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Gohla G, Schwarz R, Bier G, Estler A, Bongers MN, Ditt H, Fritz J, Kemmling A, Ernemann U, Horger M. A novel fully automated method for measuring ASPECTS to improve stroke diagnosis: Comparison to traditional ASPECTS. J Neuroimaging 2024; 34:145-151. [PMID: 37807097 DOI: 10.1111/jon.13159] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2023] [Revised: 09/20/2023] [Accepted: 09/24/2023] [Indexed: 10/10/2023] Open
Abstract
BACKGROUND AND PURPOSE To compare the accuracy of subjective Alberta Stroke Program Early CT Score (sASPECTS) evaluation and that of an automated prototype software (aASPECTS) on nonenhanced CT (NECT) in patients with early anterior territory stroke and controls using side-to-side quantification of hypoattenuated brain areas. METHODS We retrospectively analyzed the NECT scans of 42 consecutive patients with ischemic stroke before reperfusion and 42 controls using first sASPECTS and subsequently aASPECTS. We assessed the differences in Alberta Stroke Program Early CT Score (ASPECTS) and calculated the sensitivity and specificity of NECT with CT perfusion, whereas cerebral blood volume (CBV) served as the reference standard for brain infarction. RESULTS The clot was located in the middle cerebral artery (MCA) in 47.6% of cases and the internal carotid artery (ICA) in 28.6% of cases. Ten cases presented combined ICA and MCA occlusions. The stroke was right sided in 52.4% of cases and left sided in 47.6%. Reader-based NECT analysis yielded a median sASPECTS of 10. The median CBV-based ASPECTS was 7. Compared to the area of decreased CBV, sASPECTS yielded a sensitivity of 12.5% and specificity of 86.8%. The software prototype (aASPECTS) yielded an overall sensitivity of 65.5% and a specificity of 92.2%. The interreader agreement for ASPECTS evaluation of admission NECT and follow-up CT was almost perfect (κ = .93). The interreader agreement of the CBV color map evaluation was substantial (κ = .77). CONCLUSIONS aASPECTS of NECT can outperform sASPECTS for stroke detection.
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Affiliation(s)
- Georg Gohla
- Department of Diagnostic and Interventional Neuroradiology, Eberhard Karls-University Tübingen, Tübingen, Germany
| | - Ricarda Schwarz
- Department of Diagnostic and Interventional Radiology, Eberhard Karls-University Tübingen, Tübingen, Germany
| | - Georg Bier
- Department of Diagnostic and Interventional Neuroradiology, Eberhard Karls-University Tübingen, Tübingen, Germany
- Radiology Salzstraße, Muenster, Germany
| | - Arne Estler
- Department of Diagnostic and Interventional Neuroradiology, Eberhard Karls-University Tübingen, Tübingen, Germany
| | - Malte N Bongers
- Department of Diagnostic and Interventional Radiology, Eberhard Karls-University Tübingen, Tübingen, Germany
| | - Hendrik Ditt
- Siemens AG Healthcare; Imaging & Therapy Systems Computed Tomography & Radiation Oncology, Forchheim, Germany
| | - Jan Fritz
- Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - André Kemmling
- Institute of Neuroradiology, Philipps University of Marburg, Marburg, Germany
| | - Ulrike Ernemann
- Department of Diagnostic and Interventional Neuroradiology, Eberhard Karls-University Tübingen, Tübingen, Germany
| | - Marius Horger
- Department of Diagnostic and Interventional Radiology, Eberhard Karls-University Tübingen, Tübingen, Germany
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Abstract
Wake-up stroke (WUS) or ischemic stroke occurring during sleep accounts for 14%-29.6% of all ischemic strokes. Management of WUS is complicated by its narrow therapeutic time window and attributable risk factors, which can affect the safety and efficacy of administering intravenous (IV) tissue plasminogen activator (t-PA). This manuscript will review risk factors of WUS, with a focus on obstructive sleep apnea, potential mechanisms of WUS, and evaluate studies assessing safety and efficacy of IV t-PA treatment in WUS patients guided by neuroimaging to estimate time of symptom onset. The authors used PubMed (1966 to March 2018) to search for the term "Wake-Up Stroke" cross-referenced with "pathophysiology," ''pathogenesis," "pathology," "magnetic resonance imaging," "obstructive sleep apnea," or "treatment." English language Papers were reviewed. Also reviewed were pertinent papers from the reference list of the above-matched manuscripts. Studies that focused only on acute Strokes with known-onset of symptoms were not reviewed. Literature showed several potential risk factors associated with increased risk of WUS. Although the onset of WUS is unknown, a few studies investigated the potential benefit of magnetic resonance imaging (MRI) in estimating the age of onset which encouraged conducting clinical trials assessing the efficacy of MRI-guided thrombolytic therapy in WUS.
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3
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Computer-Aided Detection of Hyperacute Stroke Based on Relative Radiomic Patterns in Computed Tomography. APPLIED SCIENCES-BASEL 2019. [DOI: 10.3390/app9081668] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Ischemic stroke is one of the leading causes of disability and death. To achieve timely assessments, a computer-aided diagnosis (CAD) system was proposed to perform early recognition of hyperacute ischemic stroke based on non-contrast computed tomography (NCCT). In total, 26 patients with hyperacute ischemic stroke (with onset <6 h previous) and 56 normal controls composed the image database. For each NCCT slice, textural features were extracted from Ranklet-transformed images which had enhanced local contrast. Textural differences between the two sides of an image were calculated and combined in a machine learning classifier to detect stroke areas. The proposed CAD system using Ranklet features achieved significantly higher accuracy (81% vs. 71%), specificity (90% vs. 79%), and area under the curve (Az) (0.81 vs. 0.73) than conventional textural features. Diagnostic suggestions provided by the CAD system are fast and promising and could be useful in the pipeline of hyperacute ischemic stroke assessments.
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Dambinova SA, Aliev KT, Bondarenko EV, Ponomarev GV, Skoromets AA, Skoromets AP, Skoromets TA, Smolko DG, Shumilina MV. [The biomarkers of cerebral ischemia as a new method for the validation of the efficacy of cytoprotective therapy]. Zh Nevrol Psikhiatr Im S S Korsakova 2017. [PMID: 28638033 DOI: 10.17116/jnevro20171175162-67] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
AIM To study blood plasma concentrations of NR2-peptide in patients with ischemic stroke (IS) to assess its diagnostic value as a biomarker of cerebral ischemia and determine the dynamics of the biomarker during treatment with cortexin. MATERIAL AND METHODS One hundred and twenty patients, aged from 18 to 70 years, including 36 with transient ischemic attack (TIA) and 84 with IS in the carotid territory (n=70) and vertebral/basilar territory with the Wallenberg-Zakharchenko syndrome (n=14), were enrolled. The National Institute of Health Stroke scale (NIHSS) was used to assess neurological status. Blood plasma concentration of NR2-peptide was measured in all patients at admission and after treatment. All laboratory results were compared with neuroimaging (MRI, CT) data. RESULTS Concentrations of NR2-peptide detected in all patients were higher than in controls (>1.5 ng/ml), p<0.0001. The direct correlation between NR2-peptide (from 3.38 ng/ml to 15.6 ng/ml) and ischemic lesion (from few to 80 mm) was observed. A decrease in NR2-peptide concentration (from 8.5 to 5,.9 ng/ml, p<0.0001) was noted in patients treated with cortexin after 10-day treatment course. CONCLUSION NR2-peptide blood assay is a reliable hemotest of brain ischemia. Cortexin has a sufficient therapeutic efficacy.
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Affiliation(s)
- S A Dambinova
- Pavlov First St. Petersburg State Medical University, St. Petersburg, Russia
| | - K T Aliev
- Pavlov First St. Petersburg State Medical University, St. Petersburg, Russia
| | - E V Bondarenko
- Pavlov First St. Petersburg State Medical University, St. Petersburg, Russia
| | - G V Ponomarev
- Pavlov First St. Petersburg State Medical University, St. Petersburg, Russia
| | - A A Skoromets
- Pavlov First St. Petersburg State Medical University, St. Petersburg, Russia
| | - A P Skoromets
- Pavlov First St. Petersburg State Medical University, St. Petersburg, Russia
| | - T A Skoromets
- Pavlov First St. Petersburg State Medical University, St. Petersburg, Russia
| | - D G Smolko
- Pavlov First St. Petersburg State Medical University, St. Petersburg, Russia
| | - M V Shumilina
- Pavlov First St. Petersburg State Medical University, St. Petersburg, Russia
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5
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von Kummer R, Dzialowski I. Imaging of cerebral ischemic edema and neuronal death. Neuroradiology 2017; 59:545-553. [PMID: 28540400 DOI: 10.1007/s00234-017-1847-6] [Citation(s) in RCA: 68] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2017] [Accepted: 05/03/2017] [Indexed: 10/19/2022]
Abstract
PURPOSE In acute cerebral ischemia, the assessment of irreversible injury is crucial for treatment decisions and the patient's prognosis. There is still uncertainty how imaging can safely differentiate reversible from irreversible ischemic brain tissue in the acute phase of stroke. METHODS We have searched PubMed and Google Scholar for experimental and clinical papers describing the pathology and pathophysiology of cerebral ischemia under controlled conditions. RESULTS Within the first 6 h of stroke onset, ischemic cell injury is subtle and hard to recognize under the microscope. Functional impairment is obvious, but can be induced by ischemic blood flow allowing recovery with flow restoration. The critical cerebral blood flow (CBF) threshold for irreversible injury is ~15 ml/100 g × min. Below this threshold, ischemic brain tissue takes up water in case of any residual capillary flow (ionic edema). Because tissue water content is linearly related to X-ray attenuation, computed tomography (CT) can detect and measure ionic edema and, thus, determine ischemic brain infarction. In contrast, diffusion-weighted magnetic resonance imaging (DWI) detects cytotoxic edema that develops at higher thresholds of ischemic CBF and is thus highly sensitive for milder levels of brain ischemia, but not specific for irreversible brain tissue injury. CONCLUSION CT and MRI are complimentary in the detection of ischemic stroke pathology and are valuable for treatment decisions.
