scholarly journals Actionable vascular and other incidental findings on CTA in patients undergoing acute stroke intervention

2018 ◽  
Vol 31 (6) ◽  
pp. 572-577 ◽  
Author(s):  
Riti Kanesa-Thasan ◽  
Mougnyan Cox ◽  
Manisha Patel ◽  
Brian Curtis ◽  
Robert W Hurst ◽  
...  
Keyword(s):  
Confidence Interval ◽  
Acute Stroke ◽  
Head And Neck ◽  
Incidental Findings ◽  
Large Vessel ◽  
Large Vessel Occlusion ◽  
Vessel Occlusion ◽  
Institutional Review ◽  
Clinical Radiology

Providing a fast and accurate diagnosis of acute large-vessel occlusion on computed tomography angiograms (CTAs) is essential for timely intervention and good stroke outcomes. However, the detection and appropriate management of incidental findings are also important parts of any clinical radiology practice and can greatly affect patient care. The intricate anatomy covered by CTAs of the head and neck coupled with the time pressures of acute stroke diagnosis creates an environment in which unrelated, important findings can potentially be missed. The purpose of our study was to document clinically actionable incidental findings on CTA in 225 patients undergoing acute stroke intervention. After institutional review board approval, a retrospective six-year review of CTAs of the head and neck in patients undergoing acute stroke intervention was performed for actionable incidental vascular and nonvascular findings. A total of 225 patients undergoing acute stroke intervention with documented intracranial large-vessel occlusion on CTAs were consecutively enrolled in the study. Incidental vascular findings were identified in 17 of 225 patients (7.5%, 95% confidence interval 5% to 12%). Previously unreported aneurysms ranging from 2 mm to 10 mm in size represented 18 of 19 vascular findings in these patients. Incidental nonvascular findings were identified in 32 patients (14%, 95% confidence interval 5% to 12%). These included malpositioned support lines and tubes; pneumothorax; interstitial lung disease; newly diagnosed metastatic disease; nasopharyngeal, parotid, and pituitary masses; and cervical spine compression fractures. CTAs of the head and neck in patients undergoing acute stroke intervention contain a relatively high frequency of vascular and nonvascular incidental findings requiring further follow-up, and therefore should be evaluated carefully and systematically.

scholarly journals Combination of Rescue Stenting and Antiplatelet Infusion Improved Outcomes for Acute Intracranial Atherosclerosis-Related Large-Vessel Occlusion

2021 ◽  
Vol 12 ◽  
Author(s):  
Jang-Hyun Baek ◽  
Cheolkyu Jung ◽  
Byung Moon Kim ◽  
Ji Hoe Heo ◽  
Dong Joon Kim ◽  
...  
Keyword(s):  
Acute Stroke ◽  
Multivariable Analysis ◽  
Large Vessel ◽  
Favorable Outcome ◽  
Intracranial Atherosclerosis ◽  
Large Vessel Occlusion ◽  
Vessel Occlusion ◽  
Improved Outcomes

Background and Purpose: Intracranial atherosclerosis-related large-vessel occlusion caused by in situ thrombo-occlusion (ICAS-LVO) has been regarded an important reason for refractoriness to mechanical thrombectomy (MT). To achieve better outcomes for ICAS-LVO, different endovascular strategies should be explored. We aimed to investigate an optimal endovascular strategy for ICAS-LVO.Methods: We retrospectively reviewed three prospective registries of acute stroke underwent endovascular treatment. Among them, patients with ICAS-LVO were assigned to four groups based on their endovascular strategy: (1) MT alone, (2) rescue intracranial stenting after MT failure (MT-RS), (3) glycoprotein IIb/IIIa inhibitor infusion after MT failure (MT-GPI), and (4) a combination of MT-RS and MT-GPI (MT-RS+GPI). Baseline characteristics and outcomes were compared among the groups. To evaluate whether the endovascular strategy resulted in favorable outcome, multivariable analysis was also performed.Results: A total of 184 patients with ICAS-LVO were included. Twenty-four patients (13.0%) were treated with MT alone, 25 (13.6%) with MT-RS, 84 (45.7%) with MT-GPI, and 51 (27.7%) with MT-RS+GPI. The MT-RS+GPI group showed the highest recanalization efficiency (98.0%). Frequency of patent arteries on follow-up (98.0%, p < 0.001) and favorable outcome (84.3%, p < 0.001) were higher in the MT-RS+GPI group than other groups. The MT-RS+GPI strategy remained an independent factor for favorable outcome (odds ratio, 20.4; 95% confidence interval, 1.97–211.4; p = 0.012).Conclusion: Endovascular strategy was significantly associated with procedural and clinical outcomes in acute stroke by ICAS-LVO. A combination of RS and GPI infusion might be an optimal rescue modality when frontline MT fails.

