The document discusses the role of radiographers in stroke management and acute stroke care. It outlines how diagnostic brain imaging such as CT and MRI scans are vital for determining the type and severity of stroke in order to guide appropriate treatment. Al Ain Hospital's acute stroke pathway is described which emphasizes rapid access to imaging and interpretation within time windows to facilitate early interventions like thrombolysis. The radiographer's role in performing scans and potentially interpreting images is highlighted as critical for expediting stroke care and treatment.

1. The Role of the Radiographer in Stroke Management
By: Fathima Hasan Mohamed
Senior Radiographer
Al Ain Hospital
22/08/2016

2. Outline-Learning Points
• Stroke definition and classification.
• Warning signs of stroke.
• The role of the radiographer in early
intervention of acute stroke.
• The Acute Stroke Pathway in Al Ain Hospital.
• How diagnostic brain imaging guides therapy.

3. Introduction
• Stroke is a medical emergency in which there is an
interrupted blood supply to the brain and brain cells
begin to die.
• Stroke is one of the leading causes of death worldwide
and one of the most common causes of long-standing
disability
• Every second counts when experiencing a stroke, and
the sooner the medical treatment begins the better the
chances of survival and recovery.
•

4. Introduction
• TIME IS BRAIN : Stroke destroys two million
brain cells every minute

5. Introduction
• Hundreds of lives could be saved each year if
more people knew that stroke is a medical
emergency.

6. Warning signs of stroke

7. The F.A.S.T. acronym was created as a helper for
people to remember the main warning signs of
stroke so that they can act immediately in the case
of a stroke by dialling 999
F.A.S.T. stands for:
F – Face – has their face fallen on one side? Can
they smile?
A – Arms – Can they raise both arms and keep
them there?
S – Speech – is their speech slurred?
T –Time to call 999 if you spot any single one of
these signs.
When stroke strikes, act F.A.S.T.
F.A.S.T. can help you to rapidly recognize when a stroke is taking place and
then act quickly to get medical treatment and prevent serious damage

8. Stroke Classification
• Broadly can be two main types:
• 1. Ischaemic Stroke - triggered by a clot
narrowing or blocking a blood vessel to the
brain causing the area of brain supplied by
that vessel to be starved of oxygen, leading to
the death of brain cells.

9. Stroke Classification
• 2. Haemorrhagic Stroke (or Primary
Intracerebral Haemorrhage) - triggered by the
bursting of blood vessels leading to bleeding
into the brain which causes damage.

10. Stroke Classification
• Transient Ischaemic Attack(TIA):
• Sometimes defined as a minor stroke
• Blood supply to the brain is temporarily
disturbed, leading to stroke like symptoms,
but where the symptoms resolve within 24
hours. The cause of TIA is the same as the
cause of ischaemic stroke.

11. The Radiographer Role-Early
Intervention
• Radiographers are a vital part of the specialist stroke care
team.
• Patients with acute brain attack require rapid access to high
quality and appropriate imaging in order to diagnose the type
of stroke.
• to allow for early intervention, such as thrombolysis, which
has been shown to significantly improve patient outcome if
administered within three hours.
• Patients who suffer a Transient Ischaemic Attack (TIA)- high
risk of suffering an ischaemic stroke- require urgent imaging
after appropriate assessment- ensure reduced morbidity.

12. The Radiographer Role- Early
Intervention
• These patients also require follow up imaging,
either by Computed Tomography (CT) or
Magnetic Resonance (MR) in order to assess
the efficacy, and/or options for further
treatment.

13. The Radiographer Role- Early
Intervention
• Radiographers undertaking this work not only have
highly specialist skills in imaging modalities, but are
experienced in the care and techniques required for
scanning acutely ill patients who require urgent
assessment during a critical period of the care
pathway.
• Additionally, they may also have the advanced
practitioner skills to review and report the images
obtained to help facilitate rapid access to thrombolytic
therapy by the stroke care team, or neurosurgical
review, within the short timescale required.

14. The Radiographer Role- Early
Intervention
They may also be able to undertake the further
imaging techniques such as CT Angiography and
CT perfusion imaging.
There will also be a need for MR scanning,
specifically for TIA including Diffusion Weighted
Imaging (DWI), MR perfusion, and, in addition,
Magnetic Resonance Angiography (MRA),
Contrast Enhanced MRA (CEMRA) if appropriate,
and depending on local protocols .

15. Image interpretation and further
imaging requirements
• Interpretation of the images needs to be both rapid and
accurate.
• This may be achieved using a variety of options involving
neuroradiologists, appropriately skilled stroke physicians or
the use of tele-radiology.
• A better solution may be suitably trained, competent and
authorised advanced practitioner radiographers to provide
both imaging and reporting.
• It should be noted that postgraduate courses in
interpretation of head CT images have existed for some years
and CT head reporting by radiographers is considered normal
practice in many imaging departments.

16. Al Ain Hospital-Acute Stroke Pathway
• Al Ain Hospital opened a stroke unit on
November 2007 the first of its kind in the UAE
offering a comprehensive multimodality
stroke imaging service and enhanced
treatment to people suffering from strokes.

