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Case: Acute Left MCA Infarct with Penumbra

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This next case is another patient who came in this time

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with aphasia, and we have a CT, a CTA

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and a CT perfusion study.

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So let's look at the whole shebang, as we say, on this case.

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So on this non-contrast CT scan, which is the first thing

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that we're gonna be looking at, remember we look at the

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thick sections to see where there's hemorrhage,

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because if there's hemorrhage,

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the ball game is over pretty much for thrombectomy

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and thrombolysis therapy.

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So looking at this case, we don't see anything hyperdense.

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This is a little area of calcification that's

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partial volume averaged,

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but what we do see is an area of low density

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along the perisylvian region

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and in the frontal opercular region

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of the left frontal lobe.

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So now we're looking at imaging for stroke,

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and what we're seeing is loss

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of gray white matter differentiation

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in the left frontal region, as well as in the

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peri-insular region.

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There is something called the insular ribbon sign that is

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where there is low density to the normally bright

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insular density of gray matter.

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So on the right side, we have a slight hyper density

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to the insula.

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On the left side, we have loss of that hyperdense insula,

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as well as a more focal area of low density with loss

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of gray-white differentiation.

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So we know the patient’s had a stroke.

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It'll be unusual for this stroke to be within an hour or two,

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because, in the acute setting,

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often we do not see changes in the density of the brain

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until we’re talking at the three to six

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or more hours of age.

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But in this case, we see the stroke initially.

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So the next section of the study is going to be

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the CTA with the CT perfusion.

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What are we looking for? We’re looking

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for an occluded blood vessel that might account

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for this stroke, but we’re also looking

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to see whether this is the only area

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of the brain that is at risk for infarction,

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or whether this is just the tip of the iceberg,

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in which case, maybe there’s a lot more brain tissue

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that is in danger of infarct that we could still save.

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So let’s go to the CTA for the purposes of this review.

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Again, I’m going to stick with the thick section images.

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Normally, I would be more reliant on the thin section images,

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but just for time considerations, we’re going

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to look at the thick sections.

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So here is our study.

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I’m gonna window this so it’s a little bit better

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for a CTA.

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And we’re at the aorta,

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and we know that it’s on the left side.

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So let’s focus on

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the origin of the left common carotid artery,

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and we see it come off.

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This is the cervical portion

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of the left common carotid artery.

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We're just following that blood vessel upwards.

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We come to the carotid bifurcation, and it looks very clean.

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Here is the external carotid artery

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and the internal carotid artery.

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They both look clean.

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The left internal carotid artery courses superiorly

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to the petrous portion.

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Here we are in the petrous bone.

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That portion of the blood vessel looks a little bit narrowed

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compared to the right side.

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Again, must confirm this on the high-resolution images.

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I'm gonna magnify this so it is a little bit better seen.

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So we're contrasting the width of the

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left petrous internal carotid artery with the width of the right

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petrous internal carotid artery, as well

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as its irregular shape.

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So there is some atherosclerotic change here

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as we come into the cavernous internal carotid artery.

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Again, we compare the caliber of the left versus the right.

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It's a little bit narrowed compared to the right.

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We come to the paraclinoid portion

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of the left internal carotid artery.

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That looks good. The M1 segment is open,

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and the middle cerebral artery distal branches here

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look like they’re open on the thick sections.

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And there is that area of absence

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of blood vessels here compared to the right side,

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which may be the occluded pericallosal branch

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of the middle cerebral artery on the left side.

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Just looking quickly at the vertebral arteries,

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they look pretty good coming up.

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No areas of stenosis.

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If we look on the right side,

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and take it from the aorta

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to the right common carotid artery,

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and the carotid bifurcation looks good.

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The right internal carotid artery petrous portion looks good,

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certainly better than the left.

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And the cavernous portion looks good,

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even compared to the left.

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So at this juncture, we're gonna go

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and look at our coronal MIPs.

