NEURO IMAGING OF ACUTE STROKE
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1 1 1 NEURO IMAGING OF ACUTE STROKE ALICIA RICHARDSON, MSN, RN, ACCNS-AG, ANVP-BC WENDY SMITH, MA, RN, MBA, SCRN, FAHA LYNN HUNDLEY, APRN, CNRN, CCNS, ANVP-BC 2 2 1
2 DISCLOSURES Alicia Richardson: Stryker Neurovascular Consultant Wendy Smith: None Lynn Hundley: Medtronic: Speaker Bureau, modest; Arbor Pharmaceuticals: Speaker Bureau, modest 3 3 NCCT Bone Acute Blood Enhanced tumor Subacute Blood Muscle Grey Matter White Matter CSF Air, Fat Very White Very White Very White Light Grey Light Grey Light Grey Medium Grey Medium Grey to Black Very Black 4 4 2
3 5 5 WHAT DO THESE WORDS MEAN? Diffuse Mass effect Sulcal Effacement Cytotoxic Midline shift It s everywhere Stuff is pressing on stuff Now you can t see the difference between the sulci & gyri Swelling of white and grey matter Stuff is pressing really hard, into the other hemisphere hard 6 6 3
4 WHAT DO THESE WORDS MEAN? Encephalomalacia Hypointense Hypodense Isointense Hyperintense Hyperdense Loss of brain tissue, dark area Dark Dark area Neutral or same as other tissues Bright Bright area 7 7 Medulla 8 8 4
5 Medulla Cerebellum Cerebellum 9 9 Medulla Cerebellum Cerebellum
6 Eye Eye Pre-pontine cistern Left vertebral artery Medulla Air Vermis Eye Eye Temporal Lobe Temporal Lobe Pons Fourth Ventricle
7 Temporal Lobe Sella Temporal Lobe Pons Fourth Ventricle Temporal Lobe Temporal Lobe Pons Petrous Bone Fourth Ventricle Cerebellum
8 Basilar Artery Temporal Horn Temporal Bone Temporal Horn Fourth Ventricle Sylvian Fissure Sylvian Fissure Midbrain Aqueduct of Sylvius
9 Sylvian Fissure Sylvian Fissure Third Ventricle Frontal Horn of Lateral Ventricle Frontal Horn of Lateral Ventricle Lentiform Nucleus Third Ventricle Lentiform Nucleus Lateral Ventricle
10 Caudate Nucleus Lentiform Nucleus Caudate Nucleus Lentiform Nucleus Pineal Gland Occipital Lobe Frontal Lobe Frontal Horn of Lateral Ventricle Caudate Nucleus Internal Capsule Lentiform Nucleus Right Thalamus Frontal Horn of Lateral Ventricle Caudate Nucleus Internal Capsule Lentiform Nucleus Left Thalamus Choroid Plexus Choroid Plexus Occipital Lobe
11 Lateral Ventricle Lateral Ventricle Lateral Ventricle Lateral Ventricle Falx Lateral Ventricle Lateral Ventricle Corona Radiata Corona Radiata Falx
12 Falx
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14 27 27 Falx
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18 NCCT CHECKLIST 1. EVIDENCE OF HEMORRHAGE? a)ventricular b)subdural c) Subarachnoid d)epidural Is it intra-axial? a) Follow the distribution of an arterial branch? b) Align itself with the anatomical location of the perforating arteries? NCCT CHECKLIST 2. IS THERE FRANK HYPODENSITY? 3. IS THERE MASS EFFECT WITH A SHIFT CROSS MIDLINE? 4. EARLY INFARCT SIGNS? A) SULCALEFFACEMENT B) BLURRING OF THE GRAY- WHITE INTERFACE C) HYPERDENSEARTERY 5. DIFFUSE BRAIN EDEMA? A)OVERALL FLATTENING OF SULCI B) SMALL CISTERNAL SPACES C) SMALL VENTRICLES 36 D) DIFFUSE LOSS OF GRAY-WHITE DIFFERENTIATION 36 18
19 NCCT CHECKLIST 6. IS THERE HYDROCEPHALUS? a)opening of the temporal horns b)localized enlargement of the lateral ventricles suggesting non-communicating hydrocephalus 7. IS THERE EVIDENCE OF CALCIFICATION AND IS IT IN AREAS THAT DO BECOME CALCIFIED? 8. DO YOUR CT FINDINGS MATCH THE CLINICAL PICTURE?! JEWEL PATHOLOGY
20 ISCHEMIC CHANGES ON CT HYPERDENSE MCA SIGN
21 Cortical penetrating branches of ACA, MCA, or PCA (~20-30%) Basal Ganglia- lenticulostriate perforators (~40-50%) Thalamus- thalmogeniculate perforators (~20-30%) Pons- pontine perforators (~8%) 41 Cerebellum- AICA, PICA, or SCA penetrating branches (~8%) 41 CT ANGIOGRAPHY CTA VESSEL IMAGING Occlusions Stenosis Aneurysms SHOULD PERFORM HEAD AND NECK Carotid/vertebral arteries Dissection Road map for intervention
22 CT PERFUSION CTP CEREBRAL BLOOD FLOW/VOLUME Helps with timing- Unknown onset, late window Infarct vs penumbra to show at risk tissue MRI T1 AND T2 T1 T2 T2 Flair Bone Very Black Very Black Very Black Air Very Black Very Black VeryBlack Muscle Dark Grey Dark Grey Dark Grey Grey Matter Grey White White White Matter White Grey Grey Fat White Grey CSF Very Black Very White Very Black Acute Ischemia Dark Grey Light Grey to White Good for Anatomical Definition Good for Identifying Edema Best for Identifying Edema
23 STROKE MRI SEQUENCES GRE SWI ADC DWI Flair Highly sensitive to blood Blood-Black CSF- White Must be done with ADC/DWI otherwise hemorrhage can be missed Also highly sensitive to blood Blood- Black CSF-Grey Ischemic tissue- Dark grey/black CSF-White Normalizes by 5-10 days, good for lesion age Highly sensitive to infarcted tissue Ischemic tissue-white CSF-Dark grey/black May be positive in up to 50% of TIA patients with full symptom resolution Can be used to select tpa candidates outside window Benefit- Suppresses CSF signal to enhance older infarcts Bright white= old 46 23
24 MR Imaging in Acute Stroke DWI I N T E N S I T Y 6-24 hrs 30 min T2/FLAIR 2 days ADC T1 + Gad 4 days 7-10 days 2 weeks DWI: Bright at 30 min 7-10 days, isointense thereafter ADC: Dark at 30 min with maximum at 4 days, isointense at 7-10 days and bright thereafter T2/FLAIR: Bright at 6 hours and thereafter 2 months 47 T1+Gad: Enhancement begins at 2 days, peak enhancement at 2 weeks and no enhancement after 2 months 2010 David Ermak, DO
25 THANK YOU! ALICIA RICHARDSON: WENDY SMITH: LYNN HUNDLEY:
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