Transient Ischaemic Attack - Imaging Pathways

The Imaging
Pathway
for
TIA
Iris C, Sarah C, Sharon D, Janine E, Sam F,
Jessica K, Andrea K, Andrew N, George S, Phuong T
Transient
Ischaemic
Attacks

What is a TIA?
A brief episode of neurological dysfunction caused
by focal brain or retinal ischemia (loss of blood
flow), with clinical symptoms lasting less than one
hour, and without evidence of acute infarction.
[Solenski, 2004]
Statistics
Transient ischemic attacks is an indicator for internal
carotid arteries imaging, as there is a significantly
increased risk of stroke [Jaff, et al., 2008]. It has been
estimated that 4-20% of patients will have a stroke
within the 90 days after the first TIA and 1/2 within
the first 2 days. [Bonifati, et al., 2011]
Why is imaging important?
TIA increases a patient’s risk of developing a stroke, therefore proper diagnosis and treatment is urgently required
to reduce and prevent the risk of stroke recurrence, otherwise permanent brain injury, disability and even death
may result.
Types of Imaging
There are a number of diagnostic imaging tests available: Cranial CT, CTA (CT angiography), MRA (MR
angiography), DSA (digital subtraction angiography) and Doppler ultrasound.

Transient Ischaemic Attack (TIA)
Cranial CT
Carotid Doppler Ultrasound
Normal 30-70% stenosis +/-
“non-surgical” plaque
EndarterectomyAngioplasty
± stent
Look for other sources of emboli
-Echocardiogram
-Holter monitor
MRA
Tests congruent
Medical Treatment
> 70% stenosis on
appropriate side
MRA or CTA
Tests incongruent
Further non-invasive imaging
(do alternate test)
MRA, CTA or DSA
< 70% stenosis> 70% stenosis
Tests congruent

Cranial CT
What is Cranial CT and what role does it play
in TIA imaging?
What is Cranial CT? Cross-sectional images of the brain in
sagittal, axial and coronal planes via ionising radiation
Indications for Cranial CT:
• Known bleeding tendency
• Deteriorating level of consciousness
• Unexplained progressive / fluctuating symptoms
• Papilloedema due to increased ICH
• Neck stiffness
• Fever or severe headache
• Head injury (risk of subdural haematoma) [Solenski, N.J.,
2004 ]
What is its role in diagnosis?
• The initial imaging modality of choice
• Detects intracranial bleeding, such as subdural
haematoma, intra-cerebral haemorrhage or tumour
mass
• Detects cerebral infarction appropriate to TIA
symptoms in 15-30% of patients [Culebras, A., et.al 1997]
Technique:
• Contrast is not initially used because “there
is a theoretical concern about promoting
cerebral ‘toxicity’” [Culebras, A., 1997] – it may
disrupt the blood-brain barrier in large
infarcts
• If symptoms persist after 2 to 3 weeks, it is
recommended to have contrast as the
“fogging effect” may obscure the possibility
of demonstrating infarction [Culebras, A., 1997]

Do you agree with its position in the imaging
pathway?
Cranial CT should be the initial imaging modality
in diagnosing TIA because of its:
• Speed
• Ability to exclude other brain pathology,
especially intracerebral haemorrhage as a
cause of TIA
• Wide availability
• Clinician familiarity with the procedure [Smith,
W.S., 2003]
Cranial CT excludes ICH (near 100% sensitivity) and
subarachnoid haemorrhage (96% sensitivity) or
subdural haematoma. [Culebras, A., 1997]
CT can also detect silent infarctions (contains no
previous history) in 13% of cases and 47% of patients
with TIA and known carotid stenosis. [Culebras, A., 1997]
Limitations of Cranial CT?
• No abnormalities are detected on the CT scan in
early cases of infarction (1-4 hours), but cases of
haemorrhagic infarction and massive MCA
territory infarctions are more detectable [Culebras,
A., 1997]
• Due to increase bony artefact in the posterior
fossa, MRI is the preferred study over CT to
evaluate disease in the brainstem or cerebellum
[Tidy, C., 2010]
• Despite a normal appearance on a CT scan, an
additional CT scan is required after 24 hours
following the onset of stroke symptoms
• Pregnancy is a contraindication [Tidy, C., 2010]
Due to these limitations, other modalities such as
Carotid Doppler Ultrasound are required to correctly
diagnose TIA.
After five hours of acute onset of
symptoms, cerebral infarction is
indicated as a hypodense area

