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C2 Modules CLINICAL > Update on Imaging, thrombolysis and stenting in Stroke > Flashcards

Update on Imaging, thrombolysis and stenting in Stroke Flashcards

1
Q

What is the background for stroke?

A

11% of all deaths in England and Wales

500,000 dependent for ADLs

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2
Q

What has changed in the last 6 years for acute stroke care?

A
  • RCP audit highlights shortcomings for UK stroke care
  • Thrombolysis rate gradually improving vs up to 1-% in continental Europe
  • National Stroke Strategy published
  • NICE guidelines on Stroke
  • Stroke moved up the DOH agenda in England
  • Stroke Networks formed
  • Hyperacute stroke units set up
  • Thrombectomy becoming standard of care
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3
Q

Brain imaging should be performed immediately for people with acute stroke if any of the following apply:

A
  • Indication for thrombolysis or early anticoagulation treatment
  • On anticoagulant treatment
  • Known bleeding tendency
  • Depressed level of consciousness, GCS < 13
  • Unexplained progressive or fluctuating symptoms
  • Papilloedema, Neck stiffness or fever
  • Severe headache at an onset of stroke’s symptoms
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4
Q

What should be done for people with acute stroke without indication for immediate brain imaging scanning?

A

should be performed within 1 hour of arrival in hospital

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5
Q

What do we need know from acute CT scan in a patient with a clinical diagnosis of acute stroke:

A
  • Is the scan normal? i.e. can we start Thrombolysis refer for thrombectomy
  • Confirm diagnosis of acute stroke and size
  • Exclude haemorrhage
  • Exclude stroke mimic
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6
Q

What happens if CTA is available?

A
  • Looks at all the blood vessels
  • If you have a stroke 20% of patients will have disease of the carotid artery that needs treatment with carotid endarterectomy (CEA)
  • 10% of patients who are suitable for thrombectomy
  • Exclude significant stenosis of the carotid and vertebral arteries and any intracranial stenosis
  • Enables fast tract to endarterectomy or discharge from a HASU to SU
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7
Q

What should patients with suspected TIA undergo?

A

diffusion weighted MRI except where contraindicated

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8
Q

TIA at MRI superior to CT

A

pick up small diffusion abnormalities that may not be seen on a CT

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9
Q

NASCET and ECST:

A
  • Long term benefit of carotid endarterectomy compared with medical treatment
  • If you have a stenosis greater than 70% - absolute risk reduction is pretty good
  • Not good treating less than 50% stenosis
  • Above 99%, the flow drops in the carotid
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10
Q

When was benefit from surgery greatest in?

A

men, patients aged 75 years or older, and those randomised within 2 weeks after their last ischaemic event

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11
Q

What does the benefit from endarterectomy depend on?

A

not only on the degree of carotid stenosis, but also on several other clinical characteristics such as delay to surgery after the presenting event

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12
Q

What is readily availble on all A&e for acute stroke?

A

CT

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13
Q

What are the features for CT?

A
  • Acute haemorrhage, may show infarct
  • CTA for vessels
  • CTP for extent of perfusion defect, CBV predicts infarct volume (DWI)
  • Convenient
  • Very quick < 5 minutes scan time
  • Some time on workstation; new packages coming
  • CT easy in ill patients
  • Radiation secondary importance of having acute stroke
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14
Q

What are the features for MRI?

A
  • Sequences to detect lesion and blood
  • Gradient echo (T2*) greater than CT (microbleed)
  • DWI >CT
  • MRA
  • Perfusion – whole head
  • Longer scan time, less post processing
  • Access
  • New sequences
  • Will become easier to use in the future
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15
Q

What is the Alberta Stroke Program Early CT score ‘‘ASPECTS’’?

A

10-point quantitative topographic CT scan score used in patients with middle cerebral artery stroke

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16
Q

What has the ASPECT score been adapted for?

A

Posterior circulation

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17
Q

What do we see in CT for acute stroke?

A
  1. Thrombus in the vessels
  2. Altered tissue perfusion
  3. Cytotoxic oedema
  4. Vasogenic oedema
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18
Q

Where to look in CT in Acute Stroke?

A
  • Vessels
  • Grey: white differentiation
  • Basal ganglia/capsules
  • Insular ‘’ribbon’’
  • Cortex
  • Swelling: sulci effaced
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19
Q

What can easily be seen on the CT, and picked up quicker than MRI?

A

Haemorrhage

20
Q

What can’t MRI be used as ?

