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490
J. H. Shin
Table 44.1 Contraindications to PRG placement
Absolute Relative
Massive hepatosplenomegaly Surgically altered gastric
Colon interposed in front of
stomach
Unsatisfactory percutaneous
access route
Uncorrectable coagulopathy Peritoneal dialysis
anatomy
Gastric varices
Massive ascites
Severe gastroesophageal reux
disease
congenital heart disease, and chronic illnesses such as cystic
brosis. This patient population has difculty maintaining
their nutritional requirements with oral feeds, and nocturnal
tube feeds can provide additional calories.
While percutaneous radiologic gastrostomy (PRG)
tubes are widely available and less invasive than percutaneous endoscopic gastrostomy (PEG) tube placement,
several factors contribute to reduced success rate including an unsafe percutaneous access route. With recent
innovations in placement technique and gastrostomy tube
design, there are now fewer contraindications
(Table 44.1). While historically ventriculoperitoneal
(VP) shunts were seen as a contraindication to PRG
placement, multiple studies have indicated no increase in
peritoneal infection, and therefore PRG can be placed
safely in this patient population [2].
Percutaneous Radiologic Gastrojejunostomy (PRGJ) Tube
Conventional Therapy
In 1837, surgical gastrostomy tube was rst described by
Egeberg, but the technique was not standardized until Stamm
in the late 1800s [3]. The Stamm procedure is still used today
and requires an incision in the upper abdomen with a direct
cutdown to the stomach followed by tube placement and
securement. A less invasive surgical option was rened by
Gauderer and Ponsky in 1979 via a percutaneous endoscopic
method [4]. The percutaneous endoscopic gastrostomy
(PEG) tube is the more commonly performed procedure by
endoscopists and surgeons alike. The gastric wall is
transilluminated with an endoscope and apposed to the
anterior abdominal wall. During the “pull” technique, a
small incision is made, and a needle and suture are used to
puncture the stomach, aiming toward the light of the
endoscope. The suture string is snared and pulled out through
the mouth which is then used to pull the tube in. The simpler
“push” technique punctures the stomach in a similar manner;
however a peel-away sheath is advanced into the stomach.
The feeding tube is advanced through the sheath followed by
ination of a proximal balloon. The sheath is then peeled
away. In both instances, the tube is then afxed to the skin
with a small disc to prevent dislodgement.
Jejunostomy tubes are still surgically placed in the majority of cases due to the difculty of puncturing a decompressed and mobile small bowel. They are primarily placed
as an adjuvant procedure during major upper GI tract surgery
and in those with expected complicated postoperative recovery particularly for those needing subsequent chemotherapy
or radiation therapy. Additionally, it can be placed in patients
with neurologic and congenital illnesses.
Patients with repeated bouts of aspiration pneumonia or
at risk of gastroesophageal reflux may benefit from a gastrojejunostomy tube. This is also indicated in patients
with gastric outlet obstruction to bypass the obstruction
as well as decompress the stomach. PRGJ can be performed as an initial procedure (primary PRGJ) or by converting a prior gastrostomy tube to a gastrojejunostomy
tube (conversion PRGJ).
Percutaneous Jejunostomy (PJ) Tube
PJ is indicated for patients with previous gastric surgery (i.e.,
gastrectomy), abnormal gastric position, or chronic aspiration. Jejunostomy tubes are also used for patients with pancreatic injuries or recent pancreatic surgeries including the
Whipple procedure to bypass the pancreatic duct and allow
the pancreas to heal. However, PJ has not been widely
accepted as a primary insertion procedure because technical
feasibility is limited by the difculty in puncturing a decompressed and mobile small bowel.
Interventional Therapy
Percutaneous Radiologic Gastrostomy (PRG)
In 1981, Preshaw introduced the rst uoroscopically guided
percutaneous radiologic gastrostomy (PRG) tube. The use of
uoroscopy eliminates the need for an upper endoscopy making the procedure less invasive. As a large number of patients
are unable to undergo endoscopy, this advancement made
enteric access available for a wider patient population.
There are a wide variety of gastrostomy tubes available
(Fig.44.1). They differ in both size and retention mechanism.
