scholarly journals CT perfusion in acute stroke: Practical guidance for implementation in clinical practice

2018 ◽  
Vol 39 (9) ◽  
pp. 1664-1668 ◽  
Author(s):  
Soren Christensen ◽  
Maarten G Lansberg
Keyword(s):  
Clinical Practice ◽  
Acute Stroke ◽  
Ct Perfusion ◽  
Practical Guidance

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 Disabling stroke in persons already with a disability

Neurology ◽  
2020 ◽  
Vol 94 (7) ◽  
pp. 306-310 ◽  
Author(s):  
Michael J. Young ◽  
Robert W. Regenhardt ◽  
Thabele M. Leslie-Mazwi ◽  
Michael Ashley Stein
Keyword(s):  
Clinical Practice ◽  
Health Outcomes ◽  
Acute Stroke ◽  
Care Delivery ◽  
Stroke Care ◽  
Clinical Practices ◽  
Acute Stroke Care ◽  
Persons With Disabilities ◽  
Stroke Research ◽  
Scant Attention

Stroke is the second leading cause of death worldwide and a leading cause of adult disability worldwide. More than a third of individuals presenting with strokes are estimated to have a preexisting disability. Despite unprecedented advances in stroke research and clinical practice over the past decade, approaches to acute stroke care for persons with preexisting disability have received scant attention. Current standards of research and clinical practice are influenced by an underexplored range of biases that may hinder acute stroke care for persons with disability. These trends may exacerbate unequal health outcomes by rendering novel stroke therapies inaccessible to many persons with disabilities. Here, we explore the underpinnings and implications of biases involving persons with disability in stroke research and practice. Recent insights from bioethics, disability rights, and health law are explained and critically evaluated in the context of prevailing research and clinical practices. Allowing disability to drive decisions to withhold acute stroke interventions may perpetuate disparate health outcomes and undermine ethically resilient stroke care. Advocacy for inclusion of persons with disability in future stroke trials can improve equity in stroke care delivery.

Utility of CT perfusion scanning in patient selection for acute stroke intervention: experience at University at Buffalo Neurosurgery–Millard Fillmore Gates Circle Hospital

2011 ◽  
Vol 30 (6) ◽  
pp. E4 ◽  
Author(s):  
Peter T. Kan ◽  
Kenneth V. Snyder ◽  
Parham Yashar ◽  
Adnan H. Siddiqui ◽  
L. Nelson Hopkins ◽  
...  
Keyword(s):  
Acute Stroke ◽  
Patient Selection ◽  
Ct Perfusion ◽  
Brain Parenchyma ◽  
National Institutes Of Health ◽  
Time Interval ◽  
Case Examples ◽  
Flow Parameters ◽  
Selection For ◽  
The Brain

Computed tomography perfusion scanning generates physiological flow parameters of the brain parenchyma, allowing differentiation of ischemic penumbra and core infarct. Perfusion maps, along with the National Institutes of Health Stroke Scale score, are used as the bases for endovascular stroke intervention at the authors' institute, regardless of the time interval from stroke onset. With case examples, the authors illustrate their perfusion-based imaging guidelines in patient selection for endovascular treatment in the setting of acute stroke.

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 TP362: A Team Approach for Improving Door to needle Time for IV t-PA in Acute Stroke

Stroke ◽  
2013 ◽  
Vol 44 (suppl_1) ◽  
Author(s):  
Nili E Steiner ◽  
Nicole Wolber ◽  
Betty Robertson ◽  
Paula Rosenfield ◽  
Laurie Paletz
Keyword(s):  
Quality Improvement ◽  
Acute Stroke ◽  
Stroke Patient ◽  
Ct Perfusion ◽  
Team Approach ◽  
Acute Stroke Patient ◽  
Stroke Treatment ◽  
Perfusion Studies ◽  
Intravenous Tissue Plasminogen Activator ◽  
Ct Angiogram

