Abstract WP296: Utilization of Advanced Imaging Paradigms Improves Patient Triage at Stroke Centers in a Stroke System of Care

Stroke ◽  
2020 ◽  
Vol 51 (Suppl_1) ◽  
Author(s):  
Karan Tarasaria ◽  
Syed Daniyal Asad ◽  
Dawn Beland ◽  
Amre Nouh ◽  
Mark J Alberts
Keyword(s):  
Time Window ◽  
Systems Of Care ◽  
Ct Perfusion ◽  
Final Diagnosis ◽  
Significant Advance ◽  
Advanced Imaging ◽  
Patient Transfers ◽  
Screening Algorithm ◽  
The Mean ◽  
Stroke Systems Of Care

Background: The 24 hour time window for endovascular therapy (EVT) in ischemic strokes due to large vessel occlusions (LVO) is a significant advance. Although many stroke systems of care have adopted a paradigm of transferring all potential EVT patients to the hub center for further evaluation, we developed an approach using advanced imaging at spoke hospitals to improve transfer triage. Hypothesis: Utilizing a novel algorithm combining clinical and imaging (CTA plus CT Perfusion “RAPID”) criteria at the spoke facilities results in more appropriate patient transfer decision to the CSC (hub). Methods: We developed and implemented a clinical and imaging screening algorithm for suspected LVO patients at our 3 PSCs and 1 CSC equipped with CTA and CTP-“RAPID” capabilities. Patients at the PSCs with NIHSS> 6 or fulfilling Stroke VAN (Hemiparesis and Visual field cut, aphasia or neglect) criteria and presenting within 24 hours from last seen normal undergo CTA plus CTP, and a decision for transfer if LVO plus core ≤50cc is met. Data including diagnosis, clinical and radiographic features, transfer status and final diagnosis of 377 patients from January 2018 to January 2019 were analyzed. Results: The mean age was 69 (SD 1.7) years and mean NIHSS was 11 (SD 0.79). Out of total 377 patients, 63% (n=236) were screened at PSCs and 37% (n=141) were screened at the CSC. About half (51%) of patients screened at PSCs (n=120) and 85% at the CSC (n=121) had a final diagnosis of acute ischemic stroke. Using our algorithm, 28% (n=65) patients were found to have LVO at PSCs compared to 60% (n=85) at the CSC. Only 23% (n=54) of patients were transferred to the CSC out of which 30% (n=16) underwent EVT. Among patients transferred to the CSC, 85% (n=46) had LVO, with the remaining 8 transferred for a higher level of care per. Almost half (49%) of the 116 patients screened at PSCs were stroke mimics, none of which were transferred. Conclusion: Using our new algorithm, 64% of screened patients were ischemic strokes and 40% had LVO’s, of whom 14% qualified for EVT. Using advanced clinical and imaging paradigms, 77% of screened patients did not require transfer. Utilization of CTP imaging at spoke PSCs is feasible and improves the accuracy and efficiency of patient transfers.

Abstract P124: Stroke Patient Transfer Destination is Influenced by Hospital Affiliation

Stroke ◽  
2021 ◽  
Vol 52 (Suppl_1) ◽  
Author(s):  
Kori S Zachrison ◽  
Viviana Amati ◽  
Lee H Schwamm ◽  
Zhiyu Yan ◽  
Victoria Nielsen ◽  
...  
Keyword(s):  
Systems Of Care ◽  
Patient Transfers ◽  
Network Characteristics ◽  
Event Modeling ◽  
Primary Object ◽  
Stroke Systems Of Care ◽  
Stroke Center ◽  
Hospital Affiliation ◽  
Hospital Characteristics