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Affiliation(s)
- Rüdiger von Kummer
- Institut für Diagnostische und Interventionelle Neuroradiologie, Universitätsklinikum Carl Gustav Carus, Fetscherstr. 74, 01307, Dresden, Germany.
| | - Imanuel Dzialowski
- Elblandklinikum Meißen, Neurologische Rehabilitationsklinik Großenhain, Nassauweg 7, 01662, Meißen, Germany
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Gomolka RS, Chrzan RM, Urbanik A, Kazmierski R, Grzanka AD, Nowinski WL. Quantification of image contrast of infarcts on computed tomography scans. Neuroradiol J 2017; 30:15-22. [PMID: 28059673 DOI: 10.1177/1971400916678226] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Introduction Accurate identification of infarcts in non-contrast computed tomography (NC-CT) scans of the brain is fundamental in the diagnosis and management of patients with stroke. Quantification of image contrast properties at the boundaries of ischemic infarct regions in NC-CT can contribute to a more precise manual or automatic delineation of these regions. Here we explore these properties quantitatively. Methods We retrospectively investigated 519 NC-CT studies of 425 patients with clinically confirmed ischemic strokes. The average and standard deviation (SD) of patients' age was 67.5 ± 12.4 years and the average(median)±SD time from symptoms onset to NC-CT examination was 27.4(12)±35.7 h. For every scan with an ischemic lesion identified by experts, the image contrast of the lesion vs. normal surrounding parenchyma was calculated as a difference of mean Hounsfield Unit (HU) of 1-5 consecutive voxels (the contrast window width) belonging to the lesion and to the parenchyma. This contrast was calculated at each single voxel of ischemic lesion boundaries (previously delineated by the experts) in horizontal and vertical directions in each image. The distributions of obtained horizontal, vertical and both contrasts combined were calculated among all 519 NC-CTs. Results The highest applicative contrast window width was identified as 5 voxels. The ischemic infarcts were found to be characterized by 6.60 HU, 8.28 HU and 7.55 HU mean values for distributions of horizontal, vertical and combined contrasts. Approximately 40-50% of the infarct boundary voxels were found to refer to the image contrast below 5 HU. Conclusion Low image contrast of ischemic lesions prevents accurate delineation of the infarcts in NC-CT.
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Affiliation(s)
- R S Gomolka
- 1 The Faculty of Electronics and Information Technology, Warsaw University of Technology, Warsaw, Poland
| | - R M Chrzan
- 2 Department of Radiology, Jagiellonian University, The Cracow University Hospital, Krakow, Poland
| | - A Urbanik
- 2 Department of Radiology, Jagiellonian University, The Cracow University Hospital, Krakow, Poland
| | - R Kazmierski
- 3 Department of Neurology and Cerebrovascular Diseases, Poznan University of Medical Sciences, Poznan, Poland
| | - A D Grzanka
- 1 The Faculty of Electronics and Information Technology, Warsaw University of Technology, Warsaw, Poland
| | - W L Nowinski
- 4 John Paul II Center for Virtual Anatomy and Surgical Simulation, Cardinal Stefan Wyszynski, Warsaw, Poland
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Malhotra K, Liebeskind DS. Imaging in Endovascular Stroke Trials. J Neuroimaging 2016; 25:517-27. [PMID: 26179500 DOI: 10.1111/jon.12272] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2015] [Accepted: 05/21/2015] [Indexed: 01/19/2023] Open
Abstract
Ischemic stroke remains a leading cause of death and disability worldwide. Various endovascular trials have addressed clinical outcomes without elucidating the impact of imaging studies in patient selection. The success of recent endovascular trials was bolstered by the use of advanced imaging techniques for optimal selection of reperfusion candidates. This seminal juncture in the history of stroke trials warrants further consideration on the use of imaging to guide future refinements in the treatment of acute stroke. In this article, we systematically review the imaging methodology and key facets used in all published endovascular stroke trials to date, discuss the success of recent trials using latest advanced imaging techniques and focus on the importance of imaging studies for future patient selection.
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Affiliation(s)
| | - David S Liebeskind
- Neurovascular Imaging Research Core and the UCLA Stroke Center, Los Angeles, CA
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8
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Diagnostic accuracy of whole-brain CT perfusion in the detection of acute infratentorial infarctions. Neuroradiology 2016; 58:1077-1085. [DOI: 10.1007/s00234-016-1743-5] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2016] [Accepted: 08/17/2016] [Indexed: 10/21/2022]
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9
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Gomolka RS, Chrzan RM, Urbanik A, Nowinski WL. A Quantitative Method Using Head Noncontrast CT Scans to Detect Hyperacute Nonvisible Ischemic Changes in Patients With Stroke. J Neuroimaging 2016; 26:581-587. [PMID: 27238914 DOI: 10.1111/jon.12363] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2016] [Accepted: 04/20/2016] [Indexed: 11/28/2022] Open
Abstract
PURPOSE Because clinical evaluation of noncontrast computed tomography (CT) has a poor sensitivity in the evaluation of acute ischemic stroke, computer-aided diagnosis may be able to facilitate the performance. Recently, we introduced a computational method for the detection and localization of visible infarcts. Herein, we aimed to evaluate and extend a previous method, the Stroke Imaging Marker (SIM), to localize nonvisible hyperacute ischemia. MATERIALS AND METHODS On the basis of the SIM and its components-the ratio of percentile differences in subranges of Hounsfield Unit (HU) distribution (P-ratio), ratio of voxels count in ranges of brain CT intensity, median HU attenuation value-the infarct localization was performed in 140 early and follow-up scans of 70 patients. In none of the early scans was the infarct visible to a radiologist or an experienced stroke neuroradiologist. The infarcted hemisphere detection rate (HDR) and sensitivity of infarct localization were measured by overlapping the region of detected tissue in the initial scan, with the gold standard set for the fully visible stroke in the follow-up scan. RESULTS The best performance of the algorithm was found for the P-ratio including seven percentile subranges within the range of 35th-75th percentile. The modified SIM provided a 76% ischemic HDR and 54% sensitivity in spatial localization of hyperacute ischemia (68% among properly detected infarct sides). CONCLUSION The improved SIM is a dedicated and potentially useful tool for hyperacute nonvisible brain infarct detection from CT scans and may contribute to reduction of image-to-needle time in patients eligible for revascularization therapy.
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Affiliation(s)
- Ryszard S Gomolka
- Faculty of Electronics and Information Technology, Warsaw University of Technology, Warsaw, Poland. .,Biomedical Imaging Lab, Agency for Science Technology and Research, Singapore.
| | - Robert M Chrzan
- Department of Radiology, Jagiellonian University, The Cracow University Hospital, Kraków, Poland
| | - Andrzej Urbanik
- Department of Radiology, Jagiellonian University, The Cracow University Hospital, Kraków, Poland
| | - Wieslaw L Nowinski
- Department of Radiology, University of Washington, University District Building, Seattle, WA.,John Paul II Center for Virtual Anatomy and Surgical Simulation, Cardinal Stefan Wyszyński University, Warsaw, Poland
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10
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Menzilcioglu MS, Mete A, Ünverdi Z. Effectiveness of CT Computed Tomography Perfusion in Diagnostics of Acute Ischemic Stroke. Pol J Radiol 2015; 80:549-54. [PMID: 26740827 PMCID: PMC4692568 DOI: 10.12659/pjr.895468] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2015] [Accepted: 07/29/2015] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Stroke is the third most common death reason after the cardiovascular disorders and cancer. Cerebral ischemia is a pathology that stems from a decrease in cerebral perfusion. Computed Tomography Perfusion (CTP) is an additional method to the conventional Computed Tomography (CT) that could be performed by using developed softwares, in a short period of time and with a low risk of complications. CTP not only allows early detection of cerebral ischemia but also gives valuable information on the ischemic penumbra which are very important in early diagnosis and treatment. Acute Ischemic Stroke (AIS) can be cured by trombolytic treapy within 3-6 hours after symptom onset. Since rapid screening and accurate diagnosis increase the success of the treatment, the role of neuroradiology in acute ischemia diagnostics and treatment has become more important. Our aim was to define CT skills in early diagnosis of AIS, to define its contribution to patient's diagnosis and treatment and to define its importance regarding patient's prognosis. MATERIAL/METHODS We included 42 patients that presented to the emergency service and neurology outpatient clinic with the symptoms of acute cerebral incidence. RESULTS In our study, we found that Cerebral Blood Flow (CBF) is 90.91% sensitive and 100% specific in examining ischemia. CONCLUSIONS Tissue hemodynamic data, especially sensitivity and specificity rates, which cannot be acquired by conventional CT and MRI methods, can be acquired by the CTP method.
