Presentation on theme: "Issues in Imaging for Stroke Shawn Halpin MRCP FRCR LLM University Hospital of Wales, Cardiff."— Presentation transcript:
Issues in Imaging for Stroke Shawn Halpin MRCP FRCR LLM University Hospital of Wales, Cardiff
National Intercollegiate WP for Stroke 2004 Hospital care specialist teams weekly MDT SITS MOST
contd... “initial assessment by experienced clinician” “non specialist care costs lives, increases dependancy, less cost effective” brain imaging within 24 hours MRI if CT delayed for 10 days
Audit data: How many patients imaged within 24 hours? Wales criticised for worst UK performance But 97% patients scanned within 24 hours of request
New report Immediate imaging for certain stroke subgroups - thrombolysis, unconscious, warfarin Immediate review by an expert in stroke
Immediate (1hr) scan? Trivial to provide
Immediate clinical diagnosis Very difficult large/small vessel; TIA; migraine; SAH; dissection, watershed, global etc etc 3 patient with limb fractures referred as acute stroke patients
Plain scan in early stroke: Usually normal
Rush to treat: Undoubtedly some non-stroke patients will be treated with rTPA
Early CT signs:
Add specialist neuroradiological advice Non Trivial Network? Interested DGH radiologists? Every DGH radiologist?
Alternative? Perfusion scanning CT or MR Make decisions based on physiology
Reichenbach et al AJNR
45 yr old, large ophthalmic aneurysm
Perfusion during occlusion
Advantages of Physiology No false positives Treat only those with viable tissue Use as triage: a tool to spare the expert in stroke?
Radiology will enthusiastically support acute stroke Give us the tools to do it Help us with the out of hours reporting Bear in mind we have other responsibilities too: Most radiologists cover all emergencies, not just neuro And there are not many of us! BUT
1. Plain scan only Who reports? Fear of onerous on call duty Consultant radiologists ideal In each hospital? Network in Wales, or wider UK - local/extended? Network outside Wales? Radiographer or stroke team report??
2. ASPECT score More radiologist experience needed Greater physician input Give drug or not? No longer a yes/no, now a maybe Further need for experienced clinician Use of the Alberta Stroke Program Early CT Score (ASPECTS) for Assessing CT Scans in Patients with Acute Stroke AJNR Am J Neuroradiol 22:1534 ﾐ 1542, September Alternatively, what percentage of the MCA territory is low density?
2. ASPECTS score reporting Need consultant radiologist In house local network outsource
3.Assess other pathology Need consultant radiologist As before
4. Perfusion data Need Neuroradiologist or highly specialised other person this may change in the future, but not yet Similar issues with location
Suggestion: All hospitals support IST3 Start slowly, learn where the problems are Build resources based on local experience Radiologist, radiographer, stroke team Look to develop perfusion scanning, 24/7 services over time