Background: Brain ischemia kills 2 million nerve cells per minute. As time elapses, the odds of favorable outcome become less likely. By providing treatment rapidly, patient outcome is markedly improved. We recognized an opportunity for improvement by shortening our door-to-needle time. The door-to-needle time is defined by the time the patient arrives in the emergency department to the time the patient receives intravenous tissue plasminogen activator (IV t-PA). Methods: We evaluated the system in place to look at opportunities for improvement. We met monthly to assess every acute stroke patient case, particularly to evaluate delays in acute stroke treatment. We analyzed the results of all the acute stroke patient cases from January 2008 to January 2012. We implemented the following interventions: staff education, reducing unnecessary CT angiogram and CT perfusion studies on patients, RN telephone triage for acute stroke patients. pre-hospital activation of the stroke team for patients exhibiting acute stroke symptoms, ED pharmacist at bedside upon patient arrival with t-PA, and placing patients on portable monitors immediately upon ED arrival. Conclusion: The average door-to-needle time from January 2008 to October 2011 was 1 hour and 32 minutes. After implementing the changes above, from November 2011 to January 2012, our average door-to-needle time was 38 minutes to 54 minutes, which is within the target of less than 60 minutes. By implementing these changes, we have successfully and safely reduced and improved our door-to-needle time. Monthly quality improvement meetings are on-going to assess continuing quality improvement.

Abstract 96: CTP-Mismatch Maps Improve Interobserver Agreement

Stroke ◽  
2012 ◽  
Vol 43 (suppl_1) ◽  
Author(s):  
Waimei A Tai ◽  
Archana Purushotham ◽  
Matus Straka ◽  
Rebecca M Sugg ◽  
Naveed Akhtar ◽  
...  
Keyword(s):  
Acute Stroke ◽  
Ct Perfusion ◽  
Interobserver Reliability ◽  
Observer Agreement ◽  
Absolute Difference ◽  
Stroke Therapy ◽  
Adequate Quality ◽  
Ischemic Core ◽  
Observer Disagreement ◽  
Acute Stroke Therapy

Introduction: The use of mismatch between the ischemic core and penumbra to select patients who are likely to benefit from acute stroke therapy has gained popularity. Interpretation of the ischemic core and penumbra on standard CT-perfusion (CTP) maps is subjective. This may lead to variability among physicians in the decision if a patient is a good candidate for acute stroke therapy. A CTP-Mismatch map with outlines of the ischemic core and penumbra could limit this variability. The goal of this study was to determine if inter-observer agreement regarding a patient’s suitability for acute stroke therapy improves with the use of a CTP-Mismatch map. The figure shows a typical CTP-Mismatch map. Methods: Ninety-six consecutive patients evaluated with CTP prior to intra-arterial therapy at St. Lukes Hospital in 2008-09 were included. 79 patients had adequate quality CTP for this analysis. Standard CTP maps (CBV, CBF, MTT, and Tmax) and a CTP-Mismatch map were generated with a fully automated program for processing of CTP source images (RAPID). RAPID assessed the ischemic core using a CBF threshold <30% of the contralateral hemisphere (rCBF<30%). The ischemic penumbra was defined by a Tmax threshold of >6 sec (Tmax>6s). The standard CTP maps and the CTP-Mismatch map were independently analyzed by two vascular neurologists in a blinded fashion. The raters assessed a patient's suitability for intra-arterial therapy based on the following mismatch criteria: (1) a ratio between (Tmax>6s) and (rCBF<30%) volumes >1.8 and (2) an absolute difference between (Tmax>6s) and (CBF<30%) volumes >15ml. Interobserver reliability was assessed with Cohen’s kappa. Results: When assessment of suitability for intra-arterial therapy was based on interpretation of standard CTP maps, the two raters agreed in 58 of 79 patients (kappa=0.46; 95% CI=0.24-0.60). The agreement between observers improved when suitability was determined using CTP-Mismatch maps (agreement in 76 of 79 cases; kappa=0.92; 95% CI=0.75-0.92; p<0.001 for difference between kappa values). The 3 cases with inter-observer disagreement had artifact on the CTP-Mismatch map. Following concensus adjudication of these 3 cases, 40 of the 79 patients (51%) were deemed suitable candidates for acute stroke therapy. Conclusion: CTP-Mismatch maps with estimates of ischemic core and penumbra volumes markedly improve inter-observer agreement regarding assessment of suitability for acute stroke therapy. Such maps, which can be generated automatically, may help standardize decision making algorithms for evaluation of potential intra-arterial therapy candidates.

