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Issues in Imaging for Stroke

Issues in Imaging for Stroke. Shawn Halpin MRCP FRCR LLM University Hospital of Wales, Cardiff. National Intercollegiate WP for Stroke 2004. Hospital care specialist teams weekly MDT SITS MOST. contd. “initial assessment by experienced clinician”

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Issues in Imaging for Stroke

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  1. Issues in Imaging for Stroke • Shawn Halpin MRCP FRCR LLM • University Hospital of Wales, Cardiff

  2. National Intercollegiate WP for Stroke 2004 • Hospital care • specialist teams • weekly MDT • SITS MOST

  3. contd... • “initial assessment by experienced clinician” • “non specialist care costs lives, increases dependancy, less cost effective” • brain imaging within 24 hours • MRI if CT delayed for 10 days

  4. Audit data: • How many patients imaged within 24 hours? • Wales criticised for worst UK performance • But 97% patients scanned within 24 hours of request

  5. New report • Immediate imaging for certain stroke subgroups - thrombolysis, unconscious, warfarin • Immediate review by an expert in stroke

  6. Immediate (1hr) scan? • Trivial to provide

  7. Immediate clinical diagnosis • Very difficult • large/small vessel; TIA; migraine; SAH; dissection, watershed, global etc etc • 3 patient with limb fractures referred as acute stroke patients

  8. Plain scan in early stroke: • Usually normal

  9. Rush to treat: • Undoubtedly some non-stroke patients will be treated with rTPA

  10. Early CT signs:

  11. Add specialist neuroradiological advice • Non Trivial • Network? • Interested DGH radiologists? • Every DGH radiologist?

  12. Alternative? • Perfusion scanning • CT or MR • Make decisions based on physiology

  13. Reichenbach et al AJNR 20 1999

  14. 45 yr old, large ophthalmic aneurysm

  15. Perfusion during occlusion

  16. Tissue Classification

  17. Advantages of Physiology • No false positives • Treat only those with viable tissue • Use as triage: a tool to spare the expert in stroke?

  18. Radiology will enthusiastically support acute stroke • Give us the tools to do it • Help us with the out of hours reporting • Bear in mind we have other responsibilities too: • Most radiologists cover all emergencies, not just neuro • And there are not many of us! BUT

  19. 1. Plain scan only • Who reports? • Fear of onerous on call duty • Consultant radiologists ideal • In each hospital? • Network in Wales, or wider UK - • local/extended? • Network outside Wales? • Radiographer or stroke team report??

  20. 2. ASPECT score • More radiologist experience needed • Greater physician input • Give drug or not? • No longer a yes/no, now a maybe • Further need for experienced clinician Use of the Alberta Stroke Program Early CT Score (ASPECTS) for Assessing CT Scans in Patients with Acute Stroke AJNR Am J Neuroradiol22:1534 ﾐ1542, September 2001 . Alternatively, what percentage of the MCA territory is low density?

  21. 2. ASPECTS score reporting • Need consultant radiologist • In house • local • network • outsource

  22. 3.Assess other pathology • Need consultant radiologist • As before

  23. 4. Perfusion data • Need Neuroradiologist • or highly specialised other person • this may change in the future, but not yet • Similar issues with location

  24. Suggestion: • All hospitals support IST3 • Start slowly, learn where the problems are • Build resources based on local experience • Radiologist, radiographer, stroke team • Look to develop perfusion scanning, 24/7 services over time

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