Cranial CT
What is Carotid Doppler and what role does
it play in TIA imaging?
What is Carotid Doppler?
• Use of a high resolution linear array transducer to view
the carotid artery
• B-mode scan, Colour flow Doppler, Spectral Doppler
velocities are employed when conducting the scan
[Gaitini & Soudak 2005]
What role does it play in TIA imaging?
• 80% of ischemic events are caused by atherosclerotic
disease, commonly occurring at the carotid bifurcation
[Landwehr P et al 2001]
• Stenoses can be identified and quantified quickly
though Doppler which is used to measure blood flow
velocity and turbulence and assists in the assessment
of plaque morphology
• The degree of stenosis of the internal carotid artery is
the primary parameter used for deciding upon
therapeutic approaches for the patient. [Gaitini & Soudak
2005]

Sensitivity and Specificity
[Wardlaw et al 2006]{Wardlaw, 2006 #75}
0-49%
stenosis
50-69%
stenosis
> 70-99%
stenosis
Carotid
Doppler
Ultrasound
83% SE
84% SP
36% SE
91% SP
89% SE
84% SP
Do you agree with its position in the imaging pathway?
• Carotid Doppler Ultrasound assesses both morphology and
heamodynamic abnormalities quickly, easily, non-invasively and
accurately
• Doppler assessments are necessary in determining therapeutic
approaches, which are dependent on the degree of stenosis
found [Gaitini & Soudak 2005].
• Carotid stenosis >70% is a high risk factor for stroke and 50% of
subsequent strokes occur within 2 days [Bonifati 2011]. Doppler
allows physicians to determine the risk and monitor patients
appropriately
• MRA is identified as the imaging modality for <70% stenosis as
MRA is more sensitive in categorising moderate ranges of
stenosis [Anderson, Glenn B et al. 2000].
Advantages Disadvantages
Non-invasive Heavy calcifications may
cause shadowing and
occlude information
Cost effective Ultrasound probes cannot
accurately examine carotid
plaque under the mandible
and the inter-cranial portion
of the carotid artery (only
useful for scanning along the
patient’s neck)
Accurate Dependent on operator skill
Able to quickly diagnose
Helps to determine
potential risk of stroke
Limitations of Carotid Doppler Ultrasound?
• Doppler cannot always distinguish between severe
and complete occlusion due to undetectable blood
velocity
• CTA AND MRA is indicated for patients with
discrepant findings (e.g. with severe occlusion or
atherosclerosis extending past the neck. ) [Gaitini &
Soudak 2005]

Cranial CT
Normal
Look for other sources of emboli
-Echocardiogram
-Holter monitor

Cranial CT
30-70% stenosis +/-
“non-surgical” plaque
MRA
Medical Treatment
Tests congruent

MRA
What is MRA and what role does it play in
TIA imaging?
What is MRA?
Magnetic Resonance Angiography (MRA) uses magnetic
resonance techniques to evaluate extra- and intra-cranial
vessels and any pathology such as stenosis and aneurysm.
MRA is the manipulation of data series of the Time-of-flight
of moving protons and the spin phase of protons and the
magnetic field gradients.
Technique:
A magnetic field excites the protons in the brain’s tissue
and the amount of signal released post-‘energy boost’
determines the different structures and tissues of the
brain.
Why MRA?
In the early stages of TIA, MRA is able to identify the area
of arterial occlusion [Muir, K., & Santosh, C., 2005].
The evidence of vessel occlusion by MRA has led to a “4-
fold increased short-term risk of stroke”  earlier detection
of stroke. [Easton, J. et. al, 2009]
[Willinek, A. et. al, 2005]

Statistics:
MRA has a sensitivity of 92% and specificity of 76% in
the detection of extracranial carotid disease [Easton, J.
et. al, 2009].
MRA can identify carotid plaques, the inflammation
in the vessel and the stability of the plaque [Easton, J.
et. al, 2009].
Intracranial MRA is 90% sensitive and specific [Clifton,
A., 2000].
“Overall, the non-enhanced MRA showed sensitivity of
84.2% and specificity of 84.6%. The enhanced MRA
showed sensitivity of 69.2 and specificity of 73.6.”
[Tomanenk, A. et. al, 2006]
A 2005 study: MRA has a 100% sensitivity stenosis
and occlusions > 70% were correctly identified.
[Willinek, A. et. al, 2005].
[Townsend, T. et. al, 2003]