Pigtail-retained tubes are the easiest to insert; however they are
prone to clogging due to their small caliber (10–14 Fr) and
dislodging due to their thread retention mechanism, requiring
regular maintenance and exchange. Balloon- retained tubes
usually have larger bores (14–16 Fr) and are more secure than
pigtail-retained. Pigtail- or balloon-retained tubes are inserted
percutaneously under uoroscopic guidance. Mushroomretained tubes have a very large bore (≥20 Fr) and very secure
44 Enteric Access andFeeding Tubes
491
Fig. 44.1 Different kinds of gastrostomy tubes. (a) A pigtail-retained
tube. (b) A balloon-retained tube. Balloon (arrow) is inated with uid to
hold the tube securely in place. (c) A mushroom-retained tube (pull- type
retention mechanism and durability. However, the insertion
technique is complicated as they must be placed via the oropharynx and requires retrograde catheterization of the esophagus.
Gastropexy is required for tubes that are used in
PRG.Gastric puncture is performed with a 17-gauge puncture needle preloaded with an anchor or fastener. Typically,
two to four gastropexies are placed, and an intragastric position is conrmed by aspiration of air into a syringe and/or
injection of contrast, outlining gastric folds. Gastropexy is
advantageous in prevention of gastric leakage, peritonitis,
and tube dislodgement; moreover it aids in early maturation
of the gastrocutaneous tract. Securing a gastropexy too tight
can cause skin ischemia and potentially mucosal ulceration
and hemorrhage. Although the performance of gastropexy
has remained controversial, one prospective randomized
study has shown that it reduces the risk of initial intraperitoneal tube placement and obviates subsequent tube migration
through the formation of adhesions [5].
Key Point
Gastropexy is the term used to describe the xation of
the gastric wall to the anterior abdominal wall using an
anchor or fastener.
tube). Feeding adaptor (arrows) is connected to the tube after the tube is
cut to the desired length
Prior to placement of a gastrostomy tube, it is important
to review a patients’ history and any prior gastric surgery to
determine if the intended procedure can be successfully
completed; this will also allow planning of procedural modications. Blood parameters including CBC and coagulation
labs should be checked to ensure safe placement. A preliminary CT or ultrasound can be used to evaluate stomach position relative to the transverse colon and left hepatic lobe.
Alternatively, the colon location can be delineated uoroscopically by giving 100–200mL of barium sulfate the night
before the procedure.
A patient should be kept NPO overnight to empty the
stomach of gastric content and decrease the procedural risk
of aspiration. An NG tube placed the evening before the procedure will help decompress the stomach. This is further
used to insufate air to bring the stomach into apposition
with the anterior abdominal wall during the procedure. If
there is difculty placing the NG tube, an angiographic 5 Fr
catheter can be placed under uoroscopic guidance immediately prior to the procedure.
The procedure is performed under conscious sedation,
although it should be used judiciously in patients with respiratory compromise. A one-time dose of IV antibiotic is
required for pull-type gastrostomy tubes.
492
The How To
J. H. Shin
Several modications can be made on the traditional
gastrostomy tube for different patient requirements.
1. Administration of a smooth-muscle relaxant (e.g.,
20-mg hyoscine butylbromide) IV is helpful to
diminish gastric peristalsis.
2.
stomach via the NG tube until adequate gastric distension is achieved.
3.
44.2 and 44.3).
4. Puncture the stomach with an 18-gauge sheathed
needle with a brief, deliberate thrust so as not to
push the anterior gastric wall away from the anterior abdominal wall. Usually, the puncture needle is
directed slightly toward the fundus. However, if
conversion to a percutaneous gastrojejunostomy
(PRGJ) tube is anticipated, the needle should be
directed toward the pylorus.
5. The gastropexy anchors are then deployed by pass-
44.3).
The guidewire and needle are subsequently
removed, and the stomach is gently approximated
to the anterior abdominal wall by gently traction on
the anchor.
6. Serial dilators are introduced over the 0.038-inch
stiff guidewire to dilate the tract.
7. The gastrostomy tube is inserted over the
guidewire.
