imaging modalities in acute stroke: time is...
TRANSCRIPT
Jeremiah ScharfGillian Lieberman, MD
Imaging Modalities in Acute Stroke:
Jeremiah Scharf, Harvard Medical School, MS IVGillian Lieberman, MD
Beth Israel-Deaconess Medical CenterDepartment of Radiology
April 2001
Time is Brain
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Jeremiah ScharfGillian Lieberman, MD
Stroke - Definition and StatisticsAcute, vascular injury to CNS
<24 hrs = TIA>24 hrs = stroke (CVA)
Affects 600,000 people/ yr(that is 1 stroke per minute!)
Is #3 cause of mortality in adultsIs #1 cause of disabilityhttp://www.swmed.edu/stars/resources/stroke.html
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Types of Stroke
Hemorrhagic (20%)usually hypertensive hemorrhage
Ischemic (80%)Thrombotic (40%)
intracerebral atherosclerosis
Embolic (60%)Cardiac embolus (thrombus, tumor, septic embolus)artery-to-artery (mainly carotid thrombus)Paradoxical embolus (thrombus, fat, air)
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Jeremiah ScharfGillian Lieberman, MD
Risk Factors for Stroke
Atherosclerosis risk factorsFamily history of CVA, TIA, or MIHypertensionSmokingDiabetesHypercholesterolemia
Previous CVA, TIA, or MIAtrial fibrillation
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Our Patient - BF
86 yo F w/ Hx of HTN, CAD s/p MI,and high cholesterol
presented to PCP for routine visitFelt “funny” -> began seizingIn ED, unresponsive, L. sided hemiplegia
eyes deviated to the right
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Jeremiah ScharfGillian Lieberman, MD
Differential Diagnosis
Many CNS diseases can mimic ischemic stroke
HemorrhageMass lesion (tumor, abscess, AVM)Seizure (Todd’s paralysis)Hemiplegic migraineMS flareVenous infarct
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Goals of Imaging in Acute Stroke
1. Rule in or out other disease processes2. Define location, extent and age of infarct3. Do so as rapidly as possible
TIME IS BRAIN
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Cerebrovascular Anatomy
MGH Handbook of Neurology
PosteriorCirculation
AnteriorCirculation
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Anatomy of the Anterior Circulation
High Yield Neuroscience
Internal carotid artery
Anterior cerebral artery
Middle cerebral artery
Middle cerebral artery
Internal carotid artery
Anterior cerebral artery
MGH Handbook of Neurology
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Vascular territories in the brain
MGH Handbook of Neurology
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Imaging Modalities in Acute Stroke
CT without contrastConventional MRIDiffusion-Weighted and Perfusion MRIMRAUltrasound
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CT Imaging in Acute Stroke - 1Initial test of choiceBest modality for detecting hemorrhageIdentifies mass lesions
(tumor, abscess, AVM)Fast and readily available
= Crucial for stroke triage
BIDMCPatient #2 - LL
(rule in/out other diseases)
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CT Imaging in Acute Stroke - 2
BIDMC
HOWEVER,CT is poor at detecting acute
infarcts Only 40% sensitivity <24 h
Film Findings for our patient, BF:Normal Initial Head CT
Patient #1 – BF; 1-2 hrs post stroke
2 hours post stroke
Our Patient
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Jeremiah ScharfGillian Lieberman, MD
Our patient BF: CT#2 – 8 hours laterAs time passes, classic signs of stroke appear:
Patient #1 – BF; 8 hrs post strokeBIDMC
Loss of gray-white matterdifferentiation
Sulcal effacementNormal
sulci
Normal G/W diff.
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Jeremiah ScharfGillian Lieberman, MD
Our patient BF CT#3 - 2 days later
Patient #1 – BF; 48 hrs post strokeBIDMC
Complete loss ofgray-white matter
differentiation
Sulcal effacement
? hemorrhagictransformation
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Therefore, other imaging modalities are used to detect
strokes < 6 hours!
