CT scans, CT-angiography and CT-perfusion

in Acute Ischemic Stroke:

Practical aspects of
how we use and interpret imaging

Andrew M. Demchuk MD FRCPC

Director, Calgary Stroke Program
Heart and Stroke Foundation Chair in Stroke Research
Professor, Depts of Clinical Neurosciences/Radiology
Cumming School of Medicine
University of Calgary

1
 Disclosure Slide
• I have not received an honorarium from Hoffman LaRoche
(licensure of tPA) but have received honorarium from Medtronic
(supplier of SOLITAIRE FR stentriever) for CME events

• No stocks or direct investments with pharmaceutical or device

companies involved in stroke
• Co-founder/shareholder Quikflo Health start-up (acute stroke
software)
• Several clinical trial responsibilities:
• IMS-3- Exec committee, CT core lab PI
• ESCAPE- Neuro-PI
• REVASCAT- CT core lab co-PI
• CLOTBUST-ER – CTA substudy PI
• ARTSS-2 – CTA substudy core lab PI
• ENCHANTED – International Advisory Committee
• PRACTICE- DMC chair
• DEFUSE 3- Safety monitor
• ANNEXA-4 – Adjudication committee
 What Makes an Excellent Stroke Physician?
• Enthusiasm for hyperacute stroke investigation and treatment
regardless of when, including staying in the angio suite during EVT
• Ability to interpret neurovascular imaging studies without help
• Confident but safe hyperacute stroke decision making
• Spidey sense to sniff out stroke mimics
• Risk stratification/triage of all sudden neurologic spells
• Determined to prevent neurologic deterioration
• Competent at prevention/management of all stroke complications
• Comfort prescribing risk factor modification (chol, BP, diabetes)
• Obsessive/comprehensive approach to stroke etiology and tailored
stroke prevention with the many antithrombotic choices and
extracranial/intracranial arterial or cardiac interventions
• TCD examination skills and interpretation for all indications: its the
stethoscope of the brain!
 First Question
• For acute disabling strokes that arrive in your ED,
what imaging test(s) do you perform immediately?

1. Noncontrast CT only
2. Noncontrast CT with first strip to CT scanner followed by
a CT-angiogram later when Creatinine normal
3. Multimodal MRI
4. Noncontrast CT and CT-angiogram immediately
afterward while still on CT table irrespective of Creatinine
status
5. NCCT+CTA+CTP in all cases
 Our Philosophy:
Good Quality Plain CT immediately followed
by a CTA neck/mCTA head

CTA Don’t Leave the ED Without It!

CT perfusion in select cases

6

NCCT/CTA now standard of

care and should be performed
sequentially while on CT table
 CTA Timing from arrival in ED
Minor stroke/ Major stroke
high risk TIA

NCCT/CTA within hours NCCT/CTA STAT

wait for Creatinine do not wait
for Creatinine
“CIN” called into question
9
 Door to Imaging <15 minutes
Door to CT scanner <10 min
Quick stop at triage bay: ABCs, mimics, IVs/labs
Keep on EMS stretcher/bring EMS team to CT!
CT scan table to imaging <5 min
 Door to tPA bolus Mix tPA while CTA performed
<30 min
NCCT
Give tPA in the CT scanner
mCTA and CTP imaging are incongruent for treatment decision
right after CTA!
CTA
Phase 1 Phase 2 Phase 3

Tmax CBF Gray ma er White ma er

infarct
penumbra
 Comprehensive stroke centre
Door to tPA bolus
<30 min 30-60-90 DTN DTGP DTR rule
NCCT
mCTA and CTP imaging are incongruent for treatment decision

mCTA and CTP imaging are incongruent for treatment decision

tPA bolus to groin puncture
Phase 1 Phase 2 Phase 3
CTA
<30 min
mCTA and CTP imaging are incongruent for treatment decision

Phase 1 Phase 2 Phase 3

groin puncture
Tmax CBF Gray ma er White ma er
Phase 1 to first reperfusion
Phase 2 Phase 3

infarct
<30 min
penumbra

Tmax CBF Gray ma er White ma er

Tmax CBF Gray ma er White ma er

infarct
penumbra
infarct
penumbra

angio
EVT
 Second Question
• What is your standard NCCT and CTA protocol look
like:

1. NCCT 5 mm thickness only; single phase CTA head only

2. NCCT thicks (5mm) and thins (1mm); single phase CTA
head only
3. NCCT thicks and thins ; single phase CTA head and neck
4. NCCT thicks and thins; multiphase CTA head and single
phase CTA neck
5. I do a CTP in all cases so don’t need to worry about all
that
*2.5 mm or less thickness*

1 mm 2.5 mm

3.75 mm 5 mm
CT head 5mm thicks
CT head (thin slices)
*Sequential CT better*
HIGH QUALITY CTA=HIGH QUALITY DX!!

• RIGHT ARM!!!
“The injection site of the contrast medium is important
to the image quality of carotid CTA. Injection into the
right arm decreases reflux into the IJV, BCV and SCV
branches”.
Diagn Interv Radiol. 2011 Sep;17.
Carotid CT angiography: comparison of image quality for left versus right arm injections.
Demirpolat G1, Yüksel M, Kavukçu G, Tuncel D.
 We call the neuro-IR as soon
Door to tPA bolus
<30 min as we see the LVO!
NCCT
mCTA and CTP imaging are incongruent for treatment decision

mCTA and CTP imaging are incongruent for treatment decision

CTA
Phase 1 Phase 2 Phase 3
Phase 1 Phase 2 Phase 3

Tmax CBF Gray ma er White ma er

infarct
penumbra

Tmax CBF Gray ma er White ma er

infarct
penumbra
Head and neck CTA for catheter access choices

*Coronal MIPs
Neck and Head*
Axial/Coronal/Sagittal CTA MIPS for LVO
*23 mm sagittal and coronal thick MIPs*
Coronals MIPs- good for M2, terminal ICA
Sagittal MIPs- distal ACA&MCA occlusions