8. Following tube placement, contrast is injected,
and frontal and lateral views of the upper abdo-
1. Pull-type gastrostomy tube placement (Fig.44.5):
Peroral endoscopic placement of a pull-type gastrostomy
tube was developed to overcome retention problems of
radiologically inserted gastrostomy tubes. However, these
tubes may also be placed under uoroscopic guidance.
The stomach is insufated with air through an NG tube
or 5 Fr catheter. Following successful percutaneous gastric access under uoroscopic guidance, a 180-cm, 0.035inch guidewire is inserted to the gastric lumen through the
needle, and an 8–10F vascular sheath is placed over the
wire. A 5F endhole catheter is introduced to facilitate the
1
2
44.4). The feeding tube is secured to the
skin with sutures or commercially available
retaining devices. If a suture is placed, it should
be removed after several weeks once the tract has
matured.
Fig. 44.2 A Cope suture anchor. (a) The anchor, which is made of a
short metal bar (arrows), is attached to a surgical suture (arrowheads)
and is preloaded into a 17-gauge puncture needle. (b) The anchor
Fig. 44.3 Gastric puncture (asterisks) is performed at the mid- to distal
gastric body, equidistant from the greater and lesser curvatures. It
should be lateral to the rectus muscle or in the midline to avoid puncture
of epigastric arteries (1 and 2 indicate the superior and inferior epigastric arteries, respectively)
(arrow) is deployed when a guidewire (long arrows) is advanced
through the puncture needle. The distal end of the suture string (arrowhead) is attached to the suture needle for xation to the skin
44 Enteric Access andFeeding Tubes
493
selection of the esophagus in a retrograde manner. An
anchor(s) may be deployed to hold the anterior gastric
wall against the anterior abdominal wall, and the guidewire is advanced from the mouth to the stomach through
a 5F catheter. The guidewire is then captured by the snare.
A 5F catheter is exchanged for a 7F catheter over the
guidewire using a “through-and- through” technique. The
thread included in the kit is advanced through the catheter
from the abdominal wall to the mouth. The snare attached
to a 20 Fr mushroom (pull-type) gastrostomy tube is tied
to the thread, and the gastrostomy tube is pulled down
through the oropharynx and out the anterior abdominal
wall. The tapered tip of the gastrostomy tube is then cut to
the desired length. Since this technique can pull down
oral ora to the gastrostomy site, it is advised not to use in
patients with oropharyngeal cancers, and prophylactic
antibiotics are advised periprocedurally [6].
2. One-anchor technique:
There is controversy as to the number of anchors that
is sufcient for gastropexy. With the one-anchor technique for PRG (see Fig.44.4), a single anchor is inserted
through a preloaded 17-gauge puncture needle [7]. After
conrming an intragastric location, the anchor is released
by pushing with the guidewire. The anchor is pulled
rmly toward the anterior abdominal wall; serial dilators
are introduced over the guidewire through the same tract.
Finally, a gastrostomy tube (10–16F) is introduced over
the guidewire into the stomach. Although the one-anchor
technique is a simple procedure, risk of anchor dislodgment and related peritonitis is potentially increased [7].
3. Modied Chiba-needle puncture technique:
PRG with a Chiba-needle puncture technique coupled
with the use of single gastropexy in the same puncture
Fig. 44.4 Percutaneous radiologic gastrostomy with a one-anchor
technique. (a, b) The stomach is inated with an angiographic catheter
(arrow), and a Cope suture anchor (arrowheads) is advanced under frontal and lateral uoroscopic guidance. Gastric tenting (long arrows)
made by the anterior stomach wall is clearly seen in a lateral view. (c)
After anterior stomach wall puncture with a Cope suture anchor via a
brief thrust, the anchor (arrowheads) is deployed with advancement of
a guidewire (arrows). (d) By traction of the anchor (arrow), the anterior
stomach wall is apposed to the abdominal wall. (e) The puncture tract is
serially dilated (arrows). (f) A 14-Fr pigtail-retained tube is placed, and
its intragastric location is conrmed with contrast-agent injection
(Reprinted with permission from Shin and Park [12])
494
J. H. Shin
Fig. 44.5 Pull-type gastrostomy using a mushroom-retained tube. (a, b)
The guidewire (arrows) from the mouth to the stomach through a 5-F
endhole catheter is captured by the snare (arrowheads) which was
introduced into the stomach via the sheath and pulled out of the stomach
through the abdominal wall (not shown). (c, d) A 5F catheter is
exchanged for a 7F endhole catheter (arrows in part c) over the
tract has been reported with possible shorter procedure
time and fewer complications [8]. A 21-gauge Chibaneedle is used for gastric puncture which is then exchanged
for a 6-Fr Neff catheter. A suture anchor is deployed into
the stomach through the Neff catheter to achieve gastropexy. Then, following serial dilation, a 14-Fr pigtailretained tube is inserted.
