Transcript Issues in Imaging for Stroke

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 20 1999
45 yr old, large ophthalmic
aneurysm
Perfusion during occlusion
Tissue Classification
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
BUT
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!
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 2001 . 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