scholarly journals Diagnostic value of transcranial ultrasonography for selecting subjects with large vessel occlusion: a systematic review

2019 ◽  
Vol 11 (1) ◽  
Author(s):  
Daria Antipova ◽  
Leila Eadie ◽  
Ashish Stephen Macaden ◽  
Philip Wilson
Keyword(s):  
Systematic Review ◽  
Diagnostic Accuracy ◽  
Acute Stroke ◽  
Clinical Assessment ◽  
Assessment Tools ◽  
Large Vessel ◽  
Cochrane Library ◽  
Direct Transfer ◽  
Large Vessel Occlusion ◽  
Vessel Occlusion

Abstract Introduction A number of pre-hospital clinical assessment tools have been developed to triage subjects with acute stroke due to large vessel occlusion (LVO) to a specialised endovascular centre, but their false negative rates remain high leading to inappropriate and costly emergency transfers. Transcranial ultrasonography may represent a valuable pre-hospital tool for selecting patients with LVO who could benefit from rapid transfer to a dedicated centre. Methods Diagnostic accuracy of transcranial ultrasonography in acute stroke was subjected to systematic review. Medline, Embase, PubMed, Scopus, and The Cochrane Library were searched. Published articles reporting diagnostic accuracy of transcranial ultrasonography in comparison to a reference imaging method were selected. Studies reporting estimates of diagnostic accuracy were included in the meta-analysis. Results Twenty-seven published articles were selected for the systematic review. Transcranial Doppler findings, such as absent or diminished blood flow signal in a major cerebral artery and asymmetry index ≥ 21% were shown to be suggestive of LVO. It demonstrated sensitivity ranging from 68 to 100% and specificity of 78–99% for detecting acute steno-occlusive lesions. Area under the receiver operating characteristics curve was 0.91. Transcranial ultrasonography can also detect haemorrhagic foci, however, its application is largely restricted by lesion location. Conclusions Transcranial ultrasonography might potentially be used for the selection of subjects with acute LVO, to help streamline patient care and allow direct transfer to specialised endovascular centres. It can also assist in detecting haemorrhagic lesions in some cases, however, its applicability here is largely restricted. Additional research should optimize the scanning technique. Further work is required to demonstrate whether this diagnostic approach, possibly combined with clinical assessment, could be used at the pre-hospital stage to justify direct transfer to a regional thrombectomy centre in suitable cases.

scholarly journals Progression of cerebral infarction before and after thrombectomy is modified by prehospital pathways

2021 ◽  
pp. neurintsurg-2020-017155
Author(s):  
Alexander M Kollikowski ◽  
Franziska Cattus ◽  
Julia Haag ◽  
Jörn Feick ◽  
Alexander G März ◽  
...  
Keyword(s):  
Patient Characteristics ◽  
Large Vessel ◽  
Stroke Severity ◽  
Large Vessel Occlusion ◽  
Time Intervals ◽  
Vessel Occlusion ◽  
Before And After ◽  
Transferred Patients ◽  
Stroke Center

