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van Voorst H, Hoving JW, Koopman MS, Daems JD, Peerlings D, Buskens E, Lingsma H, Marquering HA, de Jong HWAM, Berkhemer OA, van Zwam WH, van Walderveen MAA, van den Wijngaard IR, Dippel DWJ, Yoo AJ, Campbell B, Kunz WG, Majoie CB, Emmer BJ. Costs and health effects of CT perfusion-based selection for endovascular thrombectomy within 6 hours of stroke onset: a model-based health economic evaluation. J Neurol Neurosurg Psychiatry 2024; 95:515-527. [PMID: 38124162 DOI: 10.1136/jnnp-2023-331862] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2023] [Accepted: 11/19/2023] [Indexed: 12/23/2023]
Abstract
BACKGROUND Although CT perfusion (CTP) is often incorporated in acute stroke workflows, it remains largely unclear what the associated costs and health implications are in the long run of CTP-based patient selection for endovascular treatment (EVT) in patients presenting within 6 hours after symptom onset with a large vessel occlusion. METHODS Patients with a large vessel occlusion were included from a Dutch nationwide cohort (n=703) if CTP imaging was performed before EVT within 6 hours after stroke onset. Simulated cost and health effects during 5 and 10 years follow-up were compared between CTP based patient selection for EVT and providing EVT to all patients. Outcome measures were the net monetary benefit at a willingness-to-pay of €80 000 per quality-adjusted life year, incremental cost-effectiveness ratio), difference in costs from a healthcare payer perspective (ΔCosts) and quality-adjusted life years (ΔQALY) per 1000 patients for 1000 model iterations as outcomes. RESULTS Compared with treating all patients, CTP-based selection for EVT at the optimised ischaemic core volume (ICV≥110 mL) or core-penumbra mismatch ratio (MMR≤1.4) thresholds resulted in losses of health (median ΔQALYs for ICV≥110 mL: -3.3 (IQR: -5.9 to -1.1), for MMR≤1.4: 0.0 (IQR: -1.3 to 0.0)) with median ΔCosts for ICV≥110 mL of -€348 966 (IQR: -€712 406 to -€51 158) and for MMR≤1.4 of €266 513 (IQR: €229 403 to €380 110)) per 1000 patients. Sensitivity analyses did not yield any scenarios for CTP-based selection of patients for EVT that were cost-effective for improving health, including patients aged ≥80 years CONCLUSION: In EVT-eligible patients presenting within 6 hours after symptom onset, excluding patients based on CTP parameters was not cost-effective and could potentially harm patients.
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Affiliation(s)
- Henk van Voorst
- Department of Radiology and Nuclear Medicine, Amsterdam UMC Location AMC, Amsterdam, North Holland, The Netherlands
- Department of Biomedical Engineering and Physics, Amsterdam UMC location University of Amsterdam, Amsterdam, The Netherlands
| | - Jan W Hoving
- Department of Radiology and Nuclear Medicine, Amsterdam UMC Location AMC, Amsterdam, North Holland, The Netherlands
| | - Miou S Koopman
- Department of Radiology and Nuclear Medicine, Amsterdam UMC Location AMC, Amsterdam, North Holland, The Netherlands
| | - Jasper D Daems
- Department of Neurology, Erasmus University Medical Center, Rotterdam, The Netherlands
- Department of Public Health, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Daan Peerlings
- Department of Radiology, University Medical Center Utrecht, Utrecht, Utrecht, The Netherlands
| | - Erik Buskens
- Epidemiology, University Medical Centre Groningen, Groningen, Groningen, The Netherlands
| | - Hester Lingsma
- Public Health, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Henk A Marquering
- Department of Radiology and Nuclear Medicine, Amsterdam UMC Location AMC, Amsterdam, North Holland, The Netherlands
- Biomedical Engineering and Physics, Amsterdam UMC Location AMC, Amsterdam, North Holland, The Netherlands
| | | | - Olvert A Berkhemer
- Department of Radiology and Nuclear Medicine, Erasmus MC University Medical Center, Rotterdam, The Netherlands
- Department of Radiology and Nuclear Medicine, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Wim H van Zwam
- Radiology, Maastricht University Medical Center, Maastricht, The Netherlands
| | | | - Ido R van den Wijngaard
- Neurology, HMC Westeinde, The Hague, Zuid-Holland, The Netherlands
- Neurology, Leiden University, Leiden, The Netherlands
| | | | - Albert J Yoo
- Neurointervention, Texas Stroke Institute, Plano, Texas, USA
| | - Bruce Campbell
- The Royal Melbourne Hospital, Parkville, Melbourne, Australia
| | | | - Charles B Majoie
- Department of Radiology and Nuclear Medicine, Amsterdam UMC Location AMC, Amsterdam, North Holland, The Netherlands
| | - Bart J Emmer
- Department of Radiology and Nuclear Medicine, Amsterdam UMC Location AMC, Amsterdam, North Holland, The Netherlands
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Kumar M, Beyea S, Hu S, Kamal N. Impact of early MRI in ischemic strokes beyond hyper-acute stage to improve patient outcomes, enable early discharge, and realize cost savings. J Stroke Cerebrovasc Dis 2024; 33:107662. [PMID: 38417567 DOI: 10.1016/j.jstrokecerebrovasdis.2024.107662] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2023] [Revised: 02/20/2024] [Accepted: 02/24/2024] [Indexed: 03/01/2024] Open
Abstract
BACKGROUND Early in-patient MR Imaging may assist in identifying stroke etiology, facilitating prompt secondary prevention for ischemic strokes (IS), and potentially enhancing patient outcomes. This study explores the impact of early in patient MRI on IS patient outcomes and healthcare resource use beyond the hyper-acute stage. METHODS In this retrospective registry-based study, 771 admitted transient ischemic attack (TIA) and IS patients at Halifax's QEII Health Centre from 2015 to 2019 underwent in-patient MRI. Cohort was categorized into two groups based on MRI timing: early (within 48 h) and late. Logistic regression and Poisson log-linear models, adjusted for age, sex, stroke severity, acute stroke protocol (ASP) activation, thrombolytic, and thrombectomy, were employed to examine in-hospital, discharge, post-discharge, and healthcare resource utilization outcomes. RESULTS Among the cohort, 39.6 % received early in-patient MRI. ASP activation and TIA were associated with a higher likelihood of receiving early MRI. Early MRI was independently associated with a lower rate of symptomatic changes in neurological status during hospitalization (adjusted odds ratio [OR], 0.42; 95 % confidence interval [CI], 0.20-0.88), higher odds of good functional outcomes at discharge (1.55; 1.11-2.16), lower rate of non-home discharge (0.65; 0.46-0.91), shorter length of stay (regression coefficient, 0.93; 95 % CI, 0.89-0.97), and reduced direct cost of hospitalization (0.77; 0.75-0.79). CONCLUSION Early in-patient MRI utilization in IS patients post-hyper-acute stage was independently associated with improved patient outcomes and decreased healthcare resource utilization, underscoring the potential benefits of early MRI during in-patient management of IS. Further research, including randomized controlled trials, is warranted to validate these findings.
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Affiliation(s)
- Mukesh Kumar
- Department of Industrial Engineering, Dalhousie University, Halifax, Canada.
| | - Steven Beyea
- Department of Diagnostic Radiology, Dalhousie University, Halifax, Canada; IWK Health, Halifax, Canada
| | - Sherry Hu
- Department of Medicine, Division of Neurology, Dalhousie University, Halifax, Canada
| | - Noreen Kamal
- Department of Industrial Engineering, Dalhousie University, Halifax, Canada; Department of Medicine, Division of Neurology, Dalhousie University, Halifax, Canada; Department of Community Health and Epidemiology, Dalhousie University, Halifax, Canada
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3
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van Voorst H, Hoving JW, Koopman MS, Daems JD, Peerlings D, Buskens E, Lingsma HF, Beenen LFM, de Jong HWAM, Berkhemer OA, van Zwam WH, Roos YBWEM, van Walderveen MAA, van den Wijngaard I, Dippel DWJ, Yoo AJ, Campbell BCV, Kunz WG, Emmer BJ, Majoie CBLM. Cost-effectiveness of CT perfusion for the detection of large vessel occlusion acute ischemic stroke followed by endovascular treatment: a model-based health economic evaluation study. Eur Radiol 2024; 34:2152-2167. [PMID: 37728778 PMCID: PMC10957700 DOI: 10.1007/s00330-023-10119-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2023] [Revised: 06/22/2023] [Accepted: 07/01/2023] [Indexed: 09/21/2023]
Abstract
OBJECTIVES CT perfusion (CTP) has been suggested to increase the rate of large vessel occlusion (LVO) detection in patients suspected of acute ischemic stroke (AIS) if used in addition to a standard diagnostic imaging regime of CT angiography (CTA) and non-contrast CT (NCCT). The aim of this study was to estimate the costs and health effects of additional CTP for endovascular treatment (EVT)-eligible occlusion detection using model-based analyses. METHODS In this Dutch, nationwide retrospective cohort study with model-based health economic evaluation, data from 701 EVT-treated patients with available CTP results were included (January 2018-March 2022; trialregister.nl:NL7974). We compared a cohort undergoing NCCT, CTA, and CTP (NCCT + CTA + CTP) with a generated counterfactual where NCCT and CTA (NCCT + CTA) was used for LVO detection. The NCCT + CTA strategy was simulated using diagnostic accuracy values and EVT effects from the literature. A Markov model was used to simulate 10-year follow-up. We adopted a healthcare payer perspective for costs in euros and health gains in quality-adjusted life years (QALYs). The primary outcome was the net monetary benefit (NMB) at a willingness to pay of €80,000; secondary outcomes were the difference between LVO detection strategies in QALYs (ΔQALY) and costs (ΔCosts) per LVO patient. RESULTS We included 701 patients (median age: 72, IQR: [62-81]) years). Per LVO patient, CTP-based occlusion detection resulted in cost savings (ΔCosts median: € - 2671, IQR: [€ - 4721; € - 731]), a health gain (ΔQALY median: 0.073, IQR: [0.044; 0.104]), and a positive NMB (median: €8436, IQR: [5565; 11,876]) per LVO patient. CONCLUSION CTP-based screening of suspected stroke patients for an endovascular treatment eligible large vessel occlusion was cost-effective. CLINICAL RELEVANCE STATEMENT Although CTP-based patient selection for endovascular treatment has been recently suggested to result in worse patient outcomes after ischemic stroke, an alternative CTP-based screening for endovascular treatable occlusions is cost-effective. KEY POINTS • Using CT perfusion to detect an endovascular treatment-eligible occlusions resulted in a health gain and cost savings during 10 years of follow-up. • Depending on the screening costs related to the number of patients needed to image with CT perfusion, cost savings could be considerable (median: € - 3857, IQR: [€ - 5907; € - 1916] per patient). • As the gain in quality adjusted life years was most affected by the sensitivity of CT perfusion-based occlusion detection, additional studies for the diagnostic accuracy of CT perfusion for occlusion detection are required.
