ≥ 6: favorable clinical outcome*
L
ASPECTS
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• ≥ 8: favorable clinical outcome*
Pc-ASPECTS
*Stroke, 2008. 39(9): p. 2485-90 21
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Acute stage < 6h 22
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Acute stage (6-24h) 23
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Early sub-acute stage: 48hrs - 3 weeks 24
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Late sub-acute stage 25
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Chronic stage 26
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MTT: mean transit time, CBF: Cerebral Blood Flow
TTP: Time to peak, CBV: Cerebral blood volume
MTT
CBV CBF
TTP
DWI PERFUSION - MECHANISM
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MRI Perfusion
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Match PW/DW -> no penumbra -> no indication of treatment
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Mismatch PW/DW
-> good indication for treatment
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Case Before
DWI DWI PWI PWI
After
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CT Scanner
– Low sensitivity; PW only for anterior
circulation (64 slices)
– 2 times of contrast (Angio & PW)
– Can not discover micro bleeding
– Quick
– Patient unstable -> fast scan
– Widespread access
– In case of contraindication with MRI
(Stent, pacemaker…)
MRI
• Very high Sv & Sp; PW for
whole brain
• Only 1 time of contrast (PW)
• Identify micro bleeding
• A little slower but acceptable
• Patient need to be very stable
• Mostly in big hospital
• No radiation
Comparison
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Role of DWI&PW image
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AJNR, 2002
• High sensitivity and specificity for detecting AIS • DWI and CBV best predict final volume
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• DWI = irreversible lesion = core of infarction • Bigger core, worse outcome
• In the MCA occlusion, core volume in DWI > 100cm3 -> no indication of treatment (>1/3 territory of MCA) • >70cm3: poor prognosis even rapid recanalization*
• <70cm3: good outcome (64%) after quick recanalization • Other studies**:
– V <16cm3: good outcome
– V >36cm3: bad result
DWI
(*) Stroke,2009.40:p.2046-2054 (**)Stroke,2011.42(5):p.1251-4.
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• Sn of PW ~[74-84%], Sp of PW ~[96-100%] • Mismatch DW/PW = penumbra area
• (PW – DW)/ DW x 100% > 20% -> significant difference*
DWI/PW
(*) EPITHETstudy-Stroke,2009.40:p.2046-2054
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• N = 132 • Volume of core in DWI: 43 ± 69,9cm3
p=0.00139 p=0.00028 (Fisher exact test)
In our research*
(*) NguyenDuyTrinh,PhamMinhThong2014
Time (min) <180
(n=76)
180-360
(n=29)
>360
(n=18)
V (cm3)
34,7 ± 54,1 55,2 ± 57,6 86,9 ± 114
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Volume
V<30cm3 V>30cm3 N
mRS ≤ 2 69 4 73
mRS > 2 21 37 58
Correlation between Volume of infarction and clinical recovery
• V<30cm3: good prognosis
p < 0.05
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Volume Before treatment
(cm3) After treatment
(cm3)
P
Quick
recanalization(n=47) 42,3 ±54 47,4 ±54,9 0,912
Late/failed
recanalization (n=26) 39,1± 49,8 91,8±81,8 0,01559
Follow up after treatment
• Good recanalization -> no change in infarction volume -> save penumbra tissue
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Case 1a • Male patient, 53 years old • Normal history • Suddenly right hemiplegia • Administered to hospital within 2nd hours • NIHSS = 16 • Left ICA occlusion, ASPECTS~8
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TICI = 3
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mRS = 1
Before
After
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Case 1b - Woman 75yo, 1st hour - M1 occlusion, large penumbra - Good recanalization - mRS~1pt after 3 months
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Problem
• Some patients having less penumbra -> good outcome
• In contrast, others who have good penumbra -> poor outcome
-> Other factors affect the clinical recovery (collateral?) -> Need a new method to evaluate salvageable brain quickly, reliably and widely available
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New update
• CT Angiography Multiphase is a good choice • Simple procedure
• Just published in 2015
• Data from PRoveIT (Menon et al) • N = 147, comparison between CT Multiphase, single
phase and CT Perfusion
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Protocol • Non contrast first then multiphase
• Phase 1: • Evaluate the carotid and brain circulation • Double scan with contrast, then subtraction algorithm
• Phase 2: • Just only the brain • Time for moving table+scan • Total 8sec
• Phase 3 • Similar to phase 2
Menon et al., (2015). Neuroradiology, 000 (0). 47
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Evaluation
Menon et al., (2015). Neuroradiology, 000 (0). 48