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Affiliation(s)
| | - Ahmet Mete
- Department of Radiology, Gaziantep University, Gaziantep, Turkey
| | - Zeyni Ünverdi
- Department of Radiology, Gaziantep University, Gaziantep, Turkey
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von Kummer R, Dzialowski I, Gerber J. Therapeutic efficacy of brain imaging in acute ischemic stroke patients. J Neuroradiol 2015; 42:47-54. [DOI: 10.1016/j.neurad.2014.10.004] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2014] [Accepted: 10/10/2014] [Indexed: 10/24/2022]
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12
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Stoel BC, Marquering HA, Staring M, Beenen LF, Slump CH, Roos YB, Majoie CB. Automated brain computed tomographic densitometry of early ischemic changes in acute stroke. J Med Imaging (Bellingham) 2015; 2:014004. [PMID: 26158082 PMCID: PMC4478844 DOI: 10.1117/1.jmi.2.1.014004] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2014] [Accepted: 03/03/2015] [Indexed: 11/14/2022] Open
Abstract
The Alberta Stroke Program Early CT score (ASPECTS) scoring method is frequently used for quantifying early ischemic changes (EICs) in patients with acute ischemic stroke in clinical studies. Varying interobserver agreement has been reported, however, with limited agreement. Therefore, our goal was to develop and evaluate an automated brain densitometric method. It divides CT scans of the brain into ASPECTS regions using atlas-based segmentation. EICs are quantified by comparing the brain density between contralateral sides. This method was optimized and validated using CT data from 10 and 63 patients, respectively. The automated method was validated against manual ASPECTS, stroke severity at baseline and clinical outcome after 7 to 10 days (NIH Stroke Scale, NIHSS) and 3 months (modified Rankin Scale). Manual and automated ASPECTS showed similar and statistically significant correlations with baseline NIHSS ([Formula: see text] and [Formula: see text], respectively) and with follow-up mRS ([Formula: see text] and [Formula: see text]), except for the follow-up NIHSS. Agreement between automated and consensus ASPECTS reading was similar to the interobserver agreement of manual ASPECTS (differences [Formula: see text] point in 73% of cases). The automated ASPECTS method could, therefore, be used as a supplementary tool to assist manual scoring.
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Affiliation(s)
- Berend C. Stoel
- Leiden University Medical Center, Division of Image Processing, Department of Radiology, Albinusdreef 2 Leiden 2333 AA, The Netherlands
| | - Henk A. Marquering
- Academic Medical Center, Department of Radiology, Amsterdam, The Netherlands
- Academic Medical Center, Department of Biomedical Engineering and Physics, Amsterdam, The Netherlands
| | - Marius Staring
- Leiden University Medical Center, Division of Image Processing, Department of Radiology, Albinusdreef 2 Leiden 2333 AA, The Netherlands
| | - Ludo F. Beenen
- Academic Medical Center, Department of Radiology, Amsterdam, The Netherlands
| | - Cornelis H. Slump
- University of Twente, MIRA Institute for Biomedical Technology and Technical Medicine, Enschede, The Netherlands
| | - Yvo B. Roos
- Academic Medical Center, Department of Neurology, Amsterdam, The Netherlands
| | - Charles B. Majoie
- Academic Medical Center, Department of Radiology, Amsterdam, The Netherlands
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McKean D, Kudari M, Landells M, Grant D, Johnson S, López de Heredia L, Yanny S, Woo EK. Validating a threshold of ocular gaze deviation for the prediction of acute ischaemic stroke. Clin Radiol 2014; 69:1244-8. [PMID: 25172206 DOI: 10.1016/j.crad.2014.07.011] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2014] [Revised: 05/01/2014] [Accepted: 07/09/2014] [Indexed: 10/24/2022]
Abstract
AIM To determine a threshold at which the degree of ocular gaze deviation (OGD) on axial imaging is highly specific for the prediction of acute ischaemic stroke. MATERIALS AND METHODS A retrospective analysis of 517 patients who had received MRI with diffusion-weighted imaging (DWI) for suspected acute stroke was performed. The degree of OGD was measured in all patients and the presence and location of infarction determined. The difference in OGD between groups was compared using the independent t-test for normally distributed data and the Mann-Whitney test for non-normal data. The sensitivity and specificity for degrees of OGD in the prediction of acute infarction was calculated using a receiver operating curve (ROC) analysis. RESULTS The imaging of 448 patients meeting the inclusion criteria was reviewed. Acute infarct was demonstrated in 34.8% (n=156). There was a significant difference in the degree of OGD between patients with an acute infarct and those without evidence of acute ischaemia (p<0.001). ROC curve analysis for OGD demonstrated area under the curve (AUC) = 0.619 with increasing degrees of OGD more specific for acute infarct. OGD >11.95° had a sensitivity of 17% and specificity of 95.9% in predicting acute infarction. CONCLUSION Significant OGD>11.95° has a high specificity for acute infarct. This threshold may provide a helpful additional sign in the detection of subtle acute infarct, particularly on axial CT brain imaging.
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Affiliation(s)
- D McKean
- Oxford University Hospitals National Health Service Trust, Radiology Department, John Radcliffe Hospital, Headley Way, Oxford, UK.
| | - M Kudari
- Oxford University Hospitals National Health Service Trust, Radiology Department, John Radcliffe Hospital, Headley Way, Oxford, UK
| | - M Landells
- New College, University of Oxford, Holywell St, Oxford OX1 3BN, UK
| | - D Grant
- Oxford University Hospitals National Health Service Trust, Radiology Department, John Radcliffe Hospital, Headley Way, Oxford, UK
| | - S Johnson
- Oxford University Hospitals National Health Service Trust, Radiology Department, John Radcliffe Hospital, Headley Way, Oxford, UK
| | - L López de Heredia
- Buckinghamshire Healthcare National Health Service Trust, Radiology Department, Aylesbury, UK
| | - S Yanny
- Buckinghamshire Healthcare National Health Service Trust, Radiology Department, Aylesbury, UK
| | - E K Woo
- Buckinghamshire Healthcare National Health Service Trust, Radiology Department, Aylesbury, UK
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Abstract
Neuroimaging has expanded beyond its traditional diagnostic role and become a critical tool in the evaluation and management of stroke. The objectives of imaging include prompt accurate diagnosis, treatment triage, prognosis prediction, and secondary preventative precautions. While capitalizing on the latest treatment options and expanding upon the "time is brain" doctrine, the ultimate goal of imaging is to maximize the number of treated patients and improve the outcome of one the most costly and morbid disease. A broad overview of comprehensive multimodal stroke imaging is presented here to affirm its utilization.
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Affiliation(s)
- Elizabeth Tong
- Neuroradiology Division, Department of Radiology, University of Virginia, Charlottesville, Virginia
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15
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Wintermark M, Sanelli PC, Albers GW, Bello J, Derdeyn C, Hetts SW, Johnson MH, Kidwell C, Lev MH, Liebeskind DS, Rowley H, Schaefer PW, Sunshine JL, Zaharchuk G, Meltzer CC. Imaging recommendations for acute stroke and transient ischemic attack patients: A joint statement by the American Society of Neuroradiology, the American College of Radiology, and the Society of NeuroInterventional Surgery. AJNR Am J Neuroradiol 2013; 34:E117-27. [PMID: 23907247 DOI: 10.3174/ajnr.a3690] [Citation(s) in RCA: 83] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
SUMMARY Stroke is a leading cause of death and disability worldwide. Imaging plays a critical role in evaluating patients suspected of acute stroke and transient ischemic attack, especially before initiating treatment. Over the past few decades, major advances have occurred in stroke imaging and treatment, including Food and Drug Administration approval of recanalization therapies for the treatment of acute ischemic stroke. A wide variety of imaging techniques has become available to assess vascular lesions and brain tissue status in acute stroke patients. However, the practical challenge for physicians is to understand the multiple facets of these imaging techniques, including which imaging techniques to implement and how to optimally use them, given available resources at their local institution. Important considerations include constraints of time, cost, access to imaging modalities, preferences of treating physicians, availability of expertise, and availability of endovascular therapy. The choice of which imaging techniques to employ is impacted by both the time urgency for evaluation of patients and the complexity of the literature on acute stroke imaging. Ideally, imaging algorithms should incorporate techniques that provide optimal benefit for improved patient outcomes without delaying treatment.
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Affiliation(s)
- M Wintermark
- Departments of Radiology, Neurology, Neurosurgery, and Biomedical Engineering, University of Virginia, Charlottesville, Virginia
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Oliveira-Filho J, Martins SCO, Pontes-Neto OM, Longo A, Evaristo EF, Carvalho JJFD, Fernandes JG, Zétola VF, Gagliardi RJ, Vedolin L, Freitas GRD. Guidelines for acute ischemic stroke treatment: part I. ARQUIVOS DE NEURO-PSIQUIATRIA 2013; 70:621-9. [PMID: 22899035 DOI: 10.1590/s0004-282x2012000800012] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Affiliation(s)
- Jamary Oliveira-Filho
- Rua Reitor Miguel Calmon s/n; Instituto de Ciências da Saúde / sala 455; 40110-100 Salvador BA - Brasil
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Wardlaw JM, von Kummer R, Carpenter T, Parsons M, Lindley RI, Cohen G, Murray V, Kobayashi A, Peeters A, Chappell F, Sandercock PAG. Protocol for the perfusion and angiography imaging sub-study of the Third International Stroke Trial (IST-3) of alteplase treatment within six-hours of acute ischemic stroke. Int J Stroke 2013; 10:956-68. [PMID: 23336348 DOI: 10.1111/j.1747-4949.2012.00946.x] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
RATIONALE Intravenous thrombolysis with recombinant tissue Plasminogen Activator improves outcomes in patients treated early after stroke but at the risk of causing intracranial hemorrhage. Restricting recombinant tissue Plasminogen Activator use to patients with evidence of still salvageable tissue, or with definite arterial occlusion, might help reduce risk, increase benefit and identify patients for treatment at late time windows. AIMS To determine if perfusion or angiographic imaging with computed tomography or magnetic resonance help identify patients who are more likely to benefit from recombinant tissue Plasminogen Activator in the context of a large multicenter randomized trial of recombinant tissue Plasminogen Activator given within six-hours of onset of acute ischemic stroke, the Third International Stroke Trial. DESIGN Third International Stroke Trial is a prospective multicenter randomized controlled trial testing recombinant tissue Plasminogen Activator (0·9 mg/kg, maximum dose 90 mg) started up to six-hours after onset of acute ischemic stroke, in patients with no clear indication for or contraindication to recombinant tissue Plasminogen Activator. Brain imaging (computed tomography or magnetic resonance) was mandatory pre-randomization to exclude hemorrhage. Scans were read centrally, blinded to treatment and clinical information. In centers where perfusion and/or angiography imaging were used routinely in stroke, these images were also collected centrally, processed and assessed using validated visual scores and computational measures. STUDY OUTCOMES The primary outcome in Third International Stroke Trial is alive and independent (Oxford Handicap Score 0-2) at 6 months; secondary outcomes are symptomatic and fatal intracranial hemorrhage, early and late death. The perfusion and angiography study additionally will examine interactions between recombinant tissue Plasminogen Activator and clinical outcomes, infarct growth and recanalization in the presence or absence of perfusion lesions and/or arterial occlusion at presentation. The study is registered ISRCTN25765518.
