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Arora K, Gaekwad A, Evans J, O'Brien W, Ang T, Garcia-Esperon C, Blair C, Edwards LS, Chew BLA, Delcourt C, Spratt NJ, Parsons MW, Butcher KS. Diagnostic Utility of Computed Tomography Perfusion in the Telestroke Setting. Stroke 2022; 53:2917-2925. [PMID: 35652343 DOI: 10.1161/strokeaha.122.038798] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
BACKGROUND Definitive diagnosis of acute ischemic stroke is challenging, particularly in telestroke settings. Although the prognostic utility of CT perfusion (CTP) has been questioned, its diagnostic value remains under-appreciated, especially in cases without an easily visible intracranial occlusion. We assessed the diagnostic accuracy of routine CTP in the acute telestroke setting. METHODS Acute and follow-up data collected prospectively from consecutive suspected patients with stroke assessed by a state-wide telestroke service between March 2020 and August 2021 at 12 sites in Australia were analyzed. All patients in the final analysis had been assessed with multimodal CT, including CTP, which was post-processed with automated volumetric software. Diagnostic sensitivity and specificity were calculated for multimodal CT and each individual component (noncontrast CT [NCCT], CT angiogram [CTA], and CTP). Final diagnosis determined by consensus review of follow-up imaging and clinical data was used as the reference standard. RESULTS During the study period, complete multimodal CT examination was obtained in 831 patients, 457 of whom were diagnosed with stroke. Diagnostic sensitivity for ischemic stroke increased by 19.5 percentage points when CTP was included with NCCT and CTA compared with NCCT and CTA alone (73.1% positive with NCCT+CTA+CTP [95% CI, 68.8-77.1] versus 53.6% positive with NCCT+CTA alone [95% CI, 48.9-58.3], P<0.001). No difference was observed between specificities of NCCT+CTA and NCCT+CTA+CTP (98.7% [95% CI, 98.5-100] versus 98.7% [95% CI, 96.9-99.6], P=0.13). Multimodal CT, including CTP, demonstrated the highest negative predictive value (75.0% [95% CI, 72.1-77.7]). Patients with stroke not evident on CTP had small volume infarcts on follow-up (1.2 mL, interquartile range 0.5-2.7mL). CONCLUSIONS Acquisition of CTP as part of a telestroke imaging protocol permits definitive diagnosis of cerebral ischemia in 1 in 5 patients with normal NCCT and CTA.
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Affiliation(s)
- Kshitij Arora
- Prince of Wales Clinical School, University of New South Wales, Clinical Neurosciences, Randwick, Australia (K.A., A.G., K.S.B.)
| | - Aaron Gaekwad
- Prince of Wales Clinical School, University of New South Wales, Clinical Neurosciences, Randwick, Australia (K.A., A.G., K.S.B.)
| | - James Evans
- Gosford Hospital, Department of Neurosciences, Australia (J.E., W.O.B., L.S.E.)
| | - William O'Brien
- Gosford Hospital, Department of Neurosciences, Australia (J.E., W.O.B., L.S.E.)
| | - Timothy Ang
- Departments of Neurology and Radiology, Royal Prince Alfred Hospital, Camperdown, Australia (T.A.)
| | - Carlos Garcia-Esperon
- John Hunter Hospital, Department of Neurology, and Hunter Medical Research Institute, New Lambton Heights, Australia (C.G.-E., B.L.A.C., N.J.S.).,The University of Newcastle, School of Biomedical Sciences and Pharmacy, Callaghan, Australia (C.G.-E., B.L.A.C., N.J.S.)
| | - Christopher Blair
- Sydney Brain Centre, Ingham Institute for Applied Medical Research, Liverpool, Australia (C.B., L.S.E.)
| | - Leon S Edwards
- Gosford Hospital, Department of Neurosciences, Australia (J.E., W.O.B., L.S.E.).,Sydney Brain Centre, Ingham Institute for Applied Medical Research, Liverpool, Australia (C.B., L.S.E.).,South Western Sydney Clinical School, University of New South Wales, Department of Neurology and Neurophysiology, Liverpool, Australia (L.S.E., M.W.P.)
| | - Beng L A Chew
- John Hunter Hospital, Department of Neurology, and Hunter Medical Research Institute, New Lambton Heights, Australia (C.G.-E., B.L.A.C., N.J.S.).,The University of Newcastle, School of Biomedical Sciences and Pharmacy, Callaghan, Australia (C.G.-E., B.L.A.C., N.J.S.)
| | - Candice Delcourt
- The George Institute for Global Health, University of New South Wales, Neurological and Mental Health Division, Newtown, Australia (C.D.).,Department of Clinical Medicine, Faculty of Medicine, Health and Human Sciences, Macquarie University, Sydney, NSW, Australia (C.D.)
| | - Neil J Spratt
- John Hunter Hospital, Department of Neurology, and Hunter Medical Research Institute, New Lambton Heights, Australia (C.G.-E., B.L.A.C., N.J.S.).,The University of Newcastle, School of Biomedical Sciences and Pharmacy, Callaghan, Australia (C.G.-E., B.L.A.C., N.J.S.)
| | - Mark W Parsons
- South Western Sydney Clinical School, University of New South Wales, Department of Neurology and Neurophysiology, Liverpool, Australia (L.S.E., M.W.P.)
| | - Ken S Butcher
- Prince of Wales Clinical School, University of New South Wales, Clinical Neurosciences, Randwick, Australia (K.A., A.G., K.S.B.)
