CT Perfusion In Acute Ischemic Stroke
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- Опубликовано: 23 июл 2024
- 00:00 - Intro
01:14 - Objectives
01:38 - Why CT perfusion?
04:23 - ASPECT scoring on non-contrast head CT
08:02 - Fundamental hemodynamic properties: CBF, CBV, MTT, Tmax
13:35 - Clinical uses: DEFUSE 3, DAWN, EXTEND
18:26 - Clinical examples
22:03 - Hypoperfusion index and multi-threshold Tmax maps
23:37 - Caveats and pitfalls: Caveats in estimating core
30:15 - Caveats and pitfalls: Caveats in estimating penumbra
35:37 - Summary
36:11 - Quality of study: Vessel selection, contrast opacification, patient motion
38:27 - Additional uses of CTP: Medium vessel occlusion
40:28 - Additional uses of CTP: Posterior circulation stroke
44:59 - Additional uses of CTP: Stroke mimics
46:52 - Can we use CTP like cardiologists use troponin?
47:58 - Summary and algorithm
Algorithm PDF may be found here: drive.google.com/file/d/1QLYj...
This video is intended for residents and fellows to understand the interpretation and clinical applications of CT perfusion imaging for the treatment of patients with acute ischemic stroke.
Created, produced, and narrated by:
Igor Rybinnik MD
Neurology Clerkship Director
Rutgers Robert Wood Johnson Medical School
Content experts:
Raymond Mirasol MD, Roger Cheng MD
Division of Stroke and Neurocritical Care
Department of Neurology
Rutgers Robert Wood Johnson Medical School
Sudipta Roychowdhury, MD FACR
Clinical Professor of Radiology, Neurosurgery, and Neurology
Rutgers Robert Wood Johnson Medical School
Director of Interventional Neuroradiology
Director of Magnetic Resonance Imaging
Robert Wood Johnson University Hospital
References:
1. Saver JL, et al. JAMA 2016, 316(12):1279
2. Nomani AZ, et al. Neurology 2021, 97:e2079-87
3. Sarraj A, et al. Stroke 2021, 52(1):57-69
4. Barber PA, et al. Lancet 2000;355(9216):1670-4
5. Almallouhi AZ, et al. JAMA Network Open. 2021;4(12):e2137708
6. Adapted from Sotoudeh H, et al. Acad Radiol 2019;26(11):1565-79
7. Albers GW, et al. NEJM 2018;378:708-718
8. Nogueira R, et al. NEJM 2018(1);378:11-21.
9. Ma H, et al. NEJM 2019;380(19):1795-1803
10. MacLellan A, et al. JSCVD 2022;31(1):106-208
11. Normani AZ, et al. Neurology 2021;97(21):e2079-87
12. Albers GW, Stroke 2018;49:1-5
13. Martins N, et al. Intervent Neurol 2018;7:513-521
14. Campbell BC, et al. Int J Stroke 2015;10:51-54
15. Amukotuwa SA, et al. Stroke 2021;52:3308-3317
16. Katyal A, et al. Eur J Neurol 2021;28:2657-2668
17. Tao WD, et al. Stroke 2012;43(8):2060-2065
18. Capasso R, et al. Neuroradiology 2021;63:317-330
19. Novakovic-White R, et al. Neurology 2021;97:S158-S169
20. Vagal A, et al. Neurology 2019;93(20):888-898.
21. Benson JC, et al. AJNR 2016;37:2239-44
Images adapted from:
- Articles referenced above
- Adobe Creative Cloud
- Blumenfeld H. Neuroanatomy Through Clinical Cases, 2nd ed. Sinauer, 2010.
Music:
- The Itch (Instrumental) - NEFFEX
- Icelandic Arpeggios - DivKid
- Under Cover - Wayne Jones
Disclaimer: Please note that this material was simplified for educational purposes. For patient management, please review your clinical society's guidelines and engage expert consultation where appropriate. Also, the opinions of the presenters do not necessarily reflect those of Rutgers Robert Wood Johnson Medical School, Robert Wood Johnson University Hospital, RWJBarnabus Health, or Rutgers University as a whole.