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Affiliation(s)
- Joanna M Wardlaw
- Clinical Neurosciences, University of Edinburgh, Edinburgh, UK.,Neuroimaging Sciences, University of Edinburgh, Edinburgh, UK
| | | | | | - Mark Parsons
- Department of Neurology, John Hunter Hospital, Newcastle, NSW, Australia
| | - Richard I Lindley
- Discipline of Medicine, University of Sydney and the George Institute, Sydney, NSW, Australia
| | - Geoff Cohen
- Clinical Neurosciences, University of Edinburgh, Edinburgh, UK
| | | | - Adam Kobayashi
- 2nd Department of Neurology, Institute of Psychiatry and Neurology, Warsaw, Poland
| | - Andre Peeters
- Department of Neurology, UCL St Luc, Brussels, Belgium
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18
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Hurley MC, Soltanolkotabi M, Ansari S. Neuroimaging in acute stroke: choosing the right patient for neurointervention. Tech Vasc Interv Radiol 2012; 15:19-32. [PMID: 22464299 DOI: 10.1053/j.tvir.2011.12.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Although the non-contrast computed tomography head continues as the sole mandatory imaging technique before intravenous thrombolysis, the increased availability of advanced infarct/penumbral imaging techniques and confidence in their use have led many to adopt them into routine practice--most particularly before intra-arterial interventions. Computed tomography versus magnetic resonance-based routes to imaging the cerebral vasculature, cell death, and parenchymal perfusion have differing advantages in terms of speed, availability, exposures to contrast and radiation, sensitivity, and resolution. Continued refinement and future developments, such as the ability to quantitate perfusion, promise to lead to tailored treatment protocols that respect the individual variations in anatomy, physiology, and pathology. This should lead both to an extension of treatment to patients currently excluded by rigid time windows and the avoidance of futile therapies and their associated morbidities.
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Affiliation(s)
- Michael C Hurley
- Department of Radiology, Feinberg School of Medicine, Northwestern University, Chicago, IL 60611, USA.
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19
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Dambinova SA, Bettermann K, Glynn T, Tews M, Olson D, Weissman JD, Sowell RL. Diagnostic potential of the NMDA receptor peptide assay for acute ischemic stroke. PLoS One 2012; 7:e42362. [PMID: 22848761 PMCID: PMC3407099 DOI: 10.1371/journal.pone.0042362] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2012] [Accepted: 07/04/2012] [Indexed: 01/26/2023] Open
Abstract
BACKGROUND The acute assessment of patients with suspected ischemic stroke remains challenging. The use of brain biomarker assays may improve the early diagnosis of ischemic stroke. The main goal of the study was to evaluate whether the NR2 peptide, a product of the proteolytic degradation of N-methyl-D-aspartate (NMDA) receptors, can differentiate acute ischemic stroke (IS) from stroke mimics and persons with vascular risk factors/healthy controls. A possible correlation between biomarker values and lesion sizes was investigated as the secondary objective. METHODS AND FINDINGS A total of 192 patients with suspected stroke who presented within 72 h of symptom onset were prospectively enrolled. The final diagnosis was determined based on clinical observations and radiological findings. Additionally gender- and age-matched healthy controls (n = 52) and persons with controlled vascular risk factors (n = 48) were recruited to compare NR2 peptide levels. Blinded plasma was assayed by rapid magnetic particles (MP) ELISA for NR2 peptide within 30 min and results for different groups compared using univariate and multivariate statistical analyses. There was a clinical diagnosis of IS in 101 of 192 (53%) and non-stroke in 91 (47%) subjects. The non-stroke group included presented with acute stroke symptoms who had no stroke (n = 71) and stroke mimics (n = 20). The highest NR2 peptide elevations where found in patients with IS that peaked at 12 h following symptom onset. When the biomarker cut off was set at 1.0 ug/L, this resulted in a sensitivity of 92% and a specificity of 96% to detect IS. A moderate correlation (r(s) = 0.73) between NR2 peptide values and acute ischemic cortical lesions (<200 mL) was found. CONCLUSIONS This study suggests that the NR2 peptide may be a brain specific biomarker to diagnose acute IS and may allow the differentiation of IS from stroke mimics and controls. Additional larger scale clinical validation studies are required.
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Affiliation(s)
- Svetlana A Dambinova
- WellStar College of Health and Human Services, Kennesaw State University, Kennesaw, Georgia, United States of America.
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20
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Amar AP. Brain and vascular imaging of acute stroke. World Neurosurg 2012; 76:S3-8. [PMID: 22182269 DOI: 10.1016/j.wneu.2011.07.002] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2011] [Revised: 06/07/2011] [Accepted: 07/06/2011] [Indexed: 11/25/2022]
Abstract
Contemporary imaging technologies permit the rapid and accurate assessment of the acute stroke patient. These studies form the underpinning of all therapeutic approaches. Although unenhanced computed tomography remains the principal diagnostic examination to exclude hemorrhagic stroke, multimodal computed tomography and magnetic resonance imaging can be use to assess cerebral perfusion and may reveal the ischemic penumbra, thus leading to better patient selection for intravenous or intra-arterial reperfusion strategies.
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Affiliation(s)
- Arun Paul Amar
- Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California, USA.
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21
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Abstract
The goal of stroke imaging is to appropriately select patients for different types of therapeutic management in order to optimize outcome and minimize potential complications. To accomplish this, the radiologist has to evaluate each case and tailor an imaging protocol to fit the patient's needs and best answer the clinical question. This review outlines the routinely used, current neuroimaging techniques and their role in the evaluation of the acute stroke patient. The ability of computed tomography and magnetic resonance imaging to adequately evaluate the infarcted brain parenchyma, the cerebral vasculature, and the ischemic, but potentially viable tissue, often referred to as the "ischemic penumbra," is compared The authors outline an imaging algorithm that has been employed at their institution, and briefly review endovascular therapies that can be used in specific patients for stroke treatment.
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Affiliation(s)
- Mara M Kunst
- Section of Neuroradiology, Department of Radiology, Harvard Medical School, Massachusetts General Hospital, 55 Fruit Street, Boston, MA, USA.
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22
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Huisa BN, Raman R, Ernstrom K, Tafreshi G, Stemer A, Meyer BC, Hemmen T. Alberta Stroke Program Early CT Score (ASPECTS) in patients with wake-up stroke. J Stroke Cerebrovasc Dis 2010; 19:475-9. [PMID: 20719536 DOI: 10.1016/j.jstrokecerebrovasdis.2010.03.003] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2010] [Revised: 03/15/2010] [Accepted: 03/30/2010] [Indexed: 11/28/2022] Open
Abstract
One-quarter of ischemic strokes occur during sleep, and affected patients are excluded from thrombolytic therapy because of an unknown time of stroke onset. It has been suggested that early ischemic changes detected on computed tomography (CT) are similar in patients with acute stroke and patients who recently awoke with stroke. We compared head CT scans using the Alberta Stroke Program Early CT Score (ASPECTS) in patients who were likely to suffer their stroke during sleep (awoke group) and a control group of patients with stroke of known onset time. Patients were recruited from a prospectively collected acute stroke database. The awoke group was defined as all ischemic stroke patients who were "last seen normal" more than 4 hours ago, arrived between 4 a.m. and 10 a.m., and underwent head CT within 15 hours of the time last seen normal. The control group was randomly selected from patients who underwent head CT within 4 hours of stroke onset. The ASPECTS evaluations were performed by investigators blinded to patient group and time of onset. A modified Rankin Scale (mRS) score was available in 15 awoke patients and 46 control patients at 90 days after stroke. Twenty-eight awoke patients and 68 control patients had suitable imaging for the ASPECTS. Baseline demographic characteristics and risk factors were similar in the 2 groups. The dichotomized ASPECTS analysis (≤7 vs 8-10) showed no significant differences between the groups. ASPECTS was 8-10 in 89.3% the awoke group and 95.6% in the control group (P=.353). There was a trend toward higher 90-day mRS score (0-1) in the awoke group versus controls (73% vs 45%; P=.079). Initial ASPECTS was similar in patients with wake-up stroke and those with 4 hours of symptoms. This suggests that a subset of wake-up stroke patients might be suitable for thrombolytic therapy.
