CT perfusion and angiographic assessment of pial collateral reperfusion in acute ischemic stroke: the CAPRI study

2016 ◽  
Vol 8 (12) ◽  
pp. 1211-1216 ◽  
Author(s):  
Arturo Consoli ◽  
Tommy Andersson ◽  
Ake Holmberg ◽  
Luca Verganti ◽  
Andrea Saletti ◽  
...  
Keyword(s):  
Multivariate Analysis ◽  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Cerebral Blood Volume ◽  
Ct Perfusion ◽  
Mean Transit Time ◽  
Univariate Analysis ◽  
Infarct Core ◽  
Intravenous Tissue Plasminogen Activator ◽  
Dichotomous Variable

BackgroundThe purpose of this study was to evaluate the correlation between a novel angiographic score for collaterals and CT perfusion (CTP) parameters in patients undergoing endovascular treatment for acute ischemic stroke (AIS).Methods103 patients (mean age 66.7±12.7; 48.5% men) with AIS in the anterior circulation territory, imaged with non-contrast CT, CT angiography, and CTP, admitted within 8 h from symptom onset and treated with any endovascular approach, were retrospectively included in the study. Clinical, neuroradiological data, and all time intervals were collected. Careggi Collateral Score (CCS) was used for angiographic assessment of collaterals and the Alberta Stroke Program Early CT Score (ASPECTS) for semiquantitative analysis of CTP maps. Two centralized core laboratories separately reviewed angiographic data, whereas CT findings were evaluated by an expert neuroradiologist. Univariate and multivariate analysis were performed considering CCS both as an ordinal and a dichotomous variable.Results37/103 patients (35.9%) received intravenous tissue plasminogen activator. Median (IQR) ASPECTS was 9 (6–10) for admission CT, 9 (5–10) for cerebral blood volume (CBV) maps, 3 (2–3) for mean transit time maps, 3 (2–4), for cerebral blood flow maps, and 5 (3–7) for CTP mismatch. Univariate analysis showed a significant correlation between CCS and ASPECTS for all CTP parameters. Multivariate analysis confirmed an independent association only between CCS and CBV (p=0.020 when CCS was considered as a dichotomous variable, p=0.026 with ordinal CCS).ConclusionsA correlation between angiographic assessment of the collateral circulation and CTP seems to be present, suggesting that CCS may provide an indirect evaluation of the infarct core volume to consider for patient selection in AIS.

Abstract T MP4: Quality of CT Perfusion Imaging Thresholds for Infarct and Penumbra in the Acute Ischemic Stroke Setting: An Updated Systematic Review

Stroke ◽  
2015 ◽  
Vol 46 (suppl_1) ◽  
Author(s):  
Christopher d'Esterre ◽  
Jonathan Dykeman ◽  
Mohamed Al-mekhlafi ◽  
Petra Cimflova ◽  
Shivanand Patil ◽  
...  
Keyword(s):  
Systematic Review ◽  
At Risk ◽  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Perfusion Imaging ◽  
Cerebral Blood Volume ◽  
Ct Perfusion ◽  
Mean Transit Time ◽  
Infarct Core ◽  
Not At Risk

Background: CT Perfusion (CTP) may inform treatment decisions in acute ischemic stroke (AIS). We sought to determine extent of variability with CTP thresholds for infarct core and penumbra and reasons for such variability using an up-to-date systematic review. Methods: Search strategy combined the themes of AIS, perfusion imaging, and CT/MRI. Two independent reviewers screened at all levels; disagreements were settled through consensus. Inclusion criteria were CTP within 24hrs of stroke onset and reported perfusion thresholds for infarct core, penumbra, and/or normal/not at risk tissue for mixed grey/white matter. Study demographics, QUADAS assessment of quality, and mean thresholds of cerebral blood volume (CBV), cerebral blood flow (CBF), mean transit time (MTT), relative CBV (rCBV), relative CBF (rCBF), and relative MTT (rMTT) were collected. Thresholds were reported as median mean threshold (interquartile range). Results: The search resulted in a total of 11919 abstracts from EMBASE and MEDLINE. Of these, 711 studies were identified for full-text review, 134 met all eligibility criteria. 29 studies provided thresholds for CTP and were included in the review. For CBF, median mean threshold was 8.64 (7.94-13.92) ml/min/100g for core, 19.1 (17.1-31.9) ml/min/100g for penumbra and 47.4 (35.6-59.1) ml/min/100g for normal/not at risk tissue. For CBV, median mean threshold was 1.0 (0.68-1.88) ml/100g for core, 2.45 (2.0-3.0) ml/100g for penumbra, and 2.65 (2.0-3.3) ml/100g for normal/not at risk tissue. For MTT median mean threshold was 15.6 (15.3-17.7) seconds for core, 10.5 (7.1-46.2) seconds for penumbra, and 3.9 (3.65-4.15) seconds for normal/not at risk tissue. Median mean threshold for rCBF was 29% (22.5%-35.5%) for core. Sufficient TTP and Tmax data were not reported. Overall, quality was highly variable according QUADAS ranging from 20.7% to 93.1% across the 14 variables. Conclusions: Due to heterogeneity of vendor CTP algorithms, follow-up imaging to define infarct core (NCCT, DWI), unknown recanalization times/reperfusion status and differing onset to CT times, CTP thresholds for infarct core and penumbra are highly variable. As such, a single best threshold for core could not be derived from literature.

