Pearls & Oy-sters: Calcified Cerebral Embolus: A Smoking Gun Guiding Acute Stroke Therapy and Secondary Prevention

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.

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CD36: A multi-modal target for acute stroke therapy

Journal of Neurochemistry ◽

10.1111/j.1471-4159.2009.05801.x ◽

2009 ◽

Vol 109 ◽

pp. 126-132 ◽

Cited By ~ 19

Author(s):

Sunghee Cho ◽

Eunhee Kim

Keyword(s):

Acute Stroke ◽

Stroke Therapy ◽

Acute Stroke Therapy

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Acute Stroke Therapy: Highlighting the Ischemic Penumbra

Brain Hypoxia and Ischemia ◽

10.1007/978-1-60327-579-8_16 ◽

2009 ◽

pp. 307-322 ◽

Cited By ~ 1

Author(s):

Hang Yao

Keyword(s):

Acute Stroke ◽

Ischemic Penumbra ◽

Stroke Therapy ◽

Acute Stroke Therapy

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Can transcranial ultrasound and microbubble therapy ever enter the mainstream in acute stroke therapy?

Expert Review of Cardiovascular Therapy ◽

10.1586/erc.12.35 ◽

2012 ◽

Vol 10 (5) ◽

pp. 549-551 ◽

Cited By ~ 1

Author(s):

Thomas R Porter ◽

Feng Xie

Keyword(s):

Acute Stroke ◽

Transcranial Ultrasound ◽

Stroke Therapy ◽

Acute Stroke Therapy

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Abstract WP121: Incorporating CT-Perfusion Imaging in Acute Stroke Therapy Workflow Does Not Delay Door to Needle Time for Intravenous t-PA

Stroke ◽

10.1161/str.51.suppl_1.wp121 ◽

2020 ◽

Vol 51 (Suppl_1) ◽

Author(s):

Bahareh Sianati ◽

Russel Cerejo ◽

David Wright ◽

Ashish Tayal ◽

Patty Noah ◽

...

Keyword(s):

Acute Stroke ◽

Perfusion Imaging ◽

Ct Perfusion ◽

Brain Perfusion ◽

Stroke Therapy ◽

Brain Perfusion Imaging ◽

Group 2 ◽

Acute Stroke Therapy ◽

Iv Tpa ◽

Group 1

Introduction: Brain perfusion imaging has become an integral part of acute stroke therapy, especially for the extended time window. A streamlined workflow is essential to reduce delays in acute stroke therapy. Incorporating standard and advanced imaging together may reduce time to endovascular therapy but may delay administration of intravenous (IV) tPA. Method: A retrospective analysis of all acute stroke therapy cases between August 2017 and March of 2018 was performed at a single stroke center. Brain perfusion imaging was instituted into the workflow in December of 2017. We included patients who received IV tPA before and after implementation of CT perfusion (CT-P). Demographics, clinical presentation, stroke treatment times and imaging characteristics were collected. Results: During the eight-month period, we identified 117 patients who met inclusion criteria. We divided the cohort into two groups, pre CT-P implementation (Group 1) and post CT-P implementation (Group 2). We identified 66 patients in Group 1 and 51 patients in Group 2. In Group 1, 29 (44%) were females with median age of 63 years. In Group 2, 33 (65%) were females, with median age of 72 years. There was no difference in median times for door to needle in Group 1 (57 minutes, interquartile range [IQR] 42 – 76) compared to Group 2 (53 minutes, [IQR] 40 – 68) ( P = 0.20). Conclusion: Incorporating CT-P in the imaging workflow did not delay door to needle time for IV tPA in acute stroke therapy.

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Abstract TP323: The Role of Ejection Fraction in 90 Day Functional Outcome in Acute Ischemic Infarction Patients Receiving Acute Stroke Therapy

Stroke ◽

10.1161/str.51.suppl_1.tp323 ◽

2020 ◽

Vol 51 (Suppl_1) ◽

Author(s):

Tamra Ranasinghe ◽

Brett Meyer ◽

Richard Lane ◽

Dawn Meyer

Keyword(s):

Acute Stroke ◽

Functional Outcome ◽

Pearson Correlation ◽

Recombinant Tissue Plasminogen Activator ◽

Continuous Variables ◽

Stroke Therapy ◽

Stroke Registry ◽

The Relationship ◽

Acute Stroke Therapy ◽

Iv Tpa

Background: Cardiovascular disease is associated with unfavorable outcomes following acute ischemic stroke (AIS). Left ventricularejection fraction (LVEF) alone has not been reported as a significant predictor of unfavorable outcomes in observational studies of AIS.The purpose of this study was to evaluate the relationship between LVEF and 90 day functional outcome in AIS patients who received acute stroke therapy with IV recombinant tissue plasminogen activator (rt-PA), endovascular therapy (EVT), or combination IV rt-PA+EVT. Methods: This was a retrospective review of prospectively collected data from the University of California San Diego (UCSD) Stroke registry from October 2014-June 2019. Analysis included all patients for whom a stroke code was activated and who had a transthoracic echocardiogram (TTE) during stroke admission or within the previous 30 days prior to AIS. Acute stroke therapy was defined as 1) IV tPA only; 2) EVT only; or 3) IV tPA + EVT. LVEF function was defined as: low <35%, moderately low 36 -49% and normal >50% on TTE. Primary outcome was modified ranking scale(mRS) at 90 days post stroke. Data was examined for frequencies and distribution. Continuous variables were assessed by Pearson correlation and t test. Kruskal-Wallis or ANOVA were used to evaluate group differences. ANCOVA was used for adjusted analysis. Results: In the 227 patients identified, low EF patients were more likely to have atrial fibrillation (61.9%, p=.004) and lower mean admission systolic blood pressure (132.6, p=0.009). LVEF was not significantly associated with 90 day outcome in all treated patients in both unadjusted (p=0.992) and adjusted (p=0.62). LVEF was not significantly associated with 90 day outcome for individual acute stroke therapy groups both unadjusted and adjusted. mRS at 90 days was significantly associated with baseline NIHSS (p<0.001), age (p=0.002), and treatment with IV tPA (p=0.01). Conclusion: In this study, LVEF was not independently associated with 90 day functional outcome in AIS patients who received acute stroke therapy. Further studies in more heterogenous samples are warranted to assess the relationship between LVEF and outcome in all stroke populations.

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