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Affiliation(s)
- Henk van Voorst
- Department of Radiology and Nuclear Medicine, Amsterdam UMC Location University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, the Netherlands.
- Department of Biomedical Engineering and Physics, Amsterdam UMC Location University of Amsterdam, Amsterdam, the Netherlands.
| | - Jan W Hoving
- Department of Radiology and Nuclear Medicine, Amsterdam UMC Location University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, the Netherlands
| | - Miou S Koopman
- Department of Radiology and Nuclear Medicine, Amsterdam UMC Location University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, the Netherlands
| | - Jasper D Daems
- Department of Public Health, Erasmus University Medical Center, Rotterdam, the Netherlands
- Department of Neurology, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Daan Peerlings
- Department of Biomedical Engineering and Physics, Amsterdam UMC Location University of Amsterdam, Amsterdam, the Netherlands
- Department of Radiology, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Erik Buskens
- Department of Epidemiology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Hester F Lingsma
- Department of Public Health, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Ludo F M Beenen
- Department of Radiology and Nuclear Medicine, Amsterdam UMC Location University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, the Netherlands
| | - Hugo W A M de Jong
- Department of Radiology, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Olvert A Berkhemer
- Department of Radiology and Nuclear Medicine, Amsterdam UMC Location University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, the Netherlands
- Department of Epidemiology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
- Department of Radiology and Nuclear Medicine, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Wim H van Zwam
- Department of Radiology and Nuclear Medicine, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Center+, Maastricht, the Netherlands
| | - Yvo B W E M Roos
- Department of Neurology, Amsterdam UMC Location University of Amsterdam, Amsterdam, the Netherlands
| | | | | | - Diederik W J Dippel
- Department of Neurology, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Albert J Yoo
- Department of Radiology, Texas Stroke Institute, Dallas-Fort Worth, TX, USA
| | - Bruce C V Campbell
- Department of Medicine and Neurology, Melbourne Brain Center, Royal Melbourne Hospital, University of Melbourne, Melbourne, Australia
| | - Wolfgang G Kunz
- Department of Radiology, University Hospital, LMU Munich, Munich, Germany
| | - Bart J Emmer
- Department of Radiology and Nuclear Medicine, Amsterdam UMC Location University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, the Netherlands
| | - Charles B L M Majoie
- Department of Radiology and Nuclear Medicine, Amsterdam UMC Location University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, the Netherlands
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Fappiano C, Long B. Is the Use of Computed Tomography Perfusion Versus Noncontrast Computed Tomography Associated With Improved Outcomes in Patients Presenting 6-24 Hours After Symptom Onset With Large Vessel Occlusion Acute Ischemic Stroke Undergoing Endovascular Thrombectomy? Ann Emerg Med 2024; 83:158-161. [PMID: 37725024 DOI: 10.1016/j.annemergmed.2023.08.483] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2023] [Revised: 08/20/2023] [Accepted: 08/21/2023] [Indexed: 09/21/2023]
Affiliation(s)
- Cayla Fappiano
- Department of Emergency Medicine, SAUSHEC, Fort Sam Houston, TX
| | - Brit Long
- Department of Emergency Medicine, SAUSHEC, Fort Sam Houston, TX
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Roy A, Sreekrishnan A, Camargo Faye E, Silverman S, Zachrison KS, Harriott AM, Matiello M, Manzano GS, Prasanna M, Nedelcu S, Singhal AB. Safety and Feasibility of an Emergency Department-to-Outpatient Pathway for Patients With TIA and Nondisabling Stroke. Neurol Clin Pract 2023; 13:e200209. [PMID: 37829551 PMCID: PMC10567120 DOI: 10.1212/cpj.0000000000200209] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Accepted: 08/28/2023] [Indexed: 10/14/2023]
Abstract
Background and Objectives Evaluation of transient ischemic attack/nondisabling ischemic strokes (TIA/NDS) in the emergency department (ED) contributes to capacity issues and increasing health care expenditures, especially high-cost duplicative imaging. Methods As an institutional quality improvement project, we developed a novel pathway to evaluate patients with TIA/NDS in the ED using a core set of laboratory tests and CT-based neuroimaging. Patients identified as 'low risk' through a safety checklist were discharged and scheduled for prompt outpatient tests and stroke clinic follow-up. In this prespecified analysis designed to assess feasibility and safety, we abstracted data from patients consecutively enrolled in the first 6 months. Results We compared data from 106 patients with TIA/NDS enrolled in the new pathway from April through September 2020 (age 67.9 years, 45% female), against 55 unmatched historical controls with TIA encountered from April 2016 through March 2017 (age 68.3 years, 47% female). Both groups had similar median NIHSS scores (pathway and control 0) and ABCD2 scores (pathway and control 3). Pathway-enrolled patients had a 44% decrease in mean ED length of stay (pathway 13.7 hours, control 24.4 hours, p < 0.001) and decreased utilization of ED MRI-based imaging (pathway 63%, control 91%, p < 0.001) and duplicative ED CT plus MRI-based brain and/or vascular imaging (pathway 35%, control 53%, p = 0.04). Among pathway-enrolled patients, 89% were evaluated in our stroke clinic within a median of 5 business days; only 5.5% were lost to follow-up. Both groups had similar 90-day rates of ED revisits (pathway 21%, control 18%, p = 0.84) and recurrent TIA/ischemic stroke (pathway 1%, control 2%, p = 1.0). Recurrent ischemic events among pathway-enrolled patients were attributed to errors in following the safety checklist before discharge. Discussion Our TIA/NDS pathway, implemented during the initial outbreak of COVID-19, seems feasible and safe, with significant positive impact on ED throughput and ED-based high-cost duplicative imaging. The safety checklist and option of virtual telehealth follow-up are novel features. Broader adoption of such pathways has important implications for value-based health care.
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Affiliation(s)
- Alexis Roy
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Anirudh Sreekrishnan
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Erica Camargo Faye
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Scott Silverman
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Kori S Zachrison
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Andrea M Harriott
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Marcelo Matiello
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Giovanna S Manzano
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Mrinalini Prasanna
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Simona Nedelcu
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Aneesh B Singhal
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
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6
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Sun D, Huo X, Raynald, Mo D, Gao F, Ma N, Albers GW, Miao Z. Outcome prediction value of critical area perfusion score for acute basilar artery occlusion. Interv Neuroradiol 2023; 29:702-709. [PMID: 36112757 PMCID: PMC10680966 DOI: 10.1177/15910199221125853] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2022] [Accepted: 08/25/2022] [Indexed: 11/29/2023] Open
Abstract
PURPOSE To investigate the performance of the Critical Area Perfusion Score (CAPS), based on computed tomography perfusion (CTP) time to maximum (Tmax) > 10s maps, to predict the outcome in acute basilar artery occlusion (BAO) in patients undergoing endovascular treatment (EVT). METHODS We perform a retrospective analysis of a prospectively collected database of acute BAO treated with EVT in a comprehensive stroke center. The favorable outcome was defined as the 90-day modified Rankin Scale (mRS) ≤ 3. We performed the logistic regression analysis to find the independent predictors of the favorable outcome. Then, we used receiver operating characteristic analyses to assess the predictive value of the imaging parameters, including CAPS, Posterior Circulation Alberta Stroke Program Early CT Score (PC-ASPECTS), pons midbrain index (PMI), posterior circulation computed tomography angiography (PC-CTA) score, Basilar Artery on Computed Tomography Angiography (BATMAN) score, and CTP parameters. Finally, the Delong test was used to compare the area under the curve (AUC) of CAPS against the other imaging parameters. RESULTS Of the 65 enrolled patients, the incidence of the favorable outcome was 44.6% (29/65). Low CAPS (per 1- point increased odds ratio [OR], 0.43; 95% confidence interval [CI], 0.22-0.86; P = 0.017) and admission National Institutes of Health Stroke Scale (NIHSS) (per 1- point increased OR, 0.80; 95% CI, 0.70-0.91; P = 0.001) were independently associated with favorable outcome. The AUC of CAPS was 0.83 (95% CI, 0.74-0.93; P < 0.001) with ≤ 3 cut-off value, 89.66% sensitivity, 77.22% specificity, and 80.00% accuracy, which was greater than the other imaging parameters (All P for Delong test < 0.05). CONCLUSIONS CAPS was the most accurate imaging-based outcome predictor in acute BAO patients. Future large prospective multicenter studies are needed to verify these results.
