March 10, 2023

Neuroimaging Part 2

Description: Dr. Goldstein discusses neuroimaging in suspected 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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- Transient ischemic attacks, or mini strokes, represent a big opportunity in emergency medicine. The right diagnosis can make the difference between a normal life and a life after a stroke. We had a previous talk about stroke. Here we're gonna just talk about TIAs. The right neuroimaging is critical in TIA. Are you thinking TIA or are you thinking stroke? If the person is still having their symptoms, you should be thinking and treating stroke. People sometimes think about TIA and minor stroke in the same category. The key issues are, are they still having their symptoms or not? If they're still having them, are these symptoms disabling? Can they go back to work? Can they live their lives? What's minor to you may not be minor to them. Then, when you think about imaging, you wanna image the brain and the vessels. First, for brain imaging, a non-contrast head CT is a very common readily available tool. It's a great test to rule out bleeding or screen for various non TIA causes of their symptoms. You can also do brain MRI if you have time and resources. You don't need both. You might see a small area of infarct and if it's in the right location that will suggest this patient did have cerebral ischemia and then clinically recovered. Then think about the vessels. You wanna know, is there a carotid or vertebral dissection or occlusion or stenosis? First, you can do a CTA of the head and neck. This test is commonly available. You need a CT scanner, contrast, and software. Second, you can do an MRA of the head and neck, and you can use time of flight, and you don't need contrast necessarily. And third, you can do carotid ultrasound with Doppler. This test is probably your last choice. You can't see the vertebral or intracranial arteries. That's it. Make sure you visualize both the brain and the vessels and start treatment early.

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