Value of Vascular and Non-Vascular Pattern on Computed Tomography Perfusion in Patients With Acute Isolated Aphasia

Background and Purpose: Acute onset aphasia may be due to stroke but also to other causes, which are commonly referred to as stroke mimics. We hypothesized that, in patients with acute isolated aphasia, distinct brain perfusion patterns are related to the cause and the clinical outcome. Herein, we analyzed the prognostic yield and the diagnostic usefulness of computed tomography perfusion (CTP) in patients with acute isolated aphasia. Methods: From a single-center registry, we selected a cohort of 154 patients presenting with acute isolated aphasia who had a whole-brain CTP study available. We collected the main clinical and radiological data. We categorized brain perfusion studies on CTP into vascular and nonvascular perfusion patterns and the cause of aphasia as ischemic stroke, transient ischemic attack, stroke mimic, and undetermined cause. The primary clinical outcome was the persistence of aphasia at discharge. We analyzed the sensitivity, specificity, positive and negative predictive values of perfusion patterns to predict complete clinical recovery and ischemic stroke on follow-up imaging. Results: The cause of aphasia was an ischemic stroke in 58 patients (38%), transient ischemic attack in 3 (2%), stroke mimic in 68 (44%), and undetermined in 25 (16%). CTP showed vascular and nonvascular perfusion pattern in 62 (40%) and 92 (60%) patients, respectively. Overall, complete recovery occurred in 116 patients (75%). A nonvascular perfusion pattern predicted complete recovery (sensitivity 75.9%, specificity 89.5%, positive predictive value 95.7%, and negative predictive value 54.8%), and a vascular perfusion pattern was highly predictive of ischemic stroke (sensitivity 94.8%, specificity 92.7%, positive predictive value 88.7%, and negative predictive value 96.7%). The 3 patients with ischemic stroke without a vascular perfusion pattern fully recovered at discharge. Conclusions: CTP has prognostic value in the workup of patients with acute isolated aphasia. A nonvascular pattern is associated with higher odds of full recovery and may prompt the search for alternative causes of the symptoms.

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Telestroke consultation can accurately diagnose ischemic stroke mimics

Journal of Telemedicine and Telecare ◽

10.1177/1357633x21989558 ◽

2021 ◽

pp. 1357633X2198955

Author(s):

Jason T Poon ◽

Aleksander Tkach ◽

Adam H de Havenon ◽

Knut Hoversten ◽

Jaleen Johnson ◽

...

Keyword(s):

Ischemic Stroke ◽

Predictive Value ◽

Clinical Information ◽

Excellent Correlation ◽

Stroke Mimics ◽

Intravenous Tissue Plasminogen Activator ◽

The Us ◽

Tissue Plasminogen ◽

Stroke Mimic ◽

Ischemic Attack

Introduction Telestroke (TS) networks are standard in many areas of the US. Despite TS systems having approximately 33% mimic rates, it is unknown if TS can accurately diagnose patients with acute ischemic stroke (AIS) versus stroke mimics. Methods We performed a retrospective review of consecutive TS consults to 27 TS sites in six states during 2018. Clinical information and diagnosis were extracted from discharge records and compared to those from the TS consult. Discharge diagnoses were verified and coded into 12 categories. Cases without a clear discharge diagnosis and intracerebral haemorrhage were excluded. We report agreement and a Cohen’s kappa between TS and discharge diagnoses for the category of AIS/transient ischemic attack (TIA) versus stroke mimic. Results We included 404 cases in the analysis (mean age 66 years; 54% women). Of these, 225 had a TS diagnosis of AIS/TIA; 102 (45%) received intravenous tissue plasminogen activator. Our study demonstrated a high diagnostic agreement for AIS/TIA (88%) with a kappa of 0.75 for stroke and mimics. Of the 179 patients diagnosed with a stroke mimic on TS, 27 (15%) were diagnosed with AIS/TA by discharge. TS mimic diagnosis had a positive predictive value (PPV) of 85% and a negative predictive value (NPV) of 90%; TS diagnosis of stroke/TIA had PPV 90%, NPV 85%. Discussion We found excellent correlation between TS and discharge diagnoses for patients with both stroke and stroke mimics. This suggests that TS systems can accurately assess a wider variety of patients with acute neurologic syndromes other than AIS.