Optimal thresholds for ischemic penumbra predicted by computed tomography perfusion in patients with acute ischemic stroke treated with mechanical thrombectomy

2017 ◽  
Vol 10 (3) ◽  
pp. 279-284 ◽  
Author(s):  
Katsuharu Kameda ◽  
Junji Uno ◽  
Ryosuke Otsuji ◽  
Nice Ren ◽  
Shintaro Nagaoka ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Cerebral Blood Volume ◽  
Mechanical Thrombectomy ◽  
Ct Perfusion ◽  
Characteristic Curve ◽  
Mean Transit Time ◽  
Area Under The Curve ◽  
Ischemic Penumbra ◽  
Optimal Thresholds

Background and purposeOptimal thresholds for ischemic penumbra detected by CT perfusion (CTP) in patients with acute ischemic stroke (AIS) have not been elucidated. In this study we investigated optimal thresholds for salvageable ischemic penumbra and the risk of hemorrhagic transformation (HT).MethodsA total of 156 consecutive patients with AIS treated with mechanical thrombectomy (MT) at our hospital were enrolled. Absolute (a) and relative (r) CTP parameters including cerebral blood flow (aCBF and rCBF), cerebral blood volume (aCBV and rCBV), and mean transit time (aMTT and rMTT) were evaluated for their value in detecting ischemic penumbra in each of seven arbitrary regions of interest defined by the major supplying blood vessel. Optimal thresholds were calculated by performing receiver operating characteristic curve analysis in 47 patients who achieved Thrombolysis In Cerebral Infarction (TICI) grade 3 recanalization. The risk of HT after MT was evaluated in 101 patients who achieved TICI grade 2b–3 recanalization.ResultsAbsolute CTP parameters for distinguishing ischemic penumbra from ischemic core were as follows: aCBF, 27.8 mL/100 g/min (area under the curve 0.82); aCBV, 2.1 mL/100 g (0.75); and aMTT, 7.30 s (0.70). Relative CTP parameters were as follows: rCBF, 0.62 (0.81); rCBV, 0.83 (0.87); and rMTT, 1.61 (0.73). CBF was significantly lower in areas of HT than in areas of infarction (aCBF, p<0.01; rCBF, p<0.001).ConclusionsCTP may be able to predict treatable ischemic penumbra and the risk of HT after MT in patients with AIS.

Abstract TP245: Prediction of Hemorrhagic Transformation in Patients With Acute Ischaemic Stroke and Atrial Fibrillation With Ct Perfusion Aspects Scores

Stroke ◽  
2017 ◽  
Vol 48 (suppl_1) ◽  
Author(s):  
Qiaoshu Wang ◽  
Yanyan Cao ◽  
Yongbo Zhao ◽  
Louis Caplan
Keyword(s):  
Atrial Fibrillation ◽  
Ischemic Stroke ◽  
Acute Stroke ◽  
Acute Ischemic Stroke ◽  
Roc Analysis ◽  
Cerebral Blood Volume ◽  
Ct Perfusion ◽  
Mean Transit Time ◽  
Operating Characteristics ◽  
Middle Cerebral Artery Infarction