Background: Acute ischemic stroke (AIS) patients are frequently transferred between hospitals, however it is not clear whether these transfers are optimized with respect to proximity and quality of the destination hospital. Our primary object was to identify hospital characteristics associated with sending and receiving AIS patients. Methods: Using a comprehensive statewide dataset, we identified all AIS patient transfers occurring between all 78 Massachusetts (MA) hospitals from 2007 and 2015. Hospital variables included hospital quality reputation (US News & World Report), hospital capabilities (stroke center status, annual stroke volume, and trauma center designation), and institutional affiliations (same vs. not). We also included network variables to control for the structure of hospital-to-hospital transfers. We used relational event modeling to account for complex temporal and relational dependencies associated with patient transfers. This method decomposes events into a decision to transfer, and if so, the receiving hospital destination, and models them using a discrete-choice framework. Results: Among 73,114 AIS admissions in MA during the 8-year study period, there were 7,189 (9.8%) transfers. After accounting for travel time between hospitals and structural network characteristics, factors associated with increased likelihood of being a receiving hospital included teaching hospital status, hospitals of the same or higher quality, the same or higher stroke center status, and the same hospital affiliation (Table). Conclusion: Patients experiencing AIS in MA are frequently transferred between hospitals. After accounting for multiple relevant hospital characteristics, hospital affiliation remains an important factor in determining transfer destination. While there may be some benefits to hospital affiliation, stroke systems of care should be designed to maximize patient benefit and leverage interfacility transfer accordingly.

scholarly journals Late Thrombectomy in Clinical Practice

2021 ◽  
Author(s):  
Moriz Herzberg ◽  
Korbinian Scherling ◽  
Robert Stahl ◽  
Steffen Tiedt ◽  
Frank A. Wollenweber ◽  
...  
Keyword(s):  
Clinical Practice ◽  
Clinical Outcome ◽  
Perfusion Imaging ◽  
Time Window ◽  
Ct Perfusion ◽  
Large Trial ◽  
Real World Data ◽  
Baseline Trial ◽  
Good Outcome ◽  
Number Of Patients

Abstract Background and Purpose To provide real-world data on outcome and procedural factors of late thrombectomy patients. Methods We retrospectively analyzed patients from the multicenter German Stroke Registry. The primary endpoint was clinical outcome on the modified Rankin scale (mRS) at 3 months. Trial-eligible patients and the subgroups were compared to the ineligible group. Secondary analyses included multivariate logistic regression to identify predictors of good outcome (mRS ≤ 2). Results Of 1917 patients who underwent thrombectomy, 208 (11%) were treated within a time window ≥ 6–24 h and met the baseline trial criteria. Of these, 27 patients (13%) were eligible for DAWN and 39 (19%) for DEFUSE3 and 156 patients were not eligible for DAWN or DEFUSE3 (75%), mainly because there was no perfusion imaging (62%; n = 129). Good outcome was not significantly higher in trial-ineligible (27%) than in trial-eligible (20%) patients (p = 0.343). Patients with large trial-ineligible CT perfusion imaging (CTP) lesions had significantly more hemorrhagic complications (33%) as well as unfavorable outcomes. Conclusion In clinical practice, the high number of patients with a good clinical outcome after endovascular therapy ≥ 6–24 h as in DAWN/DEFUSE3 could not be achieved. Similar outcomes are seen in patients selected for EVT ≥ 6 h based on factors other than CTP. Patients triaged without CTP showed trends for shorter arrival to reperfusion times and higher rates of independence.

scholarly journals POS1435 CLINICAL CHARACTERIZATION AND PREDICTIVE FACTORS FOR PROGRESSION IN A COHORT OF ILD PATIENTS WITH FEATURES OF AUTOIMMUNITY: ARE IPAF CRITERIA SUFFICIENT?

