Accuracy and Reliability of the Recommendation for IV Thrombolysis in Acute Ischemic Stroke Based on Interpretation of Head CT on a Smartphone or a Laptop

BACKGROUND AND PURPOSE: To determine whether Perfusion-CT (PCT) adds value to Noncontrast head CT (NCT), CT-Angiogram (CTA) and clinical assessment in patients suspected of acute ischemic stroke. METHODS: We retrospectively reviewed the clinical and imaging data collected in 165 patients with acute ischemic stroke. ASPECTS score was calculated from NCT. CTA was reviewed for site of occlusion and collateral flow score. PCT was used to calculate the volumes of infarct core and ischemic penumbra on admission. Recanalization status was assessed on follow-up imaging. Clinical data included age, time from onset to baseline imaging, time from baseline imaging to reperfusion therapy, time from baseline imaging to recanalization imaging, NIHSS at baseline, treatment type and modified Rankin score (mRS) at 90 days. In a first multivariate regression analysis, we used volume of PCT penumbra and infarct core as outcome, and assessed whether they could be predicted from clinical variables, NCT and/or CTA. In a second multivariate regression analysis, we used mRS at 90 days as outcome, and determined which imaging and clinical variables predicted it best. RESULTS: 165 patients were identified. Mean±SD time from onset to baseline imaging was 6.7±8.7 hrs. 76 had a good outcome (90-day mRS 0-2), 89 had a poor outcome. Mean±SD PCT infarct was 44.8±46.5 ml. Mean±SD PCT penumbra was 47.0±33.9 ml. PCT infarct could be predicted by clinical data, NCT, CTA, and combinations of this data (P<0.05); the best predictive model included the clinical data, plus NCT and CTA. PCT Penumbra could NOT be predicted by clinical data, NCT, and CTA. In terms of predicting mRS at 90 days, all of variables but NCT and CTA were significantly associated with 90-day mRS outcome. The single most important predictor was recanalization status (P<0.001). PCT penumbra volume (P=0.001) was also a predictor of clinical outcome, especially when considered in conjunction with recanalization through an interaction term (P<0.001). CONCLUSION: PCT penumbra represents independent information, which cannot be predicted by clinical, NCT, and CTA data. PCT penumbra is an important determinant of clinical outcome, and adds relevant clinical information compared to a stroke CT work-up including NCT and CTA.

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Impact of Initial Imaging Protocol on Likelihood of Endovascular Stroke Therapy

Stroke ◽

10.1161/strokeaha.120.030122 ◽

2020 ◽

Vol 51 (10) ◽

pp. 3055-3063 ◽

Cited By ~ 1

Author(s):

Victor Lopez-Rivera ◽

Rania Abdelkhaleq ◽

Jose-Miguel Yamal ◽

Noopur Singh ◽

Sean I. Savitz ◽

...

Keyword(s):

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Odds Ratio ◽

Time Window ◽

Tissue Type ◽

Stroke Therapy ◽

Imaging Protocol ◽

Head Ct ◽

The Impact ◽

Endovascular Stroke Therapy

Background and Purpose: Noncontrast head CT and CT perfusion (CTP) are both used to screen for endovascular stroke therapy (EST), but the impact of imaging strategy on likelihood of EST is undetermined. Here, we examine the influence of CTP utilization on likelihood of EST in patients with large vessel occlusion (LVO). Methods: We identified patients with acute ischemic stroke at 4 comprehensive stroke centers. All 4 hospitals had 24/7 CTP and EST capability and were covered by a single physician group (Neurology, NeuroIntervention, NeuroICU). All centers performed noncontrast head CT and CT angiography in the initial evaluation. One center also performed CTP routinely with high CTP utilization (CTP-H), and the others performed CTP optionally with lower utilization (CTP-L). Primary outcome was likelihood of EST. Multivariable logistic regression was used to determine whether facility type (CTP-H versus CTP-L) was associated with EST adjusting for age, prestroke mRS, National Institutes of Health Stroke Scale, Alberta Stroke Program Early CT Score, LVO location, time window, and intravenous tPA (tissue-type plasminogen activator). Results: Among 3107 patients with acute ischemic stroke, 715 had LVO, of which 403 (56%) presented to CTP-H and 312 (44%) presented to CTP-L. CTP utilization among LVO patients was greater at CTP-H centers (72% versus 18%, CTP-H versus CTP-L, P <0.01). In univariable analysis, EST rates for patients with LVO were similar between CTP-H versus CTP-L (46% versus 49%). In multivariable analysis, patients with LVO were less likely to undergo EST at CTP-H (odds ratio, 0.59 [0.41–0.85]). This finding was maintained in multiple patient subsets including late time window, anterior circulation LVO, and direct presentation patients. Ninety-day functional independence (odds ratio, 1.04 [0.70–1.54]) was not different, nor were rates of post-EST PH-2 hemorrhage (1% versus 1%). Conclusions: We identified an increased likelihood for undergoing EST in centers with lower CTP utilization, which was not associated with worse clinical outcomes or increased hemorrhage. These findings suggest under-treatment bias with routine CTP.