Background and Purpose: Hemorrhage transformation (HT) is common in patients with acute cerebral infarction caused by atrial fibrillation. The prediction of HT is crucial after acute stroke, especially for the patients received vessel recanalization therapy. The Alberta Stroke program early CT score (ASPECTS) is used to estimate early ischemic changes within the MCA territory in the acute stroke setting. Several studies indicated that CT perfusion (CTP) and MR diffusion weighted imaging (DWI) ASPECTS scores was useful to quantify the degree of ischemic brain tissue. Hereby we did the study to explore the association of CT perfusion ASPECTS scores with HT in patients with acute ischemic stroke and atrial fibrillation. Methods: This was a single center retrospective study. All patients with middle cerebral artery infarction and atrial fibrillation from September 2008 to September 2013 were included. MR imaging including DWI and gradient echo sequence (GRE), and CTP were required to identify the HT and determine the scores of CTP- ASPECTS. Demographic and clinical characteristics of the HT positive and negative groups were explored. Results: Fifty-four patients were analyzed, among them twenty-four patients (44%) developed HT. According to logistic regression analysis, mean transit time (MTT), cerebral blood volume (CBV) and DWI-ASPECTS scores were associated with HT ( p = 0.035, 0.044, and 0.020 respectively). The following receiver operating characteristics (ROC) analysis revealed area under the curve of MTT, CBV, CBF and DWI were 0.588, 0.737, 0.687, and 0.841 respectively. CBV-ASPECTS score was found to have medium prediction value of HT among all CTP-ASPECTS parameters. ROC analysis also indicated that CBV-ASPECTS score < 7 was the optimal threshold. Conclusions: CTP-ASPECTS was useful to predict the HT of acute ischemic stroke caused by atrial fibrillation and CBV-ASPECTS score < 7 was the preferable parameter.

Infarct growth despite full reperfusion in endovascular therapy for acute ischemic stroke

2014 ◽  
Vol 8 (2) ◽  
pp. 117-121 ◽  
Author(s):  
Diogo C Haussen ◽  
Raul G Nogueira ◽  
Mohamed Samy Elhammady ◽  
Dileep R Yavagal ◽  
Mohammad Ali Aziz-Sultan ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Ct Perfusion ◽  
Infarct Volume ◽  
Infarct Core ◽  
Anterior Circulation ◽  
Vessel Occlusion ◽  
Intravenous Tissue Plasminogen Activator ◽  
Stent Retrievers ◽  
Grade 3

AimTo explore the predictors of infarct core expansion despite full reperfusion after intra-arterial therapy (IAT).MethodsWe retrospectively reviewed 604 consecutive patients who underwent IAT for anterior circulation large vessel occlusion acute ischemic stroke in two tertiary centers (2008–2013/2010–2013). Sixty patients selected by MRI or CT perfusion presenting within <24 h of onset with modified Thrombolysis In Cerebral Infarction (mTICI) grade 3 or 2c reperfusion were included. Significant infarct growth (SIG) was defined as infarct expansion >11.6 mL.ResultsMean age was 67.0±13.7 years, 56% were men. Mean National Institute of Health Stroke Scale (NIHSS) score was 16.2±6.1, time from onset to puncture was 6.8±3.1 h, and procedure length was 1.3±0.6 h. MRI was used for baseline core analysis in 43% of patients. Mean baseline infarct volume was 17.1±19.1 mL, absolute infarct growth was 30.6±74.5 mL, and final infarct volume was 47.7±77.7 mL. Overall, 35% of patients had SIG. Three of 21 patients (14%) treated with stent-retrievers had SIG compared with 14 of 39 (36%) with first-generation devices. Eight of 21 patients (38%) with intravenous tissue plasminogen activator (IV t-PA) had infarct growth compared with 25/39 (64%) without. 23% of patients with SIG had a modified Rankin Scale score ≤2 at 3 months compared with 48% of those without SIG. Multivariate logistic regression indicated that race affected infarct growth. Use of IV t-PA (p=0.03) and stent-retrievers (p=0.03) were independently and inversely correlated with SIG.ConclusionsDespite full reperfusion, infarct growth is relatively frequent and may explain poor clinical outcomes in this setting. Ethnicity was found to influence SIG. Use of IV t-PA and stent-retrievers were associated with less infarct core expansion.

