This talk includes 1) Pan-scan CT for trauma, 2) CTA for active bleeding and 3) multiphase CTA in acute stroke

1. Emergency CT: Update
Rathachai Kaewlai, 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. Ramathibodi
Emergency Radiology

3. Outline
Trauma pan-scan CT
CTA for active bleeding (ICH, hemoptysis, GI bleed)
Stroke multiphase CTA

4. PAN-SCAN

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
One of 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 based on severity of
trauma and initial evaluations
(clinical exam + FAST)

8. 20-year-old woman, motorcycle vs. 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, motorcycle vs. car
SDH
Thoracic aortic injury
Complex acetabular fracture

10. “Pan Scan”
Should it replace 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 ACTIVE BLEEDING:
ICH, HEMOPTYSIS, GI BLEED

15. Active Bleeding
Timely localization of 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 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

19. 51yo F, known valvular 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
Prevalence of 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 bleeding control – mortality 50%
Indications for intervention (bronchial embolization)
Volume 200 mL/24-48h
Acute respiratory failure
Erosion of pulmonary artery

24. Clinical Bedside Evaluation vs.
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 Severe Hemoptysis
Bleeding site
Bleeding vessels (PA involved or not)
Bronchial artery network (normotopic, atypical,
ectopic, non-bronchial systemic arteries)
Etiology

26. CTA: Site of The 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
By excluding 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 hemoptysis during 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,
Bleeding site: RUL
Bleeding vessel: Bronchial systemic
BA network: as in picture
Etiology:TB

33. CTA Algorithm for Severe
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 GI Bleeding
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 GI Bleeding: 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 Angiography and 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 of Overt 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 with abdominal distension, SMA branch active contrast extravasation
CTA
Venous

40. 43yo M, HIV with lymphoma, dropped Hct
Venous
Plain
Delayed

41. CTA: Diagnostic Performance
Systematic review 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:
A NEW TOOL FOR ACUTE STROKE

43. Acute Ischemic Stroke
Newer mechanical 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 Potential Rx
Brain parenchyma – infarct core (size)
Large vessel – occlusion (presence)
Collateral circulation (grading)
MRI-DWI
CTA
Multiphase CTA
NCCT, CTA-SI

45. CTA: Cerebral Vasculature
Sensitivity 97-100% 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
Good leptomeningeal/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
147 patients
Interrater reliability
n=30, k=0.81,
P.001
Menon BK, et al. Radiology 2015;275: 510

49. Multiphase CTA
Predicting clinical outcome 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, NIHSS 20,
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, NIHSS 15,
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 Menon BK, 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
ASPECTS score = 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 for active 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 CTA in
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 VERY MUCH
FOR YOUR ATTENTION
Rathachai Kaewlai, MD