mri presentation on head trauma. acute vs chronic in road traffic accident

1. MAGNETIC RESONANCE IMAGING IN STROKE PATIENTS
AT A TERTIARY HOSPITAL
CANDIDATE DR. VAIBHAV
DNB RESIDENT
Department Of Radio-diagnosis
Guide : Dr. Sharad Chandak
MD Radiodiagnosis

2. Synopsis
AIM:
• To evaluate the role of Multimodal MRI for initial diagnosis of ischaemic stroke.
• To evaluate the role of Multimodal MRI for determining the site and size of the
infarct area.
• To evaluate the role of Multimodal MRI in determining the territory of the
involved intracranial blood vessels if any
.
Methods:
STUDY DESIGN
• Cross-sectional study.
STUDY PERIOD
• July 2023 – June 2024 (12 months)

3. STUDY SETTING
• Department of Radio-diagnosis, Ramkrishna Care Hospital, Raipur, Chhattisgarh
STUDY POPULATION
• Patients of all age groups irrespective of sex clinically suspected of stroke.
SAMPLE SIZE
• Taking Sn=88.7%=0.887
• 1.96= z value for 95% significance level
• e= Allowable error =0.10
• Cochran formula for an observational study
• Minimum Sample Size (N) = 40
• Sample size of my study is 40

4. EQUIPMENTS / INSTRUMENTS
• The study was approved by Institutional Research Committee and Institutional
Human Ethical Committee. MRI brain scans were performed on a 1.5T Magneton
Avanto, Siemens, using head coil.
• INCLUSION CRITERIA
• Consenting patients of all age groups irrespective of sex, clinically suspected of
stroke who presented to department of Radio-diagnosis, Ramkrishna Care
Hospital for MRI evaluation of brain.
•
• EXCLUSION CRITERIA
• Patients not consenting for study.
• Patients with intracranial tumors.
• Patients with history of surgical metallic implants, pacemaker placement,
aneurysm clipping, prosthetic valve implantation.
• Patients with history of claustrophobia

5. Introduction
• The annual incidence of stroke in India is about 145 per 100,000 persons in urban areas and 124 per 100,000 persons
in rural areas.
• Types of stroke are cerebral infarction (80%), primary intracranial haemorrhage (15%), non-traumatic subarachnoid
haemorrhage (5%), miscellaneous dural sinus / cerebral vein occlusion (1%). Ischaemic stroke is the commonest
type of stroke accounting for 80-90% of all strokes.
• The objective of stroke imaging is to assess the parenchyma, pipes (extra cranial and intra cranial circulation),
perfusion and penumbra. This approach aids in detection of intracranial haemorrhage, differentiating salvageable
tissue from infarcted tissue, identifying intravascular thrombi, selecting appropriate therapy and predicting the
clinical outcome.
• MRI has a greater sensitivity and specificity for detecting early infarction than conventional CT. In addition MR
techniques provide a holistic information that is paramount to early stroke management.
• Arterial occlusion may be detected with MRA. The best current estimate of the infarct core is provided by diffusion
MRI. The extent of the penumbra can be estimated using perfusion MRI. Subtle changes in the apparent diffusion
coefficient of water may also provide an estimate of the penumbra. When there is an occlusion of a major anterior
circulation artery, the core and penumbra are related by the collateral circulation. Therefore, knowledge of one
permits a clinically relevant deduction of other.

6. • A typical stroke MRI protocol consists of T1W, T2W, FLAIR, DWI, ADC and MR angiography (MRA), MR
SPECTROSCOPY. Most infarcts can be easily demonstrated on conventional MR SE sequences. Gradient
echo MR sequences are sensitive in detecting hemorrhage. The status of neck and intracranial vessels can be
assessed using MR angiography. The status of various metabolites can be evaluated by MR spectroscopy.
• MRI is sensitive modality to identify edema. Ionizing radiations have no role in MR imaging. Toxicity of
Gadolinium based contrast media are comparatively less than iodinated contrast agent employed in CT
angiography.Arriving at the diagnosis is simplified when MRI findings are correlated with the clinical
features.