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Affiliation(s)
- Dapeng Sun
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Xiaochuan Huo
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Raynald
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Dapeng Mo
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Feng Gao
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Ning Ma
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Gregory W Albers
- Department of Neurology and Neurological Sciences, Stanford University School of Medicine, Stanford, CA, USA
| | - Zhongrong Miao
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
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7
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Hirai S, Hirakawa A, Fujita K, Ishiwada T, Sasaki M, Yoshimura M, Shigeta K, Sato Y, Yamada K, Ishikawa M, Sagawa H, Aoyama J, Fujii S, Ishii Y, Sawada K, Obata Y, Karakama J, Hara M, Kawano Y, Nemoto S, Sumita K. Imaging predictors of clinical outcomes after endovascular treatment in MRI-selected patients with acute basilar artery occlusion. Clin Neurol Neurosurg 2023; 231:107824. [PMID: 37320887 DOI: 10.1016/j.clineuro.2023.107824] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Revised: 05/16/2023] [Accepted: 06/05/2023] [Indexed: 06/17/2023]
Abstract
PURPOSE We aimed to investigate the impact of baseline infarct area and collateral status (CS), which are imaging predictors of clinical outcome following stroke, after endovascular treatment (EVT) in MRI-selected patients with acute basilar artery occlusion (BAO). METHODS Patients with acute BAO who underwent EVT within 24 h after stroke from December 2013 to February 2021 were included in this retrospective, multicenter, observational study. The baseline infarct area was evaluated by the posterior circulation of Acute Stroke Prognosis Early Computed Tomography Score (pc-ASPECTS) using diffuse-weighted imaging (DWI), and CS was assessed by measuring the computed tomography angiography of the basilar artery (BATMAN) score and the posterior circulation collateral score (PC-CS) using magnetic resonance angiography (MRA). A Good outcome was defined as a modified Rankin scale score ≤ 3 at 3 months. For each imaging predictor, a multivariate logistic regression analysis was performed to evaluate its impact on good outcomes. RESULTS A total of 86 patients were analyzed, and 37 (43.0%) had a good outcome. The latter showed significantly higher pc-ASPECTS than those without good outcomes. In multivariate analyses, a pc-ASPECTS ≥ 7 was significantly associated with good outcomes (OR, 2.98 [95% CI, 1.10-8.13], P = 0.032), while PC-CS ≥ 4 (OR, 2.49 [95% CI, 0.92-6.74], P = 0.073) and BATMAN score ≥ 5 (OR, 1.51 [95% CI, 0.58-3.98], P = 0.401) were not. CONCLUSIONS In MRI-selected patients with acute BAO, pc-ASPECTS on DWI was an independent predictor of clinical outcomes after EVT, while the MRA-based CS assessments were not.
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Affiliation(s)
- Sakyo Hirai
- Department of Endovascular surgery, Tokyo Medical and Dental University, Tokyo, Japan
| | - Akihiro Hirakawa
- Department of Clinical Biostatistics, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan
| | - Kyohei Fujita
- Department of Endovascular surgery, Tokyo Medical and Dental University, Tokyo, Japan
| | | | - Masanao Sasaki
- Department of Clinical Biostatistics, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan
| | - Masataka Yoshimura
- Department of Neurosurgery, Tsuchiura Kyodo General Hospital, Ibaraki, Japan
| | - Keigo Shigeta
- Department of Neurosurgery, National Hospital Organization Disaster Medical Center, Tokyo, Japan
| | - Yohei Sato
- Department of Neurosurgery, Japanese Red Cross Musashino Hospital, Tokyo, Japan
| | - Kenji Yamada
- Department of Neurosurgery, Shuuwa General Hospital, Saitama, Japan
| | - Mariko Ishikawa
- Department of Endovascular surgery, Tokyo Medical and Dental University, Tokyo, Japan
| | - Hirotaka Sagawa
- Department of Endovascular surgery, Tokyo Medical and Dental University, Tokyo, Japan
| | - Jiro Aoyama
- Department of Endovascular surgery, Tokyo Medical and Dental University, Tokyo, Japan
| | - Shoko Fujii
- Department of Endovascular surgery, Tokyo Medical and Dental University, Tokyo, Japan
| | - Yosuke Ishii
- Department of Neurosurgery, Kanto Rosai Hospital, Kanagawa, Japan
| | - Kana Sawada
- Department of Neurosurgery, Tokyo Bay Urayasu Ichikawa Medical Center, Chiba, Japan
| | - Yoshiki Obata
- Department of Neurosurgery, Tokyo-Kita Medical Center, Tokyo, Japan
| | - Jun Karakama
- Department of Neurosurgery, Oume Municipal General Hospital, Tokyo, Japan
| | - Mutsuya Hara
- Department of Neurosurgery, Tokyo Metropolitan Toshima Hospital, Tokyo, Japan
| | - Yoshihisa Kawano
- Department of Neurosurgery, JA Toride Medical Center, Ibaraki, Japan
| | - Shigeru Nemoto
- Department of Neurosurgery, Kanto Rosai Hospital, Kanagawa, Japan
| | - Kazutaka Sumita
- Department of Endovascular surgery, Tokyo Medical and Dental University, Tokyo, Japan.
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8
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Kobeissi H, Ghozy S, Adusumilli G, Bilgin C, Tolba H, Amoukhteh M, Kadirvel R, Brinjikji W, Heit JJ, Rabinstein AA, Kallmes DF. CT Perfusion vs Noncontrast CT for Late Window Stroke Thrombectomy: A Systematic Review and Meta-analysis. Neurology 2023; 100:e2304-e2311. [PMID: 36990720 PMCID: PMC10259276 DOI: 10.1212/wnl.0000000000207262] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Accepted: 02/21/2023] [Indexed: 03/31/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Patients with acute ischemic stroke (AIS) treated with endovascular thrombectomy (EVT) in the late window (6-24 hours) can be evaluated with CT perfusion (CTP) or with noncontrast CT (NCCT) only. Whether outcomes differ depending on the type of imaging selection is unknown. We conducted a systematic review and meta-analysis comparing outcomes between CTP and NCCT for EVT selection in the late therapeutic window. METHODS This study is reported according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses 2020 guidelines. A systematic literature review of the English language literature was conducted using Web of Science, Embase, Scopus, and PubMed databases. Studies focusing on late-window AIS undergoing EVT imaged through CTP and NCCT were included. Data were pooled using a random-effects model. The primary outcome of interest was rate of functional independence, defined as modified Rankin scale 0-2. The secondary outcomes of interest included rates of successful reperfusion, defined as thrombolysis in cerebral infarction 2b-3, mortality, and symptomatic intracranial hemorrhage (sICH). RESULTS Five studies with 3,384 patients were included in our analysis. There were comparable rates of functional independence (odds ratio [OR] 1.03, 95% CI 0.87-1.22; p = 0.71) and sICH (OR 1.09, 95% CI 0.58-2.04; p = 0.80) between the 2 groups. Patients imaged with CTP had higher rates of successful reperfusion (OR 1.31, 95% CI 1.05-1.64; p = 0.015) and lower rates of mortality (OR 0.79, 95% CI 0.65-0.96; p = 0.017). DISCUSSION Although recovery of functional independence after late-window EVT was not more common in patients selected by CTP when compared with patients selected by NCCT only, patients selected by CTP had lower mortality.
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Affiliation(s)
- Hassan Kobeissi
- From the Department of Radiology (H.K., S.G., C.B., M.A., R.K., W.B., D.F.K.), Mayo Clinic, Rochester, MN; College of Medicine (H.K.), Central Michigan University, Mount Pleasant; Department of Radiology (G.A.), Massachusetts General Hospital, Boston; Department of Neurology (H.T.), Medical College of Wisconsin, Milwaukee; Department of Neurologic Surgery (R.K.), Mayo Clinic, Rochester, MN; Department of Radiology and Neurosurgery (J.J.H.), Stanford University, CA; and Department of Neurology (A.A.R.), Mayo Clinic, Rochester, MN.