A

Single sequence investigation (‘‘turbo charged CT’’)

21
Q

What must haemorrhage include?

A

Blood sensitive sequence

  • GRE or parenchyma
  • FLAIR for SAH
22
Q

What should not be used alone for acute stroke imaging?

A

DWI

23
Q

What is Low Grade Glioma and what to look for?

A
  1. Can be peripheral, wedge shaped and non-enhancing
  2. Look for:
    - Age and History
    - Density, swelling but non-enhancing
    - DWI characteristics and age of lesion
24
Q

What is the most common cause of stroke for pregnant ladies?

A

Venous thrombus

25
Q

Where is Core observed in?

A

diffusion, reduction in blood volume and an increase in MTT [mean transient time]
• Due to block of middle cerebral artery

26
Q

What is the aim of thrombolysis?

A

reperfuse penumbra before it infarcts

27
Q

What is TIA?

A

Like a stroke without core infarct in eloquent area

  • Milder perfusion deficit
  • Often has DWI lesion
28
Q

What does ASPECT aid?

A

Methodical image analysis and prognosticatio

29
Q

What is not very dark ?

A

Infarct less than 24 hours

30
Q

What do infarcts not usually present with?

A

Fits

Especially in young people

31
Q

What must be included if using MRI for acute stroke?

A

Gradient echo imaging

32
Q

What are a few tips for looking at scans?

A
  1. Ambient lighting, monitor quality etc
  2. Hang as well as scroll
  3. Correct window/centring
  4. Provide/obtain clinical info
  5. Think about anatomy
    (speech not always left dominant)
  6. Eye deviation
33
Q

What should be compared with initial scan?

A

Routinely obtain post thrombolysis follow up imaging

34
Q

What are the objectives of I.V. Thrombolysis?

A
  1. To improve clinical outcome at 3 month
    - Proportion of patients without handicap (mRS 0-1)
    - Proportion of patients without dependency (mRS 0-2)
35
Q

What are the Modified Rankin scale?

A 
0 - no symptoms
1- No significant disability despite symptoms
2- Slight disability 
3- Moderate disability 
4- Moderately severe disability 
5- Severe disability
6- Dead
36
Q

What cannot be the objectives of I.V. thrombolysis?

A
  • To reduce mortality only
  • To reduce handicap only
  • To improve recanalization only [return of blood flow to a venous segment that had previously been occluded]
37
Q

Meta-analysis of trials

A

NNT to prevenet 1 death or dependency (mRS 2-6)

  • <90 minutes: 2
  • 90-180 minutes: 7
  • 180-270 minutes: 14
38
Q

For every 20 patients treated

A
  • 1 extra will be cured (Rankin 0)

- 1 extra will do very well (Rankin 1)

39
Q

So, whom would you thrombolyse?

A
  • Patient whom you think had a stroke
  • Within 4 ½ hours
  • Normal scan
  • No contraindications
40
Q

What are the contraindications of thrombolysis?

A
  • Age under 18 or over 8- years
  • Very severe stroke
  • Prior stroke and concomitant diabetes
  • History of haemorrhagic diabetic retinopathy
  • Receiving oral anticoagulants e.g. warfarin
  • Blood pressure limits >185/110
  • IV medication needed to reduce BP to these limits
  • Extensive infarction on CT
41
Q

What are the 5 trials for thrombectomy for acute ischaemic stroke?

A
  • MR CLEAN
  • ESCAPE
  • EXTEND IA
  • SWIFT-PRIME
  • REVASCAT
  • THRACE
42
Q

Number needed to treat: 3-7

A
  • Within 2-3 hours: 3
  • Within 41/2 hours: 7
  • PCI 35-45- to get benefit
43
Q

What can marked benefits be observed in?

A

Endovascular treatment

44
Q

What are the inclusion criteria for Throbectomy?

A

Achieved within 6 hours of onset of symptoms and where:

  • Inadequate response to IV thrombolysos by time of groin puncture
  • Patients unable to receive IV thrombolysis because recent surgery or on anticoagulants
45
Q

What is the challenge for Thrombectomy?

A
  1. STAFF
  2. CTA n DGH Local HASU
  3. Drip and ship or mothership
  4. Ambulance transfer HEMS
  5. Repatriation
46
Q

What is the patient pathway?

A
  1. Admission to nearest hospital with an hyperacute stroke unit
  2. Undergo initial investigations - CT and CTA
  3. Start treatment whee appropriate with IV tPA
  4. Critical transfer to nearest thrombectomy centre

C2 Modules CLINICAL (26 decks)

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