CT Perfusion In Acute Ischemic Stroke

00:00 - Intro
01:14 - Objectives
01:38​ - Why CT perfusion?
04:23 - ASPECT scoring on non-contrast head CT
08:02 - Fundamental hemodynamic properties: CBF, CBV, MTT, Tmax
13:35 - Clinical uses: DEFUSE 3, DAWN, EXTEND
18:26 - Clinical examples
22:03 - Hypoperfusion index and multi-threshold Tmax maps
23:37 - Caveats and pitfalls: Caveats in estimating core
30:15 - Caveats and pitfalls: Caveats in estimating penumbra
35:37 - Summary
36:11 - Quality of study: Vessel selection, contrast opacification, patient motion
38:27 - Additional uses of CTP: Medium vessel occlusion
40:28 - Additional uses of CTP: Posterior circulation stroke
44:59 - Additional uses of CTP: Stroke mimics
46:52 - Can we use CTP like cardiologists use troponin?
47:58 - Summary and algorithm

This video is intended for residents and fellows to understand the interpretation and clinical applications of CT perfusion imaging for the treatment of patients with acute ischemic stroke.

Created, produced, and narrated by:
Igor Rybinnik MD
Neurology Clerkship Director
Rutgers Robert Wood Johnson Medical School

Content experts:
Raymond Mirasol MD, Roger Cheng MD
Division of Stroke and Neurocritical Care
Department of Neurology
Rutgers Robert Wood Johnson Medical School

Sudipta Roychowdhury, MD FACR
Clinical Professor of Radiology, Neurosurgery, and Neurology
Rutgers Robert Wood Johnson Medical School
Director of Interventional Neuroradiology
Director of Magnetic Resonance Imaging
Robert Wood Johnson University Hospital

References:
1. Saver JL, et al. JAMA 2016, 316(12):1279
2. Nomani AZ, et al. Neurology 2021, 97:e2079-87
3. Sarraj A, et al. Stroke 2021, 52(1):57-69
4. Barber PA, et al. Lancet 2000;355(9216):1670-4
5. Almallouhi AZ, et al. JAMA Network Open. 2021;4(12):e2137708
6. Adapted from Sotoudeh H, et al. Acad Radiol 2019;26(11):1565-79
7. Albers GW, et al. NEJM 2018;378:708-718
8. Nogueira R, et al. NEJM 2018(1);378:11-21.
9. Ma H, et al. NEJM 2019;380(19):1795-1803
10. MacLellan A, et al. JSCVD 2022;31(1):106-208
11. Normani AZ, et al. Neurology 2021;97(21):e2079-87
12. Albers GW, Stroke 2018;49:1-5
13. Martins N, et al. Intervent Neurol 2018;7:513-521
14. Campbell BC, et al. Int J Stroke 2015;10:51–54
15. Amukotuwa SA, et al. Stroke 2021;52:3308-3317
16. Katyal A, et al. Eur J Neurol 2021;28:2657-2668
17. Tao WD, et al. Stroke 2012;43(8):2060-2065
18. Capasso R, et al. Neuroradiology 2021;63:317–330
19. Novakovic-White R, et al. Neurology 2021;97:S158-S169
20. Vagal A, et al. Neurology 2019;93(20):888-898.
21. Benson JC, et al. AJNR 2016;37:2239-44

Images adapted from:
- Articles referenced above
- Adobe Creative Cloud
- Blumenfeld H. Neuroanatomy Through Clinical Cases, 2nd ed. Sinauer, 2010.

Music:
- The Itch (Instrumental) - NEFFEX
- Icelandic Arpeggios - DivKid
- Under Cover - Wayne Jones

Disclaimer: Please note that this material was simplified for educational purposes. For patient management, please review your clinical society's guidelines and engage expert consultation where appropriate. Also, the opinions of the presenters do not necessarily reflect those of Rutgers Robert Wood Johnson Medical School, Robert Wood Johnson University Hospital, RWJBarnabus Health, or Rutgers University as a whole.

[niceyesplease]

I really have to emphasize that it is ridiculous that we get this kind of content for free on YouTube as it is so good. Thank you again and again.

[le_tanmay]

I echo the thoughts of so many in the comments. Almost feels like a crime getting this content and teaching for free on YouTube! Thanks a lot!

[swwngok]

Finally! I've been waiting for a new neurology lecture for so long! Meanwhile, I watched all your other lectures several times!

[dr.shakya]

“David Attenborough of Neurology”. High quality, latest updates and the narrative, everything’s perfect.

[vxp]

Thank you Thank you and a Million Trillion Thank you!!!
we are a group of neuorology Residents who are watching your videos to help us have better understanding of brain imaging!
Please never Stop make these videos!
thank you again and again!

[mohammaddawod]

Imma about to start my residency in radiology, and I just couldn't be more grateful for such high quality, top tier and surprisingly soothing (haha) video.
Can't wait to binge watch all of your videos guys.
NEVER STOP your brilliant work guys!

[pablovargas]

Thank you very much! As a radiology resident CT perfusion was very challenging in interpreting and correlating with clinical context. Much appreciated to know what really neurologists want us to tell and help them in stroke codes.

[sinbin]

Extremely thankful for your videos ..they are so on point and emphasize the patient outcomes with these steps that needs to be taken... Neurology resident here..

[nilsoncorrea]

Incredible!!!! This take the diagnosis and treatment to another level. But I think I will not be alive to see this in real world practice. Maybe in 15 or 20 years. The EM coleagues will have much work to reach this level.

[lkhanna]

I wish I could be such a wonderful teacher as you are. This presentation is priceless. Thanks!

[drkaranpoddar]

Phenomenal content, the best resource for Neurology on YouTube, please keep them coming!

[sinemyazici]

You are a excellent lecturer, as a Neurologist, I've learned too much from your series. Thank you again for this wonderful presentation and free sharing via YouTube!

[Sally-gumq]

you are fantastic.. I feel like I must pay you for your efforts.. Great job, huge Thanks

[thiagoferreira]

I'm a neurology resident from Brazil and would like to thank you for this amazing job! It's just amazing your skills to wrap up everything that is important on each topic. This lecture by the way is fenomenal! Looking forward to see tou making more videos like this.

[cz]

Thank you so much! As a neurology resident, this was very useful! I am looking forward to how ANGEL ASPECTS and SELECT 2 trial that came out of ISC 2023 may/will affect what we do clinically!

[AkashMishra]

Absolutely Love your lectures, seen all of them several times

[DanielArmandBernard]

As an EM resident this video is GOLD and definitely something I'm going to share with all my colleagues in my residency because generally anything beyond a non-con head CT terrifies us. Neuro imaging is something that intimidates many of us and this lecture makes CTP so much more approachable and can facilitate a much higher level conversation with many of our stroke consultants. Thank you so much for making this free on youtube.

[lindalee]

Yeayyy, new video. I will inform my students to watch this one also. Your channel is a must see at our centre. Thank you for your elaborate work.

[aaAxion]

Contents starting 23:40 are pure gold.

[Mr_raqi]

2:43 i think you labelled penumbra and core wrong here (on the graphic green🟢 and purple 🟣), but the way you explained it is correct