| | - Sherief Ghozy
- From the Department of Radiology (H.K., S.G., C.B., M.A., R.K., W.B., D.F.K.), Mayo Clinic, Rochester, MN; College of Medicine (H.K.), Central Michigan University, Mount Pleasant; Department of Radiology (G.A.), Massachusetts General Hospital, Boston; Department of Neurology (H.T.), Medical College of Wisconsin, Milwaukee; Department of Neurologic Surgery (R.K.), Mayo Clinic, Rochester, MN; Department of Radiology and Neurosurgery (J.J.H.), Stanford University, CA; and Department of Neurology (A.A.R.), Mayo Clinic, Rochester, MN
| | - Gautam Adusumilli
- From the Department of Radiology (H.K., S.G., C.B., M.A., R.K., W.B., D.F.K.), Mayo Clinic, Rochester, MN; College of Medicine (H.K.), Central Michigan University, Mount Pleasant; Department of Radiology (G.A.), Massachusetts General Hospital, Boston; Department of Neurology (H.T.), Medical College of Wisconsin, Milwaukee; Department of Neurologic Surgery (R.K.), Mayo Clinic, Rochester, MN; Department of Radiology and Neurosurgery (J.J.H.), Stanford University, CA; and Department of Neurology (A.A.R.), Mayo Clinic, Rochester, MN
| | - Cem Bilgin
- From the Department of Radiology (H.K., S.G., C.B., M.A., R.K., W.B., D.F.K.), Mayo Clinic, Rochester, MN; College of Medicine (H.K.), Central Michigan University, Mount Pleasant; Department of Radiology (G.A.), Massachusetts General Hospital, Boston; Department of Neurology (H.T.), Medical College of Wisconsin, Milwaukee; Department of Neurologic Surgery (R.K.), Mayo Clinic, Rochester, MN; Department of Radiology and Neurosurgery (J.J.H.), Stanford University, CA; and Department of Neurology (A.A.R.), Mayo Clinic, Rochester, MN
| | - Hatem Tolba
- From the Department of Radiology (H.K., S.G., C.B., M.A., R.K., W.B., D.F.K.), Mayo Clinic, Rochester, MN; College of Medicine (H.K.), Central Michigan University, Mount Pleasant; Department of Radiology (G.A.), Massachusetts General Hospital, Boston; Department of Neurology (H.T.), Medical College of Wisconsin, Milwaukee; Department of Neurologic Surgery (R.K.), Mayo Clinic, Rochester, MN; Department of Radiology and Neurosurgery (J.J.H.), Stanford University, CA; and Department of Neurology (A.A.R.), Mayo Clinic, Rochester, MN
| | - Melika Amoukhteh
- From the Department of Radiology (H.K., S.G., C.B., M.A., R.K., W.B., D.F.K.), Mayo Clinic, Rochester, MN; College of Medicine (H.K.), Central Michigan University, Mount Pleasant; Department of Radiology (G.A.), Massachusetts General Hospital, Boston; Department of Neurology (H.T.), Medical College of Wisconsin, Milwaukee; Department of Neurologic Surgery (R.K.), Mayo Clinic, Rochester, MN; Department of Radiology and Neurosurgery (J.J.H.), Stanford University, CA; and Department of Neurology (A.A.R.), Mayo Clinic, Rochester, MN
| | - Ramanathan Kadirvel
- From the Department of Radiology (H.K., S.G., C.B., M.A., R.K., W.B., D.F.K.), Mayo Clinic, Rochester, MN; College of Medicine (H.K.), Central Michigan University, Mount Pleasant; Department of Radiology (G.A.), Massachusetts General Hospital, Boston; Department of Neurology (H.T.), Medical College of Wisconsin, Milwaukee; Department of Neurologic Surgery (R.K.), Mayo Clinic, Rochester, MN; Department of Radiology and Neurosurgery (J.J.H.), Stanford University, CA; and Department of Neurology (A.A.R.), Mayo Clinic, Rochester, MN
| | - Waleed Brinjikji
- From the Department of Radiology (H.K., S.G., C.B., M.A., R.K., W.B., D.F.K.), Mayo Clinic, Rochester, MN; College of Medicine (H.K.), Central Michigan University, Mount Pleasant; Department of Radiology (G.A.), Massachusetts General Hospital, Boston; Department of Neurology (H.T.), Medical College of Wisconsin, Milwaukee; Department of Neurologic Surgery (R.K.), Mayo Clinic, Rochester, MN; Department of Radiology and Neurosurgery (J.J.H.), Stanford University, CA; and Department of Neurology (A.A.R.), Mayo Clinic, Rochester, MN
| | - Jeremy J Heit
- From the Department of Radiology (H.K., S.G., C.B., M.A., R.K., W.B., D.F.K.), Mayo Clinic, Rochester, MN; College of Medicine (H.K.), Central Michigan University, Mount Pleasant; Department of Radiology (G.A.), Massachusetts General Hospital, Boston; Department of Neurology (H.T.), Medical College of Wisconsin, Milwaukee; Department of Neurologic Surgery (R.K.), Mayo Clinic, Rochester, MN; Department of Radiology and Neurosurgery (J.J.H.), Stanford University, CA; and Department of Neurology (A.A.R.), Mayo Clinic, Rochester, MN
| | - Alejandro A Rabinstein
- From the Department of Radiology (H.K., S.G., C.B., M.A., R.K., W.B., D.F.K.), Mayo Clinic, Rochester, MN; College of Medicine (H.K.), Central Michigan University, Mount Pleasant; Department of Radiology (G.A.), Massachusetts General Hospital, Boston; Department of Neurology (H.T.), Medical College of Wisconsin, Milwaukee; Department of Neurologic Surgery (R.K.), Mayo Clinic, Rochester, MN; Department of Radiology and Neurosurgery (J.J.H.), Stanford University, CA; and Department of Neurology (A.A.R.), Mayo Clinic, Rochester, MN
| | - David F Kallmes
- From the Department of Radiology (H.K., S.G., C.B., M.A., R.K., W.B., D.F.K.), Mayo Clinic, Rochester, MN; College of Medicine (H.K.), Central Michigan University, Mount Pleasant; Department of Radiology (G.A.), Massachusetts General Hospital, Boston; Department of Neurology (H.T.), Medical College of Wisconsin, Milwaukee; Department of Neurologic Surgery (R.K.), Mayo Clinic, Rochester, MN; Department of Radiology and Neurosurgery (J.J.H.), Stanford University, CA; and Department of Neurology (A.A.R.), Mayo Clinic, Rochester, MN
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9
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de Havenon A, Orlando C, Delic A, McNally JS, Majersik JJ, Harman T, Alexander M, Reddy V, Lyden S, Anzai Y. Direct cost analysis of rapid MRI in the emergency department evaluation of patients suspected of having acute ischemic stroke*. Neuroradiol J 2023; 36:142-147. [PMID: 35701745 PMCID: PMC10034695 DOI: 10.1177/19714009221108681] [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] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Abbreviated "rapid MRI" protocols have become more common for the evaluation of acute ischemic stroke (AIS). Prior research has not evaluated the effect of rapid MRIs on cost or hospital length of stay in AIS patients. METHODS We retrospectively identified AIS patients who presented within 6 h of acute neurologic symptom onset to an emergency department (ED) and activated a "brain attack" code. We included sequential patients from January 2012 to September 2015, before rapid MRI was available, who had CT perfusion (CTP) and compared them to patients from October 2015 to May 2018 who had a rapid MRI. We used inverse-probability-weighting (IPW) to balance the cohorts. The primary outcomes were direct cost to our healthcare system and total hospital length of stay (LOS). RESULTS We included 408 brain attack activations (mean ± SD age 62.1 ± 17.6 years, 47.8% male): 257 in the CTP cohort and 151 in the MRI cohort. Discharge diagnosis was ischemic stroke in 193/408 (47.3%). After patient matching, we found significant reductions for the MRI cohort in total cost (-18.7%, 95% CI -35.0, -2.4, p = 0.02) and hospital LOS (-17.0%, 95% CI -31.2, -2.8, p = 0.02), with no difference in ED LOS (p = 0.74) as compared to the CTP cohort. CONCLUSION Although these results are preliminary and hypothesis-generating, we found that the use of a rapid MRI protocol in emergency department brain attacks was associated with a 18.7% reduction in total direct cost and 17% reduction in hospital length of stay.
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Affiliation(s)
- Adam de Havenon
- Department of Neurology, Yale University, New Haven, CT, USA
| | - Chris Orlando
- Department of Neurology, University of Utah, Salt Lake City, UT, USA
| | - Alen Delic
- Department of Neurology, University of Utah, Salt Lake City, UT, USA
| | | | | | - Tyler Harman
- Department of Neurology, University of Utah, Salt Lake City, UT, USA
| | - Matthew Alexander
- Department of Radiology, University of Utah, Salt Lake City, UT, USA
| | - Vivek Reddy
- Department of Neurology, University of Utah, Salt Lake City, UT, USA
| | - Stephanie Lyden
- Department of Neurology, University of Utah, Salt Lake City, UT, USA
| | - Yoshimi Anzai
- Department of Radiology, University of Utah, Salt Lake City, UT, USA
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10
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Ahmed A, Hamam O, Niri SG, Oeltzchner G, Garg T, Elmandouh O, Intrapiromkul J, Yedavalli V. Computed tomography perfusion stroke mimics on RAPID commercial software: A case-based review. Brain Circ 2023; 9:68-76. [PMID: 37576575 PMCID: PMC10419735 DOI: 10.4103/bc.bc_100_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2022] [Revised: 02/17/2023] [Accepted: 03/01/2023] [Indexed: 08/15/2023] Open
Abstract
Acute ischemic stroke (AIS) is a leading cause of morbidity worldwide and can present with nonspecific symptoms, making diagnosis difficult. Many neurologic diseases present similarly to stroke; stroke mimics account for up to half of all hospital admissions for stroke. Stroke therapies carry risk, so accurate diagnosis of AIS is crucial for prompt treatment and prevention of adverse outcomes for patients with stroke mimics. Computed tomography (CT) perfusion techniques have been used to distinguish between nonviable tissue and penumbra. RAPID is an operator-independent, automated CT perfusion imaging software that can aid clinicians in diagnosing strokes quickly and accurately. In this case-based review, we demonstrate the applications of RAPID in differentiating between strokes and stroke mimics.