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Affiliation(s)
- Branko N Huisa
- Department of Neurosciences, University of California San Diego, San Diego, California 92103-8466, USA.
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23
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Latchaw RE, Alberts MJ, Lev MH, Connors JJ, Harbaugh RE, Higashida RT, Hobson R, Kidwell CS, Koroshetz WJ, Mathews V, Villablanca P, Warach S, Walters B. Recommendations for imaging of acute ischemic stroke: a scientific statement from the American Heart Association. Stroke 2009; 40:3646-78. [PMID: 19797189 DOI: 10.1161/strokeaha.108.192616] [Citation(s) in RCA: 291] [Impact Index Per Article: 19.4] [Reference Citation Analysis] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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Barrett KM, Levine JM, Johnston KC. DIAGNOSIS OF STROKE AND STROKE MIMICS IN THE EMERGENCY SETTING. Continuum (Minneap Minn) 2008. [DOI: 10.1212/01.con.0000275638.07451.ae] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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25
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Ozdemir O, Leung A, Bussiére M, Hachinski V, Pelz D. Hyperdense Internal Carotid Artery Sign. Stroke 2008; 39:2011-6. [DOI: 10.1161/strokeaha.107.505230] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Ozcan Ozdemir
- From the Department of Neurological Sciences (O.O., V.H.), the Department of Diagnostic Radiology and Nuclear Medicine (A.L., D.M.P.), and the Department of Clinical Neurological Sciences, Department of Diagnostic Radiology and Nuclear Medicine (B.M.), London Health Science Centre, University of Western Ontario, London, ON
| | - Andrew Leung
- From the Department of Neurological Sciences (O.O., V.H.), the Department of Diagnostic Radiology and Nuclear Medicine (A.L., D.M.P.), and the Department of Clinical Neurological Sciences, Department of Diagnostic Radiology and Nuclear Medicine (B.M.), London Health Science Centre, University of Western Ontario, London, ON
| | - Miguel Bussiére
- From the Department of Neurological Sciences (O.O., V.H.), the Department of Diagnostic Radiology and Nuclear Medicine (A.L., D.M.P.), and the Department of Clinical Neurological Sciences, Department of Diagnostic Radiology and Nuclear Medicine (B.M.), London Health Science Centre, University of Western Ontario, London, ON
| | - Vladimir Hachinski
- From the Department of Neurological Sciences (O.O., V.H.), the Department of Diagnostic Radiology and Nuclear Medicine (A.L., D.M.P.), and the Department of Clinical Neurological Sciences, Department of Diagnostic Radiology and Nuclear Medicine (B.M.), London Health Science Centre, University of Western Ontario, London, ON
| | - David Pelz
- From the Department of Neurological Sciences (O.O., V.H.), the Department of Diagnostic Radiology and Nuclear Medicine (A.L., D.M.P.), and the Department of Clinical Neurological Sciences, Department of Diagnostic Radiology and Nuclear Medicine (B.M.), London Health Science Centre, University of Western Ontario, London, ON
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26
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Lövblad KO, Altrichter S, Viallon M, Sztajzel R, Delavelle J, Vargas MI, El-Koussy M, Federspiel A, Sekoranja L. Neuro-imaging of cerebral ischemic stroke. J Neuroradiol 2008; 35:197-209. [PMID: 18329713 DOI: 10.1016/j.neurad.2008.01.002] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Major progress has recently been made in the neuro-imaging of stroke as a result of improvements in imaging hardware and software. Imaging may be based on either magnetic resonance imaging (MRI) or computed tomography (CT) techniques. Imaging should provide information on the entire vascular cervical and intracranial network, from the aortic arch to the circle of Willis. Equally, it should also give information on the viability of brain tissue and brain hemodynamics. CT has the advantage in the detection of acute hemorrhage whereas MRI offers more accurate pathophysiological information in the follow-up of patients.
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Affiliation(s)
- K O Lövblad
- Unité de neuroradiologie, service de radiologie, DISIM, hôpitaux universitaires de Genève, 24, rue Micheli-du-Crest, 1211 Genève 4, Switzerland.
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27
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Langer RD, Neidl van Gorkom K, Al Kaabi HO, Torab F, Czechowski J, Nagi M, Ashish GM. Comparison of two imaging protocols for acute stroke: unenhanced cranial CT versus a multimodality cranial CT protocol with perfusion imaging. ACTA ACUST UNITED AC 2008; 51:532-7. [PMID: 17958687 DOI: 10.1111/j.1440-1673.2007.01901.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
The aim of the study was to validate a multimodality cranial computed tomography (CCT) protocol for patients with acute stroke in the United Arab Emirates as a basic imaging procedure for a stroke unit. Therefore, a comparative study was conducted between two groups: retrospective, historical group 1 with early unenhanced CCT and prospective group 2 undergoing a multimodality CCT protocol. Follow-up unenhanced CCT>48 h served as gold standard in both groups. Group 1: Early unenhanced CCT of 50 patients were evaluated retrospectively, using Alberta Stroke Program Early CT Score, and compared with the definite infarction on follow-up CCT. Group 2: 50 patients underwent multimodality CCT (unenhanced CCT, perfusion studies: cerebral blood flow, cerebral blood volume, mean transit time and CT angiography)<8 h after clinical onset and follow-up studies. Modified National Institute of Health Stroke Scale was used clinically in both groups. Group 1 showed 38 men, 12 women, clinical onset 2-8 h before CCT and modified National Institute of Health Stroke Scale 0-28. Group 2 included 38 men, 12 women, onset 3-8 h before CCT, modified National Institute of Health Stroke Scale 0-28. Sensitivity was 58.3% in group 1 and 84.2% in group 2. Computed tomography angiography detected nine intracranial occlusions/stenoses. The higher sensitivity of the multimodality CCT protocol justifies its use as a basic diagnostic tool for the set-up of a first-stroke unit in the United Arab Emirates.
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Affiliation(s)
- R D Langer
- Department of Radiology, Faculty of Medicine and Health Sciences, UAE University, and Department of Clinical Imaging, Al Ain Hospital, United Arab Emirates.
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28
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29
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Aviv RI, Mandelcorn J, Chakraborty S, Gladstone D, Malham S, Tomlinson G, Fox AJ, Symons S. Alberta Stroke Program Early CT Scoring of CT perfusion in early stroke visualization and assessment. AJNR Am J Neuroradiol 2007; 28:1975-80. [PMID: 17921237 DOI: 10.3174/ajnr.a0689] [Citation(s) in RCA: 114] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Qualitative CT perfusion (CTP) assessment by using the Alberta Stroke Program Early CT Score (ASPECTS) allows rapid calculation of infarct extent for middle cerebral artery infarcts. Published thresholds exist for noncontrast CT (NCCT) ASPECTS, which may distinguish outcome/complication risk, but early ischemic signs are difficult to detect. We hypothesized that different ASPECTS thresholds exist for CTP parameters versus NCCT and that these may be superior at predicting clinical and radiologic outcome in the acute setting. MATERIALS AND METHODS Thirty-six baseline acute stroke NCCT and CTP studies within 3 hours of symptoms were blindly reviewed by 3 neuroradiologists, and ASPECTS were assigned. Treatment response was defined as major neurologic improvement when a > or =8-point National Institutes of Health Stroke Scale improvement at 24 hours occurred. Follow-up NCCT ASPECTS and 90-day modified Rankin score (mRS) were radiologic and clinical reference standards. Receiver operating characteristic curves derived optimal thresholds for outcome. RESULTS Cerebral blood volume and NCCT ASPECTS had similar radiologic correlations (0.6 and 0.5, respectively) and best predicted infarct size in the absence of major neurologic improvement. A NCCT ASPECT threshold of 7 and a cerebral blood volume threshold of 8 discriminated patients with poor follow-up scans (P < .0002 and P = .0001) and mRS < or =2 (P = .001 and P < .001). Only cerebral blood volume predicted major neurologic improvement (P = .02). Interobserver agreement was substantial (intraclass correlation coefficient, 0.69). Cerebral blood volume ASPECTS sensitivity, specificity, positive predictive value, and negative predictive value for clinical outcome were 60%, 100%, 100%, and 45%, respectively. No patients with cerebral blood volume ASPECTS <8 achieved good clinical outcome. CONCLUSION Cerebral blood volume ASPECTS is equivalent to NCCT for predicting radiologic outcome but may have an additional benefit in predicting patients with major neurologic improvement.
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Affiliation(s)
- R I Aviv
- Division of Neuroradiology, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.
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30
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Kloska SP, Dittrich R, Fischer T, Nabavi DG, Fischbach R, Seidensticker P, Osada N, Ringelstein EB, Heindel W. Perfusion CT in acute stroke: prediction of vessel recanalization and clinical outcome in intravenous thrombolytic therapy. Eur Radiol 2007; 17:2491-8. [PMID: 17549483 DOI: 10.1007/s00330-007-0696-9] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2007] [Revised: 04/27/2007] [Accepted: 05/11/2007] [Indexed: 10/23/2022]
Abstract
This study evaluated perfusion computed tomography (PCT) for the prediction of vessel recanalization and clinical outcome in patients undergoing intravenous thrombolysis. Thirty-nine patients with acute ischemic stroke of the middle cerebral artery territory underwent intravenous thrombolysis within 3 h of symptom onset. They all had non-enhanced CT (NECT), PCT, and CT angiography (CTA) before treatment. The Alberta Stroke Program Early Computed Tomography (ASPECT) score was applied to NECT and PCT maps to assess the extent of ischemia. CTA was assessed for the site of vessel occlusion. The National Institute of Health Stroke Scale (NIHSS) score was used for initial clinical assessment. Three-month clinical outcome was assessed using the modified Rankin scale. Vessel recanalization was determined by follow-up ultrasound. Of the PCT maps, a cerebral blood volume (CBV) ASPECT score of >6 versus < or =6 was the best predictor for clinical outcome (odds ratio, 31.43; 95% confidence interval, 3.41-289.58; P < 0.002), and was superior to NIHSS, NECT and CTA. No significant differences in ASPECT scores were found for the prediction of vessel recanalization. ASPECT score applied to PCT maps in acute stroke patients predicts the clinical outcome of intravenous thrombolysis and is superior to both early NECT and clinical parameters.