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Predictive value of brain perfusion single-photon emission computed tomography in acute ischemic stroke.

Stroke ◽

10.1161/01.str.21.6.895 ◽

1990 ◽

Vol 21 (6) ◽

pp. 895-900 ◽

Cited By ~ 78

Author(s):

F Giubilei ◽

G L Lenzi ◽

V Di Piero ◽

C Pozzilli ◽

P Pantano ◽

...

Keyword(s):

Computed Tomography ◽

Ischemic Stroke ◽

Predictive Value ◽

Single Photon ◽

Photon Emission ◽

Brain Perfusion ◽

Emission Computed Tomography ◽

Single Photon Emission ◽

Single Photon Emission Computed ◽

Photon Emission Computed Tomography

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Computed tomography perfusion in stroke mimics

International Journal of Stroke ◽

10.1177/1747493019869702 ◽

2019 ◽

Vol 15 (3) ◽

pp. 299-307 ◽

Cited By ~ 1

Author(s):

James E Siegler ◽

Jon Rosenberg ◽

Daniel Cristancho ◽

Andrew Olsen ◽

Johannes Pulst-Korenberg ◽

...

Keyword(s):

Computed Tomography ◽

Transient Ischemic Attack ◽

Clinical Symptoms ◽

Treatment Decision ◽

Residue Function ◽

Stroke Treatment ◽

Computed Tomography Perfusion ◽

Treatment Decision Making ◽

Stroke Mimic ◽

Ischemic Attack

Objective To describe the prevalence and patterns of abnormal findings on automated computed tomography perfusion in patients with stroke mimic. Methods We reviewed a retrospective multi-site cohort of consecutive patients undergoing computed tomography perfusion for suspected acute ischemic stroke within 24 h from last normal (June 2017 to December 2017). The primary outcome was the diagnosis of stroke mimic. Hypoperfusion abnormalities on iSchemaView RAPID automated computed tomography perfusion were compared between patients with stroke/transient ischemic attack and stroke mimic using mixed-effects multivariable logistic regression, focusing on absence of perfusion abnormalities and discordance with clinical symptoms and computed tomography angiography findings. Results Of 410 consecutive patients who underwent computed tomography perfusion, 348 met inclusion criteria (178 (51%) stroke, 19 (6%) transient ischemic attack, and 151 (43%) mimic). Time-to-maximum of the tissue residue function (Tmax>6s) abnormalities were seen in 42 (28%) patients with stroke mimic and 122 (62%) patients with stroke/transient ischemic attack ( p < 0.001). Patients with stroke mimic were more likely to have a normal Tmax pattern (volume = 0mL; adjusted OR: 2.2, 95% CI: 1.1–4.3, p = 0.02). When the Tmax pattern was abnormal, a higher proportion of patients with stroke mimic had Tmax patterns fully discordant with clinical symptoms than patients with stroke/transient ischemic attack (28/39 (71%) vs. 10/115 (9%), p < 0.001). Fully discordant Tmax abnormalities were strongly associated with stroke mimic (adjusted OR: 48.6, 95% CI: 7.0–336, p < 0.001), with a negative predictive value for identifying mimic of 91% (95% CI: 85–94%). Conclusion While one-quarter of patients with stroke mimic show Tmax abnormalities on automated RAPID computed tomography perfusion imaging, the majority of patterns were discordant with symptoms and vessel status. Normal or fully discordant Tmax abnormalities are were more common with stroke mimic and may inform stroke treatment decision making.

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Use of ABC/2 method for rapidly estimating the target mismatch on computed tomography perfusion imaging in patients with acute ischemic stroke

Acta Radiologica ◽

10.1177/02841851211069778 ◽

2021 ◽

pp. 028418512110697

Author(s):

Guang-Chen Shen ◽

Yue Chu ◽

Gao Ma ◽

Xiao-Quan Xu ◽

Shan-Shan Lu ◽

...