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Evaluation
Menon et al., (2015). Neuroradiology, 000 (0). 49
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Evaluation scale Điểm Đánh gia (khi so sánh với bán cầu bên bệnh với bên lành)
0 Không quan sát thất bất ky nhánh mạch máu nào đi vào vùng nhồi máu tại bất ky phase nào
1 Có một vài nhánh mạch máu nho đi vào vùng nhồi máu tại bất ky phase nào
2 Chậm 2 phase hiện hình mạch máu vùng ngoại vi VÀ giảm đậm đô-tốc đô ngấm thuốc, HOẶC chậm 1 phase nhưng có vùng không có mạch máu
3 Chậm 2 phase hiện hình mạch máu vùng ngoại vi, HOẶC chậm 1 phase nhưng sô lượng mạch máu trong vùng nhồi máu giảm
4 Chậm 1 phase hiện hình mạch máu vùng ngoại vi, nhưng đậm đô va tốc đô ngấm thuốc thi tương tư
5 Không có chậm phase, quan sát thấy ngay các nhánh mạch máu bàng hê đi vào bình thường hoặc nhiều hơn trong vùng nhồi máu
• 0-3: nghèo bàng hệ (poor), 4: vừa (moderate), 5: tốt (good) 50
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Advantages
• Quick and save the time, only 10-20 sec more after the MSCT Single phase
• 1 time inject contrast material >< twice in MSCT perfusion
• Widely available and easy to perform (no complicated mathematical algorithm post process - only MIP reconstruction in 3 phases compared to perfusion reconstruction)
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Case 3 • Male, 78 yo • Diabetes • Administered in 2nd hours • Left hemiplegia • NIHSS = 15 • Perfusion: match
ischemic ~ CBV -> not favorable penumbra area -> no indication
• BUT Multiphase score = 4 -> moderate collateral
• Good recanalization after endovascular therapy -> good result after (mRS ~ 2)
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• Menon et al., (2015). Neuroradiology, 000 (0).
Multi >< Single Phase
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Recommendation
• CT Multiphase score ≥ 4 -> good collateral
• CT Multiphase score ≤ 3 -> poor collateral
• New method, useful in ESCAPE but need more trials to proved its value
• Now applied in Bach Mai hospital protocol
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ESCAPE
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Design and results
• Methods – IV >< IV + MT in the first 4.5 hours – 238/316 received rt-PA with 118 control >< 120 intervention – Treatment up to 12 hours with anterior circulation occlusion – NO large infarct core (ASPECTs < 6), NO poor collateral (<50%
filling pial artery of the MCA in the CT Multiphase)
• Results – Stop early because of the efficacy – Times from CT non contrast to groin puncture: 60mins/ to first
reperfusion: < 90 mins – mRS 0-2: 29.3% >< 53% -> Thrombectomy is better – Mortality: 19% >< 10.4% – Symptomatic hemorrhage: 2.7% >< 3.6%
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Bach Mai hospital protocol
• Noncontrast: 3.71 sec • Phase 1:
• Scantime 6.2s • Delay (contrast injection) 14 sec • Scantime 6.2 sec
• Phase 2: • Total time 5 + 3.71 sec
• Phase 3: • Total time 5 + 3.71 sec
-> Only 17 sec more 57
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• Left M1 occlusion (19h00’ ASPECTS ~ 8 point)
Case 2a • Male, 75 years old, history of cardiac coronary disease • Stroke during hospitalizing time (17h30’) due to chest pain • Right hemiplegia, unconscious, G~13pt, NIHSS = 19
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PHASE 1 PHASE 2 PHASE 3
• Multiphase score ~ 4 point (good collateral)
Multiphase
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TTP(Time to Peak)
CBF(Cerebral Blood Flow)
CBV(Cerebral Blood Volume)
• Mismatch > 35%
Perfusion
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DSA (19h50’ – 20h10’)
• Solitaire 6/20: 1 times • TICI 3 62
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Follow up
• G ~ 15pt • NIHSS ~ 6pt • mRS ~ 2 after 2 days
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Case 2b • Female, 57 years old; Atrial fibrillation, still using anticoagulant • Administered to BM hospital in 2nd hours (13h15’->14h30’) • Left hemiplegia, NIHSS = 18
• Right ICA occlusion (14h45’ ASPECTS ~ 6 point) 64
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PHASE 1 PHASE 2 PHASE 3
Multiphase
• Multiphase score ~ 2 point (poor collateral) 65
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DSA (15h15’ – 15h57’)
• Solitaire 6/30: 4 times • TICI 3
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MRI follow up
• G 15pt • NIHSS ~ 9pt • mRS ~ 4 after 2 wks
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Conclusion • CT Scanner noncontrast and MSCT is very important
and always/strongly recommended in AIS (in new guideline 2015) before any treatment – easy and accessible in all hospital
• CT Multiphase: new choice, simple and beneficial than Perfusion and single phase
• MRI only in big hospital, very useful especially in unknown time stroke patients
• DWI/PW: good information but need more trial to prove its evidence and cut-off volume in prognosis
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THANK YOU FOR YOUR ATTENTION!