Perfusion-CT
of the Brain:
Stroke, TBI and Beyond
State-of-the-art work-up
of an acute stroke patient
Max Wintermark, MD
Associate Professor of Radiology
Director, NeuroCardioVascular Imaging Lab
University of California San Francisco,
Department of Radiology, Neuroradiology Section
State-of-the-art work-up
of an acute stroke patient
State-of-the-art work-up
of an acute stroke patient
State-of-the-art work-up
of an acute stroke patient
State-of-the-art work-up
of an acute stroke patient
State-of-the-art work-up
of an acute stroke patient
State-of-the-art work-up
of an acute stroke patient
State-of-the-art work-up
of an acute stroke patient
State-of-the-art work-up
of an acute stroke patient
State-of-the-art work-up
of an acute stroke patient
Acute Stroke Treatment
rtPA
NINDS - PROACT
NINDS
Time is Brain !
Conventional Noncontrast CT
in Acute Stroke Patients
• Identifies hemorrhagic stroke
BUT
• Limited sensitivity of conventional CT
for acute cerebral ischemia (14-43%)
• Moderate inter-observer agreement
in the identification of early cerebral ischemia
• 11% of patients inappropriately included
in ECASS
von Kummer R et al. AJNR 1996;17:1743-1748
Hacke W et al. Lancet 1998;352:1245-1251
Lansberg MG et al. Neurology 2000;54:1557-1561
(Lancet 1998)
(JAMA 1999)
Drug / Route
IV rtPA
IV rtPA
IA pro-UK
Time window
0 - 3h
0 - 6h
0 - 6h
Imaging
Outcome
90d mRS
TTT vs control
Death
CT
CT
CT / DSA
39% vs 26%
40% vs 37%
40% vs 25%
17% vs 21%
11% vs 10%
25% vs 27%
Hemorrhage
Recanalization
6% vs 0.6%
-
9% vs 3%
-
10% vs 2%
66% vs 18%
Conventional Noncontrast CT
in Acute Stroke Patients
*
Conventional Noncontrast CT
in Acute Stroke Patients
ECASS II PROACT
(NEJM 1995)
CTA
PCT
CTA
NINDS - PROACT
NINDS
ECASS II PROACT
(NEJM 1995)
(Lancet 1998)
(JAMA 1999)
Drug / Route
IV rtPA
IV rtPA
IA pro-UK
Time window
0 - 3h
0 - 6h
0 - 6h
Imaging
Outcome
90d mRS
TTT vs control
Death
CT
CT
CT / DSA
39% vs 26%
40% vs 37%
40% vs 25%
17% vs 21%
11% vs 10%
25% vs 27%
Hemorrhage
Recanalization
6% vs 0.6%
-
9% vs 3%
-
10% vs 2%
66% vs 18%
3 hour time window for i.v. thrombolysis
Combined analysis 2776 patients
“Time is brain”
mRS 0-1
at day 90
4.0
3 hours
3.5
How Many Percent of Acute
Stroke Patients are Admitted
in the 0-3h Time Window?
3%
Stroke Thrombolysis Trials
NINDS
PROACT
DIAS
(NEJM 1995)
(JAMA 1999)
(Stroke 2005)
IV desmoteplase
Drug / Route
IV rtPA
IA pro-UK
2.5
Time window
0 - 3h
0 - 6h
3 - 9h
2.0
Imaging
CT
CT / DSA
DWI/PWI (PCT)
Outcome
90d mRS
TTT vs control
39 vs 26%
40 vs 25%
60% vs 22%
4.4 vs 3.7%
3.0
1.5
1.0
0.5
0.0
60
90
120
150
180
210
240
Time to treatment [min]
Lancet 2004; 363:768-74
270
300
330
360
Death
17 vs 21%
25 vs 27%
Hemorrhage
6 vs 0.6%
10 vs 2%
3 vs 0%
Recanalization
-
66 vs 18%
71 vs 19%
How Many Percent of Acute
Stroke Patients are Admitted
in the 0-9h Time Window?
