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Emergency CT: Update
Rathachai Kaewlai, MD Division of Emergency Radiology
Department of Radiology, Ramathibodi Hospital, Bangkok, Thailand 31st Annual Scientific Meeting “Update and Future Challenges in Health Care”
Faculty of Medicine, Khon Kaen University, 7 October 2015
Ramathibodi Emergency Radiology
Outline
Trauma pan-scan CT
CTA for active bleeding (ICH, hemoptysis, GI bleed) Stroke multiphase CTA
PAN-SCAN
Trauma CT
Selective or “Pan scan”
Pan scan = scanning from head to pelvis in one shot Pre-contrast head CT
Post-contrast neck, chest, abdomen and pelvis
Trauma Pan-Scan: Indications One of these: RR >30 or <10
PR >120
sBP <100 EBL >500 mL
GCS <13
Abnormal pupil react
Clinically suspicious • Fractures >2 long bones
• Flail chest, open chest or multiple rib fractures
• Severe abdominal injury • Pelvic fracture
• Unstable vertebral fractures/spinal cord compression
Injury mechanism • Fall from height (>3m)
• Ejection from vehicle
• Death occupant in same vehicle
• Severely injured patient in same vehicle
• Wedged of trapped chest/abdomen
http://www.react2.nl/?id=16&p=14&lng=EN
“Pan Scan”
Indication based on severity of trauma and initial evaluations (clinical exam + FAST)
20-year-old woman, motorcycle vs. car SDH, SAH, midline shift, tonsillar herniation Vitreous hemorrhages, skull base fracture Pulmonary contusions, pneumothorax Gluteal hematoma with active extravasation Hypoperfusion complex
40-year-old man, motorcycle vs. car SDH Thoracic aortic injury Complex acetabular fracture
“Pan Scan”
Should it replace other imaging in the primary survey (CXR, PXR, FAST and selective CT)?
CXR PXR FAST
Selective CT
Pan scan CT V
“Pan Scan”
Caputo ND, et al. J Trauma Acute Care Surg 2014
REACT-2 Trial: Results ���(Presented at ASER2015) RCT comparing standard imaging (x-rays, FAST,
selective CT) and pan-scan CT in 5 European centers 1078 patients (539 per group) included
“Bad” trauma or mechanism of injury (65% ISS>16)
REACT-2 Trial: Results ���(Presented at ASER2015) Similar ISS, TRISS, other background info
In-hospital mortality: 2.4% lower for polytrauma patients in pan-scan, not different overall
Shorter time for imaging (similar direct costs, no difference in radiation exposure)
CTA FOR ACTIVE BLEEDING: ICH, HEMOPTYSIS, GI BLEED
Active Bleeding
Timely localization of active hemorrhage of internal organs possible because of faster CT
Especially true in trauma patients Guiding initial Rx of trauma
Use in non-trauma acute bleeds still limited but gaining attention
“Bleed” Scott Reinwand, YouTube.com
Primary Intracerebral Hemorrhage Hemorrhagic stroke = deadliest stroke
Strongest predictor of mortality = initial hematoma vol Not modifiable
“Hematoma expansion”
Potentially modifiable predictor 30% or >6 mL growth of hematoma ~40% of ICH
Correlated with poor functional outcome and death Attractive target of Rx trials
Primary Intracerebral Hemorrhage “Hematoma expansion”
30% or >6 mL growth of hematoma ~40% of ICH Correlated with poor functional outcome and death
Attractive target of Rx trials
Can We Predict Hematoma Expansion? “CTA spot sign”
Intrahematoma contrast following CTA Represents site of active extravasation in early ICH Spot sign growth =
[spot vol (delayed) – spot vol (initial)] elapsed time
Dowlatshahi D, et al. Stroke 2014;45:277 Image credit: smh.com.au
51yo F, known valvular heart disease S/P valve replacement, on warfarin
1 day 2 days
CTA Post
78yo M, HTN, CKD with AOC for 8 hrs “Multiple spot signs”
CTA Post CTV
CTA Post CTV
CTA Spot Sign
Prevalence of spot sign in primary ICH 13-32%
Predicting hematoma expansion (%) Sensitivity 38-93 Specificity 50-93
PPV 22-77
NPV 78-98 Accuracy 56-90
PLR 1.86-10.99 NLR 0.30-0.73
Giudice AD, et al. Cerebrovasc Dis 2014;37: 268
75%
CTA Spot Sign: Imaging Marker
Hematoma expansion
Active bleeding during surgery Postoperative rebleeding In-hospital death
90-day mortality
May help selecting patients with pICH for specific therapy (medical, surgical hemostasis)
Brouwers HB, et al. Neurology 2014;83: 883 Brouwers HB, et al. Stroke 2015;46: 2498
