March 10, 2023

Neuroimaging Part 1

Description: Dr. Goldstein discusses your patient with an acute stroke

Faculty: Dr. Joshua Goldstein, MD, PHD | Professor, Harvard Medical School | MGH Endowed Chair in Emergency Medicine Research | Vice Chair, Faculty Affairs | Co-Director, Center for Neurologic Emergencies | Department of Emergency Medicine | Massachusetts General Hospital

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- So, you have a patient with an acute stroke. First, is this patient a candidate for an acute therapy? If so, you want an image fast. Non-contrast head CT is typically the fastest test you can get. It's a great test to rule out intracerebral hemorrhage, just remember you won't see ischemia in the first hours. Now pause for treatment. If you're considering IV thrombolytics for someone in the right time window, treat fast. For someone in the time window for endovascular therapy, you need vessel imaging. Consider CTA or CT Angiogram. This test is commonly available. You need a CT scanner, contrast, and software. It's a great test to pick up a large vessel occlusion, or LVO, and just the kind of stroke that's the best candidate for endovascular therapy. If you can't get contrast, consider MRA with time of flight. If your patient had a wake-up stroke or stroke outside the traditional time window, you can consider CTP, or CT perfusion to help decide is this patient's still a candidate for acute therapy. If you have time, consider Brain MRI. This test is much more sensitive for stroke. It's better for small strokes, earlier strokes, strokes in the posterior circulation. Certain sequences can help guide treatment for wake-up stroke as well. So in summary, if the patient's a candidate for acute thrombolytics, think about non-contrast CT fast. If they're a candidate for endovascular therapy, think about CTA fast, and if you're thinking stroke, you wanna visualize both the brain and vessels.

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