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CT without contrastConventional MRIDiffusion-Weighted and Perfusion MRIMRAUltrasound
Imaging Modalities in Acute Stroke
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Jeremiah ScharfGillian Lieberman, MD
Conventional MR Imaging in StrokeSlight incr. detection rate over CT in early stroke
T2 hyperintensity visibleat 12-24 hrs (80% +)
represents edema
May see absent flow voids = arterial occlusion
T1 imaging basics T2 imaging basicsBIDMC BIDMC
CSF is darkSoft tissue is bright
Good for mass lesions
CSF is brightSoft tissue is dark
Good for edema (bright)
T1 T2Our Patient
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Jeremiah ScharfGillian Lieberman, MD
Conventional MR Imaging in Stroke
Our patient, BF, underwent an MRI study immediately following her initial CT, 2 hours after her stroke
T2 imageBIDMC
Patient BF; 2 hrs post stroke
Normal Initial MRI:? Absent R. MCA Flow Void
(suggestive of MCA occlusion)
Film Findings:
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Jeremiah ScharfGillian Lieberman, MD
Our patient BF - MRI #2 :30 hours later
BIDMC
At 30 hrs., classic MR signs of infarct are present
Patient BF; 30 hrs post stroke
T2 hyperintensity in temporal lobe,MCA distribution
Film Findings:
T2 image
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Conclusions - Conventional MR Imaging in Acute Stroke
Conventional MRI can detect acute infarcts slightly earlier than CT
Nonetheless, additional techniques are still needed for early stroke detection
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Jeremiah ScharfGillian Lieberman, MD
Imaging Modalities in Acute Stroke
CT without contrastConventional MRIDiffusion-Weighted and Perfusion MRIMRAUltrasound
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Jeremiah ScharfGillian Lieberman, MD
Diffusion Weighted MRI Imaging (DWI)
Osmotic pump failure is 1st event in ischemia
Fluid shift extracellular->intracellularWater in cells now can’t diffuse!
Detected as decreased diffusion coefficient (ADC)
Increased restriction of diffusion (DWI)
Detects change within 30 minutesof onset of stroke
Beats T2 signal by 3-6 hours !!!Schaefer et al. Radiology 217:331-345, 2000
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Our Patient had a DWI MRI immediately following the initial routine MRI
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Jeremiah ScharfGillian Lieberman, MD
In our patient, DWI sequences were performed during her initial MRI
A faint increase in DWI signal was observed in the temporal and insular cortex.Indicated early ischemia in
MCA territory
Led to treatment with IV thrombolytic therapy (t-PA)
BIDMC
Patient BF; 2 hrs post stroke
DWI in BF at 2 hours post-stroke
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That’s good, but could we predict how bad her stroke might get?
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Jeremiah ScharfGillian Lieberman, MD
Imaging the Penumbra: the Holy Grail of Stroke Diagnostics
DWI is thought to show the area currently infarcting.
But is there an “area at risk”where blood flow is reducedbut cells haven’t died yet?
Imaging this region (the penumbra)= goal of MR perfusion imaging
Uses gadolinium for contrastChanges magnetic properties of perfused tissue vs. non-perfusedMeasures decreased flow in penumbra!
-increased mean-transit-time(MTT) of blood flow to penumbra
http://www.swmed.edu/stars/resources/stroke.html
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Correlation of Perfusion Imaging with Infarct Progression
Baird AE and Warach S. J. Cereb. Blood Flow Metab. 18(6): 583-609, 1998.
= area of low/ slow blood flow
= area at risk forstroke extension
DWI
Late (29h):=larger area
of injury (correlates w/
2h MTT)
MTTEarly (2h):=small area
of injury
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Jeremiah ScharfGillian Lieberman, MD
Progression of Infarct in BF: DWI at 30 hrs post-stroke
BIDMC
serial,axial sections
demonstratingextent of infarct
at 30 hours
normal DWInormal brain
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DWI in 3D - 2
BIDMC
normal DWInormal brain
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DWI in 3D - 3
BIDMC
increased DWIinjured brain
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DWI in 3D - 4
BIDMC
increased DWIinjured brain
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DWI in 3D - 5
BIDMC
increased DWIinjured brain
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Jeremiah ScharfGillian Lieberman, MD
DWI in 3D - 6
BIDMC
increased DWIinjured brain
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Jeremiah ScharfGillian Lieberman, MD
DWI in 3D - 7
BIDMC
increased DWIinjured brain
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Jeremiah ScharfGillian Lieberman, MD
DWI in 3D - 8
BIDMC
increased DWIinjured brain
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Jeremiah ScharfGillian Lieberman, MD
DWI in 3D - 9
BIDMC
increased DWIinjured brain
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Jeremiah ScharfGillian Lieberman, MD
DWI in 3D - 10
BIDMC
increased DWIinjured brain
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Jeremiah ScharfGillian Lieberman, MD
DWI in 3D - 11
BIDMC
increased DWIinjured brain
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Jeremiah ScharfGillian Lieberman, MD
DWI in 3D - 12
BIDMC
increased DWIinjured brain
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Jeremiah ScharfGillian Lieberman, MD
DWI in 3D - 13
BIDMC
increased DWIinjured brain
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Jeremiah ScharfGillian Lieberman, MD
Summary – Extent of infarct
BIDMCMGH Handbook of Neurology
our patient
R. PCAterritory
(complete)
R. MCAterritory
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Jeremiah ScharfGillian Lieberman, MD
Imaging Modalities in Acute Stroke
CT without contrastConventional MRIDiffusion-Weighted and Perfusion MRIMRAUltrasound
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Jeremiah ScharfGillian Lieberman, MD
MRA/Angiography of occluded MCA
Bahn et al. JMRI 6:833-845, 1996
BIDMC
BIDMC
Patient BF; R. MCA occlusion
Patient BF; R. MCA occlusion
L. MCA occlusion -literature
our patient – R. MCA
our patient – R. MCA
companion patient –L. MCA
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Jeremiah ScharfGillian Lieberman, MD
Imaging Modalities in Acute Stroke
CT without contrastConventional MRIDiffusion-Weighted and Perfusion MRIMRAUltrasound
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Jeremiah ScharfGillian Lieberman, MD
Ultrasound in Stroke
Has a primary role in working up cause of strokeEchocardiography
TEE for LA/LV thrombusBubble echo study for PFO (paradoxical embolus)
Carotid UltrasoundEvaluates patency of carotids and degree of stenosis
Transcranial Doppler UltrasoundEvaluates patency of intracranial arteries (MCA)
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Jeremiah ScharfGillian Lieberman, MD
Summary I – Patient Course
BF was given t-PA within 3 hours of onset30% increase in recovery over controls
(31% t-PA vs. 20% placebo = minimal/ no disability @ 3 mos.)6-fold increased risk of bleeding (6% vs. 1%?)
