Computed Tomography Angiography in the Assessment of Patients With Stroke/TIA

Abstract

Rapid advance in medical technology has resulted in the availability of numerous tests and treatment strategies in the management of acute stroke. The increasingly evidence-based context of clinical medicine necessitates that clinicians use only appropriate tools to facilitate the diagnostic process and patient management. In this review, we seek to explore the use of computed tomography angiography (CTA) in the diagnosis and management of patients presenting with acute stroke (ischemic and hemorrhagic) or transient ischemic attack (TIA). We present evidence in favor of the use of CTA, highlight the disadvantages of this imaging modality, and present a heuristic model based on our experience at utilizing CTA for decision making in acute stroke and TIAs.

Optimal Workflow and Process-Based Performance Measures for Endovascular Therapy in Acute Ischemic Stroke

“…CT angiography head and neck at baseline could help the interventionist select beforehand catheters and tools to facilitate access. 32 Of note, our results show patients receiving GA had shorter overall time from stroke onset to final reperfusion, although these same patients had prolonged time from groin puncture to final reperfusion. We think this is because some patients were intubated on route to hospital or at emergency room before imaging; in such patients, workflow may have improved significantly after intubation.…”

“…31 Moreover, use of CT angiography at baseline can help identify proximal artery occlusions. 32 A workflow that offers intravenous tPA administration in parallel to rapid activation of the neurointerventional team and transfer to angiography suite has the potential to reduce time from imaging to groin puncture. Shorter imaging to groin puncture time in patients on warfarin in the STAR study is also probably because they bypass intravenous tPA.…”

Consistently Achieving Computed Tomography to Endovascular Recanalization <90 Minutes

“…An assessment of the circle of Willis and tortuosity can be used to determine the need for a distal access catheter and length and size of the stentriever, and the possibility of using direct thrombus aspiration as the primary intervention. 19 A combination of the early ischemic changes, distribution of collaterals, and size of the relevant M2 branches can help determine which M2 would be the preferred one to access. …”

Multimodality CT based imaging to determine clot characteristics and recanalization with intravenous tPA in patients with acute ischemic stroke

“…EVT is only performed for those with target clots in CTA [24,25]. Successful recanalization by IVT is dependent on clot length [22,26] or clot burden as measured by CT angiography [27].…”