Multimodal CT to Differentiate Acute Ischemic Stroke From Stroke Mimics

Background/Purpose: Intravenous Alteplase (t-PA) improves outcome in patients with acute ischemic stroke. Of those who recover fully, some may not have had ischemia. We analyzed the frequency and post-treatment outcomes of patients with no imaging evidence of stroke and aimed to delineate the frequency of strokes with full recovery from that of stroke mimics treated with t-PA. Methods: We included all adult stroke patients treated with IV t-PA within 3 hours of stroke onset from the UCSD SPOTRIAS database. Group 1: Patients with neuroimaging evidence of acute stroke (IPS); Group 2: no neuroimaging evidence of acute stroke (INS). All diagnoses were established by an independent adjudicating body. We reviewed medical records, neuroimaging, and compared discharge diagnosis, 90-day mRS, and incidence of intracranial hemorrhage. We adjusted for age, admission NIHSS, and pre-stroke mRS in multivariable models. Results: We identified 61patients with IPS and 25 with INS, with similar baseline characteristics, except for baseline NIHSS (IPS 13.4±8.2, INS 8.4±5.9, p=0.007) and incidence of cardiac arrhythmias (IPS 36.1%, INS 4.0%, p=0.002). Adjusted for age and baseline NIHSS, we found no difference in outcome. ICH was found in 23% of the IPS patients and was symptomatic in 4.9%. None of the INS patients had ICH. Conclusions: Radiologic evidence of acute ischemic stroke was absent in 10.5% of the 86 patients in the UCSD SPOTRIAS database who were treated with t-PA and given a clinical diagnosis of acute ischemic stroke on adjudicating body review at discharge. The majority (64%) of imaging negative stroke patients in our study ultimately received the clinical diagnosis of acute stroke. No significant difference in outcomes (mRS) was found between imaging negative and imaging positive stroke code patients, aside from the increased ICH frequency in imaging positive patients. This lack of outcome difference emphasizes that while imaging plays an important role as a surrogate marker in determining the diagnosis, a detailed clinical evaluation is essential in the correct treatment of acute ischemic stroke. Imaging negative stroke patients are common and future larger scale prospective data is required to analyze the true frequency of stroke mimics versus imaging negative stroke.

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Multimodal CT Imaging and Recanalizing Therapy in Acute Ischemic Stroke: Retrospective Analysis of a One-Year Single-Center Experience

European Neurology ◽

10.1159/000334724 ◽

2012 ◽

Vol 67 (4) ◽

pp. 193-199 ◽

Cited By ~ 2

Author(s):

Jens Eyding ◽

Reinhard Wiebringhaus ◽

Frauke G. Klein ◽

Sabine Skodda ◽

Uwe Schlegel ◽

...

Keyword(s):

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Retrospective Analysis ◽

Ct Imaging ◽

Single Center ◽

Single Center Experience ◽

One Year ◽

Multimodal Ct

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External Validation of Stroke Mimic Prediction Scales in the Emergency Department

10.21203/rs.3.rs-22178/v1 ◽

2020 ◽

Author(s):

Tian Ming Tu ◽

Guan Zhong Tan ◽

Seyed Ehsan Saffari ◽

Chee Keong Wee ◽

David Jeremiah Ming Siang Chee ◽

...

Keyword(s):

Ischemic Stroke ◽

Decision Tree ◽

Acute Ischemic Stroke ◽

Univariate Analysis ◽

Receiver Operating Curve ◽

Emergency Setting ◽

Predictive Values ◽

Stroke Mimics ◽

Prediction Tools ◽

Stroke Mimic

Abstract Background Acute ischemic stroke is a time-sensitive emergency where accurate diagnosis is required promptly. Due to time pressures, stroke mimics, whom present with similar signs and symptoms as acute ischemic stroke, pose a diagnostic challenge to the emergency physician. With limited access to investigative tools, clinical prediction tools, based only on clinical features, may be useful to identify stroke mimics. We aim to externally validate the performance of 4 stroke mimic prediction scales and aim to derive a novel decision tree, to improve identification of stroke mimics. Methods We performed a retrospective cross-sectional study at a primary stroke centre, served by a telestroke hub. We included consecutive patients whom were administered intravenous thrombolysis for suspected acute ischemic stroke from January 2015 to October 2017. Four stroke mimic prediction tools (FABS, simplified FABS, Telestroke Mimic Score and Khan Score) were rated simultaneously, using only clinical information prior to administration of thrombolysis. The final diagnosis was ascertained by an independent stroke neurologist. Area under receiver operating curve (AUROC) analysis was performed. A classification tree analysis was also conducted using variables which were found to be significant in the univariate analysis. Results Telestroke Mimic Score had the highest discrimination for stroke mimics among the 4 scores tested (AUROC = 0.75, 95% CI = 0.63–0.87), although it was not statistically significantly better. Telestroke Mimic Score had the highest sensitivity (91.3%), while Khan score had the highest specificity (88.2%). All 4 scores had high positive predictive value (88.1–97.5%) and low negative predictive values (4.7–32.3%). A novel decision tree, using only age, presence of migraine and psychiatric history, had a higher prediction performance (AUROC = 0.80). Conclusion Four tested stroke mimic prediction scales performed similarly well to identify stroke mimics in the emergency setting. A novel decision tree may improve the identification of stroke mimics.

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Renal Safety of Intra-Arterial Treatment after Acute Ischemic Stroke with Multimodal CT Imaging selection

Journal of Stroke and Cerebrovascular Diseases ◽

10.1016/j.jstrokecerebrovasdis.2019.02.027 ◽

2019 ◽

Vol 28 (7) ◽

pp. 2031-2037 ◽

Cited By ~ 2

Author(s):

Zicheng Hu ◽

Tingting Shang ◽

Rongzhong Huang ◽

Qi Li ◽

Peng Zheng ◽

...