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Affiliation(s)
- Amara Ahmed
- Department of Clinical Sciences, Florida State University College of Medicine, Tallahassee, FL, USA
| | - Omar Hamam
- Division of Neuroradiology, Massachusetts General Hospital, Boston, MA, USA
| | | | | | - Tushar Garg
- Department of Radiology, Mayo Clinic, Jacksonville, FL, USA
| | - Omar Elmandouh
- Russell H. Morgan Department of Radiology and Radiological Science, Division of Neuroradiology, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
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11
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Xiong Q, Wang Y, Wang Z, Tang Y, Huang L, Kang J, Feng Z. Relationship between consciousness level and perfusion computed tomography in patients with prolonged disorders of consciousness. Aging (Albany NY) 2022; 14:9668-9678. [PMID: 36470667 PMCID: PMC9792208 DOI: 10.18632/aging.204417] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2022] [Accepted: 11/23/2022] [Indexed: 12/09/2022]
Abstract
PURPOSE We assessed the relationship between consciousness level and values of cerebral blood flow (CBF), cerebral blood volume (CBV), mean transit time (MTT), and time to peak (TTP) obtained by whole-brain perfusion computed tomography (pCT) in patients with prolonged disorders of consciousness (pDOC). METHODS This study included 29 patients in vegetative state (VS), 34 with minimally consciousness state minus (MCS-), and 13 with minimally consciousness state plus (MCS+). All patients were evaluated using the Coma Recovery Scale-Revised (CRS-R), the Glasgow Coma Scale (GCS), and the Full Outline of UnResponsiveness (FOUR). The values of CBF, CBV, MTT, and TTP were obtained from patients who underwent pCT. Differences in CBF, CBV, MTT, and TTP were compared between the three types of pDOC. Correlations between the CRS-R, GCS, and FOUR scores and the pCT results were analyzed. RESULTS Among the three groups, patients in VS showed a significantly decreased CBF in the bilateral frontal lobe, thalamus, temporal lobe, occipital lobe, brainstem, and damaged part. CBV was significantly reduced in patients with VS in the bilateral frontal lobe, thalamus, temporal lobe, brainstem, and damaged part. The total CRS-R, GCS, and FOUR scores were positively correlated with CBF, CBV, and TTP in almost all regions of interest. CONCLUSION Reductions in CBF and CBV calculated with pCT are associated with impaired consciousness and perfusion CT could be a promising tool in evaluating the conscious level in patients with pDOC.
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Affiliation(s)
- Qi Xiong
- Department of Rehabilitation Medicine, The First Affiliated Hospital of Nanchang University, Nanchang 330006, Jiangxi, P.R. China
| | - Yong Wang
- Department of Medical Oncology, The First Affiliated Hospital of Nanchang University, Nanchang 330006, Jiangxi, P.R. China
| | - Ziwen Wang
- Department of Rehabilitation Medicine, The First Affiliated Hospital of Nanchang University, Nanchang 330006, Jiangxi, P.R. China
| | - Yunliang Tang
- Department of Rehabilitation Medicine, The First Affiliated Hospital of Nanchang University, Nanchang 330006, Jiangxi, P.R. China
| | - Lianghua Huang
- Department of Rehabilitation Medicine, The First Affiliated Hospital of Nanchang University, Nanchang 330006, Jiangxi, P.R. China
| | - Junwei Kang
- Department of Rehabilitation Medicine, The First Affiliated Hospital of Nanchang University, Nanchang 330006, Jiangxi, P.R. China
| | - Zhen Feng
- Department of Rehabilitation Medicine, The First Affiliated Hospital of Nanchang University, Nanchang 330006, Jiangxi, P.R. China
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12
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Christensen EW, Pelzl CE, Hemingway J, Wang JJ, Sanmartin MX, Naidich JJ, Rula EY, Sanelli PC. Drivers of Ischemic Stroke Hospital Cost Trends Among Older Adults in the United States. J Am Coll Radiol 2022; 20:411-421. [PMID: 36357310 DOI: 10.1016/j.jacr.2022.09.026] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Revised: 09/08/2022] [Accepted: 09/19/2022] [Indexed: 11/09/2022]
Abstract
PURPOSE The increased use of neuroimaging and innovations in ischemic stroke (IS) treatment have improved outcomes, but the impact on median hospital costs is not well understood. METHODS A retrospective study was conducted using Medicare 5% claims data for 75,525 consecutive index IS hospitalizations for patients aged ≥65 years from 2012 to 2019 (values in 2019 dollars). IS episode cost was calculated in each year for trend analysis and stratified by cost components, including neuroimaging (CT angiography [CTA], CT perfusion [CTP], MRI, and MR angiography [MRA]), treatment (endovascular thrombectomy [EVT] and/or intravenous thrombolysis), and patient sociodemographic factors. Logistic regression was performed to analyze the drivers of high-cost episodes and median regression to assess drivers of median costs. RESULTS The median IS episode cost increased by 4.9% from $9,509 in 2012 to $9,973 in 2019 (P = .0021). Treatment with EVT resulted in the greatest odds of having a high-cost (>$20,000) hospitalization (odds ratio [OR], 71.86; 95% confidence interval [CI], 54.62-94.55), as did intravenous thrombolysis treatment (OR, 3.19; 95% CI, 2.90-3.52). Controlling for other factors, neuroimaging with CTA (OR, 1.72; 95% CI, 1.58-1.87), CTP (OR, 1.32; 95% CI, 1.14-1.52), and/or MRA (OR, 1.26; 95% CI, 1.15-1.38) had greater odds of having high-cost episodes than those without CTA, CTP, and MRA. Length of stay > 4 days (OR, 4.34; 95% CI, 3.99-4.72) and in-hospital mortality (OR, 1.85; 95% CI, 1.63-2.10) were also associated with high-cost episodes. CONCLUSIONS From 2012 to 2019, the median IS episode cost increased by 4.9%, with EVT as the main cost driver. However, the increasing treatment cost trends have been partially offset by decreases in median length of stay and in-hospital mortality.
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13
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Jalilianhasanpour R, Huntley JH, Alvin MD, Hause S, Ali N, Urrutia V, Ghazi Sherbaf F, Johnson PT, Yousem DM, Yedavalli V. Value of acute neurovascular imaging in patients with suspected transient ischemic attack. Eur J Radiol 2022; 154:110427. [DOI: 10.1016/j.ejrad.2022.110427] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Revised: 06/14/2022] [Accepted: 06/27/2022] [Indexed: 11/25/2022]
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Mormina E, Tessitore A, Cavallaro M, Caragliano AA, Buonomo O, Longo M, Granata F, Caponnetto M, Vinci SL. Magnetic Resonance Angiography and Cisternography fused images in acute ischemic stroke may save time during endovascular procedure revealing vessel anatomy. Heliyon 2022; 8:e10288. [PMID: 36046522 PMCID: PMC9421192 DOI: 10.1016/j.heliyon.2022.e10288] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2022] [Revised: 06/29/2022] [Accepted: 08/10/2022] [Indexed: 12/13/2022] Open
Abstract
Background and purpose Endovascular treatment (EVT) is a time-dependent procedure that aims to remove the arterial blood flow obstruction in brain vessels in acute ischemic stroke. In our center, the MRI patient selection protocol in acute ischemic stroke is performed with DWI, FLAIR, MR angiography (MRA) and MR cisternography (MRC) sequences. MRA and MRC are promptly and automatically fused in order to have a clear detection of vessel anatomy, before and during EVT. Our study aim is to evaluate if the fusion process between MRA and MRC could be considered time-safe and could influence EVT duration or outcome. Materials and methods 45 patients were retrospectively selected for the study and divided into 2 groups according to the presence of MRC sequence fused with MRA (Group 1) or not (Group 2 - controls). Results MRA and MRC fusion was able to depict vessel anatomy in all subjects of Group 1 (22 patients, 12 females; age 75.59 years ± 10.87). Group 1 presented EVT time reduction (p < 0.05;p = 0.040) (51.59 min ± 30.94) when compared to Group 2 (23 patients, 13 females; age 75.04 years ± 12.12) (71.96 min ± 34.55) of 20.37 min average. No differences between groups were detected evaluating: NIHSS at admission (p = 0.49) and discharge (p = 0.67), pre-stroke mRS (p = 0.89), mRS at 90 days (p = 0.62), ASPECT (p = 0.98) and ASPECT-DWI scores (p = 0.93), time from symptom onset to groin puncture (p = 0.80), thromboaspiration vs combined technique (p = 0.67), EVT success (p = 0.63). Conclusion Fusion of MRA and MRC is a safe and promising technique in promptly revealing vascular anatomy beyond vessel obstruction, and can play a role in EVT duration reduction.