2021 ◽  
Vol 80 (Suppl 1) ◽  
pp. 1002.1-1002
Author(s):  
F. Bozzao ◽  
P. Tomietto ◽  
E. Baratella ◽  
F. Giudici ◽  
M. Kodric ◽  
...  
Keyword(s):  
Interstitial Pneumonia ◽  
Predictive Factors ◽  
Usual Interstitial Pneumonia ◽  
Final Diagnosis ◽  
Classification Criteria ◽  
Radiological Progression ◽  
Nonspecific Interstitial Pneumonia ◽  
The Mean ◽  
Functional Deterioration ◽  
Worse Prognosis

Background:It is unknown whether patients with interstitial lung disease (ILD) and only some features of autoimmunity have a different natural history from those with a defined connective tissue disease (CTD-ILD). The classification criteria for “ILD with autoimmune features” (IPAF) may not be able to characterize all these patients, especially those with a usual interstitial pneumonia (UIP) pattern [1].Objectives:To determine clinical characteristics and predictive factors for progression in a cohort of ILD patients with features of autoimmunity, through the application of classification criteria for IPAF and specific CTD, whenever possible.Methods:We retrospectively selected a cohort of consecutive patients with ILD as onset manifestation and features of autoimmunity (at least 1 autoantibody and/or 1 clinical sign/symptom), evaluated by our multidisciplinary unit from March 2009 to March 2020. All the final diagnoses were revised according to the latest CTD and IPAF criteria. Patients were followed up for 33 (16.5-69.5) months.Results:Of the 101 patients enrolled (67.4±10.9 yrs, F/M ratio 65/36), 53 (52.5%) and 37 (36.6%) respectively satisfied the CTD and IPAF criteria. Eleven patients (10.9%) did not satisfy IPAF criteria because of only 1 item (clinical or serologic) within the IPAF domains and a UIP pattern; we defined this group as “autoimmune” UIP (AI-UIP). All the 8 patients initially classified as undifferentiated CTD had sufficient IPAF criteria. Among the IPAF patients (68.2±10.1 years, F/M ratio 20/17), the most common findings were: Nonspecific interstitial pneumonia pattern (56.8%), antinuclear antibodies positivity (43.2%) and arthritis (24.3%). The combination of a positive morphologic and serologic domain was the most common to reach the diagnosis (48.6%). Some IPAF patients had features not included in IPAF criteria, such as non-anti-synthetase myositis-specific antibodies (21.6%), objective sicca syndrome (13.5%) and anti-myeloperoxidase antibodies (2.7%). Over a median of 17 months, 2 IPAF patients (5.4%) developed a definite UIP pattern, while 4 (10.8%) a specific CTD. Comparing the IPAF, CTD-ILD and AI-UIP groups, no statistically significant differences were found in the mean age, sex distribution, smoking habits and mean duration of the disease. However, IPAF patients had a significantly higher prevalence of arterial hypertension and left-sided heart failure and a lower predominance of UIP pattern as expected (10.8% vs. 32.1% vs. 100%, p<0.01). Although no differences were found at the diagnosis, at 1 year the proportion of IPAF patients with radiological progression of the fibrosis and/or functional deterioration (defined by a decline in FVC of ≥ 10% and/or DLCO of ≥ 15% predicted) was lower to that of CTD-ILD and AI-UIP (17.1% vs. 31.4% vs. 63.6%, p 0.01). Fewer IPAF patients needed oxygen support (8.6% vs. 31.4% vs. 36.4, p 0.02). Considering the overall 101 patients, having an IPAF and a UIP pattern respectively predicted a slower (OR: 0.37, p 0.04) and a faster (OR: 3.56, p 0.01) ILD progression at the multivariate analysis.Conclusion:In our cohort, IPAF criteria were useful to identify a subset of patients with a slower ILD progression and a possible evolution to CTD (10-15% of cases) [2]. These criteria do not characterize all the patients with a UIP pattern and limited features of autoimmunity, which seem to have a worse prognosis, independently from the final diagnosis. Further studies are needed to clarify if the prognosis of AI-UIP is different from that of idiopathic pulmonary fibrosis.References:[1]Graney, et al. Ann Am Thorac Soc 2019;16(5):525-33.[2]Sebastiani, et al. Biomedicines 2021,9,17.Disclosure of Interests:None declared

scholarly journals CT perfusion in peripheral arterial disease—hemodynamic differences before and after revascularisation