I really have to emphasize that it is ridiculous that we get this kind of content for free on RUclips as it is so good. Thank you again and again.
Thank you! My mission in life is to change neurological education and not to make trainees pay for knowledge.
Amazing...you're a wonderful person
@@theneurophileThat's a real doctor right there.
Thanks a ton.
We need more hero like him who provides us with ultimate knowledge to enlightening us at least to serve people life .... Not like the others who are craving for money !!!!!
Thank u doctor for changing my learning journey and also i m so astonished by your educational content specially PowerPoint presentations ; soooooo magnificent ❤
New neurology resident doing my masters degree in strokes here in Greece, i d like to express my gratitude for all that, this kind of work produces a change in our approach, in a way you help people (both doctors and patients) all around the world with your videos. Thank you.
I’m glad that you found this helpful. Thank you good your kind words of support.
Radiology resident here. Congrats! What an amazing presentation. You, sir, are a true scholar.
Wow, thank you!
Finally! I've been waiting for a new neurology lecture for so long! Meanwhile, I watched all your other lectures several times!
Me waiting for professor Alex Flournoy's lectures 🤭🤭🤭🤭
After 3 hours we finally found the best Video on the internet for understanding CTP scans. The idea of giving practical cases to practice on and tying them into the trials seems to be lost on other "educators". Well done. I feel dirty for getting this content for free.
Please enjoy. I am happy that you found this helpful.
Thank you Thank you and a Million Trillion Thank you!!!
we are a group of neuorology Residents who are watching your videos to help us have better understanding of brain imaging!
Please never Stop make these videos!
thank you again and again!
Anytime!
Incredible!!!! This take the diagnosis and treatment to another level. But I think I will not be alive to see this in real world practice. Maybe in 15 or 20 years. The EM coleagues will have much work to reach this level.
Thank you so much! As a neurology resident, this was very useful! I am looking forward to how ANGEL ASPECTS and SELECT 2 trial that came out of ISC 2023 may/will affect what we do clinically!
Unfortunately nothing is static in medicine, so the indications for thrombecomy have now changed. The mismatch ratios are still the same, but the allowable core has now increased to 150cc.
Thank you very much! As a radiology resident CT perfusion was very challenging in interpreting and correlating with clinical context. Much appreciated to know what really neurologists want us to tell and help them in stroke codes.
My pleasure.
Extremely thankful for your videos ..they are so on point and emphasize the patient outcomes with these steps that needs to be taken... Neurology resident here..
Thank you! I’m glad that you found this useful.
Absolutely Love your lectures, seen all of them several times
Contents starting 23:40 are pure gold.
Imma about to start my residency in radiology, and I just couldn't be more grateful for such high quality, top tier and surprisingly soothing (haha) video.
Can't wait to binge watch all of your videos guys.
NEVER STOP your brilliant work guys!
Phenomenal content, the best resource for Neurology on RUclips, please keep them coming!
Always great worth to revisit. Great series great teacher.
I wish I could be such a wonderful teacher as you are. This presentation is priceless. Thanks!
Perfect work as usual 👌 Best of the Best.looking forward for more Topics.
Greetings from Germany.
Great series, follow up your excellent tutorials.
You are a excellent lecturer, as a Neurologist, I've learned too much from your series. Thank you again for this wonderful presentation and free sharing via RUclips!
Always here waiting for your amazing lectures video
Accurate and effective! Thank you.
Thank you! Much appreciated as always.
you are fantastic.. I feel like I must pay you for your efforts.. Great job, huge Thanks
Awesome content. The presentation is excellent.
This is amazing. Thank you so much for putting out such informative and high quality lectures ❤❤❤
Glad you like them!
Unbelievably great content
Thank you. Things have changed a little with respect to indications for intervention. Please take a look at the newer “Managing stroke codes” video
Thank you for this awesome review!!!
Thank you so much, its really amazing explanation. Very simple, communicative, and systematic. Hope you always healthy and succes 🎉
Yeayyy, new video. I will inform my students to watch this one also. Your channel is a must see at our centre. Thank you for your elaborate work.
Thank you for your kind comments.