MRI Stroke Imaging
GRE
DWI
PWI
Hemorrhage
Ischemic
Injury
Perfusion
Status
Infarct Core
Mismatch
MRA
Vessel
Status
40%
Hemorrhage
Large Vessel
Occlusions
*
CT Stroke Imaging
NCT
PCT
PCT
Hemorrhage
Ischemic
Injury
Perfusion
Status
Infarct
Hemorrhage
Infarct Core
NCT
CTA
Vessel
Status
Penumbra
Mismatch
Large Vessel
Occlusions
Interpretation of PCT Maps
MTT
rCBF
rCBV
TIA
↑
normal
↑
Penumbra
↑
↓
↑
Infarct
↑
↓
↓
NCT/PCT/CTA
DWI-/PWI-MR
Which One to Choose?
Perfusion-CT or DWI-/PWI-MR:
Which One in Acute Stroke Patients?
Perfusion-CT
10 min
iodinated contrast medium
X-ray
NCT/PCT/CTA: Time Duration
DWI-/PWI-MR
30 min
gadolinium
RF waves
Data Acquisition
Data Acquisition
NCT: 20 sec
PCT:
40 sec +
3 min +
40 sec =
4 minutes
CTA:
10 sec
TOTAL =
5 minutes
Data Post-Processing
NCT/PCT/CTA: Time Duration
NCT: 0
PCT:
2 minutes
CTA:
5 min
Perfusion-CT or DWI-/PWI-MR:
Which One in Acute Stroke Patients?
TOTAL =
~ 10 minutes
Excellent Correlation
Between Admission Perfusion-CT
and DWI-/PWI-MR
DWI-MR
Perfusion-CT
equivalent results
widely available
10 min
iodinated contrast medium
X-ray
DWI-/PWI-MR
Infarct
less available
30 min
gadolinium
RF waves
PWI-MR (MTT)
Penumbra
Stroke 2002;33:2025-2031
Perfusion-CT or DWI-/PWI-MR:
Which One in Acute Stroke Patients?
Perfusion-CT
hemispheric strokes
DWI-/PWI-MR
small strokes/posterior fossa
equivalent results
widely available
less available
10 min
30 min
iodinated contrast medium
gadolinium
X-ray
RF waves
PCT Misses Lacunas
Admission NCT
2h
Admission PCT
2h
PCT Is Not Adequate
For Posterior Fossa
DWI
15h
Admission CT
7h
Perfusion-CT or DWI-/PWI-MR:
Which One in Acute Stroke Patients?
DWI
12h
Perfusion-CT
63 F
Right-sided
symptoms
Extent penumbra / Extent infarct
Extent < or > 1/3 ?
Brain Ischemia
present or absent?
DWI-/PWI-MR
limited spatial coverage
hemispheric strokes
whole brain
small strokes/posterior fossa
equivalent results
widely available
less available
10 min
30 min
iodinated contrast medium
gadolinium
X-ray
RF waves
Toggle-Table PCT technique
256-slice CT scanner
Perfusion-CT or DWI-/PWI-MR:
Which One in Acute Stroke Patients?
Perfusion-CT
DWI-/PWI-MR
limited spatial coverage
hemispheric strokes
whole brain
small strokes/posterior fossa
equivalent results
widely available
less available
10 min
30 min
iodinated contrast medium
gadolinium
X-ray
RF waves
Courtesy Prof. Kazuhiro Katada, Fujita, Japan
MODERN work-up
of an acute stroke patient
FUTURE
DIRECTIONS
ON ADMISSION !
Intracardiac Clots
Specific Aim #4:
Coronary Vessels
CARDIAC FUNCTION
Permeability
Imaging
Hemorrhagic Transformation
Infarct
Penumbra
CBV
CBF
MTT
BBB permeability
Follow-up CT
BBB permeability
Perfusion-CT:
not only Stroke…
but also Head Trauma
Admission PCT for Early Detection of Contusions
in Severe Head Trauma Patients
Perfusion-CT:
not only Stroke…
but also Head Trauma
Admission PCT
for Assessment of Treatment Efficiency
in Case of Epi/Subdural Hematoma
Before Treatment
Treatment
Admission PCT
for Assessment of Treatment Efficiency
in Case of Epi/Subdural Hematoma
Before Treatment
Treatment
After
After
Perfusion-CT:
a New Insight in the Concept of
Traumatic Cerebral Edema
in Severe Head Trauma Patients
NCT
PCT
CONCLUSION
•
•
•
•
Perfusion-CT
Functional Imaging
Stroke, TBI, vasospasm, etc
Positive impact on patients’
management and outcome