2021 ◽  
Author(s):  
Patrick Veit-Haibach ◽  
Martin W. Huellner ◽  
Martin Banyai ◽  
Sebastian Mafeld ◽  
Johannes Heverhagen ◽  
...  
Keyword(s):  
Peripheral Arterial Disease ◽  
Ct Perfusion ◽  
Arterial Disease ◽  
Lower Leg ◽  
Therapy Control ◽  
Non Invasive ◽  
Before And After ◽  
Invasive Method ◽  
The Mean ◽  
Peripheral Arterial

Abstract Objectives The purpose of this study was the assessment of volumetric CT perfusion (CTP) of the lower leg musculature in patients with symptomatic peripheral arterial disease (PAD) before and after interventional revascularisation. Methods Twenty-nine consecutive patients with symptomatic PAD of the lower extremities requiring interventional revascularisation were assessed prospectively. All patients underwent a CTP scan of the lower leg, and hemodynamic and angiographic assessment, before and after intervention. Ankle-brachial pressure index (ABI) was determined. CTP parameters were calculated with a perfusion software, acting on a no outflow assumption. A sequential two-compartment model was used. Differences in CTP parameters were assessed with non-parametric tests. Results The cohort consisted of 24 subjects with an occlusion, and five with a high-grade stenosis. The mean blood flow before/after (BFpre and BFpost, respectively) was 7.42 ± 2.66 and 10.95 ± 6.64 ml/100 ml*min−1. The mean blood volume before/after (BVpre and BVpost, respectively) was 0.71 ± 0.35 and 1.25 ± 1.07 ml/100 ml. BFpost and BVpost were significantly higher than BFpre and BVpre in the treated limb (p = 0.003 and 0.02, respectively), but not in the untreated limb (p = 0.641 and 0.719, respectively). Conclusions CTP seems feasible for assessing hemodynamic differences in calf muscles before and after revascularisation in patients with symptomatic PAD. We could show that CTP parameters BF and BV are significantly increased after revascularisation of the symptomatic limb. In the future, this quantitative method might serve as a non-invasive method for surveillance and therapy control of patients with peripheral arterial disease. Key Points • CTP imaging of the lower limb in patients with symptomatic PAD seems feasible for assessing hemodynamic differences before and after revascularisation in PAD patients. • This quantitative method might serve as a non-invasive method, for surveillance and therapy control of patients with PAD.

scholarly journals Novel selection paradigms for endovascular stroke treatment in the extended time window

2021 ◽  
pp. jnnp-2020-325284
Author(s):  
Mehdi Bouslama ◽  
Diogo C Haussen ◽  
Gabriel Rodrigues ◽  
Clara Barreira ◽  
Michael Frankel ◽  
...  
Keyword(s):  
Time Window ◽  
Ct Perfusion ◽  
Clinical Aspects ◽  
Anterior Circulation ◽  
Stroke Treatment ◽  
Good Outcome ◽  
Potential Alternative ◽  
The Right ◽  
Contrast Ct ◽  
Selection Methodology

Background and purposeThe optimal selection methodology for stroke thrombectomy beyond 6 hours remains to be established.MethodsReview of a prospectively collected database of thrombectomy patients with anterior circulation strokes, adequate CT perfusion (CTP) maps, National Institute of Health Stroke Scale (NIHSS)≥10 and presenting beyond 6 hours from January 2014 to October 2018. Patients were categorised according to five selection paradigms: DAWN clinical-core mismatch (DAWN-CCM): between age-adjusted NIHSS and CTP core, DEFUSE 3 perfusion imaging mismatch (DEFUSE-3-PIM): between CTP-derived perfusion defect (Tmax >6 s lesion) and ischaemic core volumes and three non-contrast CT Alberta Stroke Program Early CT Score (ASPECTS)-based criteria: age-adjusted clinical-ASPECTS mismatch (aCAM): between age-adjusted NIHSS and ASPECTS, eloquence-adjusted clinical ASPECTS mismatch (eCAM): ASPECTS 6–10 and non-involvement of the right M6 and left M4 areas and standard clinical ASPECTS mismatch (sCAM): ASPECTS 6–10.Results310 patients underwent analysis. DEFUSE-3-PIM had the highest proportion of qualifying patients followed by sCAM, eCAM, aCAM and DAWN-CCM (93.5%, 92.6%, 90.6%, 90% and 84.5%, respectively). Patients meeting aCAM, eCAM, sCAM and DAWN-CCM criteria had higher rates of 90-day good outcome compared with their non-qualifying counterparts(43.2% vs 12%,p=0.002; 42.4% vs 17.4%, p=0.02; 42.4% vs 11.2%, p=0.009; and 43.7% vs 20.5%, p=0.007, respectively). There was no difference between patients meeting DEFUSE-3-PIM criteria versus not(40.8% vs 31.3%,p=0.45). In multivariate analysis, all selection modalities except for DEFUSE-3-PIM were independently associated with 90-day good outcome.ConclusionsASPECTS-based selection paradigms for late presenting and wake-up strokes ET have comparable proportions of qualifying patients and similar 90-day functional outcomes as DAWN-CCM and DEFUSE-3-PIM. They also might lead to better outcome discrimination. These could represent a potential alternative for centres where access to advanced imaging is limited.

