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![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](https://image.slidesharecdn.com/handout20151007kkuemergencyctupdates-151006173353-lva1-app6891/75/Emergency-CT-Updates-18-2048.jpg)
Uploaded byRathachai Kaewlai
Emergency CT: Updates
The document presents an update on imaging techniques in emergency radiology, particularly focusing on pan-scan CT for trauma assessment and CTA for active bleeding. It highlights the efficacy of pan-scan CT in high-severity trauma cases, the predictive value of the CTA spot sign in cases of primary intracerebral hemorrhage, and the role of multiphase CTA in evaluating collateral circulation for acute stroke management. Recommendations for trauma protocols and the importance of accurate diagnosis in bleeding sources are emphasized.
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Emergency CT: Updates
- 1. Emergency CT: Update RathachaiKaewlai, 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
- 2.
- 3. Outline Trauma pan-scan CT CTAfor active bleeding (ICH, hemoptysis, GI bleed) Stroke multiphase CTA
- 4.
- 5. 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
- 6. Trauma Pan-Scan: Indications Oneof 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
- 7. “Pan Scan” Indication basedon severity of trauma and initial evaluations (clinical exam + FAST)
- 8. 20-year-old woman, motorcyclevs. car SDH, SAH, midline shift, tonsillar herniation Vitreous hemorrhages, skull base fracture Pulmonary contusions, pneumothorax Gluteal hematoma with active extravasation Hypoperfusion complex
- 9. 40-year-old man, motorcyclevs. car SDH Thoracic aortic injury Complex acetabular fracture
- 10. “Pan Scan” Should itreplace other imaging in the primary survey (CXR, PXR, FAST and selective CT)? CXR PXR FAST Selective CT Pan scan CT V
- 11. “Pan Scan” Caputo ND,et al. JTrauma Acute Care Surg 2014
- 12. 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% ISS16)
- 13. 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)
- 14. CTA FOR ACTIVEBLEEDING: ICH, HEMOPTYSIS, GI BLEED
- 15. Active Bleeding Timely localizationof 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
- 16. 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
- 17. 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
- 18. Can We PredictHematoma 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
- 19. 51yo F, knownvalvular heart disease S/P valve replacement, on warfarin 1 day 2 days CTA Post
- 20. 78yo M, HTN,CKD with AOC for 8 hrs “Multiple spot signs” CTA Post CTV CTA Post CTV
- 21. CTA Spot Sign Prevalenceof 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%
- 22. 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
- 23. Severe Hemoptysis Life-threatening Without bleedingcontrol – mortality 50% Indications for intervention (bronchial embolization) Volume 200 mL/24-48h Acute respiratory failure Erosion of pulmonary artery
- 24. Clinical Bedside Evaluationvs. 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
- 25. CTA in SevereHemoptysis Bleeding site Bleeding vessels (PA involved or not) Bronchial artery network (normotopic, atypical, ectopic, non-bronchial systemic arteries) Etiology
- 26. CTA: Site ofThe Bleed Bleeding side and precise localization of hemoptysis essential for Rx (airway protection, embo, surgery) Parenchymal bleed Consolidation GGO PA pseudoaneurysm
- 27. 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
- 28. Bronchial Artery Network Byexcluding 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
- 29. 76yo F hemoptysisduring PA pressure measurement Bleeding site: RML Bleeding vessel: Pulmonary artery BA network: N/A Etiology:Traumatic pseudoaneurysm of PA branch
- 30. 69yo M Bleeding site:RUL Bleeding vessel: Pulmonary artery BA network: N/A Etiology:TB Rasmussen pseudoaneurysm
- 31. 67yo F Bleeding site:RUL Bleeding vessel: Bronchial systemic BA network: as in picture Etiology: bronchiectasis
- 32. 54yo M, Bleedingsite: RUL Bleeding vessel: Bronchial systemic BA network: as in picture Etiology:TB
- 33. CTA Algorithm forSevere Hemoptysis Bleeding Site Bronchoscopy No Yes BA Network BA - Normotopic - Atypical - Ectopic NBSA Bleeding Vessels PA involvement? PA emboli zation Systemic artery embolizat ion No Yes Khalil A, et al. Diagn Interv Imaging 2015;96: 775 Etiology Cancer Bronchiectasis TB Mycetoma Others Cryptogenic
- 34. Overt Lower GIBleeding 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
- 35. Overt Lower GIBleeding: 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
- 36. Scintigraphy, Catheter Angiographyand 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
- 37. 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
- 38. CTA: Findings ofOvert 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
- 39. 78yo M withabdominal distension, SMA branch active contrast extravasation CTA Venous
- 40. 43yo M, HIVwith lymphoma, dropped Hct Venous Plain Delayed
- 41. CTA: Diagnostic Performance Systematicreview 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-BlazquezV, et al. Eur Radiol 2013;23: 1181
- 42. STROKE “MULTIPHASE” CTA: ANEW TOOL FOR ACUTE STROKE
- 43. Acute Ischemic Stroke Newermechanical 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
- 44. Factors Determining PotentialRx Brain parenchyma – infarct core (size) Large vessel – occlusion (presence) Collateral circulation (grading) MRI-DWI CTA Multiphase CTA NCCT, CTA-SI
- 45. CTA: Cerebral Vasculature Sensitivity97-100% 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
- 46. Evaluation of Collateral Circulation Goodleptomeningeal/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
- 47. 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
- 48. Multiphase CTA 147patients Interrater reliability n=30, k=0.81, P.001 Menon BK, et al. Radiology 2015;275: 510
- 49. Multiphase CTA Predicting clinicaloutcome 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
- 50. 47yo F, NIHSS20, 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
- 51. 87yo F, NIHSS15, 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
- 52. Images from MenonBK, 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
- 53. 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
- 54. 1 day 49yo M ASPECTSscore = 8 mCTA: Partial right M1 occlusion Delayed collateral 1 phase Normal prominence/extent Collaterals score = 4 (Good) IA Rx recommended but not performed
- 55. 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
- 56. Summary: CTA foractive 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
- 57. Summary: Multiphase CTAin 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)
- 58. THANK YOU VERYMUCH FOR YOUR ATTENTION Rathachai Kaewlai, MD