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Affiliation(s)
- Enricomaria Mormina
- Department of Biomedical Sciences and Morphological and Functional Images, University of Messina, Messina, Italy
| | - Agostino Tessitore
- Department of Biomedical Sciences and Morphological and Functional Images, University of Messina, Messina, Italy
| | - Marco Cavallaro
- Department of Biomedical Sciences and Morphological and Functional Images, University of Messina, Messina, Italy
| | - Antonio Armando Caragliano
- Department of Biomedical Sciences and Morphological and Functional Images, University of Messina, Messina, Italy
| | - Orazio Buonomo
- Department of Biomedical Sciences and Morphological and Functional Images, University of Messina, Messina, Italy
| | - Mirta Longo
- Department of Biomedical Sciences and Morphological and Functional Images, University of Messina, Messina, Italy
| | - Francesca Granata
- Department of Biomedical Sciences and Morphological and Functional Images, University of Messina, Messina, Italy
| | - Michele Caponnetto
- Department of Biomedical Sciences and Morphological and Functional Images, University of Messina, Messina, Italy
| | - Sergio Lucio Vinci
- Department of Biomedical Sciences and Morphological and Functional Images, University of Messina, Messina, Italy
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15
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Hirai S, Sato H, Yamamura T, Kato K, Ishikawa M, Sagawa H, Aoyama J, Fujii S, Fujita K, Arai T, Sumita K. Correlation between the CT Perfusion Parameter Values and Response to Recanalization in Patients with Acute Ischemic Stroke. JOURNAL OF NEUROENDOVASCULAR THERAPY 2022; 16:577-585. [PMID: 37502670 PMCID: PMC10370711 DOI: 10.5797/jnet.oa.2022-0026] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/27/2022] [Accepted: 06/15/2022] [Indexed: 07/29/2023]
Abstract
Objective CT perfusion (CTP) provides various hemodynamic parameters. However, it is unclear which CTP parameters are useful in predicting clinical outcome in patients with acute ischemic stroke (AIS). Methods Between February 2019 and June 2021, patients with anterior circulation large-vessel occlusion who achieved successful recanalization within 8 hours after stroke onset were included. The relative CTP parameter values analyzed by the reformulated singular value decomposition (SVD) method in the affected middle cerebral artery territories compared to those in the unaffected side were calculated. In addition, the ischemic core volume (ICV) was evaluated using a Bayesian Vitrea. The final infarct volume (FIV) was assessed by 24-hour MRI. The correlation between these CTP-derived values and clinical outcome was assessed. Results Forty-two patients were analyzed. Among the CTP-related parameters, the ICV, relative cerebral blood volume (rCBV), and relative mean transit time (rMTT) showed a strong correlation with the FIV (ρ = 0.74, p <0.0001; ρ = -0.67, p <0.0001; and ρ = -0.66, p <0.0001, respectively). In multivariate analysis, rCBV, rMTT, and ICV were significantly associated with good functional outcome, which was defined as a modified Rankin Scale score ≤2 (OR, 6.87 [95% CI, 1.20-39.30], p = 0.0303; OR, 11.27 [95% CI, 0.97-130.94], p = 0.0269; and OR, 36.22 [95% CI, 2.78-471.18], p = 0.0061, respectively). Conclusion Among the CTP parameters analyzed by the SVD deconvolution algorithms, rCBV and rMTT could be useful imaging predictors of response to recanalization in patients with AIS, and the performances of these variables were similar to that of the ICV calculated by the Bayesian Vitrea.
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Affiliation(s)
- Sakyo Hirai
- Department of Endovascular Surgery, Tokyo Medical and Dental University, Tokyo, Japan
- Department of Neurosurgery, Soka Municipal Hospital, Soka, Saitama, Japan
| | - Hirotaka Sato
- Department of Radiological Technology, Soka Municipal Hospital, Soka, Saitama, Japan
| | - Toshihiro Yamamura
- Department of Neurosurgery, Soka Municipal Hospital, Soka, Saitama, Japan
| | - Koichi Kato
- Department of Radiological Technology, Soka Municipal Hospital, Soka, Saitama, Japan
| | - Mariko Ishikawa
- Department of Endovascular Surgery, Tokyo Medical and Dental University, Tokyo, Japan
| | - Hirotaka Sagawa
- Department of Endovascular Surgery, Tokyo Medical and Dental University, Tokyo, Japan
| | - Jiro Aoyama
- Department of Endovascular Surgery, Tokyo Medical and Dental University, Tokyo, Japan
| | - Shoko Fujii
- Department of Endovascular Surgery, Tokyo Medical and Dental University, Tokyo, Japan
| | - Kyohei Fujita
- Department of Endovascular Surgery, Tokyo Medical and Dental University, Tokyo, Japan
| | - Toshinari Arai
- Department of Radiological Technology, Soka Municipal Hospital, Soka, Saitama, Japan
| | - Kazutaka Sumita
- Department of Endovascular Surgery, Tokyo Medical and Dental University, Tokyo, Japan
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16
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Updated Trends, Disparities, and Clinical Impact of Neuroimaging Utilization in Ischemic Stroke in the Medicare Population: 2012 to 2019. J Am Coll Radiol 2022; 19:854-865. [PMID: 35483436 PMCID: PMC9308737 DOI: 10.1016/j.jacr.2022.03.008] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2021] [Revised: 03/12/2022] [Accepted: 03/18/2022] [Indexed: 12/30/2022]
Abstract
OBJECTIVE The purpose of this study was to update trends, investigate sociodemographic disparities, and evaluate the impact on mortality of stroke neuroimaging across the United States from 2012 to 2019. METHODS Retrospective cohort study using CMS Medicare 5% Research Identifiable Files, representing consecutive ischemic stroke emergency department or hospitalized patients aged ≥65 years. A total of 85,547 stroke episodes with demographic and clinical information were analyzed using Cochran-Mantel-Haenszel tests and logistic regression. Outcome measures were neuroimaging (CT angiography [CTA], CT perfusion [CTP], MRI, MR angiography [MRA]) utilization, acute treatment (endovascular thrombectomy [EVT] and intravenous thrombolysis [IVT]), and mortality while in the hospital and at 30 days and 1 year post discharge. RESULTS Significantly increasing utilization trends for CTA (250%), CTP (428%) and MRI (18%), and a decreasing trend for MRA (-33%) were observed from 2012 to 2019 (P < .0001). Controlling for covariates in the logistic regression models, CTA and CTP were significantly associated with higher EVT and IVT utilization. Although CTA, MRI, and MRA were associated with lower mortality, CTP was associated with higher mortality post discharge. Less neuroimaging was performed in rural patients; older patients (≥80 years) had lower utilization of CTA, MRI, and MRA; female patients had lower rates of CTA; and Black patients had lower utilization of CTA and CTP. CONCLUSIONS CTA and CTP utilization increased in the Medicare ischemic stroke population from 2012 to 2019 and both were associated with greater EVT and IVT use. However, disparities exist in neuroimaging utilization across all demographic groups, and further understanding of the root causes of these disparities will be crucial to achieving equity in stroke care.
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Cabral Frade H, Wilson SE, Beckwith A, Powers WJ. Comparison of Outcomes of Ischemic Stroke Initially Imaged With Cranial Computed Tomography Alone vs Computed Tomography Plus Magnetic Resonance Imaging. JAMA Netw Open 2022; 5:e2219416. [PMID: 35862046 PMCID: PMC9305377 DOI: 10.1001/jamanetworkopen.2022.19416] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
IMPORTANCE Patients with acute ischemic stroke often undergo magnetic resonance imaging (MRI) in addition to computed tomography (CT), but its association with clinical outcomes is uncertain. OBJECTIVE To assess whether clinical outcomes of patients with acute ischemic stroke with initial CT alone were noninferior to those with additional MRI. DESIGN, SETTING, AND PARTICIPANTS A retrospective observational propensity score-matched cohort study of clinical outcomes at discharge and 1 year for patients hospitalized with acute ischemic stroke was conducted at an academic medical center between January 2015 and December 2017. Data collection from an electronic medical record system performed from May 2020 through January 2022 was not completely blinded. Noninferiority margins were based on the designs of previous randomized clinical trials of ischemic stroke treatments. Statistical analysis was performed in January 2022. Participants were adults hospitalized with acute ischemic stroke with admission diagnosis based on CT. Exclusion criteria were primarily missing data. From 508 eligible patients, all 123 cases with additional MRI were propensity-score matched to 123 controls without. EXPOSURE MRI after initial diagnosis. MAIN OUTCOMES AND MEASURES Death or dependence at hospital discharge (modified Rankin Scale score of 3-6) and stroke or death occurring in survivors within 1 year after discharge. RESULTS Among 246 participants, the median age was 68 years (IQR, 58-78.8 years) and 131 (53.0%) were men. Death or dependence at discharge occurred more often in patients with additional MRI (59 of 123 [48.0%]) than in those with CT alone (52 of 123 [42.3%]; absolute difference, 5.7%; 95% CI, -6.7% to 18.1%), meeting the -7.50% criterion for noninferiority. Stroke or death within 1 year after discharge determined for 225 of 235 (96%) survivors occurred more often in patients with additional MRI (22 of 113 [19.5%]) than in those with CT alone (14 of 112 [12.5%]; relative risk, 1.14; 95% CI, 0.86-1.50), meeting the 0.725 relative risk criterion for noninferiority. CONCLUSIONS AND RELEVANCE This propensity score-matched cohort study of patients hospitalized with acute ischemic stroke found that a diagnostic imaging strategy of initial CT alone was noninferior to initial CT plus additional MRI with regard to clinical outcomes at discharge and at 1 year. Further research is needed to determine which patients hospitalized with acute ischemic stroke benefit from MRI.