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Detection of Early Ischemic Changes in Noncontrast CT Head Improved with “Stroke Windows”

ISRN Neuroscience ◽

10.1155/2014/654980 ◽

2014 ◽

Vol 2014 ◽

pp. 1-4 ◽

Cited By ~ 8

Author(s):

Shraddha Mainali ◽

Mervat Wahba ◽

Lucas Elijovich

Keyword(s):

Ischemic Stroke ◽

Basal Ganglia ◽

Acute Ischemic Stroke ◽

Basilar Artery ◽

Chart Review ◽

Retrospective Chart Review ◽

Image Evaluation ◽

Head Ct ◽

Noncontrast Ct ◽

Ct Head

Introduction. Noncontrast head CT (NCCT) is the standard radiologic test for patients presenting with acute stroke. Early ischemic changes (EIC) are often overlooked on initial NCCT. We determine the sensitivity and specificity of improved EIC detection by a standardized method of image evaluation (Stroke Windows). Methods. We performed a retrospective chart review to identify patients with acute ischemic stroke who had NCCT at presentation. EIC was defined by the presence of hyperdense MCA/basilar artery sign; sulcal effacement; basal ganglia/subcortical hypodensity; and loss of cortical gray-white differentiation. NCCT was reviewed with standard window settings and with specialized Stroke Windows. Results. Fifty patients (42% females, 58% males) with a mean NIHSS of 13.4 were identified. EIC was detected in 9 patients with standard windows, while EIC was detected using Stroke Windows in 35 patients (18% versus 70%; P<0.0001). Hyperdense MCA sign was the most commonly reported EIC; it was better detected with Stroke Windows (14% and 36%; P<0.0198). Detection of the remaining EIC also improved with Stroke Windows (6% and 46%; P<0.0001). Conclusions. Detection of EIC has important implications in diagnosis and treatment of acute ischemic stroke. Utilization of Stroke Windows significantly improved detection of EIC.

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Eligibility Determination for Intravenous Thrombolysis Based on Radiology Interpretation Report of the Head CT Scan in Patients with Acute Ischemic Stroke

Journal of Neuroimaging ◽

10.1111/jon.12045 ◽

2013 ◽

Vol 24 (4) ◽

pp. 349-353 ◽

Cited By ~ 1

Author(s):

Ameer E. Hassan ◽

Shahram Majidi ◽

Nazli A. Janjua ◽

Saqib A. Chaudhry ◽

Wondwossen G. Tekle ◽

...

Keyword(s):

Ischemic Stroke ◽

Ct Scan ◽

Acute Ischemic Stroke ◽

Intravenous Thrombolysis ◽

Head Ct ◽

Eligibility Determination ◽

Radiology Interpretation

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Multimodal Computed Tomography in Acute Ischemic Stroke

US Neurology ◽

10.17925/usn.2010.06.01.50 ◽

2010 ◽

Vol 06 (01) ◽

pp. 50 ◽

Cited By ~ 1

Author(s):

Sachin Rastogi ◽

David S Liebeskind ◽

◽

Keyword(s):

Computed Tomography ◽

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Ct Perfusion ◽

Vascular Occlusion ◽

Vascular Pathology ◽

Stroke Patients ◽

Infarct Core ◽

Head Ct ◽

Ct Angiogram

Stroke is the third leading cause of death in the US, affecting 795,000 individuals annually. Currently, only a small percentage of acute stroke patients receive thrombolytic treatment. A significant limitation is the current use of strict time criteria in the decision to treat. As there are significant interindividual variations in response to an acute vascular occlusion, the goal of modern imaging such as multimodal computed tomography (CT) is to rapidly identify acute ischemic stroke patients and determine which patients are likely to benefit from treatment based on tissue perfusion status rather than time of presentation alone. Multimodal CT consists of a non-contrast head CT, CT angiogram (CTA) of the head and neck, and CT perfusion (CTP). The non-contrast head CT allows rapid triage of a patient with hemorrhagic versus ischemic stroke. The CTA allows identification of the site of vascular pathology with similar quality to digital subtraction angiography. The CTP scan allows for determination of the infarct core and surrounding ischemic penumbra, which remains at risk for infarction if perfusion is not restored. This allows the potential to prospectively treat only those patients likely to benefit from thrombolysis while protecting those patients unlikely to benefit from the risks associated with treatment.

