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What does my CT scan report indicate?

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Posted on Tue, 26 May 2015
Question: My mother had a stroke a couple months ago that was diagnosed by a CT scan. Now she has seen a neurologist and he has order another CT this time with XXXXXXX What was the first scan not sufficient for him?
doctor
Answered by Dr. Olsi Taka (50 minutes later)
Brief Answer:
Visualize blood vessels.

Detailed Answer:
Hello again. I remember from our past exchange you were having difficulties in getting your primary physician to refer you to a neurologist, so I am glad to see that you finally made it.

If I remember correctly your mother had not only a CT scan but also an MRI the first time around. In that case I don't think the CT would add much information regarding the stroke size and location, as the MRI is certainly the best means to achieve that. So that shouldn't be his goal.

My opinion is that he is requesting a particular scan with XXXXXXX aimed at visualizing her blood vessels, otherwise called CT angiography (CTA). Your mother already has had an imaging exam of her neck vessels, the ultrasound which you referred came back good.
My guess is that the neurologist after reviewing that ultrasound has decided that either its results were suspicious, or that it hadn't achieved a good enough visualization of the arteries, particularly the vertebral arteries (which cover the location of your mother's stroke). So he is ordering a CTA which permits a better evaluation when ultrasound is not satisfactory. It can also give a better view of her intracranial vessels and the aorta.

Feel free to ask further questions.
Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
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Follow up: Dr. Olsi Taka (20 hours later)
So it is a blockage he is looking for??
Also, since the previous ultrasound and echocardiogram came back
good (and even the cholesterol in the bloodwork was very good) he
decided to do this extra ct scan, as well as a sleep study for sleep
apnea and a holter moniter for afib. He said he is confused because
of her above average physical condition and lack of risk factors, and he
said that if all these tests come back good he may not be able to determine
a cause. That is concerning to me because I am not sure if that would be
good or bad. If no clear cause is found does that mean her risk for
recurrent stroke is higher because there is no condition to treat, or does it
mean the odds are better because theres is no condition to treat...I'm just not sure. Thanks!
doctor
Answered by Dr. Olsi Taka (2 hours later)
Brief Answer:
Read below

Detailed Answer:
Yes he is looking for a narrowing/blockage or some other issue of the blood vessels. At least that's what I would need a contrast CT for, as I said for the stroke size and location itself, MRI has provided sufficient information.

As both myself and Dr Saghafi had suggested in the past, he also seems to think that a longer study of the heart rhythm is necessary so he's requested the Holter study. We don't routinely do sleep study as a first step, however it won't hurt being thorough as sleep apnea confers a greater risk for heart arrhythmia and stroke.

Regarding the risk of recurrence of cryptogenic stroke (without an identifiable cause), of course the risks are there, there are not many long term studies in that regard, those few that there are, suggest a somewhat higher risk of recurrence (up to 14% yearly recurrence risk - but not many studies as I said and there are many variables at play as it depends on how extensively those patients included were investigated), so your worry is justified.
However remember that it's not that she will stay without preventive treatment she will continue the aspirin/plavix she is currently taking which is a valid treatment. Also should wait before thinking about the eventuality of it being a cryptogenic stroke, cryptogenic stroke usually is in the young, in the elderly eventually with prolonged heart study some arrhythmia is found, so I think even if 24 hour Holter is normal she should go on to have more prolonged study which have shown to increase the chance of detecting an arrhythmia.

I hope to have been of help.
Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
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Follow up: Dr. Olsi Taka (2 hours later)
Thanks and just one more thing to clarify...I am
confused about the percentages I hear and read
about. I am not sure if those percentages are
with or without treatment. So for instance, if
no cause is found is the 14% risk lowered if she
is on aspirin and Plavix? The neurologist said
she has a 30% chance of having another stroke in
the next 3 years, but he didn't clarify if his goal
was to drastically decrease that risk or if there
is still a great risk even with treatment.
Thanks and I appreciate your help.
doctor
Answered by Dr. Olsi Taka (13 hours later)
Brief Answer:
Read below.

Detailed Answer:
Thank you for coming up with some sensible questions.