CT perfusion cerebral blood volume does not always predict infarct core in acute ischemic stroke

2015 ◽  
Vol 36 (10) ◽  
pp. 1777-1783 ◽  
Author(s):  
Christopher D. d’Esterre ◽  
Gloria Roversi ◽  
Marina Padroni ◽  
Andrea Bernardoni ◽  
Carmine Tamborino ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Blood Volume ◽  
Cerebral Blood Volume ◽  
Ct Perfusion ◽  
Infarct Core

Predictive value of time-variant color-coded multiphase CT angiography (mCTA) regarding clinical outcome of acute ischemic stroke: in comparison with conventional mCTA and CT perfusion

2020 ◽  
pp. 028418512098177
Author(s):  
Yu Lin ◽  
Nannan Kang ◽  
Jianghe Kang ◽  
Shaomao Lv ◽  
Jinan Wang
Keyword(s):  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Predictive Value ◽  
Ct Perfusion ◽  
Roc Curves ◽  
Multivariate Logistic Regression Model ◽  
Infarct Core ◽  
Predictive Values ◽  
Significant Difference ◽  
Core Volume

Background Color-coded multiphase computed tomography angiography (mCTA) can provide time-variant blood flow information of collateral circulation for acute ischemic stroke (AIS). Purpose To compare the predictive values of color-coded mCTA, conventional mCTA, and CT perfusion (CTP) for the clinical outcomes of patients with AIS. Material and Methods Consecutive patients with anterior circulation AIS were retrospectively reviewed at our center. Baseline collateral scores of color-coded mCTA and conventional mCTA were assessed by a 6-point scale. The reliabilities between junior and senior observers were assessed by weighted Kappa coefficients. Receiver operating characteristic (ROC) curves and multivariate logistic regression model were applied to evaluate the predictive capabilities of color-coded mCTA and conventional mCTA scores, and CTP parameters (hypoperfusion and infarct core volume) for a favorable outcome of AIS. Results A total of 138 patients (including 70 cases of good outcomes) were included in our study. Patients with favorable prognoses were correlated with better collateral circulations on both color-coded and conventional mCTA, and smaller hypoperfusion and infarct core volume (all P < 0.05) on CTP. ROC curves revealed no significant difference between the predictive capability of color-coded and conventional mCTA ( P = 0.427). The predictive value of CTP parameters tended to be inferior to that of color-coded mCTA score (all P < 0.001). Both junior and senior observers had consistently excellent performances (κ = 0.89) when analyzing color-coded mCTA maps. Conclusion Color-coded mCTA provides prognostic information of patients with AIS equivalent to or better than that of conventional mCTA and CTP. Junior radiologists can reach high diagnostic accuracy when interpreting color-coded mCTA images.

Abstract 3200: Comparison of CT Perfusion Mismatch with Perfusion-Diffusion MRI in Ischemic Stroke - a Reliable Alternative?

Stroke ◽  
2012 ◽  
Vol 43 (suppl_1) ◽  
Author(s):  
Bruce C Campbell ◽  
Søren Christensen ◽  
Christopher R Levi ◽  
Patricia M Desmond ◽  
Geoffrey A Donnan ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Diffusion Mri ◽  
Roc Analysis ◽  
Ct Perfusion ◽  
Residue Function ◽  
Infarct Core ◽  
Widespread Application ◽  
Time To Peak ◽  
Value Decomposition

