A Clinical Approach to Computed Tomography in Acute Cerebral Ischemia

Česká verzia

Authors: V. Rohan ¹; P. Ševčík ¹; J. Polívka ¹; Z. Ambler ¹; B. Kreuzberg ²; J. Ferda ²
Authors place of work: Neurologická klinika LF UK a FN Plzeň ¹; Radiodiagnostická klinika LF UK a FN Plzeň ²
Published in the journal: Cesk Slov Neurol N 2007; 70/103(6): 643-652
Category: Review Article

Práce podpořena VZ MŠM 00 21620816.

Summary

Progress in reperfusion methods of treatment of acute cerebral ischemia has been reflected in the growing importance of imaging methods in the selection of patients profiting from the treatment. Unenhanced computed tomography brain imaging without the administration of the contrast substance is a standard examination procedure today in patients with cerebrovascular accident. Progress in computed tomography in recent years has allowed for its use for relatively thorough examination of the cerebral venous bed and of perfusion comparable with other imaging methods. The article provides basic theoretical and practical information important for correct interpretation of the results of such examination. With the knowledge of the potential and limits of the method, multimodal computed tomography can become a valuable tool and assistance to the clinician and a method of choice for patients with acute cerebrovascular accident thanks to its availability, safety and simplicity of performance.

Key words:
acute cerebral ischemia – computed tomography – brain perfusion – perfusion computed tomography – computed tomography angiography

Zdroje

1. 1999 World Health Organization. International society of hypertension guidelines for the management of hypertension. Guidelines subcommitee. J Hypertens 1999; 17: 151-183.

2. Cerebrovaskulární sekce České lékařské společnosti JEP. Národní cerebrovaskulární program. Available from: URL: http://www.cmp.cz/ncp.doc

3. Astrup J, Siesjo BK, Simon L. Thresholds in cerebral ischemia: the ischemic penumbra. Stroke 1981; 12: 723-725.

4. The National Institute of Neurological Disorders and Stroke rt-PA Stroke Study Group. Tissue plasminogen activator for acute ischemic stroke. N Engl J Med 1995; 333: 1581-1587.

5. Furlan A, Higashida R, Wechsler L, Gent M, Rowley H, Kase C et al. Intra-arterial prourokinase for acute ischemic stroke: The PROACT II Study: A randomized controlled trial. JAMA 1999; 282: 2003-2011.

6. Marler JR, Tilley BC, Lu M, Brott TG, Lyden PC, Grotta JC, et al. Early stroke treatment associated with better outcome: the NINDS rt-PA stroke study. Neurology 2000; 55(11): 1649-1655.

7. Kalvach P, Keller J. Variace mozkového průtoku v zobrazovacích metodách. Česk Slov Neurol N 2007; 70/103: 118-128.

8. Mikulík R, Neumann J, Školoudík D, Václavík D. Standard pro diagnostiku a léčbu pacientů s mozkovým infarktem. Česk Slov Neurol N 2006; 69/102: 320-325.

9. Mayer TE, Schulte-Altedorneburg G, Dorste DW, Brückmann H. Serial CT and MRI of ischemic cerebrál infarcts: frequency and clinical impact of haemorrhagic transformation. Neuroradiology 2000; 42: 233-239.

10. Barber PA, Darby DG, Desmond PM, Gerraty RP, Zang O, Li T et al. Identification of major ischemic change. Diffusion-weighted imaging versus computed tomography. Stroke 1999; 30: 2059-2065.

11. Feibach J, Jansen O, Schellinger P, Knauth M, Hartmann M, Heiland S et.al. Comparison of CT with diffusion-weighted MRI in patients with hyperacute stroke. Neuroradiology 2001; 43: 628-632.

12. Jaillard a, Hommel M, Baird AE, Linfante I, Llinas RH, Caplan LR et al. Significance of early CT signs in acute stroke – a CT scan-diffusion MR study. Cerebrovasc Dis 2002; 13: 47-56.

13. Lansberg MG, Albers GW, Beaulieu C, Marks MP. Comparison of diffusion-weighted MRI and CT in acute stroke. Neurology 2000; 54: 1557-1561.

14. Mullins ME, Lev MH, Schellingerhout D, Koroshetz WJ, Gonzalez RG. Influence of availability of clinical history on detection of early stroke using unenhanced CT and diffusion-weighted MR imaging. AJNR Am J Neuroradiol 2002; 179: 223-228.

15. Del Zoppo GJ, von Kummer R, Hamann GF. Ischemic damage of brain microvessels: inherent risks for trombolytic treatment in stroke. J Neurol Neurosurg Psychiatry 1998; 65: 1-9.

