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Multimodal CT in Acute Stroke

  • Stroke (H.C. Diener, Section Editor)
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Abstract

Purpose of Review

Multimodal CT imaging (non-contrast CT, NCCT; CT angiography, CTA; and CT Perfusion, CTP) is central to acute ischemic stroke diagnosis and treatment. We reviewed the purpose and interpretation of each component of multimodal CT, as well as the evidence for use in routine care.

Recent Findings

Acute stroke thrombolysis can be administered immediately following NCCT in acute ischemic stroke patients assessed within 4.5 h of symptom onset. Definitive identification of a large vessel occlusion (LVO) requires vascular imaging, which is easily achieved with CTA. This is critical, as the standard of care for LVO within 6 h of onset is now endovascular thrombectomy (EVT). CTA source images can also be used to estimate the efficacy of collateral flow in LVO patients. The final component (CTP) permits a more accurate assessment of the extent of the ischemic penumbra. Complete multimodal CT, including objective penumbral measurement with CTP, has been used to extend the EVT window to 24 h. There is also randomized controlled trial evidence for extension of the IV thrombolysis window to 9 h with multimodal CT. Although there have been attempts to assess for responders to reperfusion strategies beyond 6 h (“late window”) using collateral grades, the only evidence for treatment of this group of patients is based on selection using multimodal CT including CTP. The development of fully automated software providing quantitative ischemic penumbral and core volumes has facilitated the adoption of CTP and complete multimodal CT into routine clinical use.

Summary

Multimodal CT is a powerful imaging algorithm that is central to current ischemic stroke patient care.

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Authors and Affiliations

  1. Division of Neurology, University of Alberta, Edmonton, AB, Canada

    R. Wannamaker, B. Buck & K. Butcher

  2. Prince of Wales Clinical School, University of New South Wales, 1St Floor, South Wing, Edmund Blacket Building, Randwick, 2031, NSW, Australia

    K. Butcher

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  1. R. Wannamaker
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  2. B. Buck
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  3. K. Butcher
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Correspondence to K. Butcher.

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Dr. Wannamaker reports a grant from the Quality Improvement & Clinical Research Alberta Stroke Program, during the conduct of the study. Dr. Buck declares no potential conflicts of interest. Dr. Butcher has served as an advisory board consultant and received speaker’s fees and investigator-initiated grant support from Boehringer-Ingelheim, Bayer, BMS-Pfizer and Servier.

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Wannamaker, R., Buck, B. & Butcher, K. Multimodal CT in Acute Stroke. Curr Neurol Neurosci Rep 19, 63 (2019). https://doi.org/10.1007/s11910-019-0978-z

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