CT Perfusion is Essential for Stroke Triage Maarten Lansberg, MD PhD Associate Professor of Neurology Stanford University, Stanford Stroke Center
CT Perfusion is Essential for Stroke Triage Disclosures: None
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1. Speedy, simple and safe The Five Benefits of CTP
Speedy and Simple
Contrast = Safe
Radiation = Safe Hair loss with repeated scans and incorrect CT settings Brain tumors are very rare In children avoid CT
The Five Benefits of CTP 1. Speedy, simple and safe 2. Extends the time-window for EVT
Can We Select Late Window Patients with NCCT? MR CLEAN 15 16 hours Fransen P, for the MR CLEAN Investigators. JAMA Neurol. 2015
Can We Select Late Window Patients with NCCT? HERMES collaborators. JAMA 2016
Baseline DWI Volume (ml) 230 Stroke Growth Rate is Highly Variable 180 130 80 30-20 0 2 4 6 8 10 12 Time between Symptom Onset and Baseline MRI (hrs)
Baseline DWI Volume (ml) Stroke Growth Rate is Highly Variable 230 180 130 80 30-20 0 2 4 6 8 10 12 Time between Symptom Onset and Baseline MRI (hrs)
P T # Need to Identify Salvageable Tissue CTP MRI DWI (ADC < 620) volume: 10 ml Perfusion (Tmax>6s) volume: 76 ml
Effect of Time on Achieving Functional Outcome After Endovascular Reperfusion MR CLEAN DEFUSE 2 & CRISP Target Mismatch profile MR CLEAN Investigators, JAMA Neurol. 2015 DEFUSE 2 Investigators. Neurology. 2015 CRISP Investigators, Annals of Neurology. 2017
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
Primary outcome: modified Rankin Scale Favorable outcomes Unfavorable outcomes Endovascular Therapy 9% 22% 17% 13% 13% 26% Probability of superiority >0.9999 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
Key Neuroimaging Inclusion Criteria ICA or MCA-M1 occlusion + Target Mismatch Profile (core <70 ml)
Results: Primary Outcome Absolute benefit mrs 0-2: 45% vs. 17% P<0.0001 Number needed to treat: 2
Probability mrs 0-2 Common Odds Ratio Results: Time to Randomization 10 9 8 7 6 8 10 12 14 16 Time from onset to randomization (hrs) 6 5 4 3 2 1 0 6 8 10 12 14 16 Time from onset to randomization (hrs)
Late-Window AHA Recommendations
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
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.
2018 AHA Guidelines for Early Window EVT
Automated ASPECTS = 5
Manual ASPECTS = 3
ASPECTS = 3 Favorable CTP
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
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
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.
Normal CTP
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.
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
58 yo woman, Wake-up stroke*, NIHSS 13, ASPECTS 8, R MCA occlusion * Possible last know well at 7:15 am
58 yo woman, Wake-up stroke*, NIHSS 13, ASPECTS 8, R MCA occlusion CBV CBF
Following TICI 3 Reperfusion 3 hours post-procedure: NIHSS=14 10 hours post-procedure: NIHSS=32
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
Stanford Stroke Center