Advantages Limitations
- “…widely available noninvasive
technique that requires no
radiation exposure and no
administration of contrast
material.” [Bash, S. et. al, 2005]
- Can be performed in conjunction
with MRI
- If contrast is injected, it shortens
time of flight
- “…requires comparatively long
imaging times, frequently leading
to patient motion artifacts and
degradation of image quality.”
[Bash, S. et. al, 2005]
- Patients with pacemakers or severe
claustrophobia
- Non-enhanced MRA has a
comparative lower spatial
resolution than DSA and CTA [Bash,
S. et. al, 2005]
- Contrast induced images often
overestimates the severity of
stenosis in vessels [Townsend, T. et. al,
2003]

> 30%
stenosis
> 70%
stenosis
> 70-99%
stenosis
US 93% SE
82% SP
93% SE
92% SP
89% SE
93% SP
MRA 89% SE
82% SP
90% SE
95% SP
86% SE
93% SP
Is MRA justified in the flow chart?
Do you agree or disagree with the chart?:
The position is justified.
MRA has a relative high sensitivity and specificity in
regards to the detection of stenosis and occlusions as well
as plaque, in the brain.
From the table results, it is clear that the sensitivity and
specificity of stenosis > 30% is relatively high  more
sensitive modality for smaller stenoses.
Improvements?
Need for more current research for more definitive results
of TIA in MRA.
The imaging pathway does not account for the effect
voxel size has on image quality.
“...decreased voxel size improves the delineation of cervical
carotid and vertebral arteries in MR angiograms” [Willinek, A
et. al, 2005].
Need for alternative imaging?
Patients with contraindications such as
pacemakers, claustrophobia and patients whom
are presented in the Emergency Room.

Cranial CT
± stent
> 70% stenosis on
appropriate side
MRA or CTA
Tests congruent

MRA or CTA
Indications for CTA: Patients with suspected carotid
artery disease such as occlusion, stenosis and
aneurysms
Technique: Noncontrast CT of the head  Contrast
CTA from the aortic arch through the circle of Willis
Statistics? For >70% stenosis Sensitivity of CTA is
0.77 and specificity is 0.95
For patients with <70% stenosis Specificity is 0.67
and Specificity is 0.91
Why is CTA used? CTA is a quick, inexpensive and
readily available way to assess stenosis in
emergency patients after suspected TIA.
What is CTA and what role does it play in TIA imaging?

Advantages Disadvantages
More widely available
than MRI
Risks associated with us
of iodinated contrast
Less susceptible to
artefacts as it uses digital
subtraction techniques
Only accurate to assess
>70% stenosis or
occlusions.
Provides information
about surrounding
anatomy
Allows for radiation
exposure of radiosensitive
tissues (thyroid, lenses)
Faster scan time
Is CTA justified in the flowchart?
Do you agree or disagree with its position in the chart?
CTA should be used as a non-invasive imaging technique
for patients with >70% stenosis as it is fast and offers
accurate results. [Koelemay, Nederkoorn, Reitsma, & Majoie, 2004]
Need for alternative imaging? CTA has a high sensitivity
and specificity rate for patients with >70% stenosism
However it is less accurate for 50-69% stenosis of the
carotid artery.
Therefore other tests, such as MRA or DSA should be
preformed on these patients. [Wardlaw, Chappell, Best,
Wartolowska, & Berry, 2006]
Recommendations for further research: High sensitivity
of CTA for >70% stenonis
More research is needed on the accuracy of CTA in
detecting stenosis <70%. [Wardlaw, et al., 2006]

± stent
MRA
Medical Treatment
MRA or CTA
Tests incongruent
(do alternate test)
MRA, CTA or DSA
Tests congruent Tests congruent

MRAMRA or CTA
Tests incongruent
(do alternate test)
MRA, CTA or DSA

(do alternate test)
MRA, CTA or DSA
What is DSA and what role does it play in TIA
imaging?
Indications for DSA: vascular abnormalities such as
occlusion, stenosis and aneurysms, “suspected carotid
dissection unconfirmed on non-invasive neuroimaging
study, subarachnoid haemorrhage, intracerebral
haemorrhage in the absence of hypertension, and
vasculitis.” [Solenski, 2004]
Technique: IV injection pre and post contrast digital
imaging subtract precontrast images
Statistics: A study by Chilcote, et al (1981) revealed that DSA
had a sensitivity of 95%, specificity of 99% and accuracy of
97%. DSA sens 46%, spec 74% for detecting plaque ulceration
[Streifler, et al 1994]
Why is DSA considered gold standard? Superior spatial &
contrast resolution (Jong et al, 2009), diagnosing severe (70-
90%) stenosis [Herzig, et al, 2004; Silvonnoinen, 2007], it is a dynamic
study [Bash et. al, 2005]
Limitations of DSA? Very invasive procedure, 0.7% risk of
peri-procedural neurological injury [Joshi and Prabhakaran, 2010],
1% risk of stroke, 4% risk of TIA, and nearly a 1% mortality
rate.” [Silvonnoinen, 2007]
Figure 1. Still frames from an angiogram of
carotid bifurcation in pt with ICA stenosis and
stent placement