Axial Coronal Sagittal Reformats

Leptomeningeal Filling to Cortex
*multiphase CTA 3 phases- 8
second apart (4 sec for gantry
mvt and 3.4 sec for imaging
each phase)*
mCTA Phase 1 Phase 2 Phase 3

DELAY

WASHOUT

EXTENT
 Comprehensive stroke centre
Door to tPA bolus
<30 min 30-60-90 DTN DTGP DTR rule
mCTA and CTP imaging are incongruent for treatment decision
NCCT
tPA bolus to groin puncture
mCTA and CTP imaging are incongruent for treatment decision <30 min
CTA mCTA and CTP imaging are incongruent for treatment decision

Phase 1 Phase 2 Phase 3

Phase 1 Phase 2 Phase 3
groin puncture
Tmax CBF Gray ma er White ma er
Phase 1 Phase 2 Phase 3 to first reperfusion
infarct
<30 min
penumbra

Tmax CBF Gray ma er White ma er

Tmax CBF Gray ma er White ma er

infarct
penumbra
infarct
penumbra

angio
EVT
The 4 C`s of NCCT/CTA for acute stroke tx decision making

Clot (size/location)

Core

Collaterals

Catheter access
Proportion
independent mortality
outcome

140 ml

68 ml

34 ml 41 ml
8 ml
 ASPECTS: Methodology

Covidien | December 12,

29 |
2013 | Confidential
ASPECTS methodology
 NCCT ASPECTS score
ASPECTS Trichotomy
Good scan 8-10

Fair scan 5-7

Poor scan 0-4

 NCCT ASPECTS score
ASPECTS Trichotomy
Good scan 8-10

Fair scan 5-7

Poor scan 0-4

Hypoattenuation

Mild hypoattenuation
X-ray Hypoattenuation after Experimental Occlusion
of MCA

von Kummer R, Weber J Neurology 1997;49(Suppl 4):S52-S55

 Hypoattenuation
Severe hypoattenuation equal to or < than normal WM
X-ray Hypoattenuation and blood flow reduction

von Kummer R, Weber J Neurology 1997;49(Suppl 4):S52-S55

Subacute Infarct: hypoattenuation<<normal WM
aspectsinstroke.com

aspectsinstroke.com
Initial CT
Initial CT
Initial CT

M1
M1
C
C L I
L I
M2
M2
M3
Initial CT
Initial CT
 Initial CT: ASPECTS 1

M4
M4
M4
M5
M5
M5

M6
M6
CT 16 hrs from onset
We are now going to all need to screen every
HERMES
Collaboration

moderate/severe strokes for LVO!

46
 Our Philosophy:
Good Quality Plain CT immediately followed
by a CTA neck/mCTA head

CTA Don’t Leave the ED Without It!

CT perfusion in select cases

 CT Perfusion: When to perform?
Sent to ED Stroke diagnosis uncertainty
Mimic: CTP normal CBF increased
Triage assessment
Late time window
EVT ok: Small core (CBV/long Tmax)

Treatment unclear Mild stroke- occlusion

Deterioration risk:
Large region mod/sev Tmax delay
Clear treatment decision

Severe ischemic area

sICH risk: Very low CBV
Proceed without CTP
 CT Perfusion: When to perform?
Sent to ED Stroke diagnosis uncertainty
Mimic: CTP normal CBF increased
Triage assessment
Late time window
EVT ok: Small core (CBV/long Tmax)

Treatment unclear Mild stroke- occlusion

Deterioration risk:
Large region mod/sev Tmax delay
Clear treatment decision

Severe ischemic area

sICH risk: Very low CBV
Proceed without CTP
Seizures
Increased Flow on CTP = Mimic
PRES

Wernickes Encephalopathy
EVT now proven in wakeup stroke and
late window with proper selection

~10%

1-2%
 CT Perfusion: When to perform?
Sent to ED Stroke diagnosis uncertainty
Mimic: CTP normal CBF increased
Triage assessment
Late time window
EVT ok: Small core (CBV/long Tmax)

Treatment unclear Mild stroke- occlusion

Deterioration risk:
Large region mod/sev Tmax delay
Clear treatment decision

Severe ischemic area

sICH risk: Very low CBV
Proceed without CTP
RAPID Standardizes Core Estimation
Raw CBF map RAPID Segmentation

<30% relCBF Tmax>6s

Raw Diffusion MRI ADC RAPID Segmentation

ADC<620x106
iSchemaView RAPID mm2/sec
version 4.6
• CTP access

• Cost RAPID
• Annual fees 30K+
• CTP access

• Cost RAPID
• Annual fees 30K+

• Other CTP software

alternatives
• *Scan for longer than 60 sec*
• Use a >256 slice CT scanner
• Standardize arterial & venous input function determination
• Thresholds for infarction vary by timing of reperfusion
 Infarct certain even if reperfused immediately

Infarct if reperfused in 45mins

CBV <2

Tmax > 21s /rel CBF < 0.15 Infarct if reperfused in 90 mins

Tmax > 16s / rel CBF < 0.20

Infarct if reperfused in 90-180
Tmax > 12.5s / rel CBF < 0.30

Infarct if not reperfused acutely

Tmax > 9.5s / rel CBF < 0.45

 Using one CTP threshold for ischemic core doesn’t fly anymore!
 Paradigm should be used with all vendors… just different thresholds
 Thank-you for your attention!
Email me: ademchuk@ucalgary.ca