Case #01

Fig 1 A, B show FDCT images of an 89-year old female patient. An intracerebral hemorrhage can be excluded. Hypodensities (A, black arrowheads) of the right insula, caudate and lentiform nucleus result in an ASPECTS of 7.  We used a digital subtraction angiography (DSA) to time the first phase (arterial) of the mpFDCTA. The rotation was started as soon as the intravenously injected contrast agent enhanced the distal carotid artery (C, black arrow). Reconstructions of the arterial mpFDCTA phase show a proximal middle cerebral artery thrombosis on the right side (D) and just a few visible pial vessels within the occluded vascular territory (E). Note the very good depiction of even small intracranial vessels (C, e.g. the distal superior cerebellar artery) due to the technical features of the mpFDCTA acquisition. The second (venous) mpFDCTA phase (F) delineates delayed filling in of peripheral vessels with decreased prominence and extend as well as ischemic regions with no vessels. DSA images show the persistent proximal occlusion before (G) and the successful recanalization of the middle cerebral artery (H) after thrombectomy.

Symptom to door time            42 min

Door to FDCT time                8 min

Door to groin time                  23 min

Groin to reperfusion                36 min

Door to reperfusion                 59 min

Symptom to reperfusion         101 min


Case #02

Fig 2 Initial flat-panel detector CT (FDCT) on ganglionic (A) and supraganglionic (B) level of a wake-up stroke patient shows early ischemic changes of the right lentiform nucleus (arrow). This resulted in an Alberta Stroke Program Early CT score (ASPECTS) of 9. An intracranial bleeding was ruled out. C depicts a digital subtraction angiography used for bolus-tracking. The arterial phase of the multiphase flat-panel detector CT angiography (mpFDCTA) was started after contrast agent is seen in the intracranial internal carotid artery (arrow). This early phase (D) shows an occluded M1-segment of the right middle cerebral artery. Comparison of the early (E) and the late (venous) phase (F) of mpFDCTA revealed a good collateral status. A delayed filling in of peripheral vessels in the ischemic territory was observed, but their extent and prominence was similar to the asymptomatic contralateral hemisphere.

Fig 3 The first angiogram of the same patient as in Fig 2 (A) depicted a persistent occlusion of the right M1-segment. Another angiogram acquired after thrombectomy (B) showed complete revascularization of the right M1-segment and partial reperfusion of a peripheral temporal branch of the middle cerebral artery. A relevant stenosis of the proximal internal carotid artery could be excluded pre-interventionally on the first phase of the FDCTA by using the full length of the flat detector (C). Follow-up multidetector CT after 48 hours (D) showed infarct of the right caudate, lentiform nucleus and temporal operculum, resulting in an ASPECTS of 7.

Symptom to door time            N/A

Door to FDCT time                12 min

Door to groin time                  30 min

Groin to reperfusion                30 min

Door to reperfusion                 60 min

Symptom to reperfusion         N/A

Case #03

A and B show FDCT images of a patient presenting with an NIHSS of 15 and an intracerebral hemorrhage of the right thalamus. An additional intraventricular hemorrhage can be depicted on B. 

C and D delineate additional cases of one stop management with patients presenting in our emergency department with an NIHSS of >6 and a hemorrhage on noncontrast FDCT.