Severe Hemoptysis
Life-threatening
Without bleeding control – mortality >50% Indications for intervention (bronchial embolization) Volume >200 mL/24-48h
Acute respiratory failure Erosion of pulmonary artery
Clinical Bedside Evaluation vs. CTA
Clinical CTA Lateralization 93.1 87.4
Lobar location 82.7 85.0
Etiology 70.1 86.2
Rx change - Medical - Embo - Pulm a. occlusion
21.8
Comparing bedside eval vs. CTA in 87 patients with severe hemoptysis
Those needing emergent FOB excluded
67% bronchiectasis 92% bronchial systemic
bleeds
Chalumeau-Lemoine L, et al. Eur J Radiol 2013
CTA in Severe Hemoptysis
Bleeding site
Bleeding vessels (PA involved or not) Bronchial artery network (normotopic, atypical,
ectopic, non-bronchial systemic arteries)
Etiology
CTA: Site of The Bleed
Bleeding side and precise localization of hemoptysis essential for Rx (airway protection, embo, surgery)
Parenchymal bleed
Consolidation GGO
PA pseudoaneurysm
CTA: Bleeding Vessels
90% systemic arteries (BA, and non-bronchial systemic)
10% pulmonary arteries Direct signs of bleeding from pulmonary artery Pulmonary artery aneurysms
Lung consolidation with necrosis and irregular PA
Bronchial Artery Network
By excluding PA as a source, hemoptysis likely from systemic artery
CTA more accurate than angiography for identifying BA and NBSA Anatomical variants
Catheterization difficulties a/w age atherosclerosis Except: middle anterior spinal artery of high T-cord
76yo F hemoptysis during PA pressure measurement
Bleeding site: RML Bleeding vessel: Pulmonary artery BA network: N/A Etiology: Traumatic pseudoaneurysm of PA branch
69yo M
Bleeding site: RUL Bleeding vessel: Pulmonary artery BA network: N/A Etiology: TB Rasmussen pseudoaneurysm
67yo F
Bleeding site: RUL Bleeding vessel: Bronchial systemic BA network: as in picture Etiology: bronchiectasis
54yo M, Bleeding site: RUL
Bleeding vessel: Bronchial systemic BA network: as in picture
Etiology: TB
CTA Algorithm for Severe Hemoptysis
Bleeding Site
Bronchoscopy
No Yes
BA Network
BA - Normotopic
- Atypical - Ectopic
NBSA
Bleeding Vessels
PA involvement?
PA embolization
Systemic artery
embolization
No Yes
Khalil A, et al. Diagn Interv Imaging 2015;96: 775
Etiology
Cancer Bronchiectasis
TB Mycetoma
Others Cryptogenic
Overt Lower GI Bleeding
GI bleeding visible: melena, hematochezia
UGIB more common but prevalence is changing Mortality 2-20% (40% if hemodynamically unstable) Colonoscopy often not helpful
Identify source of bleed in only 13-40% of cases Limited therapeutic advantage over endovascular Rx
Overt Lower GI Bleeding: Etiology
Colonic diverticulosis
Angioectasia Colonic or small bowel neoplasm Meckel’s diverticulum
Rectal ulcers and hemorrhoids Rare: hemobilia (liver biopsy, bleeding hepatic tumors),
hemosuccus pancreaticus, aorto-enteric fistula
Scintigraphy, ���Catheter Angiography and CTA
Scintigraphy Catheter Angiography
CTA
Minimum rate of bleeding (mL/min)
0.05 0.5 0.3*
Type of bleed Intermittent Active Active
Location of bleed Limited Yes Yes
Etiology of bleed Limited Limited Probable
Soto JA, et al. Abdom Imaging 2015;40: 993 *Kuhle WG, et al. Radiology 2003;228: 743
CTA: Overt LGIB
90% source in colon and rectum
Accuracy for identifying source of bleed 80-90% Non-contrast, CTA, venous phase. No enteric contrast
CTA: Findings of Overt LGIB
Hyperattenuating focus (blush) of variable size in arterial phase (jet may be present if arterial source)
Change morphology and location on venous phase
Move distally and larger
78yo M with abdominal distension, SMA branch active contrast extravasation
CTA Venous
43yo M, HIV with lymphoma, dropped Hct
Venous Plain Delayed
CTA: Diagnostic Performance
Systematic review and meta-analysis, 672 patients in 22 studies with reference standards of endoscopy, angiography and surgery
494 positive cases (prevalence 74%) Sensitivity 85.2 %
Specificity 92.1% Accuracy 93.5%
PLR 10.8% NLR 0.16%
Garcia-Blazquez V, et al. Eur Radiol 2013;23: 1181
STROKE “MULTIPHASE” CTA:���A NEW TOOL FOR ACUTE STROKE
Acute Ischemic Stroke