Post-procedural Management
Following gastrostomy tube placement, gastrostomy tube
output should be low prior to beginning feedings. While signicant gastric residuals may indicate problems with bowel
motility or inadequate tube position, absence of symptoms
such as reux, aspiration, nausea, and bloating more accurately predicts a well-functioning feeding tube. Furthermore,
if the patient develops peritoneal signs, feeding should be
stopped immediately.
For some patients, the tube may be needed permanently;
however, for most, the tube can be removed once they are
successfully able to maintain enough caloric intake orally.
Prior to removal, a pigtail should be unlocked and balloon
should be deated. The tube can then be pulled out through
the skin taking care not to splash the patient or yourself with
gastric juices. Constant tension is needed to collapse the
mushroom-type tube through the tract. After removal, a
liquid diet in small amounts is recommended for the rst
24 h to allow closure of the gastrocutaneous stula. The
patient can progress to soft and eventually regular diet if no
leakage is noted from the tube site.
The overwhelming number of complications of gastrostomy tube placement are minor (Table 44.2) and include
supercial wound infection and peritubal leakage. While this
guidewire using “through-and-through” technique. The snare attached
to the 20F gastrostomy catheter is tied to the thread, and the gastrostomy
tube is pulled in an anterograde fashion into the stomach. The
gastrostomy tube (arrows in part d) is in place with the mushroom
(arrowheads) of the tube close to the anterior abdominal wall
Table 44.2 Complications of PRG
Complication Characteristic Management
Peristomal
infection
Tube clogging Very common Attempt declogging
Tube malfunction Leakage or break-in
Peritonitis Rare, severe,
Hemorrhage Related to
Aspiration
pneumonia
Pneumoperitoneum Not signicant
Most common,
minor; can progress
to necrotizing
fasciitis
tube
peritoneal
extravasation of
gastric contents
underlying
coagulopathy
Reux after gastric
feeding
unless peritoneal
irritation or
increasing volume
Skin care
Occasionally antibiotics
Surgical consultation
for necrotizing fasciitis
May require tube
exchange
Requires tube exchange/
upsizing
If replacement is
impossible, new access
may be required
Hold tube feeding
CT to evaluate for
abscess
Possible surgical
consultation
Correct coagulopathy
May need transarterial
embolization
Consider converting
gastrostomy to
gastrojejunostomy tube
May require tube
upsizing
can be uncomfortable for the patient, these can be treated
with antibiotics and gauze, respectively. Major complications
are infrequent, occurring in less than 3% of PRG placements,
and include peritonitis, hemorrhage, and necrotizing fasciitis. The reported rates of major complications following
PRG are less than those following surgical or endoscopic
gastrostomies [9].
44 Enteric Access andFeeding Tubes
495
Percutaneous Radiologic Gastrojejunostomy (PRGJ)
For primary PRGJ, the puncture site should be directed
toward the pylorus. Using an angled catheter-guidewire
combination, the catheter should be advanced through the
Fig. 44.6 Primary percutaneous radiologic gastrojejunostomy in a
patient with recurrent aspiration pneumonia. A 16.5-Fr, 80-cm, doublelumen gastrojejunostomy tube was placed. A friction-lock Malecot
retention device (arrows) is present to prevent inadvertent removal. The
shorter lumen (arrowheads) within the stomach is for gastric suction.
