ACUTE STROKE: IMAGING AND INTERVENTIONS PERSPECTIVE

1. ACUTE STROKE: IMAGING AND
INTERVENTIONS PERSPECTIVE
Dr. N KHANDELWAL
PROF AND HEAD
DEPARTMENT OF RADIODIAGNOSIS & IMAGING
PGIMER, Chandigarh

2. Aims of Imaging
• To rule out intracranial hemorrhage.
• To rule out stroke mimickers.
• To detect early signs of ischemia.
• To detect the site of occlusion.
• To take a treatment decision.
• To prognosticate the patient.
• EVERYTHING TO BE DONE IN 10-15 MINUTES

3. Aims of Imaging
• To rule out intracranial hemorrhage.
– NCCT
– MRI :FLAIR and gradient echo imaging.

4. Aims of Imaging
• To rule out intracranial hemorrhage.

5. Aims of Imaging
• To rule out intracranial hemorrhage.
• To rule out stroke mimickers.
• Seizure
• Mass lesion
• Hypoglycemia
• Migraine
• Metabolic
encephalopathy
• Multiple Sclerosis
• Epidural/subdural
hematoma

8. Aims of Imaging
• To rule out intracranial hemorrhage.
• To rule out stroke mimickers.
• To detect early signs of ischemia.
– Dense artery sign
– Loss of gray-white differentiation

9. Dense Artery Sign
NCCT Head Evaluation

10. Dense Artery Sign
NCCT Head Evaluation

11. Loss of gray white interface
NCCT Head Evaluation

12. Loss of insular ribbon
NCCT Head Evaluation

13. Obscure lentiform nucleus
NCCT Head Evaluation

16. 14 th JULY 11 PM

18. What we can do to increase the diagnostic
confidence ?
NCCT Head Evaluation

23. Aims of Imaging
• To rule out intracranial hemorrhage.
• To rule out stroke mimickers.
• To detect early signs of ischemia.
• To detect the site of occlusion.

24. CT Angiography Evaluation
 Advanced helical CT application.
 High spatial resolution 3d images of the
cervical and intracranial vasculature
 Permits rapid identification of vessel
stenosis/occlusion

25. CT Angiography Evaluation

26. CT Angiography Evaluation

27. CT Angiography Evaluation

28. CT Angiography Evaluation

29. • Helpful tip: if no definite occlusion……
CT Angiography Evaluation

32. Aims of Imaging
• To rule out intracranial hemorrhage.
• To rule out stroke mimickers.
• To detect early signs of ischemia.
• To detect the site of occlusion.
• To take a treatment decision.
• To prognosticate the patient.

33. Prognosticating the patient……
• NCCT based approach
• CT angiography based approach

34. Prognosticating the patient……
• NCCT based approach
• CT angiography based approach

35. Alberta Stroke Program Early CT Score (ASPECTS)
• Baseline ASPECTS correlated inversely with the NIHSS
• As the ASPECTS decreased, the probability of
dependence, death, and symptomatic hemorrhage increased

36. TOTAL SCORE =10
SUBTRACT THE NUMBER
OF HYPODENSE REGIONS
FROM THIS SCORE OF 10.
8-10= GOOD PROGNOSIS
<8= POOR PROGNOSIS

37. Alberta Stroke Program Early CT Score (ASPECTS)
SCORE : 10-2= 8- GOOD PROGNOSIS

38. 10-5=5.
POOR PROGNOSIS

40. Prognosticating the patient……
• NCCT based approach
• CT angiography based approach

41. Prognosticating the patient……
• NCCT based approach
• CT angiography based approach
– COLLATERALS IMAGING
• SINGLE PHASE CTA
• MULTIPHASE CTA

45. Role of CT Perfusion…
• Limited
– wake up strokes
– Out of window period strokes
• MR diffusion-perfusion –same status
• To decide if treatment would be helpful or
not.