Newer mechanical devices – rapid/successful recanalization possible and now standard
Clinical outcome depends on
Salvageable brain at presentation Early recanalization
Ideal imaging selection tool should enable one to detect salvageable brain quickly, reliably, and widely available
Factors Determining Potential Rx
Brain parenchyma – infarct core (size)
Large vessel – occlusion (presence) Collateral circulation (grading)
MRI-DWI
CTA
Multiphase CTA
NCCT, CTA-SI
CTA: Cerebral Vasculature
Sensitivity 97-100% and specificity 98-100% to detect proximal intracranial occlusions and stenosis
Proximal occlusion results in large infarcts, which have high likelihood of hemorrhagic transformation but greatest benefit from IA Rx
Evaluation of Collateral Circulation Good leptomeningeal/pial collaterals beneficial in stroke
Repeated acquisitions after routine CTA = multiphase “Multiphase CTA”
Degree and extent of pial arterial filling of whole brain in a time-resolved manner
Assess collaterals better than one phase Avoid pitfalls of false occlusion on CTA
Multiphase CTA - Interpretation
Score Delayed Filling
Prominence Extent
Good 5 No Normal or increased Symmetric
4 1 phase Normal Symmetric
Intermediate 3 2 phases Normal Normal
1 phase Decreased Decreased
2 2 phases Decreased Decreased
1 phase No vessels in some areas
No vessels in some areas
Poor 1 3 phases A few vessels visible A few vessels visible
0 3 phases No vessels visible No vessels visible
Menon BK, et al. Radiology 2015;275: 510
For MCA territory occlusion Comparing with contralateral asymptomatic side
Multiphase CTA
147 patients
Interrater reliability n=30, k=0.81, P<.001
Menon BK, et al. Radiology 2015;275: 510
Multiphase CTA
Predicting clinical outcome at 24 hours
Best = baseline infarct volume (<80 vs. >80 mL) 2nd best = multiphase CTA (score >3 vs. <3)
Predicting clinical outcome at 90 days
Best = multiphase CTA (score >3 vs. <3) 2nd best = single-phase CTA (score >2 vs. <2)
Better than CTP mismatch ratio
Menon BK, et al. Radiology 2015;275: 510
47yo F, NIHSS 20, Rt hemispheric symptoms 2 hrs ASPECTS score = 7
mCTA: Rt M1 occlusion Delayed collaterals filling 2 phases with decreased prominence/extent Collaterals score = 2 (Intermediate) IA Rx not recommended
Images from Menon BK, et al. Radiology 2015;275: 510
CTP: Blue = infarct core = 100 mL IA Rx not recommended
Congruent mCTA and CTP No IA Rx
87yo F, NIHSS 15, Lt hemispheric symptoms 2 hrs ASPECTS score = 6
mCTA: Lt M1 occlusion Delayed collaterals 1 phase at worst Collaterals score = 4 (Good) IA Rx recommended
CTP: Blue = infarct core = 0 mL (no blue) IA Rx recommended
Congruent mCTA and CTP IA Rx performed by not successful
Images from Menon BK, et al. Radiology 2015;275: 510
Images from Menon BK, et al. Radiology 2015;275: 510
78yo F, NIHSS 18, Rt hemispheric symptoms 1.5 hrs ASPECTS score = 8
mCTA: Rt M1 occlusion Delayed collaterals 1 phase Collaterals score = 4 (Good) IA Rx recommended
CTP: Blue = infarct core = 113 mL IA Rx not recommended
Incongruent mCTA and CTP IA Rx performed with success
ASPECTS score = 8
mCTA: Left M1 occlusion Delayed collaterals 1 phase Decreased prominence Collaterals score = 3 (intermediate)
5 days
IA Rx not recommended and was not performed
1 day
49yo M ASPECTS score = 8
mCTA: Partial right M1 occlusion Delayed collateral 1 phase Normal prominence/extent Collaterals score = 4 (Good)
IA Rx recommended but not performed
Summary: Pan-scan CT
Good to go esp. high-severity trauma
Not inferior to standard of care (CXR, PXR, FAST + selective CT)
Trauma Centers: please set up protocols and indications
Summary: CTA for active bleeding
Primary intracerebral hemorrhage
CTA spot sign Predictive of hematoma expansion and outcome
Severe hemoptysis evaluation
Bleeding site, vessels, BA network, etiology LGIB Useful for pre-embolization
Summary: Multiphase CTA in acute stroke evaluation NCCT-mCTA is a new paradigm for acute stroke
imaging Collaterals evaluation valuable for IA Rx decision,
probably better than CTP Stroke onset, NIHSS, ASPECTS, Collaterals score (+/- DWI)
THANK YOU VERY MUCH FOR YOUR ATTENTION
Rathachai Kaewlai, MD