7. Review of Literature
• Fiebach, J.B. et al1, in 2014 concluded that MRI offers an exquisite amount of structural
and physiologic information in acute stroke patients that is essential to the diagnosis of
these patients and that might be used to guide acute reperfusion therapy. A number of
ongoing clinical trials have been designed to validate such an approach to MRI-guided
stroke therapy.
• Julio A Chalela et al7 concluded in 2007 that out of 356 patients, 217 of whom had a final
clinical diagnosis of acute stroke, were assessed. MRI detected acute stroke (ischaemic or
haemorrhagic), acute ischaemic stroke, and chronic haemorrhage more frequently than
did CT (p<0·0001, for all comparisons). MRI was similar to CT for the detection of
acute intracranial haemorrhage. MRI detected acute ischaemic stroke in 164 of 356
patients (46%; 95% CI 41–51%), compared with CT in 35 of 356 patients (10%; 7–14%).
In the subset of patients scanned within 3 h of symptom onset, MRI detected acute
ischaemic stroke in 41 of 90 patients (46%; 35–56%); CT in 6 of 90 (7%; 3–14%).
Relative to the final clinical diagnosis, MRI had a sensitivity of 83% (181 of 217; 78–
88%) and CT of 26% (56 of 217; 20–32%) for the diagnosis of any acute stroke.

8. • In the year 2014, Bum Joon Kim et al11 in their study, concluded that multimodal imaging
provides information that is useful for diagnosing ischemic stroke, selecting appropriate
patients for thrombolytic therapy, and predicting the prognosis of ischemic stroke.
Depending on a single or a few parameters may not be sufficient, instead
comprehensively combining the information from each MRI parameters (i.e. DWI,
FLAIR, GRE and PWI) and using various mismatch parameters (DWI-FLAIR mismatch
and/or PWI-DWI mismatch) may be more helpful in establishing an indication of MRI-
based thrombolysis.
• Mukesh Kumar et al8 concluded in 2023 that MRI use for IS treatment, management, and
prevention is imperative and justifiable, and the latest technological advancements in MR
scanners hold the potential to enhance access.
• In the year 2011, Birenbaum D, et al4 stated that MRI with diffusion improves stroke
detection from 50% to more than 75% and is becoming the Gold standard of imaging in
acute stroke. DWI allows doctors evaluating challenging patients with neurological
defects to differentiate between an acute ischemic event versus those who are not
suffering from acute event. It aids in the differentiation of stroke from stroke mimics.

9. PATIENT INFORMATION SHEET
You are entering into a study on – “MAGNETIC RESONANCE IMAGING IN STROKE PATIENTS AT A TERTIARY
HOSPITAL”. Participation in the study is voluntary and you can withdraw from the study at anytime. The refusal
to participate will not draw any penalty or loss of benefits to which you are entitled otherwise. You would be
required to undergo monitoring. Patient will undergo a follow up for 6 months.
BENEFITS BY PARTICIPATING IN THE STUDY
The data generated will be helpful in identifying better form of management if any and will be beneficial for
the patient as well as for the future patients.
ALTERNATIVES TO PARTICIPATION
You or your patient are free not to participate in the study or to withdraw from study at any time. If you/your
patient choose not to participate and withdraw from this study, you/your patient will receive the usual care.
CONFIDENTIALITY
All information that you or your patient provides during study will be kept confidential. Free treatment will be
ensured for all research related side effects/injuries. No compensation would be provided in case of any
adverse event; however no such event is expected. In the event that at any time during course of study you or
your patients feel that you/they have not been adequately informed as to the risk benefits, alternative
procedure, or right as study subject / feel under pressure to continue against your wishes you can contact

10. PARTICIPANT INFORMED CONSENT FORM (PICF)
• Protocol / Study number : ___________
• Participant identification number for this trial: __________
• Title of project: MAGNETIC RESONANCE IMAGING IN STROKE PATIENTS AT A TERTIARY HOSPITAL
• Name of Principal Investigator: Dr. Vaibhav
• Tel.No(s). - 9837373670
• The contents of the information sheet dated that was provided have been read carefully by me /
explained in detail to me, in a language that I comprehend, and I have fully understood the
contents. I confirm that I have had the opportunity to ask questions.
•
• The nature and purpose of the study and its potential risks / benefits and expected duration of
the study, and other relevant details of the study have been explained to me in detail. I
understand that my participation is voluntary and that I am free to withdraw at any time, without
giving any reason, without my medical care or legal right being affected.

