Professional Documents
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Approach to Diagnosis
CT Scan
MRI
Angiography
CBC
Electrocardiogram
Other laboratory parameter
CT Scan
CT has the advantage of being available 24
hours a day and is the gold standard for
hemorrhage.
First tests done in a stroke evaluation,
particularly during an acute stroke in the
emergency room.
Distinguish between ischemic and
hemorrhagic stroke
Normal CT in patient with <3 hrs of
symptoms can begin rtPA therapy if no other
contraindications
CT Scan
Used when MRI is not available or
contraindicated, or in emergency
settings when hemorrhage,stroke, or
traumatic brain injuryare suspected.
The overall sensitivity of CT to
diagnose stroke is 64% and the
specificity is 85%.
CT Scan
Acute Ischemic Stroke:
Result from thrombo-embolic
occlusion of intracranial arteries
Various patterns can be seen on CT
scan in early & late stages
CT Scan
Middle Cerebral Artery:
75% of all ischemic events
Sxs vary between minor sensory or
motor deficits
More patients are scanned earlier to
rule out hemorrhage and large
infarcts due to thrombolytic therapy
CT Scan
Hyperdense MCA sign:
Clot is visible as hyperdense in MCA
Most evident along the horizontal part
Appears as vessel segment of higher
density than other parts of same vessel,
contralateral MCA and BA
Not an unequivocal sign of occlusion
Does not represent ischemic change in
parenchyma
MCA Infarction
hypodense with in 6 hours
CT Scan
Day 3 after Acute Ischemic Stroke
CT Perfusion (CTP)
With CT and MR-diffusion we can get a good
impression of the area that is infarcted, but we
cannot preclude a large ischemic penumbra (tissue
at risk).
With perfusion studies we monitor the first pass of
an iodinated contrast agent bolus through the
cerebral vasculature.
Perfusion will tell us which area is at risk.
Approximately 26% of patients will require a
perfusion study to come to the proper diagnosis.
The limitation of CT-perfusion is the limited
coverage.
CT Perfusion (CTP)
Magnetic Resonance
Imaging (MRI)
useful for detecting a wide variety of brain
and blood vessel abnormalities, and can
usually determine the area of the brain
that is damaged by an ischemic stroke.
MRA: inject intravenous dye (gadolinium)
into the blood vessels to view arteries and
veins and highlight blood flow
Angiography
Provide high resolution images of the extraintra cranial cerebral vasculature
Involves entering a catheter into the body
to inject a dye (a contrast medium) into the
carotid arteries, the vessels of the neck that
lead to the brain.
Useful for:
Occluded or stenotic vessel - Arterial dissection
Aneurysm - AVM
Vasculitic narrowing - Venous sinus thrombosis
CT Findings in Cerebral
Acute: 12-24 hrs
Infarction
1 to 3 Days:
Increasing mass
effect
Wedge-shaped low
density area
involving gray and
white matter
Possible
hemorrhagic
MR Findings in Cerebral
Infarction
Immediate
Hyperintense on DWI
(low apparent diffusion
coefficient, ADC)
IV contrast enhancement
perfusion alterations
<12 hrs
Sulcal effacement, gyral
edema, loss of graywhite interfaces on T1
12 to 24 hrs
Hyperintensity on T2
Meningeal enhancement
adjacent to infarct
Mass effect
1 to 3 days
IV and meningeal
enhancement begin
decline
Signal abnormalities
striking on T1WI, T2WI
Possible hemorrhagic
transformation
Electrocardiogram
The first sign of arrhythmia or a MI is often the
occurrence of cerebral embolism; consequently it
is advisable that an ECG and Echocardiogram be
obtained in all patient with stroke of uncertain
origin
Sometimes the only method of detecting
irregularities in heart rhythm such as atrial
fibrillation that can lead to the forming of blood
clots that can later get flow to the brain. These
blood clots can cause stroke by forming in the
heart, coming loose and then getting lodged in a
small artery of the brain.
http://www.strokecenter.org
http://
eradiology.bidmc.harvard.edu/LearningLab/central/Hoki.pdf
Underlying Disease
Cardiovascular:
- Like MI, atrial fibrillation, valvular
disease etc.
- ECG
- Chest X-ray
- Echocardigraphy
- Transesophageal ultrasound
- Blood Cultures