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Affiliation(s)
- Stephan P Kloska
- Department of Clinical Radiology, University of Münster, Albert-Schweitzer-Str 33, 48149, Münster, Germany.
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31
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Adams HP, del Zoppo G, Alberts MJ, Bhatt DL, Brass L, Furlan A, Grubb RL, Higashida RT, Jauch EC, Kidwell C, Lyden PD, Morgenstern LB, Qureshi AI, Rosenwasser RH, Scott PA, Wijdicks EFM. Guidelines for the Early Management of Adults With Ischemic Stroke. Circulation 2007; 115:e478-534. [PMID: 17515473 DOI: 10.1161/circulationaha.107.181486] [Citation(s) in RCA: 657] [Impact Index Per Article: 38.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Purpose—
Our goal is to provide an overview of the current evidence about components of the evaluation and treatment of adults with acute ischemic stroke. The intended audience is physicians and other emergency healthcare providers who treat patients within the first 48 hours after stroke. In addition, information for healthcare policy makers is included.
Methods—
Members of the panel were appointed by the American Heart Association Stroke Council’s Scientific Statement Oversight Committee and represented different areas of expertise. The panel reviewed the relevant literature with an emphasis on reports published since 2003 and used the American Heart Association Stroke Council’s Levels of Evidence grading algorithm to rate the evidence and to make recommendations. After approval of the statement by the panel, it underwent peer review and approval by the American Heart Association Science Advisory and Coordinating Committee. It is intended that this guideline be fully updated in 3 years.
Results—
Management of patients with acute ischemic stroke remains multifaceted and includes several aspects of care that have not been tested in clinical trials. This statement includes recommendations for management from the first contact by emergency medical services personnel through initial admission to the hospital. Intravenous administration of recombinant tissue plasminogen activator remains the most beneficial proven intervention for emergency treatment of stroke. Several interventions, including intra-arterial administration of thrombolytic agents and mechanical interventions, show promise. Because many of the recommendations are based on limited data, additional research on treatment of acute ischemic stroke is needed.
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32
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Adams HP, del Zoppo G, Alberts MJ, Bhatt DL, Brass L, Furlan A, Grubb RL, Higashida RT, Jauch EC, Kidwell C, Lyden PD, Morgenstern LB, Qureshi AI, Rosenwasser RH, Scott PA, Wijdicks EFM. Guidelines for the early management of adults with ischemic stroke: a guideline from the American Heart Association/American Stroke Association Stroke Council, Clinical Cardiology Council, Cardiovascular Radiology and Intervention Council, and the Atherosclerotic Peripheral Vascular Disease and Quality of Care Outcomes in Research Interdisciplinary Working Groups: the American Academy of Neurology affirms the value of this guideline as an educational tool for neurologists. Stroke 2007; 38:1655-711. [PMID: 17431204 DOI: 10.1161/strokeaha.107.181486] [Citation(s) in RCA: 1511] [Impact Index Per Article: 88.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
PURPOSE Our goal is to provide an overview of the current evidence about components of the evaluation and treatment of adults with acute ischemic stroke. The intended audience is physicians and other emergency healthcare providers who treat patients within the first 48 hours after stroke. In addition, information for healthcare policy makers is included. METHODS Members of the panel were appointed by the American Heart Association Stroke Council's Scientific Statement Oversight Committee and represented different areas of expertise. The panel reviewed the relevant literature with an emphasis on reports published since 2003 and used the American Heart Association Stroke Council's Levels of Evidence grading algorithm to rate the evidence and to make recommendations. After approval of the statement by the panel, it underwent peer review and approval by the American Heart Association Science Advisory and Coordinating Committee. It is intended that this guideline be fully updated in 3 years. RESULTS Management of patients with acute ischemic stroke remains multifaceted and includes several aspects of care that have not been tested in clinical trials. This statement includes recommendations for management from the first contact by emergency medical services personnel through initial admission to the hospital. Intravenous administration of recombinant tissue plasminogen activator remains the most beneficial proven intervention for emergency treatment of stroke. Several interventions, including intra-arterial administration of thrombolytic agents and mechanical interventions, show promise. Because many of the recommendations are based on limited data, additional research on treatment of acute ischemic stroke is needed.
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Kloska SP, Fischer T, Nabavi DG, Dittrich R, Ditt H, Klotz E, Fischbach R, Ringelstein EB, Heindel W. Color-coded perfused blood volume imaging using multidetector CT: initial results of whole-brain perfusion analysis in acute cerebral ischemia. Eur Radiol 2007; 17:2352-8. [PMID: 17318605 DOI: 10.1007/s00330-007-0580-7] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2006] [Revised: 11/05/2006] [Accepted: 01/08/2007] [Indexed: 10/23/2022]
Abstract
Computed tomography (CT) is still the primary imaging modality following acute stroke. To evaluate a prototype of software for the calculation of color-coded whole-brain perfused blood volume (PBV) images from CT angiography (CTA) and nonenhanced CT (NECT) scans, we studied 14 patients with suspected acute ischemia of the anterior cerebral circulation. PBV calculations were performed retrospectively. The detection rate of ischemic changes in the PBV images was compared with NECT. The volume of ischemic changes in PBV was correlated with the infarct volume on follow-up examination taking potential vessel recanalization into account. PBV demonstrated ischemic changes in 12/12 patients with proven infarction and was superior to NECT (8/12) in the detection of early ischemia. Moreover, PBV demonstrated the best correlation coefficient with the follow-up infarct volume (Pearson's R = 0.957; P = 0.003) for patients with proven recanalization of initially occluded cerebral arteries. In summary, PBV appears to be more accurate in the detection of early infarction compared to NECT and mainly visualizes the irreversibly damaged ischemic tissue.
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Affiliation(s)
- Stephan P Kloska
- Department of Clinical Radiology, University of Muenster, Albert-Schweitzer-Str. 33, 48149 Muenster, Germany.
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Masdeu JC, Irimia P, Asenbaum S, Bogousslavsky J, Brainin M, Chabriat H, Herholz K, Markus HS, Martínez-Vila E, Niederkorn K, Schellinger PD, Seitz RJ. EFNS guideline on neuroimaging in acute stroke. Report of an EFNS task force. Eur J Neurol 2006; 13:1271-83. [PMID: 17116208 DOI: 10.1111/j.1468-1331.2006.01507.x] [Citation(s) in RCA: 77] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Neuroimaging techniques are necessary for the evaluation of stroke, one of the leading causes of death and neurological impairment in developed countries. The multiplicity of techniques available has increased the complexity of decision making for physicians. We performed a comprehensive review of the literature in English for the period 1965-2005 and critically assessed the relevant publications. The members of the panel reviewed and corrected an initial draft, until a consensus was reached on recommendations stratified according to the European Federation of Neurological Societies (EFNS) criteria. Non-contrast computed tomography (CT) scan is the established imaging procedure for the initial evaluation of stroke patients. However, magnetic resonance imaging (MRI) has a higher sensitivity than CT for the demonstration of infarcted or ischemic areas and depicts well acute and chronic intracerebral hemorrhage. Perfusion and diffusion MRI together with MR angiography (MRA) are very helpful for the acute evaluation of patients with ischemic stroke. MRI and MRA are the recommended techniques for screening cerebral aneurysms and for the diagnosis of cerebral venous thrombosis and arterial dissection. For the non-invasive study of extracranial vessels, MRA is less portable and more expensive than ultrasonography but it has higher sensitivity and specificity for carotid stenosis. Transcranial Doppler is very useful for monitoring arterial reperfusion after thrombolysis, for the diagnosis of intracranial stenosis and of right-to-left shunts, and for monitoring vasospasm after subarachnoid hemorrhage. Currently, single photon emission computed tomography and positron emission tomography have a more limited role in the evaluation of the acute stroke patient.
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Affiliation(s)
- J C Masdeu
- Department of Neurology and Neurosurgery, University of Navarra, Pamplona, Spain.
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Naggara O, Hamon M, Oppenheim C, Rodrigo S, Leclerc X, Pruvo JP, Meder JF. [Imaging of acute stroke]. JOURNAL DES MALADIES VASCULAIRES 2006; 31:252-9. [PMID: 17202978 DOI: 10.1016/s0398-0499(06)76624-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/13/2023]
Abstract
Acute stroke patients represent an important diagnostic and therapeutic challenge. Patients with brain damage in the ischemic, but not yet infarcted, phase have the greatest potential for recovery. Here we review the most commonly employed diagnostic tools that are currently used before stroke therapy. While computed tomography is pertinent to differentiate ischemic from hemorrhagic stroke, this technique cannot be used as an etiological screening too. The ischemic origin of symptoms can be confirmed with magnetic resonance imaging which also contributes to for therapeutic decision making, prognosis assessment and etiological screening.
