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"Code-Stroke" CT Perfusion; Challenges and Pitfalls
Houman Sotoudeh1, Asim K Bag2, Michael David Brooks3
1Department of Neuroradiology, University of Alabama at Birmingham, 619 19th St S, Birmingham, AL 35294; Department of Neuroradiology; University of Alabama at Birmingham, Birmingham, Alabama.
Insights
CT perfusion imaging is vital for acute ischemic stroke treatment up to 24 hours. Understanding subacute CT perfusion findings is crucial for timely, effective patient care and avoiding treatment complications.
Area of Science:
- Neuroradiology
- Emergency Medicine
- Stroke Imaging
Background:
- Current guidelines recommend perfusion imaging up to 24 hours post-ischemic stroke.
- Patients with salvageable brain tissue benefit from reperfusion therapies.
- CT perfusion is increasingly utilized in the subacute stroke phase.
Purpose of the Study:
- To explain the fundamental concepts of "code-stroke" CT perfusion.
- To detail typical findings and common pitfalls in subacute ischemic stroke CT perfusion.
- To provide a practical guide for interpreting urgent CT perfusion studies.
Main Methods:
- Review of CT perfusion imaging in the subacute phase of ischemic stroke.
- Discussion of "code-stroke" protocols and interpretation challenges.
- Highlighting differences between hyper-acute and subacute CT perfusion findings.
Main Results:
- Subacute CT perfusion findings differ from hyper-acute findings.
- Accurate interpretation is critical due to time-sensitive treatment decisions.
- Misinterpretation can lead to exclusion from beneficial treatments or unnecessary, dangerous interventions.
Conclusions:
- Radiologists must be proficient in interpreting urgent CT perfusion studies.
- Correctly identifying salvageable tissue is essential for guiding reperfusion therapy.
- Accurate CT perfusion interpretation directly impacts patient outcomes in acute ischemic stroke.
Rationale And Objectives:
Regarding the most recent ischemic stroke treatment guideline, perfusion imaging has been recommended up to 24 hours after initial symptoms of brain infarction. Patients with a significant amount of salvageable peri-infarct ischemia and no contraindications benefit from delayed thrombolysis and intra-arterial thrombectomy. This approach causes increasingly more CT perfusion to be done in the subacute phase of ischemic stroke. CT perfusion findings in this "subacute phase" are slightly different from "hyper-acute" ischemic stroke. The interpreting radiologist must be confident in reporting the CT perfusion study in an urgent setting since these studies are under the umbrella of "code-stroke" and should be read in minutes. In addition, results of the CT perfusion have a critical effect on the patient's outcome and misinterpretation can be fatal in that underestimation of the salvageable ischemia excludes the patient from potential effective treatment. Underestimation of infarct volume may cause unnecessary thrombolysis/thrombectomy and potentially fatal intracranial hemorrhage.
Materials And Methods:
In this review, we are trying to explain the basic concept of "code-stroke" CT perfusion, typical findings, and pitfalls in a practical way.