BackgroundEvidence of the consequences of different prehospital pathways before mechanical thrombectomy (MT) in large vessel occlusion stroke is inconclusive. The aim of this study was to investigate the infarct extent and progression before and after MT in directly admitted (mothership) versus transferred (drip and ship) patients using the Alberta Stroke Program Early CT Score (ASPECTS).MethodsASPECTS of 535 consecutive large vessel occlusion stroke patients eligible for MT between 2015 to 2019 were retrospectively analyzed for differences in the extent of baseline, post-referral, and post-recanalization infarction between the mothership and drip and ship pathways. Time intervals and transport distances of both pathways were analyzed. Multiple linear regression was used to examine the association between infarct progression (baseline to post-recanalization ASPECTS decline), patient characteristics, and logistic key figures.ResultsASPECTS declined during transfer (9 (8–10) vs 7 (6-9), p<0.0001), resulting in lower ASPECTS at stroke center presentation (mothership 9 (7–10) vs drip and ship 7 (6–9), p<0.0001) and on follow-up imaging (mothership 7 (4–8) vs drip and ship 6 (3–7), p=0.001) compared with mothership patients. Infarct progression was significantly higher in transferred patients (points lost, mothership 2 (0–3) vs drip and ship 3 (2–6), p<0.0001). After multivariable adjustment, only interfacility transfer, preinterventional clinical stroke severity, the degree of angiographic recanalization, and the duration of the thrombectomy procedure remained predictors of infarct progression (R2=0.209, p<0.0001).ConclusionsInfarct progression and postinterventional infarct extent, as assessed by ASPECTS, varied between the drip and ship and mothership pathway, leading to more pronounced infarction in transferred patients. ASPECTS may serve as a radiological measure to monitor the benefit or harm of different prehospital pathways for MT.

Abstract 1122‐000022: Delays in Care for Patients with Acute Stroke During Hospitalization for Other Reasons

2021 ◽  
Vol 1 (S1) ◽  
Author(s):  
Nicholas Vigilante ◽  
Parth Patel ◽  
Prasanth Romiyo ◽  
Lauren Thau ◽  
Mark Heslin ◽  
...  
Keyword(s):  
Acute Stroke ◽  
Acute Care ◽  
Large Vessel ◽  
Large Vessel Occlusion ◽  
Single Center ◽  
Anterior Circulation ◽  
Vessel Occlusion ◽  
Symptom Recognition ◽  
Risk Patients ◽  
Recognition Imaging

Introduction : In‐hospital stroke (IHS) is defined as stroke that occurs during hospitalization for non‐stroke conditions. We aimed to understand the timing of symptom recognition for patients who experienced IHS and its impact on the care they receive. Methods : A prospective, single center registry of adult patients (9/20/19‐2/28/21) was queried for acute anterior circulation IHS. Indications for hospitalization, delays from last known well (LKW) to symptom recognition, imaging, and treatment were explored. Results : Of 928 consecutively evaluated adults with acute stroke, 85 (9%) developed an anterior circulation IHS, 39 (46%) of whom were female, with a median age of 67 years (IQR 60–76) and median NIHSS of 15 (IQR 4–22). Sixty‐eight (80%) had a >1 hour delay from last known well to symptom recognition. Two patients (2%) received IV thrombolysis, although another 38 (45%) would have been eligible if not for a delay in symptom recognition. An ICA, M1, or M2 occlusion was observed in 18 patients (21%), 7 of whom were treated at a median of 174 minutes after LKW (IQR 65–219). Compared to the 11 patients who did not undergo thrombectomy with large vessel occlusion, those who underwent thrombectomy had non‐significantly shorter delays from LKW until neuroimaging (median 85 [IQR 65‐162] vs. 216 [IQR 133‐507], p = 0.12). Conclusions : While uncommon, patients with IHS experience delays in symptom recognition and treatment, which lead to exclusion from acute care treatment such as thrombolysis and thrombectomy. Earlier detection with more frequent nursing assessments or advanced neuromonitoring devices in at‐risk patients may reduce delays in care.

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.

Abstract WMP14: Accuracy of Smartphone-based Evaluation of Large Vessel Occlusion on CTA

Stroke ◽  
2017 ◽  
Vol 48 (suppl_1) ◽  
Author(s):  
Douglas T Hidlay ◽  
Ryan McTaggart ◽  
Shadi Yaghi ◽  
Eleanor Dibiasio ◽  
Eric Tung ◽  
...  
Keyword(s):  
Head And Neck ◽  
Mechanical Thrombectomy ◽  
Smartphone Application ◽  
Large Vessel ◽  
Complete Agreement ◽  
Kappa Statistics ◽  
Large Vessel Occlusion ◽  
Vessel Occlusion ◽  
Observer Reliability ◽  
Actual Use