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Affiliation(s)
- Heitor Cabral Frade
- Department of Neurology, the University of Texas Medical Branch at Galveston
| | - Susan E. Wilson
- Department of Neurology, University of North Carolina School of Medicine, Chapel Hill
| | - Anne Beckwith
- Department of Neurology, University of North Carolina School of Medicine, Chapel Hill
| | - William J. Powers
- Department of Neurology, University of North Carolina School of Medicine, Chapel Hill
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18
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Potential of Stroke Imaging Using a New Prototype of Low-Field MRI: A Prospective Direct 0.55 T/1.5 T Scanner Comparison. J Clin Med 2022; 11:jcm11102798. [PMID: 35628923 PMCID: PMC9147033 DOI: 10.3390/jcm11102798] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Revised: 05/06/2022] [Accepted: 05/13/2022] [Indexed: 12/05/2022] Open
Abstract
Objectives: Ischemic stroke is a leading cause of mortality and acquired disability worldwide and thus plays an enormous health-economic role. Imaging of choice is computed-tomographic (CT) or magnetic resonance imaging (MRI), especially diffusion-weighted (DW) sequences. However, MR imaging is associated with high costs and therefore has a limited availability leading to low-field-MRI techniques increasingly coming into focus. Thus, the aim of our study was to assess the potential of stroke imaging with low-field MRI. Material and Methods: A scanner comparison was performed including 27 patients (17 stroke cohort, 10 control group). For each patient, a brain scan was performed first with a 1.5T scanner and afterwards with a 0.55T scanner. Scan protocols were as identical as possible and optimized. Data analysis was performed in three steps: All DWI/ADC (apparent diffusion coefficient) and FLAIR (fluid attenuated inversion recovery) sequences underwent Likert rating with respect to image impression, resolution, noise, contrast, and diagnostic quality and were evaluated by two radiologists regarding number and localization of DWI and FLAIR lesions in a blinded fashion. Then segmentation of lesion volumes was performed by two other radiologists on DWI/ADC and FLAIR. Results: DWI/ADC lesions could be diagnosed with the same reliability by the most experienced reader in the 0.55T and 1.5T sequences (specificity 100% and sensitivity 92.9%, respectively). False positive findings did not occur. Detection of number/location of FLAIR lesions was mostly equivalent between 0.55T and 1.5T sequences. No significant difference (p = 0.789−0.104) for FLAIR resolution and contrast was observed regarding Likert scaling. For DWI/ADC noise, the 0.55T sequences were significantly superior (p < 0.026). Otherwise, the 1.5T sequences were significantly superior (p < 0.029). There was no significant difference in infarct volume and volume of infarct demarcation between the 0.55T and 1.5T sequences, when detectable. Conclusions: Low-field MRI stroke imaging at 0.55T may not be inferior to scanners with higher field strengths and thus has great potential as a low-cost alternative in future stroke diagnostics. However, there are limitations in the detection of very small infarcts. Further technical developments with follow-up studies must show whether this problem can be solved.
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Endovascular Thrombectomy for Acute Basilar Artery Occlusion: Latest Findings and Critical Thinking on Future Study Design. Transl Stroke Res 2022; 13:913-922. [PMID: 35349051 DOI: 10.1007/s12975-022-01008-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2022] [Revised: 03/11/2022] [Accepted: 03/14/2022] [Indexed: 10/18/2022]
Abstract
Randomized controlled trials (RCTs) have demonstrated powerful efficacy of endovascular thrombectomy (EVT) for large vessel occlusion in the anterior circulation. The effect of EVT for acute basilar artery occlusion (BAO) in the posterior circulation remains unproven. Here, we highlight the latest findings of observational studies and RCTs of EVT for BAO, with a focus on the predictors of functional outcomes, the limitations of recent RCTs, and critical thinking on future study design. Pooled data from large retrospective studies showed 36.4% favorable outcome at 3 months and 4.6% symptomatic intracranial hemorrhage (sICH). Multivariate logistic regression analysis revealed that higher baseline NIHSS score, pc-ASPECTS < 8, extensive baseline infarction, large pontine infarct, and sICH were independent predictors of poor outcome. Two recent randomized trial BEST (Endovascular treatment vs. standard medical treatment for vertebrobasilar artery occlusion) and BASICS (Basilar Artery International Cooperation Study) failed to demonstrate significant benefit of EVT within 6 or 8 h after stroke symptom onset. The limitations of these studies include slow enrollment, selection bias, high crossover rate, and inclusion of patients with mild deficit. To improve enrollment and minimize risk of diluting the overall treatment effect, futile recanalization and re-occlusion, optimal inclusion/exclusion criteria, including enrollment within 24 h of last known well, NIHSS score ≥ 10, pc-ASPECTS ≥ 8, no large pontine infarct, and the use of rescue therapy for underlying atherosclerotic stenosis, should be considered for future clinical trials.
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20
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Lin SY, Law KM, Yeh YC, Wu KC, Lai JH, Lin CH, Hsu WH, Lin CC, Kao CH. Applying Machine Learning to Carotid Sonographic Features for Recurrent Stroke in Patients With Acute Stroke. Front Cardiovasc Med 2022; 9:804410. [PMID: 35155629 PMCID: PMC8833232 DOI: 10.3389/fcvm.2022.804410] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2021] [Accepted: 01/04/2022] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Although carotid sonographic features have been used as predictors of recurrent stroke, few large-scale studies have explored the use of machine learning analysis of carotid sonographic features for the prediction of recurrent stroke. METHODS We retrospectively collected electronic medical records of enrolled patients from the data warehouse of China Medical University Hospital, a tertiary medical center in central Taiwan, from January 2012 to November 2018. We included patients who underwent a documented carotid ultrasound within 30 days of experiencing an acute first stroke during the study period. We classified these participants into two groups: those with non-recurrent stroke (those who has not been diagnosed with acute stroke again during the study period) and those with recurrent stoke (those who has been diagnosed with acute stroke during the study period). A total of 1,235 carotid sonographic parameters were analyzed. Data on the patients' demographic characteristics and comorbidities were also collected. Python 3.7 was used as the programming language, and the scikit-learn toolkit was used to complete the derivation and verification of the machine learning methods. RESULTS In total, 2,411 patients were enrolled in this study, of whom 1,896 and 515 had non-recurrent and recurrent stroke, respectively. After extraction, 43 features of carotid sonography (36 carotid sonographic parameters and seven transcranial color Doppler sonographic parameter) were analyzed. For predicting recurrent stroke, CatBoost achieved the highest area under the curve (0.844, CIs 95% 0.824-0.868), followed by the Light Gradient Boosting Machine (0.832, CIs 95% 0.813-0.851), random forest (0.819, CIs 95% 0.802-0.846), support-vector machine (0.759, CIs 95% 0.739-0.781), logistic regression (0.781, CIs 95% 0.764-0.800), and decision tree (0.735, CIs 95% 0.717-0.755) models. CONCLUSION When using the CatBoost model, the top three features for predicting recurrent stroke were determined to be the use of anticoagulation medications, the use of NSAID medications, and the resistive index of the left subclavian artery. The CatBoost model demonstrated efficiency and achieved optimal performance in the predictive classification of non-recurrent and recurrent stroke.
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Affiliation(s)
- Shih-Yi Lin
- Graduate Institute of Biomedical Sciences, College of Medicine, China Medical University, Taichung, Taiwan
- Division of Nephrology and Kidney Institute, China Medical University Hospital, Taichung, Taiwan
| | - Kin-Man Law
- Center of Augmented Intelligence in Healthcare, China Medical University Hospital, Taichung, Taiwan
- Department of Computer Science and Engineering, National Chung Hsing University, Taichung, Taiwan
| | - Yi-Chun Yeh
- Center of Augmented Intelligence in Healthcare, China Medical University Hospital, Taichung, Taiwan
| | - Kuo-Chen Wu
- Center of Augmented Intelligence in Healthcare, China Medical University Hospital, Taichung, Taiwan
- Graduate Institute of Biomedical Electronics and Bioinformatics, National Taiwan University, Taipei, Taiwan
| | - Jhih-Han Lai
- Division of Nephrology and Kidney Institute, China Medical University Hospital, Taichung, Taiwan
| | - Chih-Hsueh Lin
- Graduate Institute of Biomedical Sciences, College of Medicine, China Medical University, Taichung, Taiwan
- Department of Family Medicine, China Medical University Hospital, Taichung, Taiwan
| | - Wu-Huei Hsu
- Graduate Institute of Biomedical Sciences, College of Medicine, China Medical University, Taichung, Taiwan
- Division of Pulmonary and Critical Care Medicine, China Medical University Hospital and China Medical University, Taichung, Taiwan
| | - Cheng-Chieh Lin
- Graduate Institute of Biomedical Sciences, College of Medicine, China Medical University, Taichung, Taiwan
- Department of Family Medicine, China Medical University Hospital, Taichung, Taiwan
| | - Chia-Hung Kao
- Graduate Institute of Biomedical Sciences, College of Medicine, China Medical University, Taichung, Taiwan
- Center of Augmented Intelligence in Healthcare, China Medical University Hospital, Taichung, Taiwan
- Department of Nuclear Medicine and Positron Emission Tomography Center, China Medical University Hospital, Taichung, Taiwan
- Department of Bioinformatics and Medical Engineering, Asia University, Taichung, Taiwan
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21
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Boltyenkov AT, Martinez G, Pandya A, Katz JM, Wang JJ, Naidich JJ, Rula E, Sanelli PC. Cost-Consequence Analysis of Advanced Imaging in Acute Ischemic Stroke Care. Front Neurol 2021; 12:774657. [PMID: 34899583 PMCID: PMC8662622 DOI: 10.3389/fneur.2021.774657] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2021] [Accepted: 11/02/2021] [Indexed: 12/02/2022] Open
Abstract
Introduction: The purpose of this study was to illustrate the potential costs and health consequences of implementing advanced CT angiography and perfusion (CTAP) as the initial imaging in patients presenting with acute ischemic stroke (AIS) symptoms at a comprehensive stroke center (CSC). Methods: A decision-simulation model based on the American Heart Association's recommendations for AIS care pathways was developed to assess imaging strategies for a 5-year period from the institutional perspective. The following strategies were compared: (1) advanced CTAP imaging: NCCT + CTA + CT perfusion at the time of presentation; (2) standard-of-care: non-contrast CT (NCCT) at the time of presentation, with CT angiography (CTA) ± CT perfusion only in select patients (initial imaging to exclude hemorrhage and extensive ischemia) for mechanical thrombectomy (MT) evaluation. Model parameters were defined with evidence-based data. Cost-consequence and sensitivity analyses were performed. The modified Rankin Scale (mRS) at 90 days was used as the outcome measure. Results: The decision-simulation modeling revealed that adoption of the advanced CTAP imaging increased per-patient imaging costs by 1.19% ($9.28/$779.72), increased per-patient treatment costs by 33.25% ($729.96/$2,195.24), and decreased other per-patient acute care costs by 0.7% (–$114.12/$16,285.85). The large increase in treatment costs was caused by higher proportion of patients being treated. However, improved outcomes lowered the other per-patient acute care costs. Over the five-year period, advanced CTAP imaging led to 1.63% (66/4,040) more patients with good outcomes (90-day mRS 0-2), 2.23% (66/2,960) fewer patients with poor outcomes (90-day mRS 3-5), and no change in mortality (90-day mRS 6). Our CT equipment utilization analysis showed that the demand for CT equipment in terms of scanner time (minutes) was 24% lower in the advanced CTAP imaging strategy compared to the standard-of-care strategy. The number of EVT procedures performed at the CSC may increase by 50%. Conclusions: Our study reveals that adoption of advanced CTAP imaging at presentation increases the demand for treatment of acute ischemic stroke patients as more patients are diagnosed within the treatment time window compared to standard-of-care imaging. Advanced imaging also leads to more patients with good functional outcomes and fewer patients with dependent functional status.