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Abstract WP242: A Drill Down Analysis of Door-to-Needle Time of Acute Ischemic Stroke Patients Treated with Intravenous Tissue Plasminogen Activator

Stroke ◽

10.1161/str.44.suppl_1.awp242 ◽

2013 ◽

Vol 44 (suppl_1) ◽

Author(s):

Marija Lum ◽

Jon Schrock

Keyword(s):

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Plasminogen Activator ◽

Tissue Plasminogen Activator ◽

Symptom Onset ◽

Demographic Data ◽

Head Ct ◽

Intravenous Tissue Plasminogen Activator ◽

Tissue Plasminogen ◽

Iv Tpa

Background: Target stroke guidelines recommend a door-to-needle time (DNT) ≤60 minutes for acute ischemic stroke (AIS) patients treated with tissue plasminogen activator (tPA). Research has shown that <30% of patients achieve this goal. It is unclear how the timing of chest radiography (CXR) and electrocardiography (EKG) affect DNT. We studied all steps involved in the evaluation and treatment of AIS with IV tPA to look for causes of delay. Methods: A retrospective review of all AIS patients treated in the ED with IV tPA over a four year period was performed. Transferred patients were excluded. Times comparing intervals from door to head CT, CT result, EKG, CXR, and IV tPA treatment, were evaluated. Demographic data and length of symptom onset were recorded. Non-modifiable delays in treatment were recorded. Data are presented in minutes (min) as medians with interquartile range and χ 2 testing was used as appropriate. Results: A total of 79 AIS patients met inclusion criteria, with 22 (28%) receiving IV tPA ≤60 minutes. Treatment with tPA in ≤60 minutes was significantly greater if symptom onset was >90 minutes (p<0.05) and if the EKG was done after the head CT (p<0.05). There was a change in median CT times with those who received EKG before CT and those who did not, 23 min (15-36 min) and 17 min (10-24min), respectively. Patients who received a CXR before CT had a median CT time of 32 min (21-38min) compared to 19 min (13-27min) for patients who did not. Unavoidable delays related to trauma, intubation, or delayed familial consent occurred in 7 (9%) patients. Post-tPA hemorrhage occurred in 13 (16%) patients. Eight (10%) patients expired. Conclusion: Non-critical studies performed prior to head CT increase DNT. An EKG performed before the head CT is completed increased CT time by 6 minutes and a CXR obtained before the head CT increased CT time by 13 minutes. Physician urgency is also a critical factor in DNT and is diminished in patients who arrive soon after symptom onset. DNT ≤60 minutes for AIS patients are affected by the level of urgency and order of diagnostic studies. Current primary stroke center recommendations of an EKG and CXR within 45 minutes may result in delayed treatment if these studies are performed before the head CT.

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Abstract TP56: The Impact of Early Ischemic Changes on Head CT on Hemorrhagic Conversion and Outcomes in Patients With Acute Ischemic Stroke

Stroke ◽

10.1161/str.47.suppl_1.tp56 ◽

2016 ◽

Vol 47 (suppl_1) ◽

Author(s):

Ayaz Khawaja ◽

Karen Albright ◽

Angela Hays Shapshak ◽

Harn Shiue ◽

April Sisson ◽

...

Keyword(s):