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Affiliation(s)
- O Naggara
- Département d'Imagerie Morphologique et Fonctionnelle, Centre Hospitalier Sainte-Anne, CHU Paris, 1 rue Cabanis, 75674 Paris Cedex 14
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Wang KW, Chang WN, Ho JT, Chang HW, Lui CC, Cheng MH, Hung KS, Wang HC, Tsai NW, Sun TK, Lu CH. Factors predictive of fatality in massive middle cerebral artery territory infarction and clinical experience of decompressive hemicraniectomy. Eur J Neurol 2006; 13:765-71. [PMID: 16834708 DOI: 10.1111/j.1468-1331.2006.01365.x] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
To determine the factors predictive of fatality in massive middle cerebral artery (MCA) territory infarction and outcome of decompressive hemicraniectomy, 62 patients who were retrospectively verified with first event massive MCA infarctions were enrolled in this study. Amongst them, 21 received decompressive hemicraniectomy during hospitalization. Clinical data between early and late hemicraniectomy groups were also compared. Significant deterioration occurred in 40 cases, 21 of whom received decompressive hemicraniectomy. The other 19 received conservative treatment. The mortality rate of these 40 cases between decompressive hemicraniectomy and conservative treatment was 29% (six of 21) and 42% (eight of 19), respectively. Factors that predicted fatalities in our massive MCA infarction patients with or without decompressive hemicraniectomy were total scores of baseline GCS at the time of admission, associated with coronary artery diseases, and significant deterioration during hospitalization. This study confirms the lifesaving procedure of hemicraniectomy that prevents death in patients deteriorating because of cerebral edema after infarction, although it may produce severe disability with an unacceptably poor quality of life in survival. Despite high mortality and morbidity, decompressive hemicraniectomy to prevent cerebral herniation when significant deterioration is demonstrated are essential for maximizing the potential for survival.
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Affiliation(s)
- K-W Wang
- Department of Neurosurgery, Chang Gung Memorial Hospital-Kaohsiung Medical Centre, Kaohsiung, Taiwan
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Todo K, Moriwaki H, Saito K, Tanaka M, Oe H, Naritomi H. Early CT Findings in Unknown-Onset and Wake-Up Strokes. Cerebrovasc Dis 2006; 21:367-71. [PMID: 16490949 DOI: 10.1159/000091545] [Citation(s) in RCA: 70] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2005] [Accepted: 11/17/2005] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Approximately one quarter of the acute ischemic stroke patients notice the event at awakening. Such patients with stroke at awakening are usually excluded from thrombolysis, since the time of stroke onset cannot be definitely identified. We compared the hyperacute CT findings of awakening stroke patients with those of stroke patients with known onset to assess whether the time of stroke onset is shortly before awakening. METHODS Subjects were cardioembolic stroke patients who were consecutively admitted to our department within 3 h after the recognition of stroke during the period between January 2000 and March 2003. The patients were classified into three groups: group A with stroke of known onset, group B with stroke at awakening, and group C with stroke of unknown onset due to lack of a witness. The clinical and CT findings in each group were compared. RESULTS A total of 81 patients fulfilled the study criteria. There were 46 patients in group A, 17 patients in group B, and 18 patients in group C. There was no significant difference in CT findings between groups A and B. In group C, however, definite hypodense areas were more commonly found than in group A (56 vs. 0%; p<0.001) or in group B (56 vs. 11%; p=0.012). CONCLUSION Based on our CT findings, stroke at awakening seems to be developing shortly before in a large subset of patients, making them potential candidates for acute stroke therapies.
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Affiliation(s)
- Kenichi Todo
- Cerebrovascular Division, Department of Medicine, National Cardiovascular Center, Osaka, Japan.
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Kidwell CS, Hsia AW. Imaging of the brain and cerebral vasculature in patients with suspected stroke: advantages and disadvantages of CT and MRI. Curr Neurol Neurosci Rep 2006; 6:9-16. [PMID: 16469265 DOI: 10.1007/s11910-996-0003-1] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Although neuroimaging remains the foundation for the diagnosis of cerebrovascular disease, ongoing technologic advances have now opened up new frontiers for stroke evaluation and treatment. Neuroimaging studies can provide crucial information regarding tissue injury (size, location, and degree of reversibility of ischemic injury as well as presence of hemorrhage), vessel status (site and severity of stenoses and occlusions), and cerebral perfusion (size, location, and severity of hypoperfusion). This information can be combined to identify patients with salvageable penumbral tissue who may benefit most from acute therapies. The multimodal combinations of advanced imaging techniques, particularly in the realm of CT and MRI, have emerged as the most promising noninvasive approaches to acute stroke evaluation.
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Affiliation(s)
- Chelsea S Kidwell
- WHC Stroke Center, 110 Irving Street NW, East Building Room 6126, Washington, DC 20010, USA.
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Scharf J, Brockmann MA, Daffertshofer M, Diepers M, Neumaier-Probst E, Weiss C, Paschke T, Groden C. Improvement of Sensitivity and Interrater Reliability to Detect Acute Stroke by Dynamic Perfusion Computed Tomography and Computed Tomography Angiography. J Comput Assist Tomogr 2006; 30:105-10. [PMID: 16365583 DOI: 10.1097/01.rct.0000187417.15321.ca] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To assess the benefits of additional computed tomography perfusion (CTP) and computed tomography angiography (CTA) on the detection of early stroke, vessel occlusion, estimated infarct size, and interrater reliability. METHODS Sixty-seven consecutive patients underwent nonenhanced computed tomography (CT) imaging, CTA, and CTP. The final diagnosis of stroke was made from follow-up neuroimaging. A first diagnosis was made on-site by the physician on duty. Three experienced neuroradiologists blinded to follow-up findings analyzed the data set off-line, evaluated CT for signs of acute stroke, and subsequently evaluated CTP and CTA for infarction-related perfusion deficits and vessel abnormalities. RESULTS Computed tomography perfusion and CTA increased the time from CT start to diagnosis from 2 minutes to 10 minutes. Sensitivity to detect acute stroke increased significantly in all investigators from 0.46-0.58 to 0.79-0.90 compared with CT (<0.005). The interrater weighted kappa value increased from 0.35 to 0.64. Estimation of infarct size was not improved. CONCLUSION Computed tomography perfusion and CTA provide an effective add-on to standard CT in acute stroke imaging by significantly increasing the sensitivity and reliability of infarct detection.
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Affiliation(s)
- Johann Scharf
- Department of Neuroradiology, University Hospital Mannheim, Mannheim, Germany.
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Abstract
The hyperdense artery sign on noncontrast head CT is thought to be one of the earliest and most useful signs of intra-arterial clot and probable (clinical) stroke. It should be evaluated in the context of the clinical scenario. Rigorous criteria should be applied in order to reduce potential false positives. The hyperdense middle cerebral artery sign is the most studied version and correlates with patient outcome. Our data suggest that the density on noncontrast head CT is not likely to universally represent in situ clot.
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Affiliation(s)
- Mark E Mullins
- Division of Neuroradiology, Massachusetts General Hospital, Boston 02114, USA.
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Oppenheim C, Naggara O, Arquizan C, Brami-Zylberberg F, Mas JL, Meder JF, Frédy D. Imagerie de l’ischémie cérébrale dans les premières heures : IRM. ACTA ACUST UNITED AC 2005; 86:1069-78. [PMID: 16227903 DOI: 10.1016/s0221-0363(05)81495-7] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
The advent of new MR techniques such as perfusion and diffusion weighted imaging has revolutionized diagnostic imaging in stroke. In some institutions, MRI is used as the sole screening imaging technique for acute stroke patients. In this document, the authors will review the MR pattern of acute ischemic arterial stroke, highlight the usefulness of MRI for the identification of acute hematomas and stroke like episodes, present the potential use of MRI in the management of acute stroke patients, especially when thrombolysis is contemplated, and discuss the role of MRI for imaging transient ischemic attack.
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Affiliation(s)
- C Oppenheim
- Département d'Imagerie Morphologique et Fonctionnelle, Centre Hospitalier Sainte-Anne, 1, rue Cabanis, 75014 Paris.
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Abstract
Stroke is a common cause of death and disability throughout the world. Acute neurologic deficits due to ischemic injury deserve rapid recognition and diagnosis in order to provide effective therapy. Intravenous tissue plasminogen activator (t-PA) provided to carefully selected patients that can be treated within 3 hours of stroke onset results in improved outcome in these patients. Intra-arterial administration of t-PA within a 6-hour window is performed at several academic centers in patients with middle cerebral and other intracranial artery occlusions based on results of one randomized clinical trial and numerous case reports. Although acute therapy of ischemic stroke has received much attention since the approval of intravenous t-PA, only a small percentage of individuals suffering a stroke actually receive t-PA. This article will review the optimal management of the acute stroke patient and discuss thrombolytic clinical trials that have been completed as well as those that are in progress.
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Affiliation(s)
- Kathleen M Burger
- Department of Neurology, Mount Sinai School of Medicine, New York, NY 10029, USA.
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Schellinger PD. The Evolving Role of Advanced MR Imaging as a Management Tool for Adult Ischemic Stroke: A Western-European Perspective. Neuroimaging Clin N Am 2005; 15:245-58, ix. [PMID: 16198938 DOI: 10.1016/j.nic.2005.06.003] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
New and more advanced diagnostic imaging techniques for acute stroke triage have the potential to not only improve the quality of care but also reduce health care costs. Although sufficiently large and methodologically sound studies with regard to cost effectiveness of MR imaging are lacking, the overall impression is that MR imaging has revolutionized not only the diagnosis but also the open and investigational management of neurologically ill patients.
