CT Perfusion is Essential for Stroke Triage. Maarten Lansberg, MD PhD Associate Professor of Neurology Stanford University, Stanford Stroke Center

Transcription

1 CT Perfusion is Essential for Stroke Triage Maarten Lansberg, MD PhD Associate Professor of Neurology Stanford University, Stanford Stroke Center

2 CT Perfusion is Essential for Stroke Triage Disclosures: None

3 Responding with Poll Everywhere 1.Click icon to write a new text Type To: Type in text: MAARTENLANSB295 T MAARTENLANSB Click send Text voting

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5 1. Speedy, simple and safe The Five Benefits of CTP

6 Speedy and Simple

7 Contrast = Safe

8 Radiation = Safe Hair loss with repeated scans and incorrect CT settings Brain tumors are very rare In children avoid CT

9 The Five Benefits of CTP 1. Speedy, simple and safe 2. Extends the time-window for EVT

10 Can We Select Late Window Patients with NCCT? MR CLEAN hours Fransen P, for the MR CLEAN Investigators. JAMA Neurol. 2015

11 Can We Select Late Window Patients with NCCT? HERMES collaborators. JAMA 2016

12 Baseline DWI Volume (ml) 230 Stroke Growth Rate is Highly Variable Time between Symptom Onset and Baseline MRI (hrs)

13 Baseline DWI Volume (ml) Stroke Growth Rate is Highly Variable Time between Symptom Onset and Baseline MRI (hrs)

14 P T # Need to Identify Salvageable Tissue CTP MRI DWI (ADC < 620) volume: 10 ml Perfusion (Tmax>6s) volume: 76 ml

15 Effect of Time on Achieving Functional Outcome After Endovascular Reperfusion MR CLEAN DEFUSE 2 & CRISP Target Mismatch profile MR CLEAN Investigators, JAMA Neurol DEFUSE 2 Investigators. Neurology CRISP Investigators, Annals of Neurology. 2017

16 DAWN CTP/DWI Inclusion Criteria A. 80 y/o: NIHSS 10 + core <21cc B. <80 y/o: NIHSS 10 + core <31cc NIHSS 20 + core <51cc

17 Primary outcome: modified Rankin Scale Favorable outcomes Unfavorable outcomes Endovascular Therapy 9% 22% 17% 13% 13% 26% Probability of superiority > Control 4% 5% 4% 16% 34% 36% 35% absolute increase in functional outcomes Number needed to treat for any lower disability = 2 Jovin. NEJM 2018

18 Key Neuroimaging Inclusion Criteria ICA or MCA-M1 occlusion + Target Mismatch Profile (core <70 ml)

19 Results: Primary Outcome Absolute benefit mrs 0-2: 45% vs. 17% P< Number needed to treat: 2

20 Probability mrs 0-2 Common Odds Ratio Results: Time to Randomization Time from onset to randomization (hrs) Time from onset to randomization (hrs)

21 Late-Window AHA Recommendations

22 The Five Benefits of CTP 1. Speedy, simple and safe 2. Extends the time-window for EVT 3. Never miss a good cath case because of low ASPECTS

23 Case History 63 year-old man previously living independent developed acute onset speech impairment and right hemiparesis. Arrives to hospital 2.5 hours after symptom onset with NIHSS of 15. Received tpa at 3 hours CTA shows a proximal left MCA vessel occlusion.

24 2018 AHA Guidelines for Early Window EVT

25 Automated ASPECTS = 5

26 Manual ASPECTS = 3

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28 ASPECTS = 3 Favorable CTP

29 Target Mismatch Early Window Endovascular Therapy Patients who benefit Patients who do not benefit Guidelines: ASPECTS <6 All Early Window Patients ASPECTS 6 ASPECTS <6 No Benefit Benefit No Benefit With a Large Vessel Occlusion

30 The Five Benefits of CTP 1. Speedy, simple and safe 2. Extends the time-window for EVT 3. Never miss a good cath case because of low ASPECTS 4. Stroke diagnosis when history and NCCT inconclusive

31 Case History 78 year-old man with a history of hypertension presents to the ER two hours after the onset of speech difficulty. On exam patient follows some simple non-verbal commands but cannot follow three-step comments. He is unable to repeat and name objects. He is unable to provide a history. He says yeah repeatedly to all questions. Motor and sensory testing appear intact. NIHSS score is 4. NCCT is normal and CTA shows no proximal vessel occlusion.

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33 Normal CTP

34 Case History 52 year-old woman with a history of migraine presents to the ER 90 minutes after the onset of mild expressive aphasia and mild right arm weakness. NIHSS score is 2. NCCT is normal and CTA shows no proximal vessel occlusion.

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37 The Five Benefits of CTP 1. Speedy, simple and safe 2. Extends the time-window for EVT 3. Never miss a good cath case because of low ASPECTS 4. Stroke diagnosis when history and NCCT inconclusive 5. Exclude patients from EVT who will not benefit

38 58 yo woman, Wake-up stroke*, NIHSS 13, ASPECTS 8, R MCA occlusion * Possible last know well at 7:15 am

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40 58 yo woman, Wake-up stroke*, NIHSS 13, ASPECTS 8, R MCA occlusion CBV CBF

41 Following TICI 3 Reperfusion 3 hours post-procedure: NIHSS=14 10 hours post-procedure: NIHSS=32

42 The Five Benefits of CTP S peedy, simple and safe E xtends the time-window for EVT N ever miss a good cath case because of low ASPECTS S troke diagnosis when history and NCCT inconclusive E xclude patients from EVT who will not benefit

43 Stanford Stroke Center