Background and purpose: CT-perfusion (CTP) is widely and rapidly accessible for imaging acute ischemic stroke. However, there has been limited validation of CTP parameters against the more intensively studied MRI perfusion-diffusion mismatch paradigm. We tested the correspondence of CTP with contemporaneous perfusion-diffusion MRI. Methods: Acute ischemic stroke patients <6hr after onset had CTP and perfusion-diffusion MRI within 1hr, before reperfusion therapies. Relative cerebral blood flow (relCBF) and time-to-peak of the deconvolved tissue-residue-function (Tmax) were calculated (standard singular value decomposition deconvolution). The diffusion lesion was registered to the CTP slabs and manually outlined to its maximal visual extent. CT-infarct core was defined as relCBF<31% contralateral mean as previously published using this software. The volumetric accuracy of relCBF core compared to the diffusion lesion was tested in isolation, but also when restricted to pixels with relative time-to-peak (TTP) >4sec, to reduce artifactual false positive low CBF (eg in leukoaraiosis). The MR Tmax>6sec perfusion lesion (previously validated to define penumbral tissue at risk of infarction) was automatically segmented and registered to the CTP slabs. Receiver operating characteristic (ROC) analysis determined the optimal CT-Tmax threshold to match MR-Tmax>6sec, confidence intervals generated by bootstrapping. Agreement of these CT parameters with MR perfusion-diffusion mismatch on co-registered slabs was assessed (mismatch ratio >1.2, absolute mismatch>10mL, infarct core<70mL). Results: In analysis of 98 CTP slabs (54 patients, median onset to CT 190min, median CT to MR 30min), volumetric agreement with the diffusion lesion was substantially improved by constraining relCBF<31% within the automated TTP perfusion lesion ROI (median magnitude of volume difference 9.0mL vs unconstrained 13.9mL, p<0.001). ROC analysis demonstrated the best CT-Tmax threshold to match MR-Tmax>6sec was 6.2sec (95% confidence interval 5.6-7.3sec, ie not significantly different to 6sec), sensitivity 91%, specificity 70%, AUC 0.87. Using CT-Tmax>6s “penumbra” and relCBF<31% (restricted to TTP>4s) “core”, volumetric agreement was sufficient for 90% concordance between CT and MRI-based mismatch status (kappa 0.80). Conclusions: Automated CTP mismatch classification using relCBF and Tmax is similar to perfusion-diffusion MRI. CTP may allow more widespread application of the “mismatch” paradigm in clinical practice and trials.

What is the impact of head movement on automated CT perfusion mismatch evaluation in acute ischemic stroke?

2021 ◽  
pp. neurintsurg-2021-017510
Author(s):  
Arne Potreck ◽  
Fatih Seker ◽  
Matthias Anthony Mutke ◽  
Charlotte Sabine Weyland ◽  
Christian Herweh ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Head Movement ◽  
Ct Perfusion ◽  
Treatment Decision ◽  
Brain Perfusion ◽  
Left Middle Cerebral Artery ◽  
Ct Scanner ◽  
Infarct Core ◽  
The Impact

ObjectivesAutomated CT perfusion mismatch assessment is an established treatment decision tool in acute ischemic stroke. However, the reliability of this method in patients with head motion is unclear. We therefore sought to evaluate the influence of head movement on automated CT perfusion mismatch evaluation.MethodsUsing a realistic CT brain-perfusion-phantom, 7 perfusion mismatch scenarios were simulated within the left middle cerebral artery territory. Real CT noise and artificial head movement were added. Thereafter, ischemic core, penumbra volumes and mismatch ratios were evaluated using an automated mismatch analysis software (RAPID, iSchemaView) and compared with ground truth simulated values.ResultsWhile CT scanner noise alone had only a minor impact on mismatch evaluation, a tendency towards smaller infarct core estimates (mean difference of −5.3 (−14 to 3.5) mL for subtle head movement and −7.0 (−14.7 to 0.7) mL for strong head movement), larger penumbral estimates (+9.9 (−25 to 44) mL and +35 (−14 to 85) mL, respectively) and consequently larger mismatch ratios (+0.8 (−1.5 to 3.0) for subtle head movement and +1.9 (−1.3 to 5.1) for strong head movement) were noted in dependence of patient head movement.ConclusionsMotion during CT perfusion acquisition influences automated mismatch evaluation. Potentially treatment-relevant changes in mismatch classifications in dependence of head movement were observed and occurred in favor of mechanical thrombectomy.

Abstract TP38: Core Growth Speed as a Marker of Collateral Circulation Status in Acute Ischemic Stroke with Known Onset Time

Stroke ◽  
2017 ◽  
Vol 48 (suppl_1) ◽  
Author(s):  
Laura Blanco-García ◽  
Elisa Cortijo ◽  
Mercedes De Lera ◽  
Ana Calleja ◽  
María Usero ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Collateral Circulation ◽  
Cerebral Blood Volume ◽  
Onset Time ◽  
Growth Speed ◽  
Infarct Core ◽  
Anterior Circulation ◽  
Unaffected Side ◽  
Core Volume