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Turner AC, Etherton MR. Utilization of Telestroke Prior to and Following the COVID-19 Pandemic. Semin Neurol 2022; 42:3-11. [PMID: 35576926 DOI: 10.1055/s-0041-1742181] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
For over two decades, telestroke has been utilized as a means for improving acute access to a stroke specialist when this expertise is otherwise unavailable. During this time, telestroke use has increased and improvements in care metrics have been widely reported. Several telestroke model variations are utilized; each has different workflow implications. A successful telestroke system should include adequate protocols and training, equipment, documentation system, and tracking of quality metrics. Upfront costs of needed technology and devices, credentialing hurdles, and limited reimbursement are all reported barriers to the utilization of telestroke. Emphasis on safety measures during the COVID-19 pandemic resulted in the dramatic upscaling of telehealth utilization, although overall stroke volumes declined in many areas in the early phases of the pandemic. Going forward, continued reduction in cost of required devices and broadband connections, increased use of automated and advanced analytical software, and a universal licensing and credentialing system are needed to continue the expansion of telestroke use.
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Affiliation(s)
- Ashby C Turner
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Mark R Etherton
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
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Nicolas-Jilwan M, Wintermark M. Automated Brain Perfusion Imaging in Acute Ischemic Stroke: Interpretation Pearls and Pitfalls. Stroke 2021; 52:3728-3738. [PMID: 34565174 DOI: 10.1161/strokeaha.121.035049] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Recent advancements in computed tomography technology, including improved brain coverage and automated processing of the perfusion data, have reinforced the use of perfusion computed tomography imaging in the routine evaluation of patients with acute ischemic stroke. The DAWN (Diffusion Weighted Imaging or Computerized Tomography Perfusion Assessment With Clinical Mismatch in the Triage of Wake Up and Late Presenting Strokes Undergoing Neurointervention) and DEFUSE 3 (Endovascular Therapy Following Imaging Evaluation for Ischemic Stroke 3) trials have established the benefit of endovascular thrombectomy in patients with acute ischemic stroke with anterior circulation large vessel occlusion up to 24 hours of last seen normal, using perfusion imaging-based patient selection. The compelling data has prompted stroke centers to increasingly introduce automated perfusion computed tomography imaging in the routine evaluation of patients with acute ischemic stroke. We present a comprehensive overview of the acquisition and interpretation of automated perfusion imaging in patients with acute ischemic stroke with a special emphasis on the interpretation pearls, pitfalls, and stroke mimicking conditions.
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Affiliation(s)
- Manal Nicolas-Jilwan
- Division of Neuroradiology, Department of Radiology, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia (M.N.-J.)
| | - Max Wintermark
- Division of Neuroimaging and Neurointervention, Department of Radiology, Stanford Healthcare, CA (M.W.)
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Byrne D, Walsh JP, Sugrue G, Nicolaou S, Rohr A. CT Imaging of Acute Ischemic Stroke [Formula: see text]. Can Assoc Radiol J 2020; 71:266-280. [PMID: 32157894 DOI: 10.1177/0846537120902068] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Although acute ischemic stroke remains one of the most common causes of death and disability worldwide, it is a potentially treatable condition if appropriately managed in a timely manner. The goals of acute stroke imaging include establishing a diagnosis as fast as possible with (1) accurate infarct quantification, (2) intracranial and cervical vasculature assessment, and (3) brain perfusion analysis for detection of infarct core and potentially salvageable penumbra allowing optimal patient selection for appropriate therapy. Given the extensive number of images generated from acute stroke imaging studies and as "time is brain," this article aims to highlight a logical approach for the radiologist in acute stroke computed tomography imaging in order to accurately interpret and communicate results in a timely manner.
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Affiliation(s)
- D Byrne
- Division of Neuroradiology, Vancouver General Hospital, Vancouver, British Columbia, Canada.,University of British Columbia, Vancouver, British Columbia, Canada
| | - J P Walsh
- University of British Columbia, Vancouver, British Columbia, Canada.,Division of Emergency Radiology, Vancouver General Hospital, Vancouver, British Columbia, Canada
| | - G Sugrue
- University of British Columbia, Vancouver, British Columbia, Canada.,Division of Emergency Radiology, Vancouver General Hospital, Vancouver, British Columbia, Canada
| | - S Nicolaou
- University of British Columbia, Vancouver, British Columbia, Canada.,Division of Emergency Radiology, Vancouver General Hospital, Vancouver, British Columbia, Canada
| | - A Rohr
- Division of Neuroradiology, Vancouver General Hospital, Vancouver, British Columbia, Canada.,University of British Columbia, Vancouver, British Columbia, Canada
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