Perfusion CT in Patients with Acute Ischemic Stroke Treated with Intra-Arterial Thrombolysis: Predictive Value of Infarct Core Size on Clinical Outcome

Background : The clot burden score (CBS) is a scoring system used in acute ischemic stroke (AIS) to predict patient outcome and guide treatment decision. However, CBS is not routinely practiced in many institutions. This study aimed to investigate the feasibility of CBS as a relevant predictor of good clinical outcome in AIS cases. Methods: A retrospective data collection and review of AIS patients in a teaching hospital was done from June 2010 until June 2015. Patients were selected following the inclusion and exclusion criteria. These patients were followed up after 90 days of discharge. The Modified Rankin scale (mRS) was used to assess their outcome (functional status). Linear regression Spearman Rank correlation was performed between the CBS and mRS. The quality performance of the correlations was evaluated using Receiver operating characteristic (ROC) curves. Results: A total of 89 patients with AIS were analysed, 67.4% (n=60) male and 32.6% (n=29) female. Twenty-nine (29) patients (33.7%) had a CBS ?6, 6 patients (6.7%) had CBS <6, while 53 patients (59.6%) were deemed clot free. Ninety (90) days post insult, clinical assessment showed that 57 (67.6%) patients were functionally independent, 27 (30.3%) patients functionally dependent, and 5 (5.6%) patients were deceased. Data analysis reported a significant negative correlation (r= -0.611, p<0.001). ROC curves analysis showed an area under the curve of 0.81 at the cut-off point of 6.5. This showed that a CBS of more than 6 predicted a good mRS clinical outcome in AIS patients; with sensitivity of 98.2%, specificity of 53.1%, positive predictive value (PPV) of 76%, and negative predictive value (NPV) of 21%. Conclusion: CBS is a useful additional variable for the management of AIS cases, and should be incorporated into the routine radiological reporting for acute ischemic stroke (AIS) cases.

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Predictive value of time-variant color-coded multiphase CT angiography (mCTA) regarding clinical outcome of acute ischemic stroke: in comparison with conventional mCTA and CT perfusion

Acta Radiologica ◽

10.1177/0284185120981770 ◽

2020 ◽

pp. 028418512098177

Author(s):

Yu Lin ◽

Nannan Kang ◽

Jianghe Kang ◽

Shaomao Lv ◽

Jinan Wang

Keyword(s):

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Predictive Value ◽

Ct Perfusion ◽

Roc Curves ◽

Multivariate Logistic Regression Model ◽

Infarct Core ◽

Predictive Values ◽

Significant Difference ◽

Core Volume

Background Color-coded multiphase computed tomography angiography (mCTA) can provide time-variant blood flow information of collateral circulation for acute ischemic stroke (AIS). Purpose To compare the predictive values of color-coded mCTA, conventional mCTA, and CT perfusion (CTP) for the clinical outcomes of patients with AIS. Material and Methods Consecutive patients with anterior circulation AIS were retrospectively reviewed at our center. Baseline collateral scores of color-coded mCTA and conventional mCTA were assessed by a 6-point scale. The reliabilities between junior and senior observers were assessed by weighted Kappa coefficients. Receiver operating characteristic (ROC) curves and multivariate logistic regression model were applied to evaluate the predictive capabilities of color-coded mCTA and conventional mCTA scores, and CTP parameters (hypoperfusion and infarct core volume) for a favorable outcome of AIS. Results A total of 138 patients (including 70 cases of good outcomes) were included in our study. Patients with favorable prognoses were correlated with better collateral circulations on both color-coded and conventional mCTA, and smaller hypoperfusion and infarct core volume (all P < 0.05) on CTP. ROC curves revealed no significant difference between the predictive capability of color-coded and conventional mCTA ( P = 0.427). The predictive value of CTP parameters tended to be inferior to that of color-coded mCTA score (all P < 0.001). Both junior and senior observers had consistently excellent performances (κ = 0.89) when analyzing color-coded mCTA maps. Conclusion Color-coded mCTA provides prognostic information of patients with AIS equivalent to or better than that of conventional mCTA and CTP. Junior radiologists can reach high diagnostic accuracy when interpreting color-coded mCTA images.

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Abstract WMP18: CT Work-Up of Patients Suspected of Acute Ischemic Stroke: Perfusion-CT Adds Value Compared to Clinical Evaluation, Noncontrast Head CT and CT-Angiogram in Terms of Predicting Outcome

Stroke ◽

10.1161/str.44.suppl_1.awmp18 ◽

2013 ◽

Vol 44 (suppl_1) ◽

Author(s):

Guangming Zhu ◽

Patrik Michel ◽

Amin Aghaebrahim ◽

James T Patrie ◽

Wenjun Xin ◽

...

