Imaging-Based Selection for Endovascular Treatment in Stroke

Targeted CE per ARRT’s Discipline, Category, and Subcategory classification:

Computed Tomography: 2.50
Procedures: 2.50
Head, Spine, and Musculoskeletal: 2.50

Magnetic Resonance Imaging: 2.50
Procedures: 2.50
Neurological: 2.50

Registered Radiologist Assistant: 2.50
Procedures: 2.50
Neurological, Vascular, and Lymphatic Sections: 2.50

Vascular-Interventional Radiography: 2.50
Procedures: 2.50
Vascular Interventional Procedures: 2.50

Outline

1. Introduction
2. Neuroimaging
   1. Computed Tomography
   2. MR Imaging
   3. Collateral Status
   4. Imaging Workflow
3. Imaging-Based Treatment Selection
   1. Early Window (<6 Hours
   2. Late Window (6-24 Hours
4. Patient Subgroups with Limited Evidence
   1. Low NIHSS Score
   2. Distal Occlusion
   3. Large Ischemic Core
   4. Posterior Circulation LVO
   5. LVO Beyond 24 Hours
5. Conclusion

Objectives

Upon completion of this course, students will:

1. know which six randomized trials revolutionized acute stroke care in 2015
2. know which trial extended EVT into the late window in 2018
3. understand in what ways the DAWN and DEFUSE trials varied
4. be familiar with the role of vascular imaging for acute stroke patients
5. understand the ultimate goal of neuroimaging in patients with AIS
6. know the purpose of perfusion CT as part of a multimodal CT-based workup
7. be familiar with the scoring system of the ASPECTS scale
8. understand what useful information CT angiography provides to facilitate treatment planning and achieve safer and faster reperfusion
9. know the advantages that CT has over MRI that make it the imaging workhorse in the vast majority of stroke centers
10. understand the purpose of the FLAIR sequence included as part of a comprehensive MRI protocol for evaluating patients with early ischemia
11. know the purpose of the MR angiography sequence included as part of a comprehensive MRI protocol for evaluating patients with early ischemia
12. be familiar with the most commonly used imaging modality for assessing the extent of collaterals
13. be familiar with the two commonly used scoring systems for the extent of collaterals
14. understand which physician specialists should be part of a multidisciplinary stroke team to optimize treatment times and patient outcomes
15. be familiar with the disadvantages of additional imaging in the early window
16. know the five trials that were included in the HERMES pooled analysis
17. understand what collateral circulation, when used for patient selection, may help to predict
18. know how moderate-to-good collateral circulation is generally defined at CT angiography
19. explain what the discrepancy between having an LVO and a low NIHSS score is often due to
20. know what percentage of all LVOs are posterior circulation LVOs