Usefulness of point-of-care ultrasound in military medical emergencies performed by young military medicine residents

2019 ◽  
pp. jramc-2018-001132
Author(s):  
Pierre Perrier ◽  
J Leyral ◽  
O Thabouillot ◽  
D Papeix ◽  
G Comat ◽  
...  
Keyword(s):  
Diagnostic Accuracy ◽  
Clinical Examination ◽  
Point Of Care ◽  
Military Medicine ◽  
Final Diagnosis ◽  
Absolute Difference ◽  
Point Of Care Ultrasound ◽  
Medical Emergencies ◽  
The Mean ◽  
A Prospective Study

IntroductionTo evaluate the usefulness of point-of-care ultrasound (POCUS) performed by young military medicine residents after short training in the diagnosis of medical emergencies.MethodsA prospective study was performed in the emergency department of a French army teaching hospital. Two young military medicine residents received ultrasound training focused on gall bladder, kidneys and lower limb veins. After clinical examination, they assigned a ‘clinicaldiagnostic probability’ (CP) on a visual analogue scale from 0 (definitely not diagnosis) to 10 (definitive diagnosis). The same student performed ultrasound examination and assigned an ‘ultrasounddiagnostic probability’ (UP) in the same way. The absolute difference between CP and UP was calculated. This result corresponded to the Ultrasound Diagnostic Index (UDI), which was positive if UP was closer to the final diagnosis than CP (POCUS improved the diagnostic accuracy), and negative conversely (POCUS decreased the diagnostic accuracy).ResultsForty-eight patients were included and 48 ultrasound examinations were performed. The present pathologies were found in 14 patients (29%). The mean UDI value was +3 (0–5). UDI was positive in 35 exams (73%), zero in 12 exams (25%) and negative in only one exam (2%).ConclusionPOCUS performed after clinical examination increases the diagnostic accuracy of young military medicine residents.

scholarly journals Cerebral CT Perfusion in Acute Stroke: The Effect of Lowering the Tube Load and Sampling Rate on the Reproducibility of Parametric Maps

Diagnostics ◽  
2021 ◽  
Vol 11 (6) ◽  
pp. 1121
Author(s):  
Georgios S. Ioannidis ◽  
Søren Christensen ◽  
Katerina Nikiforaki ◽  
Eleftherios Trivizakis ◽  
Kostas Perisinakis ◽  
...  
Keyword(s):  
Cerebral Blood Volume ◽  
Ct Perfusion ◽  
Sampling Rate ◽  
Volumetric Analysis ◽  
Sampling Interval ◽  
Diagnostic Efficiency ◽  
Temporal Sampling ◽  
Sampling Intervals ◽  
The Mean ◽  
Parametric Maps