CT Perfusion in Acute Stroke*

2005 ◽  
Vol 26 (6) ◽  
pp. 404-421 ◽  
Author(s):  
Sanjay K. Shetty ◽  
Michael H. Lev
Keyword(s):  
Acute Stroke ◽  
Ct Perfusion

scholarly journals Interpreting CT perfusion in stroke

2018 ◽  
Vol 19 (2) ◽  
pp. 136-142 ◽  
Author(s):  
Stevan Christopher Wing ◽  
Hugh S Markus
Keyword(s):  
Acute Stroke ◽  
Perfusion Imaging ◽  
Treatment Time ◽  
Ct Perfusion ◽  
Time Windows ◽  
Onset Time ◽  
Brain Perfusion ◽  
Reperfusion Therapy ◽  
Imaging Protocol ◽  
Stroke Imaging

CT perfusion images can be rapidly obtained on all modern CT scanners and easily incorporated into an acute stroke imaging protocol. Here we discuss the technique of CT perfusion imaging, how to interpret the data and how it can contribute to the diagnosis of acute stroke and selection of patients for treatment. Many patients with acute stroke are excluded from reperfusion therapy if the onset time is not known or if they present outside of traditional treatment time windows. There is a growing body of evidence supporting the use of perfusion imaging in these patients to identify patterns of brain perfusion that are favourable for recanalisation therapy.

scholarly journals Epidemiological Surveillance of the Impact of the COVID-19 Pandemic on Stroke Care Using Artificial Intelligence

Stroke ◽  
2021 ◽  
Author(s):  
Raul G. Nogueira ◽  
Jason M. Davies ◽  
Rishi Gupta ◽  
Ameer E. Hassan ◽  
Thomas Devlin ◽  
...  
Keyword(s):  
Artificial Intelligence ◽  
Acute Stroke ◽  
Systems Of Care ◽  
Ct Perfusion ◽  
Stroke Care ◽  
Large Vessel ◽  
Large Vessel Occlusion ◽  
Vessel Occlusion ◽  
Number Of Patients ◽  
The Impact

Background and Purpose: The degree to which the coronavirus disease 2019 (COVID-19) pandemic has affected systems of care, in particular, those for time-sensitive conditions such as stroke, remains poorly quantified. We sought to evaluate the impact of COVID-19 in the overall screening for acute stroke utilizing a commercial clinical artificial intelligence platform. Methods: Data were derived from the Viz Platform, an artificial intelligence application designed to optimize the workflow of patients with acute stroke. Neuroimaging data on suspected patients with stroke across 97 hospitals in 20 US states were collected in real time and retrospectively analyzed with the number of patients undergoing imaging screening serving as a surrogate for the amount of stroke care. The main outcome measures were the number of computed tomography (CT) angiography, CT perfusion, large vessel occlusions (defined according to the automated software detection), and severe strokes on CT perfusion (defined as those with hypoperfusion volumes >70 mL) normalized as number of patients per day per hospital. Data from the prepandemic (November 4, 2019 to February 29, 2020) and pandemic (March 1 to May 10, 2020) periods were compared at national and state levels. Correlations were made between the inter-period changes in imaging screening, stroke hospitalizations, and thrombectomy procedures using state-specific sampling. Results: A total of 23 223 patients were included. The incidence of large vessel occlusion on CT angiography and severe strokes on CT perfusion were 11.2% (n=2602) and 14.7% (n=1229/8328), respectively. There were significant declines in the overall number of CT angiographies (−22.8%; 1.39–1.07 patients/day per hospital, P <0.001) and CT perfusion (−26.1%; 0.50–0.37 patients/day per hospital, P <0.001) as well as in the incidence of large vessel occlusion (−17.1%; 0.15–0.13 patients/day per hospital, P <0.001) and severe strokes on CT perfusion (−16.7%; 0.12–0.10 patients/day per hospital, P <0.005). The sampled cohort showed similar declines in the rates of large vessel occlusions versus thrombectomy (18.8% versus 19.5%, P =0.9) and comprehensive stroke center hospitalizations (18.8% versus 11.0%, P =0.4). Conclusions: A significant decline in stroke imaging screening has occurred during the COVID-19 pandemic. This analysis underscores the broader application of artificial intelligence neuroimaging platforms for the real-time monitoring of stroke systems of care.

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