You are amazing! Thank you, that's very clear
Thank you so much fo this great lecture... The way of presentation is so good and easy to understand... Love it a lot and share it with my colleagues.
I'm a neurology resident from Brazil and would like to thank you for this amazing job! It's just amazing your skills to wrap up everything that is important on each topic. This lecture by the way is fenomenal! Looking forward to see tou making more videos like this.
Thank you!
Amazing lecture - Thank you so much
excellent stuff
gracias! excelente contenido
As an EM resident this video is GOLD and definitely something I'm going to share with all my colleagues in my residency because generally anything beyond a non-con head CT terrifies us. Neuro imaging is something that intimidates many of us and this lecture makes CTP so much more approachable and can facilitate a much higher level conversation with many of our stroke consultants. Thank you so much for making this free on youtube.
Thank you! Enjoy.
Enjoyed this and learned something today. Shared with my neurosurgeon I dreaded Hemorragic Stroke because it was this my Maternal Grandmother died of. He reassured me this probably wouldn't take Me, that and Clot blockage, doubtful but he would guess ischemic if ever I had one, but my arteries are younger than my calendar years. So maybe my postive interventions are working.
Aahh... Love you man keep uploading 👍🏻
Love and Respect ❤️...
Thanks from depths of my heart sir ...
2:43 i think you labelled penumbra and core wrong here (on the graphic green🟢 and purple 🟣) , but the way you explained it is correct
Yes, you are right. I apologize for that one.
great talk. thanks
You are great. Thanks.
awesome lectures thank you
great! tanks
thank you
Great lecture and presentation as usual Dr.igor....but I think with new trials showing the benefit of mechanical thrombectomy even in patients with low aspects (3-5) (Rescue-japan trial) ..I think the guidelines are gonna be change and you will be in need to update this lecture :D
Yep. That's the problem with these talks. TIMELESS trial will come out soon as well.
At around 4 minutes into the video, i suggest to correct the color code name to reverse for ischemic core to penumbra
Yes, that is a typo.
6 you can, do a presentation on arterial and venous strokes and whatever else is your favorite topic. Thanks
Excellent as always. Dr. Could you make a video about how you make these videos and/or animations this good? what software do you use?
Thank you. I generally use PowerPoint as the only software. Yes, when I get the chance, I will make a course.
This is amazing! Any thoughts to adding some management caveats now with the various larger core trials coming out? I suppose it's probably hard to edit a video, but maybe overlays can provide context.
Unfortunately, RUclips doesn’t allow editing. Watch the “Mastering Stroke Codes” video for a newer algorithm that accounts for large core.
Hey Igor from America, didn't you want to make a short tutorial on how to make awesome slide design ;-). However I am a resident in vascular surgery, with a very high interest in neurovascular stuff. How about a video about Plaque morphology and Stroke Risk. Or one could start with NASCET and hemdynamic evaluation of carotid artery disease or something.
Lets say if I would butcher some slides, (hypothetically of course :-D) would you have time to review them and give some tips on Design? Best regards Igor from Germany.
Great video and slides! May I ask, what software did you use for the graphs and figures? Thanks alot!
Thank you. Most of the graphs and figures are actually built in PowerPoint. Occasionally for more complex projects, I resort to Adobe Illustrator.
Could you please make a Video about dementia?
Thank you for the presentation :) Could you share your thoughts about the new CT perfusion criteria for LVO within 24 hours, based on the SELECT2 and ANGELASPECT trials? It seems that with ASPECT >3, the core is no longer a significant concern...thanks!
This is a rapidly evolving area. The core infarction no longer matters, but at least for now I would stick to >1.8x mismatch of DEFUSE 3. Take a look at our “Mastering Stroke Codes” video.
Great stuff as always. 3:17 I believe you were trying to indicate ischemic core as purple and penumbra as green. Please correct me if I'm wrong.
Appreciated.
From a neuro resident in OH.
Yes, you are right. It’s a typo.
Hello,
According to my interpretation of the 2021 European Stroke Organization Thrombolysis Guidelines, for wake-up strokes there is no time limit on the use of intravenous thrombolysis as long as there is a DWI-FLAIR mismatch on MRI. Is this true?