16. von Kummer R, Bourquain H, Bastianello S, Bozzao L, Manelfe C, Meier D, et al. Early prediction of irreversible brain damage after ischemic stroke at CT. Radiology 2001; 219: 95-100.

17. Von Kummer R. Effect of training in reading CT scans on patient selection for ECASS II. Neurology 1998; 51: 850–852.

18. Grotta JC, Chiu D, Lu M, Patel S, Levine SR, Tilley BC et al. Agreement and variability in the interpretation of early CT changes in stroke patients qualifying for intravenous rtPA therapy. Stroke 1999; 30: 1528–1533.

19. Lev MH, Farkas J, Gemmete JJ, Hossain ST, Hunter GJ, Koroshetz WJ et al. Acute stroke: improved nonenhanced CT detection: benefits of soft-copy interpretation by using variable window width and center level settings. Radiology 1999; 213: 150–155.

20. Barber PA, Demchuk AM, Zhang J, Buchan AM. Validity and reliability of a quantitative computed tomography score in predicting outcome of hyperacute stroke before thrombolytic therapy. ASPECTS Study Group. Alberta Stroke Programme Early CT Score. Lancet 2000; 355: 1670–1674.

21. Levy DE, Brott TG, Haley EC Jr, Marler JR, Sheppard GL, Barsan W et al. Factors related to intracranial hematoma formation in patients receiving tissue-type plasminogen activator for acute ischemic stroke. Stroke 1994; 25: 291–297.

22. Hacke W, Kaste M, Fieschi C, Toni D, Lesaffre E, von Kummer R et al. Intravenous thrombolysis with recombinant tissue plasminogen activator for acute hemispheric stroke: the European Cooperative Acute Stroke Study (ECASS). JAMA 1995; 274: 1017–1025.

23. Larrue V, von Kummer RR, Muller A, Bluhmki E. Risk factors for severe hemorrhagic transformation in ischemic stroke patients treated with recombinant tissue plasminogen activator: a secondary analysis of the European-Australasian Acute Stroke Study (ECASS II). Stroke 2001; 32: 438–441.

24. Jaillard A, Cornu C, Durieux A, Moulin T, Boutitie F, Lees KR et al. Hemorrhagic transformation in acute ischemic stroke: the MAST-E study. MAST-E Group. Stroke 1999; 30: 1326–1332.

25. Tanne D, Kasner SE, Demchuk AM, Koren-Morag N, Hanson S, Grond M et al. Markers of increased risk of intracerebral hemorrhage after intravenous recombinant tissue plasminogen activator therapy for acute ischemic stroke in clinical practice: the Multicenter rt-PA Stroke Survey. Circulation 2002; 105: 1679–1685.

26. Patel SC, Levine SR, Tilley BC, Grotta JC, Lu M, Frankel M et al. Lack of clinical significance of early ischemic changes on computed tomography in acute stroke. JAMA 2001; 286: 2830–2838.

27. Gilligan A, Markus R, Read S, Srikanth V, Hirano T, Fitt G et al. Baseline blood pressure and not early CT changes predict major hemorrhage after streptokinase in acute ischemic stroke. Stroke 2002; 33: 2236-2242.

28. Roberts HC, Dillon WP, Furlan AJ, Wechsler LR, Rowley HA, Fischbein NJ et al. Computed tomographic findings in patients undergoing intra-arterial thrombolysis for acute ischemic stroke due to middle cerebral artery occlusion: results from the PROACT-II trial. Stroke 2002; 33: 1557–1565.

29. Donnan GA, Davis SM. Neuroimaging, the ischemic penumbra, and selection of patients for acute stroke therapy. Lancet Neurology 2002; 1: 417-425.

30. Hacke W, Albers G, Al-Rawi Y, Bogousslavsky J, Davalos A, Eliasziw M et al. The Desmoteplase in Acute Ischemic Stroke Trial (DIAS): a phase II MRI-based 9-hour window acute stroke thrombolysis trial with intravenous desmoteplase. Stroke 2005; 36: 66–73.

31. Furlan AJ, Eyding D, Albers GW, Al-Rawi Y, Lees KR, Rowley HA et al. Dose Escalation of Desmoteplase for Acute Ischemic Stroke (DEDAS): evidence of safety and efficacy 3–9-hours after stroke onset. Stroke 2006; 37:1227–1231.

32. Traupe H, Heiss WD, Hoeffken W, Zulch KJ. Hyperperfusion and enhancement in dynamic computed tomography of ischemic stroke patients. J Comput Assist Tomogr 1979; 3: 627-632.

33. Coutts SB, Simon JE, Tomanek AI, Barber PA, Chan J, Hudon ME et al. Reliability of assessing percentage of diffusion-perfusion mismatch. Stroke 2003; 34(7): 1681-3.