46. CT Perfusion
Parameters
CT Perfusion
Parameters
MTT:+++
CBF: Normal
CBV: Normal
MTT:+++
CBF: Normal
CBV: Normal
MTT: +++
CBF: Decreased
CBV: Normal
MTT: +++
CBF: Decreased
CBV: Normal
Treatment indicatedTreatment indicated
Treatment may be
given
Treatment may be
given
MTT: +++
CBF: Decreased
CBV: Decreased
MTT: +++
CBF: Decreased
CBV: Decreased Treatment might be
harmful
Treatment might be
harmful

48. Aims of Imaging
• To rule out intracranial hemorrhage.
• To rule out stroke mimickers.
• To detect early signs of ischemia.
• To detect the site of occlusion.
• To take a treatment decision.

49. Protocol Based Treatment
In Window
Period
Outside
Window Period
Distal
Occlusion
Proximal
Occlusion
Contraindications
to tPA
Clot Burden

50. Site of OcclusionSite of Occlusion
ProximalProximal
DistalDistal
• ICA bifurcation
• M1-MCA
• MCA bifurcation
• A1-ACA
• Vertebral-Basilar
artery
• P1-PCA
• ICA bifurcation
• M1-MCA
• MCA bifurcation
• A1-ACA
• Vertebral-Basilar
artery
• P1-PCA
• M2-M4 MCA
• A2-A4-ACA
• P2-P4 PCA
• M2-M4 MCA
• A2-A4-ACA
• P2-P4 PCA
Mechanical
thrombectomy
Mechanical
thrombectomy
ThrombolysisThrombolysis

51. INTERVENTIONS IN ACUTE STROKE
CHOICE OF INTERVENTIONS
– IV THROMBOLYSIS
– IA THROMBOLYSIS
– MECHANICAL THROMBECTOMY
– MECHANICAL ASPIRATION

52. • Intravenous Thrombolysis (t-PA)
– Treatment of choice in small vessel acute stroke
(<4.5hrs).
– Treatment of choice in large vessel stroke but in
combination with mechanical thrombectomy
INTERVENTIONS IN ACUTE STROKE

53. AHA/ASA Guideline
2015 AHA/ASA Focused Update of the 2013 Guidelines for the Early Management of
Patients With Acute Ischemic Stroke Regarding Endovascular Treatment
A Guideline for Healthcare Professionals From the American Heart Association/American
Stroke Association
The American Academy of Neurology affirms the value of this guideline as an educational tool
for neurologists.
Endorsed by the American Association of Neurological Surgeons (AANS); Congress of
Neurological Surgeons (CNS); AANS/CNS Cerebrovascular Section; American Society of
wers et al 1 DOI: 10.1161/STR.0000000000000074
ECOMMENDATIONS
ndovascular Interventions
1. Patients eligible for intravenous r-tPA should receive intravenous r-tPA even if
endovascular treatments are being considered (Class I; Level of Evidence A). (Unchanged
from the 2013 guideline)
2. Patients should receive endovascular therapy with a stent retriever if they meet all the
following criteria (Class I; Level of Evidence A). (New recommendation):
(a) prestroke mRS score 0 to 1,
26 DOI: 10.1161/STR.00000000000
INTERVENTIONS IN ACUTE STROKE