Yep, true. We tend to use CTP first because it's faster. However, CTP won't help with lacunar strokes. In those cases, we perform a stat MRI.
Since we're in the topic of ischemic stroke, what's the topographic diagnosis (i.e. Localization) of acute onset tetraplegia with intitial loss of consciousness and subsequent aphasia (not dysarthria) and monoplegia?
I'd love to hear more about anterior circulation strokes in this case!
There are several locations where this may happen, but top-of-the-basilar is my best bet. Aphasia will be caused by thalamic ischemia, while tetraplegia and depressed consciousness is a result of the cerebral peduncle and reticular activating system involvement in the midbrain.
@@theneurophile thank you for your reply! It's a fascinating discussion. The MRA of the patient showed stenosis of the intracranial vessels (bilateral C3, bilateral ACA and bilateral PCA with a complete occlusion of the right MCA), does it change anything to your topographic hypothesis? (I must add that there was facial involvement and a history of amaurosis fugax)
Multifocal intracranial stenosis can certainly cause multifocal lesions (you would have to invoke multiple locations). The only way to prove which of the stenosed vessels is symptomatic is to document ischemic changes on MRI.
@@theneurophile alright! From what I can see, the MRI shows white matter ischemic lesions in the centrum semiovale and subcortical ischemic lesions in the frontal and parietal regions and in the elft occipital region. So I deduce that it's pretty much indicative of a vasculitis. However, I hope to be able to correlate the MRI features to the clinical presentation, in particular, the stroke that manifested as a tetraplegia.
Thank you for your help, it's really appreciated, I'm an avid fan of the channel!
I would pay cash to have more of these lectures!! If you design an online emergency video course and sell it, it would be greatly successful!!!
Thank you for the kind words. Do you mean a course on neurological emergencies?
@@theneurophile yes!!👍
Do you think you could also teach us something about small vessel disease? White matter hypointensities, cerebral microbleeds, ICH... there is a lot to see there.
Yep. I am waiting TIMELESS trial to get published (hopefully shortly) to post a revised stroke code where this will be discussed.
@@theneurophile Oh wow, sounds fantastic. I look forward to it!
Around 3:20 I’m wondering the whole picture why penumbra is at the middle of the ischemic core. Could anyone answer for me?
Penumbra illustrates the entire territory that is hypoperfused. By definition, ischemic core will be within that territory. With MCA occlusion, basal ganglia structures often become ischemic early because there is limited collateral flow in those areas. So those areas tend to convert to ischemic core. The cortical MCA territory often received ACA and PCA collaterals and may survive for longer.
Penumbra is green 🟢 larger than is ischemic core which is is purple 🟣
I think they mislabelled it by mistake （it is a long video, mistakes happen 😁)
@@Mr_3raqi thanks!! this is also what i thought as. just to make sure. still, great video. fully appreciate.
How do I get to do your slides making class? They are superb
Thank you. I will make a class in the future.
@@theneurophile Is there a waiting list I can sign up for? I would love this class!
@@MichaelTeitcher Thanks for the enthusiasm! It's still in the conceptual stages. I will post a short video on the channel informing everyone when the course is ready.
I miss your videos sir☹️ when will you be uploading again?
Very soon. Next video is 90% done.
@@theneurophile 🤎 eagerly waiting to see it ☺️
Our Movement Disorders video is up.
At around 3:38 in your video, the description of the ischemic core (infarct area) and penumbra seems to be reversed. The green area should be the penumbra and the pink one ischemic core.
Yes, sorry about that. The colors are correct on the image but not in the legend.
Is it possible to make the algorithm accessible per PDF or picture? :)
I updated the video description with a link to a PDF.
@@theneurophile wow, thank you very much! Appreciate it a lot!
At last!
what software do you use for presentaions ?
Good old PowerPoint.
@@theneurophile it must be a special power point because i have never seen it before
@13:49
i think your colors are off in the WHY CT PERFUSION SLIDE. I feel like ischemic core was the purple and penumbra was the green
Yep. Sorry about that. The narration and colors on the slide are correct. The legend is wrong. Purple is core, and green is penumbra.
@@theneurophile the video was great other than that, thank you!