34. Cohnen M, Wittsack HJ, Assadi S, Muskalla K, Ringelstein A et al. Radiation Exposure of Patients in Comprehensive Computed Tomography of the Head in Acute Stroke. AJNR Am J Neuroradiol 2006; 27: 1741-1745.

35. Kendell B, Pullicono P. Intravascular contrast injection in ischemic lesions, II. Effect on prognosis. Neuroradiology 1980; 19: 241-243.

36. Doerfler A, Engelhorn T, von Kummer R, Weber J, Knauth M, Sartor K et al. Are iodinated contrast agents detrimental in acute cerebral ischemia? An experimental study in rats. Radiology 1998; 206: 211-217.

37. Palomaki H, Muuronen A, Raininko R, Piilonen A, Kaste M. Administration of nonionic iodinated contrast medium does not influence the outcome of patients with ischemic brain infarction. Cerebrovasc Dis 2003; 15(1–2):45-50.

38. Aspelin P, Aubry P, Fransson SG, Strasser R, Willenbrock R, Lundkvist J. Nephrotoxic effects in high-risk patients undergoing angiography. N Engl J Med 2003; 348(6): 491-499.

39. Meier P, Zieler K. On the theory of the indicator dilution method for measurement of blood flow and volume. J Appl Physiol 1954; 6: 731-744.

40. Roberts G, Larson K. The interpretation of mean transit time measurements for multi-phase tissue systems. J Theor Biol 1973; 39:447-75.

41. Ferda J. CT angiografie. 1st ed. Praha: Galén 2004.

42. König M, Klotz E, Heuser L. Cerebral perfusion CT: theoretical aspects, practical implementation and clinical experience in acute ischemic stroke (German). Fortschr Röntgenstr 2000; 172: 210-218.

43. Wintermark M, Maeder P, Thiran JP, Schnyder P, Meuli R. Quantitative assessment of regional cerebral blood flows by perfusion CT studies at low injection rates: a critical review of the underlying theoretical models. Eur Radiol 2001; 11(7): 1220-1230.

44. Wirestam R, Andersson L, Ostergaard L, Bowling M, Aunola JP, Lindgren A et al. Assessment of regional cerebral blood flow by dynamic susceptibility contrast MRI using different deconvolution techniques. Magn Reson Med 2000; 43(5): 691-700.

45. Cenic A, Nabavi DG, Craen RA, Gelb AW, Lee TY. Dynamic CT measurement of cerebral blood flow: a validation study. AJNR Am J Neuroradiol 1999; 20(1): 63-73.

46. Nabavi DG, Cenic A, Craen RA, Gelb AW, Bennett JD, Kozak R et al. CT assessment of cerebral perfusion: experimental validation and initial clinical experience. Radiology 1999; 213(1): 141-149.

47. Lev MH, Farkas J, Rodriguez VR, Schwamm LH, Hunter GJ, Gonzalez RG et al. CT angiography in the rapid triage of patients with hyperacute stroke to intraarterial thrombolysis accuracy in the detection of large vessel thrombus. J Comput Assist Tomogr 2001; 25(4): 520–528.

48. Lev MH, Romero JM, Goodman DNF, Bagga R, Kim HYK, Gonzalez RG. Total occlusion versus hairline residual lumen of the internal carotid arteries accuracy of single section helical CT angiography. AJNR Am J Neuroradiol 2003 24: 1123–1129.

49. Schramm P, Schellinger PD, Klotz E, Maeder P, Thiran JP, Schnyder P et al. Comparison of perfusion computed tomography and computed tomography angiography source images with perfusion-weighted imaging and diffusion-weighted imaging in patients with acute stroke of less than 6 hours’ duration. Stroke 2004; 35: 1652–1658.

50. Schwamm LH, Rosenthal ES, Swap CJ, Rosand J, Rordorf G, Lev HM et al. Hypoattenuation on CT Angiographic Source Images Predicts Risk of Intracerebral Hemorrhage and Outcome after Intra-Arterial Reperfusion Therapy. AJNR Am J Neuroradiol 2005; 26: 1798-1803.

51. Sylaja PN, Dzialowski I, Krol A, Roy J, Federico P, Demchuk AM, and Calgary Stroke Program. Role of CT Angiography in Thrombolysis Decision-Making for Patients With Presumed Seizure at Stroke Onset. Stroke 2006; 37(3): 915-917.

52. Lev MH, Segal AZ, Farkas J, Hossain ST, Putman C, Hunter GJ et al. Utility of perfusion-weighted CT imaging in acute middle cerebral artery stroke treated with intraarterial thrombolysis: prediction of final infarct volume and clinical outcome. Stroke 2001; 32(9): 2021-2028.