Symptoms of stroke did not improve considerablyIntubated in ICU for 1 weekTransferred to floor with residual weaknessDischarged to rehabilitation facility after 10 days
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Jeremiah ScharfGillian Lieberman, MD
Summary II – Timing of stroke detection in our patient
CT without contrast
Conventional MRI
DWI MRI
MRA
Imaging Modality Time of post-stroke imaging2h 8h 30h
- + +
ND +
ND ++
+
-
ND+
+ = evidence of acute stroke; - = no evidence of acute stroke; ND = not determined
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Jeremiah ScharfGillian Lieberman, MD
Summary III – Imaging in Stroke
Acute Stroke (<6 hours)CT (without contrast!!)
Excellent for ruling out hemorrhage, other diseasesPoor in defining early infarcts
Conventional MRI (T1,T2)Bad for hemorrhage, fair for early infarcts
Diffusion-Weighted and Perfusion MRIExcellent for defining early infarcts (1-2 hrs)
and for estimating areas at risk
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Jeremiah ScharfGillian Lieberman, MD
Summary IV - Imaging in Stroke
Sub-acute Stroke (>6 hours)CT (without contrast)
Excellent in defining late infarcts (>24 h)sulcal effacement, loss of gray-white differentiation
Conventional MRI (T1,T2)Better than CT at 6-24h; Same as CT in infarcts > 24h
T2 hyperintensity is most indicative of injury
UltrasoundCritical for workup of origin of stroke (TEE, TCD,
Carotid Doppler)
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Jeremiah ScharfGillian Lieberman, MD
Summary V - Imaging in Stroke
In the near future, there will hopefully be effective treatments for acute stroke.
Patients will need to come to the ER at first sign of “brain attack”.
Patients will need to be imaged by multiple modalities rapidly.
Remember ...
TIME IS BRAIN
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Jeremiah ScharfGillian Lieberman, MD
ReferencesAHA Website: http://www.americanheart.org/statistics/stroke.htmlBahn MM, Oser AB, Cross DT. CT and MRI of Stroke. JMRI 6:833-845, 1996.Baird AE and Warach S. Magnetic Resonance Imaging in Acute Stroke. J. Cereb. Blood Flow Metab.
18(6): 583-609, 1998.Beauchamp NJ, Barker PB, Yang PY, vanZijl PCM. Imaging of Acute Cerebral Ischemia. Radiology
212:307-324, 1999.Culebras A et al. AHA Scientific Statement: Practice Guidelines for the Use of Imaging in Transient
Ischemic Attacks and Acute Stroke. Stroke. 28:1480-1497, 1997.Flaherty AW. MGH Handbook of Neurology. Lippincott Williams and Wilkins 2000.Fix J. High-Yield Anatomy. Lippincott Williams & Wilkins. Philadelphia. 2000.Lev MH, Farkas J, Gemmete JJ, Hossain ST, Hunter GJ, Kroshetz WJ, Gonzalez RG. Acute Stroke:
Improved Nonenhanced CT Detection – Benefits of Soft-Copy Interpretation by Using Variable Window Width and Center Level Settings. Radiology 213: 150-155, 1999.
Petrella JR and Provenzale JM. MR Perfusion Imaging of the Brain. AJR 175:207-219, 2000.Schaefer PW, Grant PE, Gonzalez RG. Diffusion Weighted MR Imaging of the Brain. Radiology
217:331-345, 2000Simon RP, Aminoff MJ, Greenberg DA. Clinical Neurology. Appleton & Lange: Connecticut, 1999.UT Southwestern STARS Website: http://www.swmed.edu/stars/resources/stroke.html
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Acknowledgments
Andru Bageac and Daniel Saurborn- for help with case identification
Beverlee Turner-for help with Power point and PACS
Gillian Lieberman-for her enthusiasm in teaching medical students
My classmates-for enduring this talk