54. C o c h r a n e
T r u s t e d e v id e n c e .
In f o r m e d d e c is io n s .
B e t t e r h e a lt h .
C lo t -d is s o lv in g d r u g s f o r t r e a t in g is c h a e m ic s t r o k e in t h e e a r ly
s t a g e s
Q u e s t io n
W e w a n t e d t o c o m p a r e t h e sa fe t y a n d o f c lo t -d isso lv in g (t h r o m b o ly t ic ) d r u g s v e r su s
o r n o t r e a t m e n t in t h e e a r ly st a g e s o f isc h a e m ic st r o k e t o se e if c lo t -d isso lv in g d r u g s im p r o v e
a ft e r st r o k e .
B a c k g r o u n d
M o st st r o k e s a r e d u e t o b lo c k a g e o f a n a r t e r y in t h e b r a in b y a b lo o d c lo t . P r o m p t t re a t m e n t w it h c lo t -
d isso lv in g (t h r o m b o ly t ic ) d r u g s c a n r e st o r e b lo o d flo w b e fo r e m a jo r b r a in d a m a g e h a s o c c u r re d a n d
c o u ld t h a t p e o p le a r e m o r e lik e ly t o m a k e a g o o d r e c o v e r y fr o m t h e ir st r o k e . T h r o m b o ly t ic
d r u g s c a n a lso , h o w e v e r , c a u se se rio u s b le e d in g in t h e b r a in , w h ic h c a n b e fa t a l. T h r o m b o ly t ic
h a s n o w b e e n e v a lu a t e d in m a n y ra n d o m ise d t r ia ls in isc h a e m ic st r o k e . T h e t h r o m b o ly t ic d r u g
a lt e p la se h a s b e e n lic e n se d fo r u se w it h in t h r e e h o u r s o f st r o k e in t h e U S A a n d C a n a d a , a n d w it h in 4 .5
h o u r s in m o st E u r o p e a n c o u n t r ie s. T h e n u m b e r s o f p e o p le r e c e iv in g t h is t r e a t m e n t su c c e ssiv e ly a r e
in c r e a sin g .
e ffic a c y p la c e b o
o u t c o m e
m e a n
t h e r a p y
a c u t e
P A ), is lic e n se d fo r u se in se le c t e d p a t ie n t s w it h in 4 .5 h o u r s o f st r o k e in E u r
h o u r s in t h e U S A . T h e r e is a n u p p e r a g e lim it o f 8 0 y e a r s in so m e c o u n t r ie s,
m a in ly n o n -se v e r e st r o k e in o t h e rs. F o r t y p e r c e n t m o r e a r e a v a ila b le
la st u p d a t e d in 2 0 0 9 .
O b je c t iv e s :
T o d e t e r m in e w h e t h e r , a n d in w h a t c ir c u m st a n c e s, t h r o m b o ly t ic m
a n d sa fe t r e a t m e n t fo r isc h a e m ic st ro k e .
S e a r c h s t r a t e g y :
W e se a r c h e d t h e C o c h r a n e S t r o k e G r o u p T r ia ls R e g ist e r (la st se a r c h e d N o v
d a t a
t h e r a p y
a c u t e
M a in r e s u l t s :
W e in c lu d e d 2 7 t r ia ls, in v o lv in g 1 0 ,1 8 7 p a r t ic ip a n t s, t e st in g u r o k in a se , st r
r e c o m b in a n t p r o -u r o k in a se o r d e sm o t e p la se . F o u r t r ia ls u se d in t r a -a r t e r
t h e r e st u se d t h e r o u t e . M o st c o m e fr o m t r ia ls t h a t st a r
h o u r s a ft e r st r o k e . A b o u t 4 4 % o f t h e t r ia ls (a b o u t 7 0 % o f t h e p a r t ic ip a n t s
r t -P A . In e a r lie r st u d ie s v e r y fe w o f t h e p a r t ic ip a n t s (0 .5 % ) w e
in t r a v e n o u s d a t a
in t r a v e n o u s
C o c h r a n e
T r u s t e d e v id e n c e .
In f o r m e d d e c isio n s.
B e t t e r h e a lt h .
C lo t -d iss o lv in g d r u g s f o r t r e a t in g is c h a e m ic s t r o k e in t h e e a r ly
s t a g e s
Q u e s t io n
W e w a n t e d t o c o m p a r e t h e sa fe t y a n d o f c lo t -d isso lv in g (t h r o m b o ly t ic ) d r u g s v e r su s
o r n o t r e a t m e n t in t h e e a r ly st a g e s o f isc h a e m ic st r o k e t o se e if c lo t -d isso lv in g d r u g s im p r o v e
a ft e r st r o k e .
B a c k g r o u n d
M o st st ro k e s a r e d u e t o b lo c k a g e o f a n a rt e r y in t h e b r a in b y a b lo o d c lo t . P r o m p t t r e a t m e n t w it h c lo t -
d isso lv in g (t h r o m b o ly t ic ) d r u g s c a n r e st o r e b lo o d flo w b e fo r e m a jo r b r a in d a m a g e h a s o c c u r r e d a n d
c o u ld t h a t p e o p le a r e m o re lik e ly t o m a k e a g o o d r e c o v e r y fr o m t h e ir st r o k e . T h r o m b o ly t ic