Keyword(s):

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Ct Imaging ◽

Multimodal Ct ◽

Renal Safety

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Multimodal CT assessment of acute ischemic stroke

The Egyptian Journal of Radiology and Nuclear Medicine ◽

10.1016/j.ejrnm.2012.12.006 ◽

2013 ◽

Vol 44 (1) ◽

pp. 71-81 ◽

Cited By ~ 3

Author(s):

Amani Ezzat Mousa ◽

Mohamed M. Elrakhawy ◽

Ashraf A. Zaher

Keyword(s):

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Multimodal Ct

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Stroke Mimics: An Important Source of Bias in Acute Ischemic Stroke Research

Journal of Stroke and Cerebrovascular Diseases ◽

10.1016/j.jstrokecerebrovasdis.2019.06.019 ◽

2019 ◽

Vol 28 (9) ◽

pp. 2475-2480

Author(s):

Ravi Garg ◽

Megan A. Rech ◽

Michael Schneck

Keyword(s):

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Stroke Mimics ◽

Stroke Research

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Can perfusion CT unmask postictal stroke mimics?

Neurology ◽

10.1212/wnl.0000000000006501 ◽

2018 ◽

Vol 91 (20) ◽

pp. e1918-e1927 ◽

Cited By ~ 9

Author(s):

Margot G.A. Van Cauwenberge ◽

Sven Dekeyzer ◽

Omid Nikoubashman ◽

Manuel Dafotakis ◽

Martin Wiesmann

Keyword(s):

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Predictive Value ◽

Diagnostic Algorithm ◽

Epileptic Seizures ◽

Diagnostic Value ◽

Perfusion Ct ◽

Retrospective Case ◽

Stroke Mimics ◽

Neurologic Deficits

ObjectiveTo study the diagnostic value of volume perfusion CT (VPCT) in patients with transient focal neurologic deficits following and during epileptic seizures, that mimic symptoms of stroke.MethodsA retrospective case-control study was performed on 159 patients who presented with a seizure and received an emergency VPCT within the first 3.5 hours of admission, after being misjudged to have an acute stroke. The reference test was a clinical-based, EEG-supported diagnostic algorithm for seizure.ResultsWe included 133 patients: 94 stroke-mimicking cases with postictal focal neurologic deficits (“Todd phenomenon,” n = 67) or ongoing seizure on hospital admission (“ictal patients,” n = 27), and 39 postictal controls without focal neurologic deficits. Patients with Todd phenomenon showed normal perfusion (64%), hypoperfusion (21%), and hyperperfusion (14%) on early VPCT. Ictal patients displayed more hyperperfusion compared to postictal patients (p = 0.015). Test sensitivity of hyperperfusion for ictal patients is 38% (95% confidence interval [CI] 20.7%–57.7%), specificity 86% (95% CI 77.3%–91.7%), positive predictive value is 42% (95% CI 27.5%–58.7%), and the negative predictive value 83% (95% CI 78.6%–86.9%). A cortical distribution was seen in all hyperperfusion scans, compared to a cortico-subcortical pattern in hypoperfusion (p < 0.001). A history of complex focal seizure and age were associated with hyperperfusion (p = 0.046 and 0.038, respectively).ConclusionVPCT can differentiate ictal stroke mimics with hyperperfusion from acute ischemic stroke, but not postictal patients who display perfusion patterns overlapping with ischemic stroke.Classification of evidenceThis study provides Class IV evidence that VPCT accurately differentiates ictal stroke mimics from acute ischemic stroke.

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Incidence and Risk Factors of Postcontrast Acute Kidney Injury in Patients with Acute Ischemic Stroke

Stroke Research and Treatment ◽

10.1155/2020/7182826 ◽

2020 ◽

Vol 2020 ◽

pp. 1-6 ◽

Cited By ~ 1

Author(s):

Sirichai Chusiri ◽

Aurauma Chutinet ◽

Nijasri Charnnarong Suwanwela ◽

Chankit Puttilerpong

Keyword(s):

Risk Factors ◽

Acute Kidney Injury ◽

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Mechanical Thrombectomy ◽

Kidney Injury ◽

Stroke Patients ◽

Two Factors ◽

Real Practice ◽

Multimodal Ct

Background. Multimodal computed tomography (CT) guides decision-making regarding use of thrombolytic agents in acute ischemic stroke patients. However, postcontrast acute kidney injury (PC-AKI) is a potential adverse effect of the contrast media used, which may require hemodialysis and cause a longer hospital stay. The incidence and risk factors of PC-AKI in acute ischemic stroke patients, particularly in Thailand, remain unclear. Goal. We aimed at determining the incidence and risk factors of PC-AKI in patients with acute ischemic stroke undergoing multimodal CT. Methods. We conducted a retrospective review of Thai acute ischemic stroke patients admitted to the King Chulalongkorn Memorial Hospital between January 2014 and December 2017 who received multimodal CT and thrombolytic treatment with alteplase. Result. Overall, 109 patients were included for analysis; eight patients (7.3%) developed PC-AKI. Estimated glomerular filtration rate eGFR≤30 mL/min and mechanical thrombectomy were risk factors significantly associated with PC-AKI. Conclusion. The incidence of PC-AKI in a real practice setting did not differ from previous reports. Two factors were associated with PC-AKI, eGFR≤30 mL/min and mechanical thrombectomy. Patients without these risk factors may not need to wait for the results of renal function testing prior to multimodal CT.

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