Keyword(s):

Computed Tomography ◽

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Predictive Value ◽

Anterior Circulation ◽

Computed Tomography Perfusion ◽

Significant Difference ◽

Feasible Alternative ◽

Ischemic Core ◽

The Difference

Background Target mismatch (ischemic core, mismatch volume and mismatch ratio) in patients with acute ischemic stroke (AIS) highly relies on the automated perfusion analysis software. Purpose To evaluate the feasibility and accuracy of using the ABC/2 method to rapidly estimate the target mismatch on computed tomography perfusion (CTP) imaging in patients with AIS, using RAPID results as a reference. Material and Methods In total, 243 patients with anterior circulation AIS who underwent CTP imaging were retrospectively reviewed. Target mismatch associated perfusion parameters were derived from RAPID results and calculated using the ABC/2 method. Paired t-test was used to assess the difference of volumetric parameters between the two methods. The ability of using the ABC/2 method to predict the important cutoff volumetric metrics was also evaluated. Result There was no significant difference in the volumes of ischemic core ( P = 0.068), ischemic area ( P = 0.209), and mismatch volume ( P = 0.518) between ABC/2 and RAPID. Using RAPID results as reference, the ABC/2 method showed high accuracy for predicting perfusion parameters (70 mL and 90 mL: sensitivity=98.5% and 98.5%, specificity=100% and 100%, positive predictive value [PPV]=100% and 100%, negative predictive value [NPV]=93.8% and 92.9%; 10 mL and 15mL: sensitivity=99.6% and 99.5%, specificity=55.6% and 50.0%, PPV=96.6% and 94.8%, NPV=90.9% and 92.3%; 1.2 and 1.8: sensitivity=99.6% and 94.8%, specificity=75.0% and 96.9%, PPV=98.7% and 99.5%, NPV=90.0% and 73.8%). Conclusion The ABC/2 method may be a feasible alternative to RAPID for estimation of target mismatch parameters on CTP in patients with AIS.

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Evaluation of the clot burden score (cbs) for acute ischemic stroke (ais) in intent-to-treat patients.

Journal Of Cardiovascular, Neurovascular & Stroke ◽

10.32896/cvns.v1n1.11-15 ◽

2019 ◽

Vol 1 (1) ◽

pp. 11-15 ◽

Cited By ~ 1

Author(s):

Sarah Yaziz ◽

Ahmad Sobri Muda ◽

Wan Asyraf Wan Zaidi ◽

Nik Azuan Nik Ismail

Keyword(s):

Ischemic Stroke ◽

Clinical Outcome ◽

Acute Ischemic Stroke ◽

Predictive Value ◽

Area Under The Curve ◽

Rank Correlation ◽

Treatment Decision ◽

Roc Curves ◽

Significant Negative Correlation ◽

Clot Burden

Background : The clot burden score (CBS) is a scoring system used in acute ischemic stroke (AIS) to predict patient outcome and guide treatment decision. However, CBS is not routinely practiced in many institutions. This study aimed to investigate the feasibility of CBS as a relevant predictor of good clinical outcome in AIS cases. Methods: A retrospective data collection and review of AIS patients in a teaching hospital was done from June 2010 until June 2015. Patients were selected following the inclusion and exclusion criteria. These patients were followed up after 90 days of discharge. The Modified Rankin scale (mRS) was used to assess their outcome (functional status). Linear regression Spearman Rank correlation was performed between the CBS and mRS. The quality performance of the correlations was evaluated using Receiver operating characteristic (ROC) curves. Results: A total of 89 patients with AIS were analysed, 67.4% (n=60) male and 32.6% (n=29) female. Twenty-nine (29) patients (33.7%) had a CBS ?6, 6 patients (6.7%) had CBS <6, while 53 patients (59.6%) were deemed clot free. Ninety (90) days post insult, clinical assessment showed that 57 (67.6%) patients were functionally independent, 27 (30.3%) patients functionally dependent, and 5 (5.6%) patients were deceased. Data analysis reported a significant negative correlation (r= -0.611, p<0.001). ROC curves analysis showed an area under the curve of 0.81 at the cut-off point of 6.5. This showed that a CBS of more than 6 predicted a good mRS clinical outcome in AIS patients; with sensitivity of 98.2%, specificity of 53.1%, positive predictive value (PPV) of 76%, and negative predictive value (NPV) of 21%. Conclusion: CBS is a useful additional variable for the management of AIS cases, and should be incorporated into the routine radiological reporting for acute ischemic stroke (AIS) cases.