d r u g s c a n a lso , h o w e v e r , c a u se se r io u s b le e d in g in t h e b r a in , w h ic h c a n b e fa t a l. T h ro m b o ly t ic
h a s n o w b e e n e v a lu a t e d in m a n y r a n d o m ise d t r ia ls in isc h a e m ic st r o k e . T h e t h r o m b o ly t ic d r u g
a lt e p la se h a s b e e n lic e n se d fo r u se w it h in t h r e e h o u r s o f st r o k e in t h e U S A a n d C a n a d a , a n d w it h in 4 .5
h o u r s in m o st E u r o p e a n c o u n t r ie s. T h e n u m b e r s o f p e o p le r e c e iv in g t h is t r e a t m e n t su c c e ssiv e ly a r e
in c r e a sin g .
S t u d y c h a r a c t e r is t ic s
W e id e n t ifie d 2 7 t r ia ls w it h a t o t a l o f 1 0 ,1 8 7 p a r t ic ip a n t s in se a r c h e s c o n d u c t e d u p t o N o v e m b e r 2 0 1 3 .
M o st c o m e fr o m t r ia ls t e st in g o n e d r u g (r e c o m b in a n t P la sm in o g e n A c t iv a t o r , r t -P A ) g iv e n
in t o a v e in u p t o six h o u r s a ft e r isc h a e m ic st r o k e , b u t se v e ra l o t h e r d r u g s w e r e a lso t e st e d a n d a t
d iffe r e n t t im e s t o t r e a t m e n t a ft e r st r o k e a n d g iv e n in t o a n a r t e r y in t h e b r a in r a t h e r t h a n in t o a v e in in
t h e a r m . A ll t r ia ls c o m p a r e d a c lo t -d isso lv in g d r u g w it h a ( ) g r o u p . M o st t r ia ls in c lu d e d
e ffic a c y p la c e b o
o u t c o m e
m e a n
t h e r a p y
a c u t e
d a t a t issu e
a c u t e
p la c e b o c o n t r o l
P A ), is lic e n se d fo r u se in se le c t e d p a t ie n t s w it h in 4 .5 h o u r s o f st r o k e in E u r o p e a n d w it h in t h r e e
h o u r s in t h e U S A . T h e r e is a n u p p e r a g e lim it o f 8 0 y e a r s in so m e c o u n t r ie s, a n d a lim it a t io n t o
m a in ly n o n -se v e r e st r o k e in o t h e r s. F o r t y p e r c e n t m o r e a r e a v a ila b le sin c e t h is w a s
la st u p d a t e d in 2 0 0 9 .
O b je c t iv e s :
T o d e t e r m in e w h e t h e r , a n d in w h a t c ir c u m st a n c e s, t h r o m b o ly t ic m ig h t b e a n e ffe c t iv e
a n d sa fe t r e a t m e n t fo r isc h a e m ic s t r o k e .
S e a r c h s t r a t e g y :
W e se a r c h e d t h e C o c h r a n e S t r o k e G r o u p T r ia ls R e g ist e r (la st se a r c h e d N o v e m b e r 2 0 1 3 ),
(1 9 6 6 t o N o v e m b e r 2 0 1 3 ) a n d (1 9 8 0 t o N o v e m b e r 2 0 1 3 ). W e a lso h a n d se a r c h e d
c o n fe r e n c e p r o c e e d in g s a n d jo u r n a ls, se a r c h e d r e fe r e n c e list s a n d c o n t a c t e d p h a r m a c e u t ic a l
c o m p a n ie s a n d t r ia list s.
d a t a r e v ie w
t h e r a p y
a c u t e
M E D L IN E
E M B A S E
M a in r e s u l t s :
W e in c lu d e d 2 7 t r ia ls, in v o lv in g 1 0 ,1 8 7 p a r t ic ip a n t s, t e st in g u r o k in a se , st r e p t o k in a se , r t -P A ,
r e c o m b in a n t p r o -u r o k in a se o r d e sm o t e p la se . F o u r t r ia ls u se d in t r a -a r t e r ia l a d m in ist r a t io n , w h ile
t h e r e st u se d t h e r o u t e . M o st c o m e fr o m t r ia ls t h a t st a r t e d t r e a t m e n t u p t o six
h o u r s a ft e r st r o k e . A b o u t 4 4 % o f t h e t r ia ls (a b o u t 7 0 % o f t h e p a r t ic ip a n t s) w e r e t e st in g
r t -P A . In e a r lie r st u d ie s v e r y fe w o f t h e p a r t ic ip a n t s (0 .5 % ) w e r e a g e d o v e r 8 0 y e a r s; in
t h is u p d a t e , 1 6 % o f p a r t ic ip a n t s a r e o v e r 8 0 y e a r s o f a g e d u e t o t h e in c lu sio n o f IS T -3 (5 3 % o f
p a r t ic ip a n t s in t h is w e r e a g e d o v e r 8 0 y e a r s). T r ia ls p u b lish e d m o r e r e c e n t ly u t ilise d
c o m p u t e r ise d , so t h e r e a r e le ss lik e ly t o b e b a se lin e im b a la n c e s t h a n in p r e v io u s
in t r a v e n o u s d a t a
in t r a v e n o u s
t r ia l
r a n d o m isa t io n