17. Al Ain Hospital-Acute Stroke Pathway
• The doctors at Al Ain Hospital are experts in
treating stroke patients and can quickly and
effectively assess whether a patient is having a
stroke, type of stroke, and determine viable
treatment options for specific circumstances.
• Stroke team skilled staff and state-of-the-art
facilities can assure everyone to receive some
of the best care available in UAE.

18. Al Ain Hospital- Acute Stroke Pathway
• Six qualified Competent Neurologist are available
for the Stroke patients. Each patient admitted to
the Stroke Unit will be assessed by neurologist
within 12 hours from admission and the plan of
management will be started from the time of
admission.
• Multidisciplinary team(MDT) consist of
Rehabilitation , Neurologist , Nurses ,Speech
therapist, Neuropsychology ,Dietician Case
management ,Social workers &clinical
pharmacists ED team.

19. Al Ain Hospital- Acute Stroke Pathway
• In Al Ain Hospital physicians are available to
evaluate imaging studies 24/7 basis.
• Our department has highly qualified Consultants
as well as Radiologist Specialists available in-
house 24/7 for urgent neuroimaging studies.
• Our physicians are experienced in interpreting
head CT and brain MRI studies.
• They must be available to read these scans within
20 minutes of their completion.

20. Al Ain Hospital- Acute Stroke Pathway
• Because of the need for the performance of a CT scan within
25 minutes Radiology department provides an in-house
technologist capable of performing a CT scan and any CT-
based studies.
• Al Ain hospital provides minimum of 4 certified radiology
technologist trained in CT techniques- in-house on a 24/7
basis.
• As a requirement for comprehensive stroke unit for
performing MRI studies on a 24/7 basis a qualified MR
technologist is available (but not always in-house) on a 24/7
basis.
• Technologist will be at the hospital within 30 minutes after
receiving a call from hospital if he/she is not available at

21. Al Ain Hospital- Acute Stroke Pathway
• A similar requirement applies to technologists
needed to perform a cerebral angiogram.
• U/S and various cerebral perfusion studies are
commonly elective based on the availability of
technologists.

22. Al Ain Hospital- Acute Stroke Pathway
• Al Ain hospital provides minimum of 4 certified
radiology technologist trained in CT techniques.
• CT technologist is available in-house on a 24/7
basis .
• All CT technologist were trained to perform
stroke imaging protocols including :
• Non contrast CT head ,
• CT cerebral perfusion,
• Fast angiogram of head and neck.
•

23. Al Ain Hospital- Acute Stroke Pathway
• To optimize our services further in order to
minimize delay for stroke patients starting 2 years
back all radiographers are trained and competent
to perform a non-contrast CT head scan.
• They are required to maintain their competency
and are re-evaluated every 3 months.
• Therefore during on call hours they will start to
do the non-contrast CT head for acute stroke
patients.

24. Al Ain Hospital- Acute Stroke Pathway
• Radiographer role extension: common in
countries like UK.
• Practice whereby radiographers adopt duties
that were previously only within the scope of
the radiologist.
• Motivation for general radiographer –
acquiring new knowledge and technology.

25. Al Ain Hospital- Acute Stroke
Pathway
• Recent achievement in al Ain hospital is newly
developed stroke code.
• Stroke code will be announced once acute stroke
patient reaches ED.
• The code will only be heard on the phones in the
Emergency Department, Radiology and the
Stroke Ward. SMS sent on mobile phone.
• Mock “Stroke” drills are periodically carried out
to ensure that time frames are met in acute
stroke management.

26. Al Ain Hospital- Acute Stroke Pathway

27. Al Ain Hospital-Acute Stroke Pathway
• Al Ain Hospital has an integrated system with
the community paramedics/Ambulance.
• There is an LCD screen in the ED Triage area
connected to EMS wirelss system to receive
pre-arrival notification and ED staff will call
the CT technologist to keep the CT room ready
upon patient arrival.

28. Al Ain Hospital-Acute Stroke Pathway
• The window time for acute stroke in Al Ain
Hospital is 4.5 hours.

29. Al Ain Hospital-Acute Stroke Pathway
• The stroke management time in AAH?
• Door to Triage Emergency 0-5,
• Door to ED doctor less than 10 min,
• Door to physician on call/stroke team 15 min,
• Door to CT scan completion less than 25 min
&Door to CT scan interpretation less than 45 min
• Door to rtPA less than 60 min,
• Admission to stroke unit or ICU Done ASAP (by
passing admission office) less than 3 hours.
•

30. How Imaging guides therapy
• Computed tomography scanning in Al Ain Hospital is
a state-of-the-art medical imaging technology
essential for acute stroke imaging and other
neurological and spinal procedures.
• This system is capable of fast rotation times resulting
in more rapid scanning and less time for patients to
spend in the machine in addition delivering
significant improvement of image quality and
increment in isotropic resolution.
• Al Ain Hospital has a state of art Siemens Definition
dual source 64 slice CT scanner as well as GE 64 slice
scanner.