Objective: We aimed to evaluate the parameter core growth speed (CGS) as a marker of collateral circulation status (CC) in acute ischemic stroke, and to compare it with other brain perfusion-derived markers of collateral capacity. Methods: We retrospectively studied acute ischemic stroke patients who were evaluated with urgent computed tomography perfusion (CTP) and CT angiography. Inclusion criteria comprised known time of onset and anterior circulation proximal occlusion. Collateral circulation was assessed on CTP-source images and rated as poor (0-1) vs. good (2-3) following a previously published scale. CTP maps were computed using Neuroscape 2.0 software by Olea Medical. Infarct core volume was calculated as the brain tissue with >70% reduction in cerebral blood flow (CBF) as compared to the unaffected side. CGS was obtained by dividing core volume by the time from stroke onset to CTP acquisition. Relative cerebral blood volume (rCBV), relative CBF, and hypoperfusion index ratio (HIR = Tmax>10s/Tmax>6s) were used as comparators. Results: We included 41 patients (mean age 71 years; median NIHSS 17; median onset-CTP time 150 minutes). We observed a positive correlation between CGS and HIR (ρ= 0.517 p< 0.001), and negative correlations between rCBV and CGS (ρ= -0.669 p<0.0001), and rCBF and CGS (ρ= -0.749 p<0.0001). Collateral circulation was categorized as poor or good in 15 and 26 patients respectively. A gradual descend in CGS was seen as CC improved (p=0.0005). A logistic regression model adjusted by rCBV, rCBF and HIR identified CGS as independently associated with CC. The association of CGS with good CC in a ROC curve was highly significant (p=0.002, area under the curve 0.8). Conclusion: Core growth speed is robustly associated with collateral circulation status. This parameter can be directly obtained from infarct core volume without the need to process other perfusion or angiographic images, if the time of onset is well known.

Abstract P188: Transfer Time From Spoke ER Arrival to CSC Arrival in a Hub-Spoke Transfer Model of Thrombolysis for Acute Ischemic Stroke

Stroke ◽  
2021 ◽  
Vol 52 (Suppl_1) ◽  
Author(s):  
Vivien H Lee ◽  
Paul A Segerstrom ◽  
Ciarán J Powers ◽  
Sharon Heaton ◽  
Shahid M Nimjee ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Univariate Analysis ◽  
Transfer Model ◽  
Transfer Time ◽  
Intravenous Tissue Plasminogen Activator ◽  
The Mean ◽  
Comprehensive Stroke Center ◽  
Stroke Center ◽  
Er Status

Introduction: Acute ischemic stroke (AIS) patients who present to a spoke Emergency Room (ER) and require transfer to a comprehensive stroke center (CSC) hub face potential delays Methods: We performed a retrospective review of 269 suspected AIS patients who received intravenous tissue plasminogen activator (tPA) from July 2016 to October 2017 in our academic telestroke network. During this period, nearly all tPA patients were transferred to the CSC hub. Data was collected on patient demographics, National Institutes of Health Stroke Scale (NIHSS), door to needle time (DTN), and distance to CSC. ER-to-CSC was defined as the time from patient arrival at Spoke ER to arrival at CSC. Top volume ER status was assigned to the 4 Spoke ERs with the highest volume of tPA. Results: Among 269 AIS patients who received tPA at spoke ERs, the mean age was 65.4 years (range, 21 to 95), 49% were female, and 91.8% were white. The initial median NIHSS was 6 (range, 0 to 30) and the mean DTN was 73.1 minutes (range, 14 to 234). The mean distance from Spoke ER to CSC was 55.2 miles (range 5.8 to 125) and the mean ER-to-CSC was 2.6 hours (range 0.62 to 6.3) (Figure 1). In univariate analysis, the following factors were significantly associated with ER-to-CSC: distance (p < 0.0001), DTN (p < 0.0001), NIHSS (p 0.0007), and top volume ER status (p 0.0034). Patient sex, age, race, SBP, weight, initial NIHSS, daytime shift, and weekend status were not significantly associated with ER-to-CSC. Significant variables from the univariate analysis were included in multivariate linear regression model in which DTN (P < 0.0001), distance (P < 0.0001), and NIHSS (P 0.024) association with ER-to-CSC remained significant. Conclusions: In our series of AIS tPA patients transferred to CSC, the mean time from spoke ER arrival to CSC arrival was 2.6 hours. Factors associated with CSC arrival time include markers of ER performance (DTN), severity (NIHSS), and distance. Further study is warranted to improve transfer time in AIS.

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