Keyword(s):

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Clinical Data ◽

Multivariate Regression ◽

Multivariate Regression Analysis ◽

Perfusion Ct ◽

Infarct Core ◽

Head Ct ◽

Ct Angiogram ◽

Work Up

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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The relationship of platelet-to-lymphocyte ratio with clinical outcome and final infarct core in acute ischemic stroke patients who have undergone endovascular therapy

Neurological Research ◽

10.1080/01616412.2016.1215030 ◽

2016 ◽

Vol 38 (9) ◽

pp. 759-765 ◽

Cited By ~ 19

Author(s):

Ozge Altintas ◽

Mehmet Ozgen Altintas ◽

Abdurrahman Tasal ◽

Okkes Taha Kucukdagli ◽

Talip Asil

Keyword(s):

Ischemic Stroke ◽

Clinical Outcome ◽

Acute Ischemic Stroke ◽

Endovascular Therapy ◽

Stroke Patients ◽

Platelet To Lymphocyte Ratio ◽

Infarct Core ◽

Lymphocyte Ratio ◽

Relationship Of ◽

The Relationship

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The Prognostic Value of CT Angiography and CT Perfusion in Acute Ischemic Stroke

Cerebrovascular Diseases ◽

10.1159/000441088 ◽

2015 ◽

Vol 40 (5-6) ◽

pp. 258-269 ◽

Cited By ~ 39

Author(s):

Tom van Seeters ◽

Geert Jan Biessels ◽

L. Jaap Kappelle ◽

Irene C. van der Schaaf ◽

Jan Willem Dankbaar ◽

...

Keyword(s):

Ischemic Stroke ◽

Clinical Outcome ◽

Acute Ischemic Stroke ◽

Ct Angiography ◽

Predictive Value ◽

Prognostic Value ◽

Ct Perfusion ◽

Patient Characteristics ◽

Poor Clinical Outcome ◽

Poor Outcome

Background: CT angiography (CTA) and CT perfusion (CTP) are important diagnostic tools in acute ischemic stroke. We investigated the prognostic value of CTA and CTP for clinical outcome and determined whether they have additional prognostic value over patient characteristics and non-contrast CT (NCCT). Methods: We included 1,374 patients with suspected acute ischemic stroke in the prospective multicenter Dutch acute stroke study. Sixty percent of the cohort was used for deriving the predictors and the remaining 40% for validating them. We calculated the predictive values of CTA and CTP predictors for poor clinical outcome (modified Rankin Scale score 3-6). Associations between CTA and CTP predictors and poor clinical outcome were assessed with odds ratios (OR). Multivariable logistic regression models were developed based on patient characteristics and NCCT predictors, and subsequently CTA and CTP predictors were added. The increase in area under the curve (AUC) value was determined to assess the additional prognostic value of CTA and CTP. Model validation was performed by assessing discrimination and calibration. Results: Poor outcome occurred in 501 patients (36.5%). Each of the evaluated CTA measures strongly predicted outcome in univariable analyses: the positive predictive value (PPV) was 59% for Alberta Stroke Program Early CT Score (ASPECTS) ≤7 on CTA source images (OR 3.3; 95% CI 2.3-4.8), 63% for presence of a proximal intracranial occlusion (OR 5.1; 95% CI 3.7-7.1), 66% for poor leptomeningeal collaterals (OR 4.3; 95% CI 2.8-6.6), and 58% for a >70% carotid or vertebrobasilar stenosis/occlusion (OR 3.2; 95% CI 2.2-4.6). The same applied to the CTP measures, as the PPVs were 65% for ASPECTS ≤7 on cerebral blood volume maps (OR 5.1; 95% CI 3.7-7.2) and 53% for ASPECTS ≤7 on mean transit time maps (OR 3.9; 95% CI 2.9-5.3). The prognostic model based on patient characteristics and NCCT measures was highly predictive for poor clinical outcome (AUC 0.84; 95% CI 0.81-0.86). Adding CTA and CTP predictors to this model did not improve the predictive value (AUC 0.85; 95% CI 0.83-0.88). In the validation cohort, the AUC values were 0.78 (95% CI 0.73-0.82) and 0.79 (95% CI 0.75-0.83), respectively. Calibration of the models was satisfactory. Conclusions: In patients with suspected acute ischemic stroke, admission CTA and CTP parameters are strong predictors of poor outcome and can be used to predict long-term clinical outcome. In multivariable prediction models, however, their additional prognostic value over patient characteristics and NCCT is limited in an unselected stroke population.