Contrast injection through the longer lumen reveals good opacication
of the jejunum
stomach and duodenum past the ligament of Treitz under
uoroscopic guidance. Once the catheter is manipulated into
the jejunum, the tract is dilated over a stiff wire, and a peelaway sheath is placed, followed by tube insertion. Usually,
two to four gastropexy devices are recommended to provide
additional manipulations necessary to access the jejunum;
however, one-anchor technique, as in PRG, can be successfully used (Fig.44.6) [10].
Percutaneous Jejunostomy (PJ)
Percutaneous jejunostomy (PJ) tube placement can be technically challenging due to the limited ability to distend the jejunum and its relatively mobile nature. A modied Chiba-needle
puncture technique can be utilized [11], as in PRG.A 5 Fr catheter and a 0.035-in. guidewire are introduced into the jejunum
through the nostril under uoroscopic guidance. Using frontal
and lateral uoroscopy, the catheter tip is located in an air-contrast lled proximal jejunum, as a target, in a portion that is
sufciently close to the anterior abdominal wall. The bowel is
punctured with a Chiba-needle technique, followed by
exchange for a 6-Fr Neff catheter, gastropexy, serial dilation,
and insertion of a 14-Fr pigtail- retained tube (Fig.44.7) [11].
Percutaneous radiologic gastrostomy and gastrojejunostomy tubes are considered both safe and effective procedures
for enteral access. Multiple studies have demonstrated lower
complications and higher success rates for PRG and PRGJ
than surgical or endoscopic gastrostomy tube placement,
making it the preferred method in most patients.
Fig. 44.7 Percutaneous jejunostomy with a 21-gauge needle puncture
in a patient with total gastrectomy. (a, b) A catheter and guidewire were
passed from the nostril into the jejunum for targeting. Anteroposterior
and lateral radiographs show the most supercial puncture target
(arrows) of the inserted 7.5-F multifunctional coil catheter in the jejunum. (c) A Chiba needle (arrow) is then inserted into the area of the
jejunum closest to the abdominal wall after contrast and air injection
through the catheter. (d) After exchange of the Chiba needle with a 6-F
Neff catheter over a 0.018-inch guide wire, a Cope suture anchor
(arrowheads) was pushed into the jejunum by a 0.035-inch Amplatz
guidewire (arrows). (e) Tract dilation is performed with serial dilators
(arrow). (f) A 14-F pigtail-type tube is inserted into the jejunal lumen,
and the image shows good contrast opacication of the bowel without
evidence of extraluminal contrast
496
Fig. 44.7 (continued)
References
1. Norton B, Homer-Ward M, Donnelly MT, Long RG, Holmes
GK.A randomized prospective comparison of percutaneous endoscopic gastrostomy and nasogastric tube feeding after acute dysphagic stroke. BMJ. 1996;312(7022):13–6.
2. Kim JS, Park YW, Kim HK, Cho YS, Kim SS, Youn NR, Chae
HS.Is percutaneous endoscopic gastrostomy tube placement safe
in patients with ventriculoperitoneal shunts? World JGastroenterol.
2009;15(25):3148–52.
3. Cunha F. Gastostomy: its inception and evolution. Am J Surg.
1946;72:610–34.
4. Gauderer MW, Ponsky JL, Izant RJ Jr. Gastrostomy without laparoscopy: a percutaneous endoscopic technique. J Pediatr Surg.
1980;15:872–5.
5. Thornton FJ, Fotheringham T, Haslam PJ, McGrath FP, Keeling
F, Lee MJ.Percutaneous radiologic gastrostomy with and without
T-fastener gastropexy: a randomized comparison study. Cardiovasc
Intervent Radiol. 2002;25(6):467–71.
6. Ahmed O, Jilani D, Sheth S, Giger M, Funaki B. Radiologically
guided placement of mushroom-retained gastrostomy catheters:
J. H. Shin
long-term outcomes of use in 300 patients at a single center.
Radiology. 2015;276(2):588–96.
7. Kim JW, Song HY, Kim KR, Shin JH, Choi EK.The one-anchor
technique of gastropexy for percutaneous radiologic gastrostomy: results of 248 consecutive procedures. JVasc Interv Radiol.
2008;19(7):1048–53.