55. iv thrombolysis work….
Why do we need alternative form of
treatment ?
INTERVENTIONS IN ACUTE STROKE

58. Limitations of iv-tPA
– Moderate to poor efficacy in large strokes
– Window period too short
– Risk of bleed
INTERVENTIONS IN ACUTE STROKE

59. Available Techniques:
•Intra-arterial thrombolysis
•Mechanical clot removal
– MERCI
– PENUMBRA
– STENTRIEVERS
– DIRECT ASPIRATION
INTERVENTIONS IN ACUTE STROKE

60. ESCAPE
EXTEND-IA
SWIFT PRIME
MR-CLEAN

63. RECOMMENDATIONS
Endovascular Interventions
1. Patients eligible for intravenous r-tPA should receive intravenous r-tPA even if
endovascular treatments are being considered (Class I; Level of Evidence A). (Unchanged
from the 2013 guideline)
2. Patients should receive endovascular therapy with a stent retriever if they meet all the
following criteria (Class I; Level of Evidence A). (New recommendation):
(a) prestroke mRS score 0 to 1,
(b) acute ischemic stroke receiving intravenous r-tPA within 4.5 hours of onset
according to guidelines from professional medical societies,
(c) causative occlusion of the internal carotid artery or proximal MCA (M1),
(d) age ≥18 years,
(e) NIHSS score of ≥6,
(f) ASPECTS of ≥6, and
(g) treatment can be initiated (groin puncture) within 6 hours of symptom onset
3. As with intravenous r-tPA, reduced time from symptom onset to reperfusion with
2015 AHA/ASA Focused Update of the 2013 Guidelines for the Early Management of
Patients With Acute Ischemic Stroke Regarding Endovascular Treatment
A Guideline for Healthcare Professionals From the American Heart Association/American
Stroke Association
The American Academy of Neurology affirms the value of this guideline as an educational tool
for neurologists.
Endorsed by the American Association of Neurological Surgeons (AANS); Congress of
Neurological Surgeons (CNS); AANS/CNS Cerebrovascular Section; American Society of
Neuroradiology; and Society of Vascular and Interventional Neurology