Advantages of
DSA
Advantages of
Conventional Arteriography
• Decreased morbidity
• Decreased patient discomfort
• Decreased hospitalisation time
• Decreased procedure time
• Decreased film cost
• Increased contrast resolution
• Usefulness in patients with limited
arterial access
• Lower cost per examination
• Increased spatial resolution
• Feasibility of selective injections
• Less degradation of patient
motion
• Visualisation of small blood
vessels
Table: Comparative advantages of DSA and conventional arteriography.
Retrieved from: http://www.princeton.edu/~ota/disk2/1985/8506/850605.PDF

CTA MRA DUS
Sensitivity 0.65 1.0 0.85
Specificity 1.0 0.57 0.71
Recommendations for further research: DSA assumed as gold
standard (reference)  no paper up-to-date that can evaluates
the sensitivity and specificity of DSA alone.
US CTA CTA+US
Sensitivity 1.0 1.0 1.0
Specificity 0.75 0.844 0.844
Is DSA justified in the flowchart?
Do you agree or disagree with the chart? The position is justified.
Non- invasive imaging is the first line investigation for TIA.
Need for alternative imaging? Alternative non-invasive imaging
methods are available and widely used.
• DUS, CTA and MRA all show similar accuracy in diagnosis of
symptomatic carotid stenosis. No technique on its own is
accurate enough to replace DSA.” [Patel, 2002]
• “A recent review of literature suggests that a carefully
planned approach using non-invasive imaging can replace
invasive angiography for carotid artery assessment in a cost-
effective and safe manner” [Jaff, 2008]
Figure 1: Retrieved from Patel, 2002
Figure 2: Herzig, et al, 2004

MRAMRA or CTA
Tests incongruent
(do alternate test)
MRA, CTA or DSA

± stent
MRA
Medical Treatment
MRA or CTA
Tests incongruent
(do alternate test)
MRA, CTA or DSA

± stent
Carotid Angioplasty +/- Stent (CAS) and Endarterectomy (CEA)
CEA and CAS  reduce and prevent embolic stroke recurrence/formation
CEA CAS
What is it? Invasive surgical removal of plaque
through an incision of blood vessel
Intra-arterial expansion using a balloon +/-
stent
Indications - ICA stenosis > 70%, surgically accessible
stenosis, patient is stable, stenosis is
symptomatic, rates of surgical
complication <6% [Findlay, et al., 1997]
- Suitable for high-risk patients who are
not suitable for CEA
Contraindications - Asymptomatic stenosis <60%,
uncontrolled hypertension, diabetes,
congestive heart failure, unstable angina
or major neurological deficits [Findlay, et al.,
1997]
- Diabetes mellitus
- >80 y.o. [Hobson, et al., 2004]
- Ulceration of CA stenosis, >50%
contralateral stenosis, echolucent plaque
- Morphology increases risk of stroke in
CAS, unfavourable anatomy [Maldonado, T.,
2007]
What type of
imaging is
involved?
- Digital fluoroscopic imaging
- Intraoperative Duplex US sens 100%,
spec 100% [Wallaert, et al., 2011]
- Angioscopy [Osman and Gibbons, 2001]
- CT angiography sens and spec 90%
- Transcranial Doppler Sonography +
electroencephalography [Roh, et al, 2005]
- Digital fluoroscopic imaging
- Intraoperative Duplex US, C arm post-
stent angiography [Branchereau, A. and Jacobs,
M., 2005]

Conclusion
Imaging TIA to determine degree of stenosis  medical/surgical intervention
 decrease stroke recurrence
Cranial CT is justified 
initial imaging modality due
to its speed, availability,
accessibility, and ability to
identify and exclude brain
pathology.
Stenosis > 70% : MRA + CT
Angiography is justified.
CTA  preferred over MRA,
more readily available,
inexpensive and fast for
emergency patients.
is quick, easy, relatively
accurate, non-invasive and
is able to identify degree of
stenosis  justified as a
compliment to CT.
Stenosis 30-70%: MR
Angiography is justified
 suitable for plaque
identification.
Digital Subtraction
Angiography (DSA)
the "gold standard” BUT
is fast being replaced by
non-invasive imaging 
last resort imaging

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