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Evaluation of the clot burden score (cbs) for acute ischemic stroke (ais) in intent-to-treat patients.

Journal Of Cardiovascular, Neurovascular & Stroke ◽

10.32896/cvns.11.11-15 ◽

2019 ◽

pp. 11-15

Author(s):

Sarah Yaziz ◽

Ahmad Sobri Muda ◽

Wan Asyraf Wan Zaidi ◽

Nik Azuan Nik Ismail

Keyword(s):

Ischemic Stroke ◽

Clinical Outcome ◽

Acute Ischemic Stroke ◽

Predictive Value ◽

Area Under The Curve ◽

Rank Correlation ◽

Treatment Decision ◽

Roc Curves ◽

Significant Negative Correlation ◽

Clot Burden

Background : The clot burden score (CBS) is a scoring system used in acute ischemic stroke (AIS) to predict patient outcome and guide treatment decision. However, CBS is not routinely practiced in many institutions. This study aimed to investigate the feasibility of CBS as a relevant predictor of good clinical outcome in AIS cases. Methods: A retrospective data collection and review of AIS patients in a teaching hospital was done from June 2010 until June 2015. Patients were selected following the inclusion and exclusion criteria. These patients were followed up after 90 days of discharge. The Modified Rankin scale (mRS) was used to assess their outcome (functional status). Linear regression Spearman Rank correlation was performed between the CBS and mRS. The quality performance of the correlations was evaluated using Receiver operating characteristic (ROC) curves. Results: A total of 89 patients with AIS were analysed, 67.4% (n=60) male and 32.6% (n=29) female. Twenty-nine (29) patients (33.7%) had a CBS ?6, 6 patients (6.7%) had CBS <6, while 53 patients (59.6%) were deemed clot free. Ninety (90) days post insult, clinical assessment showed that 57 (67.6%) patients were functionally independent, 27 (30.3%) patients functionally dependent, and 5 (5.6%) patients were deceased. Data analysis reported a significant negative correlation (r= -0.611, p<0.001). ROC curves analysis showed an area under the curve of 0.81 at the cut-off point of 6.5. This showed that a CBS of more than 6 predicted a good mRS clinical outcome in AIS patients; with sensitivity of 98.2%, specificity of 53.1%, positive predictive value (PPV) of 76%, and negative predictive value (NPV) of 21%. Conclusion: CBS is a useful additional variable for the management of AIS cases, and should be incorporated into the routine radiological reporting for acute ischemic stroke (AIS) cases.

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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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Association between Blood Urea Nitrogen-to-creatinine Ratio and Three-Month Outcome in Patients with Acute Ischemic Stroke

Current Neurovascular Research ◽

10.2174/1567202616666190412123705 ◽

2019 ◽

Vol 16 (2) ◽

pp. 166-172 ◽

Cited By ~ 1

Author(s):

Linghui Deng ◽

Changyi Wang ◽

Shi Qiu ◽

Haiyang Bian ◽

Lu Wang ◽

...

Keyword(s):

Logistic Regression ◽

Ischemic Stroke ◽

Clinical Outcome ◽

Acute Ischemic Stroke ◽

Blood Urea Nitrogen ◽

Univariate Analysis ◽

Density Lipoprotein ◽

Hydration Status ◽

Creatinine Ratio ◽

Urea Nitrogen

Background: Hydration status significantly affects the clinical outcome of acute ischemic stroke (AIS) patients. Blood urea nitrogen-to-creatinine ratio (BUN/Cr) is a biomarker of hydration status. However, it is not known whether there is a relationship between BUN/Cr and three-month outcome as assessed by the modified Rankin Scale (mRS) score in AIS patients. Methods: AIS patients admitted to West China Hospital from 2012 to 2016 were prospectively and consecutively enrolled and baseline data were collected. Poor clinical outcome was defined as three-month mRS > 2. Univariate and multivariate logistic regression analyses were performed to determine the relationship between BUN/Cr and three-month outcome. Confounding factors were identified by univariate analysis. Stratified logistic regression analysis was performed to identify effect modifiers. Results: A total of 1738 patients were included in the study. BUN/Cr showed a positive correlation with the three-month outcome (OR 1.02, 95% CI 1.00-1.03, p=0.04). However, after adjusting for potential confounders, the correlation was no longer significant (p=0.95). An interaction between BUN/Cr and high-density lipoprotein (HDL) was discovered (p=0.03), with a significant correlation between BUN/Cr and three-month outcome in patients with higher HDL (OR 1.03, 95% CI 1.00-1.07, p=0.04). Conclusion: Elevated BUN/Cr is associated with poor three-month outcome in AIS patients with high HDL levels.