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A multicenter randomized controlled trial of endovascular therapy following imaging evaluation for ischemic stroke (DEFUSE 3)

International Journal of Stroke ◽

10.1177/1747493017701147 ◽

2017 ◽

Vol 12 (8) ◽

pp. 896-905 ◽

Cited By ~ 93

Author(s):

Gregory W Albers ◽

Maarten G Lansberg ◽

Stephanie Kemp ◽

Jenny P Tsai ◽

Phil Lavori ◽

...

Keyword(s):

Computed Tomography ◽

Ischemic Stroke ◽

Magnetic Resonance ◽

Primary Endpoint ◽

Endovascular Therapy ◽

Symptom Onset ◽

Medical Management ◽

Controlled Trial ◽

Modified Rankin Scale ◽

Computed Tomography Perfusion

Rationale Early reperfusion in patients experiencing acute ischemic stroke is effective in patients with large vessel occlusion. No randomized data are available regarding the safety and efficacy of endovascular therapy beyond 6 h from symptom onset. Aim The aim of the study is to demonstrate that, among patients with large vessel anterior circulation occlusion who have a favorable imaging profile on computed tomography perfusion or magnetic resonance imaging, endovascular therapy with a Food and Drug Administration 510 K-cleared mechanical thrombectomy device reduces the degree of disability three months post stroke. Design The study is a prospective, randomized, multicenter, phase III, adaptive, blinded endpoint, controlled trial. A maximum of 476 patients will be randomized and treated between 6 and 16 h of symptom onset. Procedures Patients undergo imaging with computed tomography perfusion or magnetic resonance diffusion/perfusion, and automated software (RAPID) determines if the Target Mismatch Profile is present. Patients who meet both clinical and imaging selection criteria are randomized 1:1 to endovascular therapy plus medical management or medical management alone. The individual endovascular therapist chooses the specific device (or devices) employed. Study outcomes The primary endpoint is the distribution of scores on the modified Rankin Scale at day 90. The secondary endpoint is the proportion of patients with modified Rankin Scale 0–2 at day 90 (indicating functional independence). Analysis Statistical analysis for the primary endpoint will be conducted using a normal approximation of the Wilcoxon–Mann–Whitney test (the generalized likelihood ratio test).

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Value of pre-intervention computed tomography perfusion imaging in the assessment of tissue outcome and long-term clinical prognosis in patients with anterior circulation acute ischemic stroke receiving reperfusion therapy: a systematic review

Acta Radiologica ◽

10.1177/02841851211035892 ◽

2021 ◽

pp. 028418512110358

Author(s):

Anubhav Katyal ◽

Sonu Menachem Maimonides Bhaskar

Keyword(s):

Computed Tomography ◽

Systematic Review ◽

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Reperfusion Therapy ◽

Imaging Biomarkers ◽

Cochrane Central Register ◽

Clinical Prognosis ◽

Computed Tomography Perfusion

Background Computed tomography perfusion (CTP) imaging has emerged as an important adjunct to the current armamentarium of acute ischemic stroke (AIS) workflow. However, its adoption in routine clinical practice is far from optimal. Purpose To investigate the putative association of CTP imaging biomarkers in the assessment of prognosis in acute ischemic stroke. Material and Methods We performed a systematic review of the literature using MEDLINE, EMBASE, and Cochrane Central Register of Clinical Trials focusing on CTP biomarkers, tissue-based and clinical-based patient outcomes. We included randomized controlled trials, prospective cohort studies, and case-controlled studies published from January 2005 to 28 August 2020. Two independent reviewers conducted the study appraisal, data extraction, and quality assessment of the studies. Results A total of 60 full-text studies were included in the final systematic review analysis. Increasing infarct core volume is associated with reduced odds of achieving functional independence (modified Rankin score 0–2) at 90 days and is correlated with the final infarct volume when reperfusion is achieved. Conclusion CTP has value in assessing tissue perfusion status in the hyperacute stroke setting and the long-term clinical prognosis of patients with AIS receiving reperfusion therapy. However, the prognostic use of CTP requires optimization and further validation.