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Here we see the anterior cerebral arteries,

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two vessels looking good.

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Here is our A1 segment

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of our right middle cerebral M1 segment,

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of the right middle cerebral, A1 segment

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of the right anterior cerebral artery,

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small area of narrowing.

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Here on the left side,

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the A1 segment also shows

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some narrowing distally.

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We'll have to confirm that on the axial M.

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Here's our M1 segment, which looks good.

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And here are our middle cerebral artery branches.

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Let's look on the axial MIP (Maximum Intensity

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Projection) reconstruction.

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And we note that in that area where we saw the infarction,

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it looks like we have a paucity of blood vessels compared

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to the contralateral MIP image.

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So there probably is indeed.

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Let's magnify this so we can convince you of that.

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So right here, we have a vessel,

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which looks like there is narrowing of the vessel

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and possibly a luminal thrombus.

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Here, you can tell it's different in density

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than the more distal portion

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and then the neighboring vessel.

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And when we compare it to the contralateral side, again,

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a lot of times this is not symmetrical,

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but there is something wrong with this blood vessel,

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and it kind of fits where there is the area of infarction.

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So we have a thrombus in one of the Sylvian branches

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of the left middle cerebral artery,

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which is demonstrated here.

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Maybe we can see that on our sagittal images.

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Again, we see this vessel that comes up,

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and it looks like it kind of peters out,

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not showing the distal branches,

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and it's less dense than some of the neighboring vessels.

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So that's likely to be the area

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where the thrombus has lodged.

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The purpose of this study really is not to go over the CTA,

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as much as to show you the CT perfusion.

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So this is the CT perfusion analysis package.

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Most institutions have adopted the

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RAPID analysis package.

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This is a CT perfusion package, which allows you

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to have cerebral blood flow, cerebral blood volume,

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Tmax, and time-to-drain images.

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In this case, what we're seeing here

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is the cerebral blood flow image,

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and we see that there is an area of diminished

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perfusion in cerebral blood flow.

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The lower numbers are gonna be more purple.

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The reddish-yellowish are gonna be the highest values.

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So this is an area of diminished perfusion,

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which is more focal in the left frontal region,

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which is more focal in the left frontal region

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where there was that low density on the CT scan.

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This is cerebral blood volume.

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It too is showing a similar area going out to the cortex,

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It too is showing a similar area going out to the cortex

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where there is diminished cerebral blood volume, indicative

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of an area of infarction.

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The more important thing is the Tmax images.

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The Tmax images are gonna show you what part of the

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brain tissue is at risk for

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potential infarction.

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So although there was that area of existing

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infarction, the Tmax image will show you

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that there is tissue at risk above

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and beyond the area of existing infarction.

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That means that there may be value in trying

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for thrombolysis or thrombectomy.

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If there is a matched deficit of perfusion,

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ischemic tissue, and infarction,

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then there is likely no benefit for going out

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and trying to do a thrombectomy,

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because the tissue

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that is infarcted is the only tissue at risk.

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It's already been infarcted. You're not gonna get

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that tissue back.

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There are other parameters, including the mean transit time

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and the time to drain,

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and the time to drain

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that are calculated in perfusion imaging.

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But for the purposes of analysis by neurology

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and stroke teams, they look at cerebral blood flow,

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less than 30% change, as well as

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Tmax greater than six seconds.

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And you can identify the perfusion

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versus infarction mismatch.

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So this is a nice data set, which identifies that

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there is a blood vessel, a distal middle

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cerebral artery blood vessel, that has a clot within it.

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There is an infarction,

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but there is additional tissue that may be salvageable

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with either thrombolysis or a thrombectomy.

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So we have the non-contrast CT, the CTA,

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and finally, the CT perfusion series.

Report

Faculty

David M Yousem, MD, MBA

Professor of Radiology, Vice Chairman and Associate Dean

Johns Hopkins University

Tags

Vascular

Neuroradiology

Emergency

CTP

CTA

CT

Brain

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