The aim of this study was to define lower dose parameters (tube load and temporal sampling) for CT perfusion that still preserve the diagnostic efficiency of the derived parametric maps. Ninety stroke CT examinations from four clinical sites with 1 s temporal sampling and a range of tube loads (mAs) (100–180) were studied. Realistic CT noise was retrospectively added to simulate a CT perfusion protocol, with a maximum reduction of 40% tube load (mAs) combined with increased sampling intervals (up to 3 s). Perfusion maps from the original and simulated protocols were compared by: (a) similarity using a voxel-wise Pearson’s correlation coefficient r with in-house software; (b) volumetric analysis of the infarcted and hypoperfused volumes using commercial software. Pearson’s r values varied for the different perfusion metrics from 0.1 to 0.85. The mean slope of increase and cerebral blood volume present the highest r values, remaining consistently above 0.7 for all protocol versions with 2 s sampling interval. Reduction of the sampling rate from 2 s to 1 s had only modest impacts on a TMAX volume of 0.4 mL (IQR −1–3) (p = 0.04) and core volume of −1.1 mL (IQR −4–0) (p < 0.001), indicating dose savings of 50%, with no practical loss of diagnostic accuracy. The lowest possible dose protocol was 2 s temporal sampling and a tube load of 100 mAs.

Tracheobronchial Foreign Bodies: The Impact of a Postgraduate Educational Program on Diagnosis, Morbidity, and Treatment

PEDIATRICS ◽  
1982 ◽  
Vol 70 (1) ◽  
pp. 96-98
Author(s):  
Marc Puterman ◽  
Rafael Gorodischer ◽  
Alberto Leiberman
Keyword(s):  
Educational Program ◽  
Foreign Bodies ◽  
Final Diagnosis ◽  
Physician Performance ◽  
Postgraduate Educational ◽  
Before And After ◽  
History Of ◽  
The Mean ◽  
Hospital Days ◽  
The Impact

Aspirated foreign bodies (FBs) may remain undetected and cause serious complications. As part of a postgraduate educational program, results of a local survey were presented to the local medical staff in order to increase its awareness of this diagnostic possibility. The present study was carried out in order to evaluate the management of children with tracheobronchial FBs during two 2-year periods, before and after teaching sessions held in December 1976. In comparison with the previous two years during the 1977-1978 period, the percentage of cases in which a positive history of aspiration was obtained increased from 47.6% to 84.0%; the mean number of hospitalizations due to tracheobronchial FBs decreased from 1.9 to 1.04 per infant, and the mean number of hospital days required for final diagnosis decreased from 17.6 to 5.3. The postgraduate educational program had a positive effect on physician performance and patient care.

Abstract 3268: Ct Perfusion As A Tool To Predict The Risk Of Hemorrhagic Transformation In Ischemic Stroke Treated With Tissue Plasminogen Activator: A Single Center Experience.

Stroke ◽  
2012 ◽  
Vol 43 (suppl_1) ◽  
Author(s):  
Tareq Kass-Hout ◽  
Maxim Mokin ◽  
Omar Kass-Hout ◽  
Emad Nourollahzadeh ◽  
David Wack ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Acute Stroke ◽  
Brain Tissue ◽  
Cerebral Blood Volume ◽  
Ct Perfusion ◽  
Intravenous Thrombolysis ◽  
Hemorrhagic Transformation ◽  
Stroke Therapy ◽  
Two Phase ◽  
The Mean