8. Shin JH, Song HY, Kim TH, Kim KR, Choi KE, Kim JH.
Percutaneous radiologic gastrostomy: a modied Chiba-needle
puncture technique with single gastropexy. Abdom Imaging.
2010;35(2):189–94.
9. Wollman B, D’Agostino HB, Walus-Wigle JR, Easter DW, Beale
A. Radiologic, endoscopic, and surgical gastrostomy: an institutional evaluation and meta-analysis of the literature. Radiology.
1995;197(3):699–704.
10. Shin KH, Shin JH, Song HY, Yang ZQ, Kim JH, Kim KR.Primary
and conversion percutaneous gastrojejunostomy under uoroscopic
guidance: 10 years of experience. Clin Imaging. 2008;32(4):274–9.
11. HT H, Shin JH, Song HY, Kim JH, Yoon HK, Gwon DI, Ko GY,
Sung KB.Fluoroscopically guided percutaneous jejunostomy with
use of a 21-gauge needle: a prospective study in 51 patients. JVasc
Interv Radiol. 2009;20(12):1583–7.
12. Shin JH, Park AW.Updates on percutaneous radiologic gastrostomy/gastrojejunostomy and jejunostomy. Gut Liver. 2010;4(Suppl 1):S25–31.
Part XII
Neuro-IR
Stroke
ChristopherKim andMaryE.Jensen
45
Pathophysiology
In 2015, stroke was the second leading cause of death
worldwide, trailed only by ischemic heart disease in global
mortality [1]. In the United States alone, stroke is the leading preventable cause of disability and accounts for an estimated $33 billion each year in healthcare services,
medications, and lost employment [2]. Risk factors for
stroke include age, hypertension, hyperlipidemia, and diabetes with smoking and tobacco use representing the single
most impactful lifestyle modiable risk factor for cardiovascular disease. Recognized symptoms include facial
droop, extremity weakness, altered mental status, and
aphasia.
Strokes can be categorized into ischemic or hemorrhagic
based on imaging features. Ischemic strokes of either thrombotic or embolic origin account for nearly 87% of all strokes
[3]. While hemorrhagic strokes are managed medically and/
or surgically, the acute ischemic stroke patient may benet
from the administration of intravenous recombinant tissue
plasminogen activator (rt-PA) or endovascular therapy
within the proper timeframe and in the proper clinical setting. A recognized indication for endovascular therapy in the
setting of an acute ischemic stroke is the presence of a large
vessel occlusion, which is anatomically dened as the proximal blockage of a major intracranial vessel.
C. Kim · M. E. Jensen (*)
University of Virginia Health System, Department of Radiology
and Medical Imaging, Charlottesville, VA, USA
e-mail: ck6rt@virginia.edu; mej4u@virginia.edu
Key Point
Cerebral vascular occlusions that warrant treatment:
Internal carotid artery
Middle cerebral artery (MCA)
M1– Origin to bifurcation/trifurcation
M2– Insular segment
Anterior cerebral artery (ACA)
A1 – Origin to anterior communicating artery
(ACOM)
Posterior cerebral artery (PCA)
P1 – Origin to posterior communicating artery
(PCOM)
P2– Posterior communicating artery to the ambient
cistern
Basilar artery– Special consideration given the severe
morbidity and mortality associated with basilar
artery stroke
Clinical Indication
The initial management of acute ischemic stroke is a multidisciplinary effort centered at minimizing cerebral hypoperfusion time. A focused neurologic evaluation should establish
time of symptom onset, which is often dened as the time the
patient was last known to be awake and free of stroke symptoms [1]. Predetermined stroke scales such as the National
Institutes of Health Stroke Scale (NIHSS) provide a quantiable and easily conveyable assessment of neurologic impact
to other healthcare providers and are frequently used as
benchmarks for patients pre- and post- intervention [4]. The
NIHSS is heavily weighted toward left hemispheric decits
limiting its use for suspected posterior fossa strokes.