Introduction: Since mechanical thrombectomy was established as the gold standard for treatment of stroke caused by an emergent large vessel occlusion (ELVO), comprehensive stroke centers have worked to streamline their workflow and minimize time-to-intervention; the ability to rapidly review CT angiography (CTA) is one hurdle in that process. To that end, we evaluated the diagnostic accuracy and confidence in review of CTA of the head and neck for ELVO via a smartphone-based application (LifeImage) as compared to review on a PACS workstation. Methods: Seventy-six head and neck CTA studies performed for potential stroke from one comprehensive and seven primary stroke centers were independently reviewed remotely on smartphone by two blinded neurointerventional radiologists in actual-use circumstances. The presence and location of large vessel occlusion(s), diagnostic quality, and confidence in interpretation were recorded. Comparison was made to blinded review of these studies on a PACS workstation performed at a delayed interval. Kappa statistics were calculated to evaluate intra- and inter-observer reliability. Results: Over 76 studies, occlusion of the M1 segment was demonstrated in 14 (18%); carotid artery in 2 (3%); tandem carotid and M1 in 2 (3%); basilar artery in 2 (3%); and no large vessel occlusion in 56 (73%). There was complete agreement between CTA interpretations on smartphone and on PACS with excellent intra- and inter-observer reliability (Table 1). No ELVOs were missed on smartphone review of these studies. Conclusion: In actual-use circumstances, experienced neurointerventional radiologists are able to utilize a smartphone application to diagnose an ELVO on CTA as accurately as on a PACS workstation with similar levels of confidence. These findings support the use of mobile electronic devices by stroke networks to rapidly triage patients for mechanical thrombectomy.

Abstract TP38: Re-Occlusion During Endovascular Therapy for Acute Stroke Patients With Large Vessel Occlusion

Stroke ◽  
2019 ◽  
Vol 50 (Suppl_1) ◽  
Author(s):  
Qing Hao ◽  
Jacob Morey ◽  
Xiangnan Zhang ◽  
Emily Chapman ◽  
Reade DeLeacy ◽  
...  
Keyword(s):  
Acute Stroke ◽  
Endovascular Therapy ◽  
Large Vessel ◽  
Large Vessel Occlusion ◽  
Stroke Patients ◽  
Vessel Occlusion

scholarly journals Effect of Statin Administration After Onset of Acute Ischemic Stroke With Large Vessel Occlusion: Insights From RESCUE‐Japan Registry 2

2020 ◽  
Vol 9 (23) ◽  
Author(s):  
Kazutaka Uchida ◽  
Shinichi Yoshimura ◽  
Hirotoshi Imamura ◽  
Nobuyuki Ohara ◽  
Nobuyuki Sakai ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Large Vessel ◽  
Modified Rankin Scale ◽  
Large Vessel Occlusion ◽  
Odds Ratios ◽  
Vessel Occlusion ◽  
Statin Group ◽  
Younger Age

Background Statins have been associated with reduced recurrence and better functional outcomes in patients with acute ischemic stroke. However, the effect of statins in patients with acute large vessel occlusion (LVO) is not well scrutinized. Methods and Results RESCUE (Recovery by Endovascular Salvage for Cerebral Ultra‐Acute Embolism)‐Japan Registry 2, a physician‐initiated registry, enrolled 2420 consecutive patients with acute LVO who were admitted to 46 centers across Japan within 24 hours of onset. We compared patients with and without statin use after acute LVO onset (statin group and nonstatin group, respectively) in terms of the modified Rankin scale at 90 days. We estimated that the odds ratios for the primary outcome was modified Rankin scale and we estimated the odds ratios for a 1‐scale lower modified Rankin scale adjusting for confounders. After excluding 12 patients without LVO and 9 patients without follow‐up, the mean age of 2399 patients was 75.9 years; men accounted for 55% of patients. Statins were administered to 447 (19%) patients after acute LVO onset. Patients in the statin group had more atherothrombotic cerebral infarctions (34.2% versus 12.1%, P <0.0001), younger age (73.4 years versus 76.5 years, P <0.0001), and lower median National Institutes of Health Stroke Scale on admission (14 versus 17, P <0.0001) than the nonstatin group. The adjusted common OR of the statin group for lower modified Rankin scale was 1.29 (95% CI, 1.04–1.37; P =0.02). The mortality at 90 days was lower in the statin group (4.7%) than the nonstatin group (12.5%; P <0.0001). The adjusted OR of the statin group relative to the nonstatin group for mortality was 0.36 (95% CI, 0.21–0.62; P =0.02). Conclusions Statin administration after acute LVO onset is significantly associated with better functional outcome and mortality at 90 days.

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