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Abstract WMP20: E-Aspects Derived Acute Ischemic Volumes on Non-Contrast Enhanced Computed Tomography Images Correlate With Diffusion Weighted Imaging Lesion Volumes and Predict Clinical Outcome in Acute Ischemic Stroke Patients

Stroke ◽

10.1161/str.50.suppl_1.wmp20 ◽

2019 ◽

Vol 50 (Suppl_1) ◽

Author(s):

Simon Nagel ◽

Olivier Joly ◽

Johannes Pfaff ◽

Panagiotes Papanagiotou ◽

Klaus Fassbender ◽

...

Keyword(s):

Computed Tomography ◽

Ischemic Stroke ◽

Clinical Outcome ◽

Acute Ischemic Stroke ◽

Diffusion Weighted Imaging ◽

Stroke Patients ◽

Computed Tomography Images ◽

Contrast Enhanced ◽

Enhanced Computed Tomography ◽

Contrast Enhanced Computed Tomography

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e-ASPECTS derived acute ischemic volumes on non-contrast-enhanced computed tomography images

International Journal of Stroke ◽

10.1177/1747493019879661 ◽

2019 ◽

Vol 15 (9) ◽

pp. 995-1001

Author(s):

Simon Nagel ◽

Olivier Joly ◽

Johannes Pfaff ◽

Panagiotis Papanagiotou ◽

Klaus Fassbender ◽

...

Keyword(s):

Computed Tomography ◽

Clinical Outcome ◽

Diffusion Weighted Imaging ◽

Clinical Severity ◽

Stroke Severity ◽

Lesion Volume ◽

Computed Tomography Perfusion ◽

Computed Tomography Images ◽

Diffusion Weighted ◽

Ischemic Core

Background and purpose Validation of automatically derived acute ischemic volumes (AAIV) from e-ASPECTS on non-contrast computed tomography (NCCT). Materials and methods Data from three studies were reanalyzed with e-ASPECTS Version 7. AAIV was calculated in milliliters (ml) in all scored ASPECTS regions of the hemisphere detected by e-ASPECTS. The National Institute of Health Stroke Scale (NIHSS) determined stroke severity at baseline and clinical outcome was measured with the modified Rankin Scale (mRS) between 45 and 120 days. Spearman ranked correlation coefficients (R) of AAIV and e-ASPECTS scores with NIHSS and mRS as well as Pearson correlation of AAIV with diffusion-weighted imaging and CT perfusion-estimated ischemic “core” volumes were calculated. Multivariate regression analysis (odds ratio, OR with 95% confidence intervals, CI) and Bland–Altman plots were performed. Results We included 388 patients. Mean AAIV was 11.6 ± 18.9 ml and e-ASPECTS was 9 (8–10: median and interquartile range). AAIV, respectively e-ASPECTS correlated with NIHSS at baseline (R = 0.35, p < 0.001; R = −0.36, p < 0.001) and follow-up mRS (R = 0.29, p < 0.001; R = −0.3, p < 0.001). In subsets of patients, AAIV correlated strongly with diffusion-weighted imaging ( n = 37, R = 0.68, p < 0.001) and computed tomography perfusion-derived ischemic “core” ( n = 41, R = 0.76, p < 0.001) lesion volume and Bland–Altman plots showed a bias close to zero (−2.65 ml for diffusion-weighted imaging and 0.45 ml forcomputed tomography perfusion “core”). Within the whole cohort, the AAIV (OR 0.98 per ml, 95% CI 0.96–0.99) and e-ASPECTS scores (OR 1.3, 95%CI 1.07–1.57) were independent predictors of good outcome Conclusion AAIV on NCCT correlated moderately with clinical severity but strongly with diffusion-weighted imaging lesion and computed tomography perfusion ischemic “core” volumes and predicted clinical outcome.

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