Ischemic Stroke ◽

Hospital Mortality ◽

Acute Ischemic Stroke ◽

Functional Outcome ◽

Hemorrhagic Transformation ◽

Poor Functional Outcome ◽

Head Ct ◽

Increased Risk ◽

The Impact ◽

Iv Tpa

Background: Early ischemic changes (EIC) on head CT are associated with increased hemorrhagic transformation (HT) following treatment with TPA. We examined the associations between EIC, HT, and outcomes in patients treated and not treated with IV TPA. Methods: We conducted a retrospective review of consecutive acute ischemic stroke (AIS) patients presenting to our CSC from April 2014 to March 2015. Demographic and clinical data, including initial head CT findings (parenchymal hypodensity, loss of gray-white differentiation, sulcal effacement, hyperdense vessel) were collected. HT on repeat neuroimaging, poor functional outcome, as measured by a modified Rankin Scale (mRS) of 3-6, and in-hospital mortality were assessed. Results: A total of 679 patients were included (50.4% men). One hundred and eight patients (15.9%) received IV TPA. EIC were observed in 38.5% of untreated patients and 17.6% in IV TPA treated patients (p<0.0001). For patients treated with IV TPA, EIC was seen more frequently in patients with pre-stroke anticoagulant use (26.3% vs. 6.7%, p=0.010) and less frequently in patients with pre-stroke statin use (15.8% vs. 43.3%, p=0.025). A higher proportion of HT was observed in patients with EIC (12.8% vs. 6.8%, p=0.016 untreated, 36.8% vs. 14.6%, p=0.024 IV TPA) and with hyperdense artery sign (8.2% vs. 3.7%, p=0.022 untreated, 36.8% vs. 15.7%, p=0.035 IV TPA). For untreated patients, EIC was observed in a larger proportion of patients with an NIHSS>14 (14.8% vs. 9.6%, p=0.016), and discharge mRS 3-6 (53.6% vs. 44.5%, p=0.040). For patients treated with IV TPA, in-hospital mortality was more common in patients with EIC (31.6% vs. 10.0%, p=0.013). Conclusions: In untreated patients, EIC may serve as a harbinger for HT on repeat imaging and poor functional outcome at discharge, whereas in patients treated with IV TPA, it is associated with HT and in-hospital mortality. Patients with EIC may be at increased risk of HT and poor outcomes even without thrombolytics.

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Venous Outflow Profiles Are Linked to Cerebral Edema Formation at Noncontrast Head CT after Treatment in Acute Ischemic Stroke Regardless of Collateral Vessel Status at CT Angiography

Radiology ◽

10.1148/radiol.2021203651 ◽

2021 ◽

pp. 203651

Author(s):

Tobias D. Faizy ◽

Reza Kabiri ◽

Soren Christensen ◽

Michael Mlynash ◽

Gabriella Kuraitis ◽

...

Keyword(s):

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Ct Angiography ◽

Cerebral Edema ◽

Venous Outflow ◽

Collateral Vessel ◽

Edema Formation ◽

Head Ct

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Symptomatic Intracerebral Hemorrhage Complicating Intra-Arterial Mechanical Thrombectomy in Acute Ischemic Stroke

Open Access Macedonian Journal of Medical Sciences ◽

10.3889/oamjms.2020.4827 ◽

2020 ◽

Vol 8 (C) ◽

pp. 140-145

Author(s):

Muhammad Yunus Amran ◽

Ashari Bahar

Keyword(s):

Ischemic Stroke ◽

Intracerebral Hemorrhage ◽

Endovascular Treatment ◽

Ct Scan ◽

Acute Ischemic Stroke ◽

Mechanical Thrombectomy ◽

Left Ventricular Ejection ◽

Treatment Recommendation ◽

Head Ct ◽

Symptomatic Intracerebral Hemorrhage

BACKGROUND: Acute ischemic stroke (AIS) is the most common type of stroke. The endovascular treatment of AIS depends on stroke subtype, whether caused by large vessel occlusion (LVO) or not. We presented a case of AIS due to LVO that has complication in the form of symptomatic intracerebral hemorrhage (sICH) after an intra-arterial mechanical thrombectomy. CASE PRESENTATION: An 80-year-old woman was admitted to the emergency department with sudden onset left side weakness since <1 h before admission, when the patient had woke up in the morning. The patient had history of hypertension, diabetes mellitus, and dyslipidemia. She also had cardiac disorders in the form of non-valvular atrial fibrillation with 55% left ventricular ejection fraction (LVEF). Her blood pressure was 148/84 mmHg, heart rate was 65 beats/minute, respiratory rate was 17 times/min, and body temperature was 36.2°C. Glasgow coma scale (GCS) was E3V4M5; National Institutes of Health Stroke Scale (NIHSS) was 15. She had moderate aphasia. Head CT scan did not show any hyper- or hypodens areas and Alberta Stroke Program Early CT score was 10. RAPID automated CT perfusion using Quantitative Software showed that the mismatch volume was 192 ml and the mismatch ratio was 7.4. Endovascular therapy in the form of intra-arterial mechanical thrombectomy was performed, and blood flow in the right internal carotid artery (ICA) was restored with the score of Modified Thrombolysis in Cerebral Infarction (mTICI) was III. Follow-up non-contrast head CT scan was performed and revealed acute infarction with hemorrhagic transformation in the middle cerebral artery (MCA) territory. CONCLUSION: Early and accurate treatment of AIS is paramount. Endovascular treatment in the form of intra-arterial mechanical thrombectomy is the current treatment recommendation in LVO although there is a risk of symptomatic intracerebral hemorrhage, as in this case.

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