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Efficacy of Mechanical Thrombectomy using Penumbra ACETM Aspiration Catheter Compared to Stent Retriever SolitaireTM FR in Patients with Acute Ischemic Stroke

Brain Sciences ◽

10.3390/brainsci11040504 ◽

2021 ◽

Vol 11 (4) ◽

pp. 504

Author(s):

Dalibor Sila ◽

Markus Lenski ◽

Maria Vojtková ◽

Mustafa Elgharbawy ◽

František Charvát ◽

...

Keyword(s):

Ischemic Stroke ◽

Clinical Outcome ◽

Acute Ischemic Stroke ◽

Clinical Outcomes ◽

Mechanical Thrombectomy ◽

Binary Logistic Regression ◽

Stent Retriever ◽

Good Clinical Outcome ◽

Significant Difference ◽

Aspiration Technique

Background: Mechanical thrombectomy is the standard therapy in patients with acute ischemic stroke (AIS). The primary aim of our study was to compare the procedural efficacy of the direct aspiration technique, using Penumbra ACETM aspiration catheter, and the stent retriever technique, with a SolitaireTM FR stent. Secondarily, we investigated treatment-dependent and treatment-independent factors that predict a good clinical outcome. Methods: We analyzed our series of mechanical thrombectomies using a SolitaireTM FR stent and a Penumbra ACETM catheter. The clinical and radiographic data of 76 patients were retrospectively reviewed. Using binary logistic regression, we looked for the predictors of a good clinical outcome. Results: In the Penumbra ACETM group we achieved significantly higher rates of complete vessel recanalization with lower device passage counts, shorter recanalization times, shorter procedure times and shorter fluoroscopy times (p < 0.001) compared to the SolitaireTM FR group. We observed no significant difference in good clinical outcomes (52.4% vs. 56.4%, p = 0.756). Predictors of a good clinical outcome were lower initial NIHSS scores, pial arterial collateralization on admission head CT angiography scan, shorter recanalization times and device passage counts. Conclusions: The aspiration technique using Penumbra ACETM catheter is comparable to the stent retriever technique with SolitaireTM FR regarding clinical outcomes.

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Impact of Early Blood Pressure Lowering in Patients Presenting with Acute Ischemic Stroke

Current Cardiology Reports ◽

10.1007/s11886-021-01497-0 ◽

2021 ◽

Vol 23 (6) ◽

Author(s):

A. Maud ◽

G. J. Rodriguez ◽

A. Vellipuram ◽

F. Sheriff ◽

M. Ghatali ◽

...

Keyword(s):

Blood Pressure ◽

Ischemic Stroke ◽

Clinical Outcome ◽

Acute Ischemic Stroke ◽

Negative Impact ◽

Systemic Blood Pressure ◽

Hemodynamic Response ◽

Collateral Flow ◽

Early Management ◽

Ischemic Tissue

Abstract Purpose of Review In this review article we will discuss the acute hypertensive response in the context of acute ischemic stroke and present the latest evidence-based concepts of the significance and management of the hemodynamic response in acute ischemic stroke. Recent Findings Acute hypertensive response is considered a common hemodynamic physiologic response in the early setting of an acute ischemic stroke. The significance of the acute hypertensive response is not entirely well understood. However, in certain types of acute ischemic strokes, the systemic elevation of the blood pressure helps to maintain the collateral blood flow in the penumbral ischemic tissue. The magnitude of the elevation of the systemic blood pressure that contributes to the maintenance of the collateral flow is not well established. The overcorrection of this physiologic hemodynamic response before an effective vessel recanalization takes place can carry a negative impact in the final clinical outcome. The significance of the persistence of the acute hypertensive response after an effective vessel recanalization is poorly understood, and it may negatively affect the final outcome due to reperfusion injury. Summary Acute hypertensive response is considered a common hemodynamic reaction of the cardiovascular system in the context of an acute ischemic stroke. The reaction is particularly common in acute brain embolic occlusion of large intracranial vessels. Its early management before, during, and immediately after arterial reperfusion has a repercussion in the final fate of the ischemic tissue and the clinical outcome.

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