31. The three most crucial diagnostic questions in
stroke to be answered by our state of the art CT
• Is the stroke caused by bleeding?
by using a non-contrast CT scan to detect if
the stroke is caused by hemorrhage or
ischemia we can determine the potential
benefit or harm of thrombolytic drugs.

32. Non-enhanced CT scan shows slight hypoattenuation of the right basal ganglia
3-Acute stroke (2 hours evolution) in a 46-year-old man with left hemiparesis

33. How Imaging guides therapy
• What is the size and location of the clot?
When planning interventional clot retrieval,
the size of the clot may be overestimated on
axial CTA source images. The CT Neuro Engine
and syngo.CT Dynamic Angio can help you
better characterize the occlusion length and
collateral status. Also visualization of contrast
flow from the arteries to the veins enable a
dynamic evaluation so we can see ante grade
and delayed collateral blood flow.

34. Axial and coronal MIP reformatted CT angiographic images show
obstruction of the right MCA and right carotid artery

35. Volume-rendered and curved reformatted images show
significant stenosis of the right internal carotid artery

36. How Imaging guides therapy
• How big is the infarct?
It takes just five simple steps to see the core
infarct and penumbra.
• The guided workflow in syngo. CT Neuro
Perfusion facilitates a routine 24/7 operation.
• Tissue at risk can be easily visualized in 3D color
maps, based on the mismatch between cerebral
blood volume (CBV) and cerebral blood flow
(CBF). There is also Possibility to define a custom
mismatch based on parameters we select.
•

37. Perfusion CT show 70% mismatch in the right frontotemporal region and basal ganglia
MTT CBF CBV Summary map

38. How Imaging guides therapy
CT perfusion (CTP) is a tool that has been successfully employed to assess
the extent of salvageable tissue
It is important to understand the meaning of potentially salvageable tissue
Whenever there is a decrease in the flow of blood to a particular area of the
brain collateral supply from the leptomeningeal vessels and from normal
surrounding vessels tries to compensate
This results in a central area, the infarct, which receives little or no blood
supply and a larger peripheral area where autoregulatory compensation
tries to ensure the maintenance of adequate blood supply.
This peripheral area is potentially salvageable by thrombolytic therapy and
is called the ‘penumbra.’

39. CTP Protocol
Perfusion CT is performed by monitoring only the first pass of an
iodinated contrast agent bolus through the cerebral circulation
Motion artifact is the main challenge in many acute stroke patients
since sedation is frequently not possible but immobilization of the
patient’s head can limit motion
continuous cine imaging for 45 seconds
over the same slab of tissue (1–32 sections)
dynamic administration of a small (50-mL)
high-flow contrast material bolus with injection rate of 4–5 mL/sec
No need to check the createnin level in acute SP (neuron over nephron)
How Imaging guides therapy

40. How Imaging Guides therapy
• MRI in Al Ain Hospital
• Al Ain Hospital successfully upgraded its old MRI machine
GE 1.5 Tesla (LX horizon) to GE 1.5 tesla (HD23) in
December 2013.
• With this new version of MRI machine and advances in
hardware and software our MRI has the capability to
perform advance imaging in evaluation of acute stroke
which can be achieved by using a combination of
conventional and more advanced imaging such diffusion
and perfusion weighted imaging as well as high resolution
MR Angiography techniques.
•

41. How Imaging guides therapy
• Plus the addition of other new sequences like
SWI (Susceptibility-weighted image) and
SWAN (Susceptibility-weighted angiography) -
T2 Star-Weighted angiography volumetric 3D
acquisition technique that is sensitive to
differences in susceptibility between different
tissues help us to enhance the evaluation of
acute ischemic stroke.
•

42. Radiological approach to acute stroke
patients
• 1-Once ED activated the stroke code, the radiologist and experienced
CT technologist receives an sms on mobile or via operator on landline
in CT.
• 2- Radiologist immediately informs firstly the trained radiographer
who is available 24h/7 day to perform non contrast CT examination.
Aim is to rule out IC hemorrhage
• 3- Radiologist also immediately informs the experienced CT
technologist by telephone regarding acute stroke patient within
window hour
• Experienced CT technologist who is either available in the house or if
not he has to be present within 15 min to perform more advanced
imaging like CTA and CTP if it is needed.
• 4- Report has to be generated within 20 min after completion of CT
scan. KPI to be met.
• 5- Upon request in special circumstances urgent MRI with MR
perfusion shall be performed.

43. Summary
• Imaging is vital in helping to identify the causes of acute
stroke.
• Definitive diagnosis- undertaken initially by CT brain
scanning.
• effective treatment, which is very different, depending
on the type of stroke diagnosed, cannot be commenced
until imaging and interpretation of these scans has taken
place.
• The importance of the radiography workforce,
• therefore, cannot be overestimated.
• AAH will be undergoing the German Stroke Accreditation
on 8 November 2015.

44. Thank you for your attention !
Fathima Hasan Mohamed
Clinical Imaging Institute
Al Ain Hospital
3 November 2015

45. References
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