After I gave my last answer I actually began to kind of regret expressing a percentage.
That is because there are so many variables at play, containing age, heredity, race, environmental factors, causes found (and how hard it is looked for them), what treatment was chosen and even what one considers recurrence. For example that 14% figure is pretty high because it was from a study which considered a new stroke minor ischemic changes in MRI in the absence of any new clinical signs. In that same study, the percentage of patients which had a new stroke with new symptoms was somewhere between 1-2% (under treatment by the way). As I said there aren't many quality studies about cryptogenic stroke. And even its definition could vary in time, 20 years ago perhaps a simple EKG could be called enough to exclude atrial fibrillation, now it's being spoken of implantable devices with monitoring up to 3 years to exclude it, or a transesophageal ultrasound instead of a simple echocardiography.

I am not sure where your neurologist took that 30% figure, I suppose it was under treatment, it may be correct as an average, but it could be totally different for your mother. Again so many variables at play, while reading a review on this matter on a stroke journal I find 1 year risk 3 times higher in China than Portugal, 5 year risk over two times higher in Japan than in London, even differences between South London and Oxfordshire, both in UK.

What I am trying to say, in perhaps not a very eloquent way, is that the stroke population is very vast including many subtypes, with different risk percentages, so you shouldn't really try to get a number assigned to your mother, as there are the tests results to be waited for first and even then it might be difficult to make an estimation. What matters for now is that she gets what tests modern medicine has available to find the cause, your neurologist seems to be intending to do more in that direction than your primary physician so that you can be sure that Aspirin or Plavix are the best and anticoagulants aren't needed.

I remain at your disposal for further questions
Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
doctor
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Follow up: Dr. Olsi Taka (1 hour later)
I appreciate your help and do apologize that I
keep coming up with more questions the more
I think and research!!! Just one last thing...if
she does have afib from what I understand in my
research the only likely change in her treatment
would be that she would take Warfin instead of
Plavix, is that correct? Or is there actually some
treatment to correct the afib itself. I was hoping
maybe there is a "cure" for it but I can't find that
there is. Thanks for your patience and your help!
doctor
Answered by Dr. Olsi Taka (2 hours later)
Brief Answer:
Read below

Detailed Answer:
In principle yes, it will be a choice between anticoagulants or antiaggregants (I doubt any cause requiring surgery will be needed). Warfarin is at about twice as effective as Aspirin in reducing the risk if there is atrial fibrillation.

As for a cure there is unfortunately no cure to exclude the possibility of these paroxysms of afib, if that turns out to be the case, I am sorry, it's about preventing the complications.

Regarding warfarin though, it is the traditionally used anticoagulant, but now in recent years there are on the market the new oral anticoagulants (dabigatran, apixaban, rivaroxaban, edoxaban) which up to now seem to have the same or better efficacy, fewer complications, fewer interactions with specific foods or drugs and no need to have regular blood testing as warfarin.
So if there will be a need for an anticoagulant I would definitely go for one of those.

Also since your mother is on Aspirin and Plavix for about 8 weeks now I believe, XXXXXXX stroke association recommendations state that there is no proven benefit beyond 3 months only added risk of complications, so she should be put continued with only one of those two in the future if antiaggregants will be the final choice. Your neurologists probably is aware of that himself.
Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
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What does my CT scan report indicate?

Brief Answer: Visualize blood vessels. Detailed Answer: Hello again. I remember from our past exchange you were having difficulties in getting your primary physician to refer you to a neurologist, so I am glad to see that you finally made it. If I remember correctly your mother had not only a CT scan but also an MRI the first time around. In that case I don't think the CT would add much information regarding the stroke size and location, as the MRI is certainly the best means to achieve that. So that shouldn't be his goal. My opinion is that he is requesting a particular scan with XXXXXXX aimed at visualizing her blood vessels, otherwise called CT angiography (CTA). Your mother already has had an imaging exam of her neck vessels, the ultrasound which you referred came back good. My guess is that the neurologist after reviewing that ultrasound has decided that either its results were suspicious, or that it hadn't achieved a good enough visualization of the arteries, particularly the vertebral arteries (which cover the location of your mother's stroke). So he is ordering a CTA which permits a better evaluation when ultrasound is not satisfactory. It can also give a better view of her intracranial vessels and the aorta. Feel free to ask further questions.