Objective: To use the Computed Tomography Perfusion (CTP) parameters at the time of hospital admission, including Cerebral Blood Volume (CBV) and Permeability Surface area product (PS), to identify patients with higher risk to develop hemorrhagic transformation in the setting of acute stroke therapy with intravenous thrombolysis. Methods: Retrospective study that compared admission CTP variables between patients with Hemorrhagic Transformation (HT) acute stroke and those with no hemorrhagic transformation. Both groups received standard of care intravenous thrombolysis with tPA. Twenty patients presented to our stroke center between the years 2007 - 2011 within 3 hours after stroke symptoms onset. All patients underwent two-phase 320 slice CTP which creates CBV and PS measurements. Patients were divided into two groups according to whether or not they had HT on a follow up CT head without contrast, done within 36 hours of the thrombolysis therapy. Clinical, demographic and CTP variables were compared between the HT and non-HT groups using logistic regression analyses. Results: HT developed in 8 (40%) patients. Patients with HT had lower ASPECT score ( P =.03), higher NIHSS on admission ( P= .01) and worse outcome ( P= .04) compared to patients who did not develop HT. Baseline blood flow defects were comparable between the two groups. The mean PS for the HT group was 0.53 mL/min/100g brain tissue, which was significantly higher than that for the non-HT group of 0.04 mL/min/100g brain tissue ( P <.0001). The mean area under the curve was 0.92 (95% CI). The PS threshold of 0.26 mL/min/100g brain tissue had a sensitivity of 80% and a specificity of 92% for detecting patients with high risk of hemorrhagic transformation after intravenous thrombolysis. Conclusions: Admission CTP measurements might be useful to predict patients who are at higher risk to develop hemorrhagic transformation after acute ischemic stroke therapy.

Abstract 94: Patient Selection using CT Perfusion (CTP) Imaging Improves Effectiveness of Stroke Thrombolysis in the 0-4.5 Hour Time Window

Stroke ◽  
2012 ◽  
Vol 43 (suppl_1) ◽  
Author(s):  
Dulka Manawadu ◽  
Shankranand Bodla ◽  
Laszlo Sztriha ◽  
Josef Jarosz ◽  
Lalit Kalra
Keyword(s):  
Patient Selection ◽  
Functional Outcomes ◽  
Time Window ◽  
Ct Perfusion ◽  
Treatment Protocol ◽  
Early Improvement ◽  
Nihss Score ◽  
Ct Perfusion Imaging ◽  
Mean Blood Glucose

Background: The role of CT perfusion (CTP) in thrombolysis decisions remains controversial and there are no studies that compare outcomes of thrombolysis in patients with or without mismatch on CT perfusion imaging. Methods: We analysed registry data between Jan 2009 and December 2010 for patients thrombolysed within 0-4.5 hours of stroke onset in whom CTP studies were performed prior to thrombolysis. The centre followed thrombolysis guidelines but patients >80 years were included. CTP was not obligatory in the treatment protocol and failure to demonstrate a mismatch was not a contraindication to thrombolysis. We retrospectively analysed data for estimated CTP mismatch of ≥ 100% according to pre-defined criteria and compared outcomes of thrombolysed patients showing perfusion mismatch with those showing no mismatch. Findings: The sample included 160 patients aged between 32-95 years of whom 63 had no mismatch and 97 had a significant mismatch. The two groups were comparable for mean age (73 v 70 years, p=0.18), sex (49% v 54% male, p=0.75), premorbid Rankin Score (mRS) 0-2 (81% v 92%, p=0.77), vascular risk factors profile, mean baseline BP (148/87 v 148/79 mm Hg, p=0.92), mean blood glucose (6.6 v 6.6 mmols/L, p=0.98) and mean National Institute of Health Stroke Scale (NIHSS) score (14.0 v 12.6,p=0.12). Patients who had mismatch prior to thrombolysis showed lower mean 24 hour NIHSS score (7.6 v 11.8, p=0.002) and greater mean 24 hour improvement in NIHSS score (5.1 v 2.0, p=0.010). A higher proportion of patients with mismatch achieved mRS 0-1 and mRS 0-2 at 3 months (36% v 18%, p= 0.012 and 51% v 32%, p=0.015 respectively) but there were no differences in symptomatic sICH rates (1.1% v 0%). Mortality (29% v 18%) and any intracranial haemorrhages (19% v 13%) were lower in mismatch patients but did not achieve significance. Regression analyses showed that PCT mismatch prior to thrombolysis was an independent predictor of both early improvement and functional outcomes at 3 months. Conclusion: Stroke patients who have perfusion mismatch on CTP imaging prior to thrombolysis within the 4.5 hour time window show better early and 3 month outcomes compared with those in whom mismatch cannot be demonstrated. Patient selection using multimodal CT may improve the effectiveness of thrombolysis.

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