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Abstract
Unenhanced CT remains the most widely used imaging technique and is the standard of care for acute stroke evaluation. Early ischemic signs (EIS) within the first 3 to 6 hours of symptom onset (eg, parenchymal hypodensity, sulcal effacement, and dense vessel) have been advocated as a triage tool for thrombolytic therapy. Recent studies have challenged the relevance of these EIS within 3 hours of stroke onset, with advanced MR and CT methods increasingly competing with unenhanced CT as the primary imaging modality for acute ischemia. Nonetheless, the insights regarding acute stroke physiology provided by studying the CT evolution of early ischemic signs continue to be valuable for the informed interpretation of all stroke images. It is these insights that comprise the topic of this article.
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Affiliation(s)
- Thomas Kucinski
- Department of Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.
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Wardlaw JM, Mielke O. Early Signs of Brain Infarction at CT: Observer Reliability and Outcome after Thrombolytic Treatment—Systematic Review. Radiology 2005; 235:444-53. [PMID: 15858087 DOI: 10.1148/radiol.2352040262] [Citation(s) in RCA: 181] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
PURPOSE To review systematically all reported early computed tomographic (CT) signs in acute ischemic stroke to determine interobserver agreement and the relationship between early CT signs and patient outcome with or without thrombolysis. MATERIALS AND METHODS A systematic review of the literature was conducted by using Cochrane Stroke Group methodology to identify studies published between 1990 and 2003 that were performed to assess interobserver agreement about early signs of infarction on CT scans obtained within 6 hours after onset of stroke symptoms and determine the relation of early signs of infarction to clinical outcome, including any interactive effect of thrombolysis. Interobserver agreement was measured with the kappa statistic, sensitivity, and specificity. The relation of early signs to clinical outcome with or without thrombolysis was assessed with calculated odds ratios and 95% confidence intervals. RESULTS In 15 studies of interobserver agreement (median of 30 CT scans and six raters), the prevalence of all early infarction signs was 61% +/- 21 (standard deviation). Interobserver agreement (kappa statistics) ranged from 0.14 to 0.78 for any early infarction sign. The mean sensitivity and specificity for detection of early infarction signs with CT were 66% (range, 20%-87%) and 87% (range, 56%-100%), respectively. Experience improved detection, but knowledge of symptoms did not. In 15 studies of early infarction signs and outcome (including seven thrombolysis trials) in 3468 patients, any early infarction sign increased the risk of poor outcome (odds ratio, 3.11; 95% confidence interval: 2.77, 3.49). Two studies that sought interaction between early infarction signs and thrombolysis found no evidence that thrombolysis given in the presence of early infarction signs resulted in worse outcome than that due to early signs alone. CONCLUSION Further work is required to determine which signs are most reliably detected, whether scoring systems help to improve detection, and whether any early infarction sign should influence decisions concerning thrombolysis.
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Affiliation(s)
- Joanna M Wardlaw
- Division of Clinical Neurosciences, University of Edinburgh, Western General Hospital, Crewe Rd, Edinburgh EH4 2XU, Scotland.
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Sims J, Schwamm LH. The Evolving Role of Acute Stroke Imaging in Intravenous Thrombolytic Therapy: Patient Selection and Outcomes Assessment. Neuroimaging Clin N Am 2005; 15:421-40, xii. [PMID: 16198950 DOI: 10.1016/j.nic.2005.06.001] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
In early trials of thrombolysis, unenhanced CT was used to exclude patients with brain hemorrhage or large infarctions but was insensitive to stroke pathophysiology or early signs of cerebral ischemia or infarction. Currently, CT angiography, CT perfusion, and MR imaging can provide information about stroke mechanisms and prognosis, quantify penumbral tissue, and support risk stratification and patient selection. This article reviews the role of neuroimaging in the original intravenous thrombolytic trials, current application of these technologies, and the potential future role of imaging to extend the time window for thrombolysis and to augment therapeutic success.
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Affiliation(s)
- John Sims
- Stroke and Neurovascular Regulation Laboratory, Charlestown, MA, USA
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Burger KM, Tuhrim S. Antithrombotic trials in acute ischaemic stroke: a selective review. Expert Opin Emerg Drugs 2005; 9:303-12. [PMID: 15571487 DOI: 10.1517/14728214.9.2.303] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Stroke is a common cause of morbidity and mortality throughout the US and the world. Given the highly disabling nature of this disease, it is important to provide acute therapy when indicated to improve individual outcomes. Recombinant tissue plasminogen activator (rt-PA) is, at present, the only approved drug for the treatment of acute strokes due to cerebral ischaemia. It can be given intravenously within a 3-h window of the onset of neurological deficits. Intra-arterial administration of rt-PA within a 6-h window is performed at several academic centres in patients with middle cerebral and other intracranial artery occlusions based on results of a randomised clinical trial. Other thrombolytic agents are being studied in randomised trials. Although acute therapy of ischaemic stroke has received much attention since the approval of rt-PA, only a small percentage of individuals actually receive rt-PA. This article will review the main thrombolytic agents and the trials performed thus far, as well as examine some important ongoing trials. How administration of acute thrombolytic therapy may evolve in the future will also be addressed.
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Affiliation(s)
- Kathleen M Burger
- Mount Sinai School of Medicine, 1 Gustave Place Box 1137, New York, NY 10029, USA.
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Abstract
Thrombolytic therapy is an essential tool in the array of therapies designed to reopen arteries and veins occluded with thrombus. As the use of thrombolytic agents has entered mainstream practice, their application has expanded to include a wide variety of indications and settings. Thrombolytic agents are used in patients who have thrombosis of coronary arteries, precerebral and cerebral arteries, the aorta, iliac and mesenteric arteries, and peripheral arteries. The use of thrombolysis in venous thrombosis has included deep venous thrombosis of the upper and lower extremities and vena cava, mesenteric veins, cerebral veins, and central access catheters. Guidelines are available from the American College of Cardiology/American Heart Association regarding thrombolysis in myocardial infarction and from the American Stroke Association regarding thrombolysis in acute ischemic stroke.
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Affiliation(s)
- William F Baker
- Center for Health Sciences, University of California-Los Angeles, Los Angeles, CA, USA.
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Abstract
Treatment of ischemic stroke is a very frustrating topic for neurologists. Presently, the most promising therapy seems to be thrombolysis of the clot. However, this intervention is associated with complication risks, most significantly the risk of post-treatment hemorrhage. This risk of bleeding increases not only with the size of the ischemic brain tissue but also with the time-to-treatment interval. Studies suggest a time window of 3 hours for most effective treatment. Hence, there is demand for a rapid imaging workup, which thus far has been accomplished with computed tomography. Because of the risks associated with thrombolytic therapy, more detailed information is desirable. The distinction between patients with viable ischemically challenged neural tissue and those with complete infarcts is of great importance, and computed tomography is insufficient for this task. This is also true for outlining the etiology of stroke, which may impact treatment. For these tasks, magnetic resonance imaging has been proposed. However, comprehensive imaging protocols take time, which is limited in stroke treatment. Therefore, new imaging techniques are required that provide both in-depth information and short scanning times. Parallel imaging is uniquely suited for this purpose.
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Affiliation(s)
- Michael Augustin
- Department of Radiology, Auenbruggerplatz 9, Medical University, 8036 Graz, Austria.
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Kloska SP, Nabavi DG, Gaus C, Nam EM, Klotz E, Ringelstein EB, Heindel W. Acute Stroke Assessment with CT: Do We Need Multimodal Evaluation? Radiology 2004; 233:79-86. [PMID: 15340177 DOI: 10.1148/radiol.2331030028] [Citation(s) in RCA: 94] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
PURPOSE To assess detection of stroke and prediction of extent of infarction with multimodal computed tomographic (CT) evaluation (unenhanced CT, perfusion CT, and CT angiography) in patients suspected of having acute stroke. MATERIALS AND METHODS Forty-four consecutive patients with a mean National Institutes of Health Stroke Scale score of 10.45 and suspected of having ischemic stroke of the anterior circulation were examined with multi-detector row CT within 8 hours (mean, 3.05 hours) of onset of symptoms. All evaluations were performed with the knowledge that acute stroke was suspected but without detailed clinical information. The extent of ischemia or final infarction on the baseline unenhanced CT scan and follow-up images was assessed with the Alberta Stroke Program Early CT score. Different perfusion maps and follow-up images were assessed to determine the percentage of the ischemia-affected hemisphere. Each component, as well as the multimodal CT evaluation, was compared with follow-up unenhanced CT scans or magnetic resonance images after a mean time of 2.32 days. RESULTS Multimodal CT revealed true-positive findings in 30 of 41 patients and true-negative findings in three, resulting in a sensitivity of 78.9%. Unenhanced CT, CT angiography, and perfusion CT showed sensitivities of 55.3%, 57.9%, and 76.3%, respectively. In eight patients, small infarctions (mean size, 1.47 cm) that were proved at follow-up were missed with all modalities at initial multimodal CT. With perfusion CT, four of these small infarctions were missed within the white matter of the section levels. Maps of cerebral blood flow showed the best correlation with the final size of infarction with an r(2) value of 0.71. CONCLUSION The presented multimodal CT evaluation improves detection rate and prediction of the final size of infarction in comparison with unenhanced CT, CT angiography, and perfusion CT alone.
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Affiliation(s)
- Stephan P Kloska
- Departments of Clinical Radiology and Neurology, University Hospital of Muenster, Albert-Schweitzer-Strasse 33, 48149 Muenster, Germany.
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