In your practice - when do you end up ordering CTA Brain?

[pinipig523]

---

Members don't see this ad.

In your practice - when do you guys end up ordering CTA of the brain?

I've never really ordered this unless the consultant (neurosurg) wants it to map out a potential aneurysm in a patient with a known ongoing, acute SAH. Usually prior to going in.

However, they end up seesawing between a CTA and an actual angio with IR to prevent further, unnecessary dye load.

Do you guys order CTA brain any other times?

 

[Old_Mil]

In your practice - when do you guys end up ordering CTA of the brain?

I've never really ordered this unless the consultant (neurosurg) wants it to map out a potential aneurysm in a patient with a known ongoing, acute SAH. Usually prior to going in.

However, they end up seesawing between a CTA and an actual angio with IR to prevent further, unnecessary dye load.

Do you guys order CTA brain any other times?

All potential strokes. All old people with syncope after their cardiac rule outs.

 

[WilcoWorld]

All potential strokes. All old people with syncope after their cardiac rule outs.

What is "old" and why for syncope?

 

[ghost dog]

In your practice - when do you guys end up ordering CTA of the brain?

I've never really ordered this unless the consultant (neurosurg) wants it to map out a potential aneurysm in a patient with a known ongoing, acute SAH. Usually prior to going in.

However, they end up seesawing between a CTA and an actual angio with IR to prevent further, unnecessary dye load.

Do you guys order CTA brain any other times?

http://www.acr.org/SecondaryMainMen...ologicImaging/CerebrovascularDiseaseDoc2.aspx

http://www.acr.org/ac

 

[zinjanthropus]

we were doing CT w/o, CTA head, CTA neck as part of our stroke alert up until recently - now we are back to CT w/o first but often neuro comes and wants CTAs or MRAs

 

[Hamhock]

We end up doing CT, CTA head and neck (and perfusion) for all stroke codes by protocol.

I have seen neuro make what seem like logical decisions based on CTA results and certainly perfusion results when considering tpa. I suspect that neuro is implicitly admitting there is only a subset of cases that tpa benefits. OTOH, I have no idea if there's any EBM (doubt it) to back them up.

Occasionally, on equivocal cases, we'll CTA for aneurysm.

Other reasons are even less common.

HH

 

[la gringa]

same as the above - have only ordered one ct brain w/ contrast since residency even... fyi, since we trained at the same place 😉

 

[dotcb]

I work in a stroke center w/ 24 hr in-house neuro. Like others, our stroke protocol CT is CTH, CTA head & neck, + perfusion scan. I order it for stroke alerts. All others (ex. TIA or subacute stroke) I call neuro w/ the story & exam, tell them I'm ultimately gonna want a consult, and ask them which study they'd like me to order.

If I worked rural locums, I'd probably only order CTA for specific concern of aneurysm or dissection (rare).

 

[southerndoc]

Are you guys able to get 3D reconstructions of your CTA's after hours? Our studies are limited to prelims during the night pending 3D reconstructions that are done during business hours.

 

[pinipig523]

Interesting that you all order CT w/o, CTA, CT neck w/ perfusion for all your strokes. I have worked at several ERs and I have only been ordering CT w/o and base tPa on that.

I can see why you'd order all the rest of the tests, but I thought that could be more of an inpatient w/up.

Wrong or right?

 

[Interpolfanclub]

Been out several years and have never ordered a CTA for stroke. CT only and if no exclusion criteria likely to get TPA.

 

[Rendar5]

Interesting that you all order CT w/o, CTA, CT neck w/ perfusion for all your strokes. I have worked at several ERs and I have only been ordering CT w/o and base tPa on that.

I can see why you'd order all the rest of the tests, but I thought that could be more of an inpatient w/up.

Wrong or right?

If it's a question of tpa or not, i agree with you. but some places have other interventions available.

 

[pinipig523]

If it's a question of tpa or not, i agree with you. but some places have other interventions available.

Gotcha... so it is hospital system dependent. Makes sense.

 

[suckstobeme]

Strokes that are within the window get plain CT and then we start TPA where indicated, before they get CTA.
If pt is a candidate for our neuro-interventional guys to do something (ie within 12 hrs of onset, no hhistory of intracranial bleeding, and significant functional deficit/stroke scale) then they get CT Perfusion protocol which also includes CTA.

I also get it once in while for possible carotid dissection, and have caught two using it in the last yr.

Usually if someone has a confirmed SAH, Neurosurg will ask for CTA.

Some of the guys in my group use it to rule out SAH, though this practice is not really on secure footing. They basically get a plain CT, and instead of doing an LP, they get CTA. The logic goes that if there's a normal plain CT and no aneurysm on CTA, they basically have excluded the disease. I have never done it myself, and my understanding is that there is not great data to support it; at the same time, I dunno if people get SAH with a neg CT and CTA. Have not looked into it extensively. I actually kinda like LPs.

 

[Old_Mil]

What is "old" and why for syncope?

Old = a judgement call, really.

Syncope = VBI

Why = because they say so.

I've found that in medicine, you should stop using your brain at some point and just do what nurses, patients, administrators, and laywers tell you to do.

 

[pinipig523]

Old = a judgement call, really.

Syncope = VBI

Why = because they say so.

I've found that in medicine, you should stop using your brain at some point and just do what nurses, patients, administrators, and laywers tell you to do.

CTA can assess vertebrals adequately?

 

[suckstobeme]

I looked this up about 2 yrs ago.
In the setting of trauma, non-64 slice CT is not so great, but some articles say 64 slice is acutally better than MRI/MRA. The gold standard is still Angiography.

 

[tima]

If a patient says, "worst headache of his life," do you automatically do a CT scan for a subarachnoid hemorrhage? Are there any exceptions to this rule?

 

[deleted109597]

I have never done it myself, and my understanding is that there is not great data to support it; at the same time, I dunno if people get SAH with a neg CT and CTA. Have not looked into it extensively. I actually kinda like LPs.

There's pretty reasonable data. Because the number they miss is likely comparable to the traumatic tap rate. But since some people apparently never have traumatic taps, they like to argue that the data is bad.

I do think that the CT/CTA likely overdiagnoses symptomatic aneurysms, in that the vast majority of people out there with aneurysms (5%) aren't bleeding from them.

 

[Groove]

I'll admit that I'm one that will use CTA while out in a community ED to help "r/o SAH" when a CT Head is negative and I still have a clinical suspicion and the pt either doesn't want the LP or there is some other issue.

Here's a blip from emedicine.....

The diagnosis of subarachnoid hemorrhage (SAH) usually depends on a high index of clinical suspicion combined with radiologic confirmation via urgent computed tomography (CT) scan without contrast. Traditionally, a negative CT scan is followed with lumbar puncture (LP). However, noncontrast CT followed by CT angiography (CTA) of the brain can rule out SAH with greater than 99% sensitivity.[1]

CTA "is" part of my stroke workup, but I think it largely also depends on where you are. If I'm out in a not so big community ED and I get a pt that looks like a stroke with even a negative head CT, I generally am not taking time to get further studies and delay transfer to a tertiary care center or someone with neurology. It's either tPA and ship or just ship and I'm usually already on the phone before the radiology nighthawk read is even back, talking to the neurologist. Back at my training institution though... it's part of our standard stroke workup protocol.