What is the best assessment method for acute stroke? Talk about your thoughts

*For medical professionals to read only for reference CT, CTA, CTP and multi-temporal CTA, which one do you choose? The broad definition of community hospitals includes small centers without acute stroke preparation, hospitals with acute stroke preparation, primary stroke centers, and primary stroke centers with endovascular treatment capabilities.

At the 2021 International Stroke Conference held recently, four experts from internationally renowned medical centers launched a wonderful debate on the choice of imaging examination for acute stroke.

This debate is not about the increasing number of endovascular treatments and the discussion of no large vessel occlusion, but to find a practical, effective, economical, and the best acute brain in community hospitals that can be implemented on a global scale.
Imaging plan for stroke.

CT is everything! First of all, Dr.
Achala Vagal from the University of Cincinnati Medical Center believes that CT can provide everything a community hospital needs.

For intravenous thrombolysis, CT is a necessary basic examination, which can help us quickly determine whether there is cerebral hemorrhage and middle cerebral artery high density sign.

For community hospitals, there are many challenges in performing CTA or CTP examinations, such as the need for plan optimization, professional hardware and software, etc.
Moreover, who reads the images is also a problem.
After all, the proportion of radiologists in community hospitals is small.

In addition, CTP also has many diagnostic pitfalls, such as the ischemic penumbra and core infarct area which are easy to be confused, overestimated or underestimated, and the effect differences between different software are also obvious.

Another question that needs to be considered is, if multimodal imaging is performed in a community hospital, can re-imaging at an advanced stroke center be avoided? It can be avoided if the transfer time is less than one hour, but if the transfer time between hospitals exceeds 90 minutes, it is more likely to repeat the imaging.

If every stroke patient completes CT, CTA, CTP and other examinations, it will not only cause excessive use of images, but also increase the cost of medical care.

Therefore, Dr.
Achala Vagal appealed that our goal is not to follow the minimum standards, but to choose the best and most practical to obtain the image results we want.

More importantly, we must pay attention to efficiency, because time is the brain! CTA is the most suitable! Dr.
Richard Aviv from the University of Ottawa believes that CTA is the most suitable community hospital.

CTA can be used to determine the location of occlusion or stenosis of the blood vessel and the evaluation of collateral circulation compensation.

He reviewed a review in 2015, which examined the impact of endovascular treatment and CTA use, illustrating the important role of CTA in primary stroke centers.

He also mentioned that in the 2018 Early Management Guidelines for Patients with Acute Ischemic Stroke, the implementation of acute non-invasive intracranial angiography can better select patients for endovascular treatment.

(2018 Guidelines for the early management of patients with acute ischemic stroke) So he believes that CTA is the most suitable for community hospitals, and it has been carried out in many primary stroke centers.

However, for patients with acute stroke undergoing CTA, the images need to be processed quickly to avoid delays in the disease, diagnose as soon as possible, and if they need to be transferred to a comprehensive stroke center, the care path needs to be coordinated.

I choose CTP, simple and precise! The third expert is Dr.
Jeremy J.
Heit from Stanford University Medical Center.
He believes that CTP is easier and more accurate to judge large vessel occlusion in community hospitals.

The suitable population for large vessel occlusion generally has a smaller core infarct area and a larger area of ​​the ischemic penumbra.

At present, the intravascular treatment time window for large vessel occlusion can be extended to 16-24 hours, so for patients with large vessel occlusion, there is sufficient time to perfect CTP.

CTP is also helpful for potential treatment options before referral.

Studies have shown that CTP has a sensitivity of 97.
3% and a specificity of 98.
7% for the selection of patients with thrombus removal.

CTP has the advantage of thrombectomy triage, which can predict the core infarct area through data, but further research is needed to guide thrombectomy treatment for large-area core infarction.

To monitor great vessel occlusion, choose multi-phase CTA! Dr.
Arindam Rano Chatterjee from MIR Mallinckrodt believes that multi-phase CTA is the most suitable method for monitoring large vessel occlusion in community hospitals.

Multi-temporal CTA is a new imaging technology that is convenient to operate, without additional contrast, does not require complex post-processing to reduce motion artifacts, images are easy to quickly diagnose, and does not require post-processing vendor software.

Multi-phase CTA improves the time resolution.
By collecting images in the arterial and venous phases, the perfusion of the pial arterial can be more accurately assessed.

Multi-phase CTA has 20% more radiation dose than single-phase CTA, and CTP is 70% more than single-phase CTA.
In addition, the additional radiation of CTP to the eye is 4 times that of multi-phase CTA, so multi-phase CTA is superior to CTP in terms of radiation.
.

Multi-phase CTA is also superior to single-phase CTA, because it can better detect vascular obstruction, can judge the length of thrombus, and there is no additional calculation or cost, and a slight increase in radiation dose, which reduces the successful implementation in community hospitals.
obstacle.

So is multi-phase CTA the most suitable method for community hospitals to detect large vessel occlusion? Perhaps yes, it is better than not being able to do CTP in a community hospital.

Summary: The author believes that the above-mentioned examinations have their own advantages and disadvantages.
CT is an entry choice for acute stroke.
CTA helps us to judge intracranial angiography early, which can better screen patients for endovascular treatment, and CTP is easier It is more suitable for large-vessel occlusion to accurately judge large-vessel occlusion, and to screen patients with small infarct core and large ischemic penumbra.
As a new imaging technology, multi-phase CTA can also quickly identify large-vessel occlusion, and the operation is simple.
A good choice.

So for patients with acute stroke in community hospitals, which imaging evaluation would you choose? Please tell us your answer in the message area.