65. Mechanical Thrombectomy
Stent retrievers
INTERVENTIONS IN ACUTE STROKE

66. Mechanical Thrombectomy
INTERVENTIONS IN ACUTE STROKE

67. • Ability to restore blood flow immediately,
administer medical therapy and retrieve clot.
• Basically a dedicated, low profile retrievable
stent system which catches the clot and retrieves
it.
INTERVENTIONS IN ACUTE STROKE

68. 67y/M
• Weakness over left side of the body
• deviation of face towards left side
• inability to speak
• Duration 4hrs
• Known case of Type 2 DM since 20 years, on
medication

81. Post procedure NCCT

83. 60Y/F
CLINICAL DETAILS:
• Known hypertensive and DM on treatment.
• c/o unresponsiveness at 8:20pm with left facial deviation.
• h/o vomiting – 2episodes.
O/E:
• E1V1M3 status with non reacting pupils ? Posterior
circulation stroke.
• NCCT HEAD WITH CT ANGIO.
• IV THROMBOLYSIS

96. Mr.VA; 26 M
• Left facial weakness and right lower limb
paresis of 16 hours duration.
• Upper limb paresis 4hrs.

109. Follow up
• Patient improved in the DSA room.
• Discharge with mRS of 4

110. • Mechanical Thrombectomy leads to good
outcomes
• Limitation is still the time of intervention
• Puncture to reperfusion time should be
minimized
INTERVENTIONS IN ACUTE STROKE

118. Disadvantages:
•Blind negotiation of the occluded segment.
•Distal migration of clot fragments
•Complication rate 3-5%.
INTERVENTIONS IN ACUTE STROKE

119. • Direct Catheter Aspiration
– Attractive concept
– No handling of thrombus
– Minimally invasive
– No blind progression of microcatheter
• Problems:
– Larger bore catheters usually too stiff
– No dedicated systems
INTERVENTIONS IN ACUTE STROKE

120. INTERVENTIONS IN ACUTE STROKE

121. Turk AS, et al. J NeuroIntervent Surg 2014;0:1–5.
doi:10.1136/neurintsurg-2014-011125
INTERVENTIONS IN ACUTE STROKE

122. INTERVENTIONS IN ACUTE STROKE

125. or proximal MCA (M1) (Class IIb; Level of Evidence B-R). Additional randomized trial
data are needed. (New recommendation)
9. Observing patients after intravenous r-tPA to assess for clinical response before pursuing
endovascular therapy is not required to achieve beneficial outcomes and is not
recommended. (Class III; Level of Evidence B-R). (New recommendation)
10. Use of stent retrievers is indicated in preference to the MERCI device. (Class I; Level of
Evidence A). The use of mechanical thrombectomy devices other than stent retrievers may
be reasonable in some circumstances (Class IIb, Level B-NR). (New recommendation)
11. The use of proximal balloon guide catheter or a large bore distal access catheter rather than
a cervical guide catheter alone in conjunction with stent retrievers may be beneficial (Class
IIa; Level of Evidence C). Future studies should examine which systems provide the
highest recanalization rates with the lowest risk for nontarget embolization. (New
INTERVENTIONS IN ACUTE STROKE
AHA GUIDELINES:

126. Towards end……
• NCCT
– Rule out hemorrhage
– Early signs of
ischemia
– Prognostication
(ASPECTS scoring)
• CT angiography
– Site of blockage
– Collateral mapping
• CT Perfusion
– Wake up strokes.
• INTERVENTIONS
– iv t-PA
– Stentrievers
– Direct aspiration technique
Time is the key.
NCCT and CT angiography mainstay of imaging.

127. November 11-13, 2016
Venue: Lecture theatre complex, PGIMER, Chandigarh
In collaboration with Society of Breast Imaging (SBI), USA

128. Thank You