Additional important clinical data include the prehospital
© Springer International Publishing AG, part of Springer Nature 2018
N. A. Keefe et al. (eds.), IR Playbook, https://doi.org/10.1007/978-3-319-71300-7_45
499
500
C. Kim and M. E. Jensen
Table 45.1 Modied Rankin scale for the degree of disability follow-
ing stroke or other neurologic disability
Scale Degree of disability
0 No disability
1 No signicant disability. Can carry out all ADLs with some
symptoms
2 Slight disability. Unable to carry out all ADLs independently
3 Moderate disability. Requires aid for ADLs. Can walk
unassisted.
4 Moderately severe disability. Requires aid for ADLs. Cannot
walk unassisted and requires help for bodily needs.
5 Severe disability. Requires constant nursing care
6 Dead
Abbreviation: ADL activities of daily living
performance status of the patient as measured by the modied Rankin scale (mRS, Table45.1) as well as any contraindications to recombinant tissue plasminogen activator (rt-PA)
administration [5].
Key Point
NIHSS stroke scale examination:
• Level of consciousness
• Language
• Neglect
• Visual-eld loss
• Extraocular movement
• Motor strength
• Ataxia
• Dysarthria
• Sensory loss
Table 45.2 Alberta stroke program early CT score (ASPECTS) is a
10-point quantitative topographic CT score for evaluating MCA stroke
ASPECTS scale MCA territories
Caudate Internal capsule
Putamen Insular cortex
M1 frontal operculum M4, anterior cortex superior to M1
M2 anterior temporal lobe M5, lateral cortex superior to M2
M3 posterior temporal lobe M6, posterior cortex superior to M3
Initial score of 10 with 1 point deducted for each region involved. M1–
M3 are at the level of the basal ganglia. M4–M6 are at the level of the
ventricles
patients for intravenous or intra- arterial therapy in most
cases. The insular cortex along the lateral sulcus is a territory
susceptible to hypoperfusion given its lack of collateral supply. The “insular ribbon sign,” or loss of the normal graywhite differentiation along the lateral margin of the insular
cortex, is an early nding on non-contrast head CT of potential MCA territory hyperacute infarct. Non-contrast CT of
the head may also suggest large vessel occlusion in the setting of a “hyperdense MCA sign” where increased density of
the proximal middle cerebral artery is present secondary to
arterial thrombus formation.
Key Point
CT ndings of acute stroke:
• Hyperdense vessel
• Loss of grey-white matter differentiation
• Insular ribbon sign
• Disappearing basal ganglia sign
Multiple randomized controlled trials have also demonstrated the importance of selection criteria in identifying
appropriate candidates for intervention. In the setting of an
acute stroke, a non-contrast CT of the head serves as a rapid
means of excluding intracranial hemorrhage and other nonischemic pathologies (e.g., tumor and metastases) as well as
evaluating core infarct size. It is important to note that the
headCT can look normal in the acute period. The Alberta
Stroke Program Early CT Score (ASPECTS) is a 10-point
quantitative scale (Table 45.2) for identifying the affected
territory in the setting of a middle cerebral artery (MCA)
stroke and has been used as both a predictor of outcome after
the administration of systemic rt-PA as well as selection criterion for endovascular therapy [6]. A score corresponding to
the severity and size of the infarcted region is calculated by
categorizing affected regions of the MCA territory. Lower
scores (≤5) are indicative of large territory infarctions
already present on non-contrast CT scan, which disqualies
In the absence of a contraindication to endovascular
therapy, computed tomographic angiography (CTA) of the
head and neck is critical in evaluating for large vessel
occlusion, collateral supply to the ischemic brain territory,
and anatomic mapping of the neck and brachiocephalic
vessels. Multiphase CT angiography generates timeresolved images of pial arteries from which the robustness
of the collateral circulation can be determined [7].
Additional advanced imaging techniques including strokespecic MRI diffusion-weighted imaging, CT perfusion,
and MR perfusion may provide useful information regarding at-risk brain tissue (the ischemic penumbra) versus the
core infarct region. However, in contrast to the near-universal rapid acquisition of a non-contrast CT and CTA of the
head, immediate availability of these advanced imaging
techniques is widely disparate and should not delay treatment when clinically indicated. The algorithm in Fig.45.1
describes the patient selection pathway based upon the time
of symptom onset and the imaging ndings.