53. Schramm P, Schellinger PD, Fiebach JB, Heiland S, Jansen O, Knauth M et al. Comparison of CT and CT angiography source images with diffusion-weighted imaging in patients with acute stroke within 6 hours after onset. Stroke 2002; 33(10): 2426-2432.

54. Wintermark M, Fischbein NJ, Smith WS, Ko NU, Quist M, Dillon WP. Accuracy of dynamic perfusion CT with deconvolution in detecting acute hemispheric stroke. AJNR Am J Neuroradiol 2005; 26(1): 104-112.

55. Kidwell CS, Saver JL, Mattiello J, Starkman S, Vinuela F, Duckwiler G et al. Thrombolytic reversal of acute human cerebral ischemic injury shown by diffusion/perfusion magnetic resonance imaging. Ann Neurol 2000; 47(4): 462-469.

56. Hunter GJ, Silvennoinen HM, Hamberg LM, Koroshetz WJ, Buonanno FS, Schwamm LH et al. Whole-brain CT perfusion measurement of perfused cerebral blood volume in acute ischemic stroke: probability curve for regional infarction. Radiology 2003; 227(3): 725-730.

57. Bisdas S, Donnerstag F, Ahl B, Bohrer I, Weissenborn K, Becker H et al. Comparison of perfusion computed tomography with diffusion-weighted magnetic resonance imaging in hyperacute ischemic stroke. J Comput Assist Tomogr 2004; 28(6): 747-755.

58. Wintermark M, Flanders AE, Velthuis B, Meuli R, van Leeuwen M, Goldsher D et al. Perfusion-CT Assessment of Infarct Core and Penumbra. Stroke 2006; 37: 979-985.

59. Eastwood JD, Lev MH, Wintermark M, Fitzek C, Barboriak DP, Delong DM et al. Correlation of early dynamic CT perfusion imaging with whole-brain MR diffusion and perfusion imaging in acute hemispheric stroke. AJNR Am J Neuroradiol 2003; 24: 1869–1875.

60. Eastwood JD, Lev MH, Azhari T, Lee TY, Barboriak DP, Delong DM et al. CT perfusion scanning with deconvolution analysis: pilot study in patients with acute middle cerebral artery stroke. Radiology 2002; 222: 227–236.

61. Wintermark M, Reichhart M, Cuisenaire O, Maeder P, Thiran JP, Schnyder P et al. Comparison of admission perfusion computed tomography and qualitative diffusion- and perfusion-weighted magnetic resonance imaging in acute stroke patients. Stroke 2002; 33: 2025–2031.

62. Wintermark M, Reichhart M, Thiran JP, Maeder P, Chalaron M, Schnyder P et al. Prognostic accuracy of cerebral blood flow measurement by perfusion computed tomography, at the time of emergency room admission, in acute stroke patients. Ann Neurol 2002; 51: 417–432.

63. Mayer TE, Hamann GF, Baranczyk J, Rosengarten B, Klotz E, Wiesmann M et al. Dynamic CT perfusion imaging of acute stroke. AJNR Am J Neuroradiol 2000; 21: 1441–1449.

64. Reichenbach JR, Rother J, Jonetz-Mentzel L, Rosengarten B, Klotz E, Wiesmann M et al. Acute stroke evaluated by time-to-peak mapping during initial and early follow-up perfusion CT studies. AJNR Am J Neuroradiol 1999; 20: 1842–1850.

65. Schaefer PW, Roccatagliata L, Ledezma C, Hoh B, Schwamm LH, Koroshetz W et al. First-pass quantitative CT perfusion identifies thresholds for salvageable penumbra in acute stroke patients treated with intra-arterial therapy. AJNR Am J Neuroradiol 2006; 27: 20–25.

66. Marchal G, Rioux P, Petit-Taboue MC, Sette G, Travere JM, Le Poec C et al. Regional cerebral oxygen consumption, blood flow, and blood volume in healthy human aging. Arch Neurol 1992; 49: 1013–1020.

67. Murphy BD, Fox AJ, Lee DH, Sahlas DJ, Black SE, Hogan MJ et al. Identification of penumbra and infarct in acute ischemic stroke using computed tomography perfusion-derived blood flow and blood volume measurements. Stroke 2006; 37: 1771–1777.

68. Parsons MW, Pepper EM, Chan V, Siddique S, Rajaratnam S, Bateman GA et al. Perfusion Computed Tomography: Prediction of Final Infarct Extent and Stroke Outcome. Ann Neurol 2005; 58: 672–679.