11. • I understand that the information collected about me from my participation in this research and sections of any of my
medical notes may be looked at by responsible individuals. I give permission for these individuals to have access to my
records.
• I agree to take part in the above study.
Date:
(Signatures / Left Thumb Impression)
Place :
Name of the Participant: Son / Daughter / Spouse of: Complete postal address:
This is to certify that the above consent has been obtained in my presence.
Signatures of the Principal Investigator Date:
Place:

12. • 1) Witness – 1 2) Witness – 2
• Signatures Signatures
• Name: Name:
• Address: Address:
• NB Three copies should be made for (1) Patient, (2) Researcher,
(3)Institution

13. • INFORMED CONSENT IN VERNACULAR LANGUAGE (HINDI)
• इस परीक्षण क
े लिए लिषय पहचान संख्या __________________________________
• पररयोजना का शीषषक: “Magnetic Resonance Imaging In Stroke Patients At A
Tertiary Hospital”
• प्रधान अन्वेषक का नाम : Dr. Vaibhav
• मैंने उपरोक्त अध्ययन क
े बारे में सूचना पत्र प्राप्त कर लिया है और / या पढ़ लिया है लिखित
जानकारी को समझा।
• मुझे अध्ययन पर चचाष करने और सिाि पूछने का मौका लिया गया है।
• मैं अध्ययन में भाग िेने क
े लिए सहमत हं और मुझे पता है लक मेरी भागीिारी स्वैखिक है।
• मैंसमझता हं लक मैं अपने भलिष्यकी िेि भािको प्रभालित लकए लबना लकसी भी समय िापस
िे सकता हं।
• मैं समझता हं लक इसमें मेरी भागीिारी से मेरे बारे में जानकारी एकत्र की गई है। मेरे लकसी
भी मेलिकि नोट क
े अनुसंधान और अनुभागों को लजम्मेिार द्वारा िेिा जा सकता है।
व्यखक्तयों (नैलतकता सलमलत क
े सिस्य / लनयाम क प्रालधकरण)।मैं इन तक पहुँच िेता हुँ
• मेरे ररकॉिष तक िोगों की पहंच है।

14. • मैं समझता हं लक मुझे रोगी सूचना पत्र और सूलचत की एक प्रलत प्राप्त होगी
• सहमलत पत्र।
• ___________________________ __________________
• हस्ताक्षर / अंगूठे का लनशान
• _____________________________________________
• लिषय का मुलित नाम
• __________________
• हस्ताक्षर / अंगूठे का लनशान
• <<कानूनी रूप से स्वीकायष प्रलतलनलध हस्ताक्षर जोडा जाना चालहए यलि लिषए है
नाबालिग या िुि क
े लिए हस्ताक्षर करने में असमर्ष है ।लिषय और क
े बीच संबंध
कानूनी रूप से स्वीकायष प्रलतलनलध को बताया जाना चालहए।लनष्पक्ष गिाह यलि लिषय /
कानूनी रूप से स्वीकायष प्रलतलनलध असमर्ष है, तो हस्ताक्षर को जोडा जाना चालहए
पढ़ने या लििने और सहमलत उनकी उपखथर्लत में प्राप्त की जानी चालहए।
• _____________________________________________________
• कानूनी रूप से स्वीकायष प्रलतलनलध का मुलित नाम
• ______________________________________________________

15. • कानूनी रूप से स्वीक
ृ त प्रलतलनलध का संबंध
• _______________________________________ _______________
• हस्ताक्षर की तारीि का संचािन करने िािे व्यखक्त का हस्ताक्षर
• _______________________________________________________
• सहमलत चचाष की जानकारी िी
• _______________________________________________________
• आचरण करने िािे व्यखक्त का मुलित नाम
• _______________________________________________________
• सहमलत चचाष की जानकारी िी
• _______________________________________________________
• लनष्पक्ष गिाह का हस्ताक्षर हस्ताक्षर की तारीि
• _______________________________________________
• लनष्पक्ष गिाह का मुलित नाम