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Affiliation(s)
- Artem T Boltyenkov
- Center for Health Innovations and Outcomes Research, Feinstein Institute for Medical Research, Manhasset, NY, United States.,Siemens Healthcare, Malvern, PA, United States.,Department of Radiology, Donald and Barbara Zucker School of Medicine at Hofstra-Northwell, Hempstead, NY, United States
| | - Gabriela Martinez
- Center for Health Innovations and Outcomes Research, Feinstein Institute for Medical Research, Manhasset, NY, United States.,Siemens Healthcare, Malvern, PA, United States.,Department of Radiology, Donald and Barbara Zucker School of Medicine at Hofstra-Northwell, Hempstead, NY, United States
| | - Ankur Pandya
- Department of Health Policy and Management, School of Public Health, Harvard University, Boston, MA, United States
| | - Jeffrey M Katz
- Department of Radiology, Donald and Barbara Zucker School of Medicine at Hofstra-Northwell, Hempstead, NY, United States.,Department of Neurology, Donald and Barbara Zucker School of Medicine at Hofstra-Northwell, Hempstead, NY, United States
| | - Jason J Wang
- Center for Health Innovations and Outcomes Research, Feinstein Institute for Medical Research, Manhasset, NY, United States
| | - Jason J Naidich
- Center for Health Innovations and Outcomes Research, Feinstein Institute for Medical Research, Manhasset, NY, United States.,Department of Radiology, Donald and Barbara Zucker School of Medicine at Hofstra-Northwell, Hempstead, NY, United States
| | - Elizabeth Rula
- Harvey L. Neiman Health Policy Institute, Reston, VA, United States
| | - Pina C Sanelli
- Center for Health Innovations and Outcomes Research, Feinstein Institute for Medical Research, Manhasset, NY, United States.,Department of Radiology, Donald and Barbara Zucker School of Medicine at Hofstra-Northwell, Hempstead, NY, United States
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22
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Katz JM, Wang JJ, Boltyenkov AT, Martinez G, O'Hara J, Feizullayeva C, Gribko M, Pandya A, Sanelli PC. Rescan Time Delays in Ischemic Stroke Imaging: A Retrospective Observation and Analysis of Causes and Clinical Impact. AJNR Am J Neuroradiol 2021; 42:1798-1806. [PMID: 34385142 DOI: 10.3174/ajnr.a7227] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2021] [Accepted: 05/03/2021] [Indexed: 01/08/2023]
Abstract
BACKGROUND AND PURPOSE Delays to reperfusion negatively impact outcomes of patients with ischemic stroke, yet current guidelines recommend selective sequential imaging for thrombectomy candidates. We aimed to quantify and analyze time delays associated with rescanning in sequential acute stroke imaging. MATERIALS AND METHODS This was a retrospective cohort study of consecutive patients with acute ischemic stroke who underwent imaging for treatment decision-making from January 1, 2017, to June 30, 2020. Rescan time delay was defined as ≥10-minute difference between initial NCCT and CTA ± CTP. Mean rescan time delays in comprehensive and primary stroke centers were compared. Bivariate and multivariable regression analyses assessed clinical and imaging factors associated with rescanning time delays and early outcomes. RESULTS A total of 588 patients with acute ischemic were included in statistical analyses. Rescanning occurred in 27.9% (164/588 patients), with a mean time delay of 53.7 (SD, 43.4) minutes. For patients presenting at primary compared with comprehensive stroke centers, rescan time delays were more common (59.6% versus 11.8%, P < .001), with longer delays (65.4 [SD, 45.4] minutes versus 23.6 [SD, 14.0] minutes, P < .001). Independent predictors of rescan time delays included primary stroke center presentation, intravenous thrombolysis administration, black race, admission NIHSS ≥10, baseline independent ambulation, and onset-to-comprehensive stroke center arrival in ≥6 hours. Protocols for early simultaneous comprehensive CT (NCCT + CTA + CTP) were associated with lower odds of time delays (OR = 0.34; 95% CI, 0.21-0.55). Rescanning was associated with lower odds of home discharge (OR = 0.53; 95% CI, 0.30-0.95). CONCLUSIONS A sequential approach to CT-based imaging may be significantly associated with prolonged acute stroke evaluations. Adoption of early simultaneous comprehensive CT could minimize treatment delays and improve outcomes.
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Affiliation(s)
- J M Katz
- From the Department of Neurology (J.M.K., M.G.), Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York
- Department of Radiology (J.M.K., A.T.B., G.M., P.C.S.), Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York
| | - J J Wang
- Feinstein Institutes for Medical Research (J.J.W., A.T.B., G.M. J.O., C.F., P.C.S.), Manhasset, New York
| | - A T Boltyenkov
- Department of Radiology (J.M.K., A.T.B., G.M., P.C.S.), Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York
- Feinstein Institutes for Medical Research (J.J.W., A.T.B., G.M. J.O., C.F., P.C.S.), Manhasset, New York
- Siemens Medical Solutions (A.T.B., G.M.), Malvern, Pennsylvania
| | - G Martinez
- Department of Radiology (J.M.K., A.T.B., G.M., P.C.S.), Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York
- Feinstein Institutes for Medical Research (J.J.W., A.T.B., G.M. J.O., C.F., P.C.S.), Manhasset, New York
- Siemens Medical Solutions (A.T.B., G.M.), Malvern, Pennsylvania
| | - J O'Hara
- Feinstein Institutes for Medical Research (J.J.W., A.T.B., G.M. J.O., C.F., P.C.S.), Manhasset, New York
| | - C Feizullayeva
- Feinstein Institutes for Medical Research (J.J.W., A.T.B., G.M. J.O., C.F., P.C.S.), Manhasset, New York
| | - M Gribko
- From the Department of Neurology (J.M.K., M.G.), Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York
| | - A Pandya
- Department of Health Policy and Management (A.P.), Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - P C Sanelli
- Department of Radiology (J.M.K., A.T.B., G.M., P.C.S.), Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York
- Feinstein Institutes for Medical Research (J.J.W., A.T.B., G.M. J.O., C.F., P.C.S.), Manhasset, New York
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23
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Amidon RF, Ordookhanian C, Vartanian T, Kaloostian P. Utilization of Cerebral Blood Flow Study With Computed Tomography for Subdural Hematoma Management. Cureus 2021; 13:e16314. [PMID: 34405072 PMCID: PMC8354623 DOI: 10.7759/cureus.16314] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/11/2021] [Indexed: 11/05/2022] Open
Abstract
Stroke is among the leading causes of death in the United States, and with our aging population, it will remain a pertinent obstacle in the acute setting. While the field of neuroradiology has advanced tremendously over the years, particularly in improving what we can visualize and quantify, the phrase “time is brain” yet dominates acute stroke management. Optimizing diagnostic protocols for suspected stroke requires a careful balance of data acquisition and speed, as well as taking into account available resources. We present a case of a middle-aged patient with notable risk factors for stroke presenting to the emergency department with altered mental status and suspected stroke. Radiography revealed a large subacute subdural hematoma (SDH) with a mild mass effect on the surface of the brain. The evaluation was supplemented by a computed tomography (CT) and perfusion cerebral blood flow (CBF) study indicating cortical ischemia with penumbra from the SDH compression. SDH evacuation was successfully performed, and patient recovery was achieved within the intensive care unit (ICU). Rapid data acquisition via CBF with CT imaging is crucial for guiding treatment decisions for SDHs. While protocols for ischemic stroke are well-established, SDH protocols are not studied. Thus, we discuss the value of a multimodal CT imaging approach, including CBF studies, in SDH evaluation.
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Affiliation(s)
- Ryan F Amidon
- Medicine, Medical College of Wisconsin, Milwaukee, USA
| | | | - Talia Vartanian
- Physical Medicine and Rehabilitation, University of Southern California, Los Angeles, USA
| | - Paul Kaloostian
- Neurological Surgery, Riverside Community Hospital, Riverside, USA.,Neurological Surgery, Paul Kaloostian M.D. Inc., Riverside, USA
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24
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Hoyer C, Szabo K. Pitfalls in the Diagnosis of Posterior Circulation Stroke in the Emergency Setting. Front Neurol 2021; 12:682827. [PMID: 34335448 PMCID: PMC8317999 DOI: 10.3389/fneur.2021.682827] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2021] [Accepted: 06/14/2021] [Indexed: 12/14/2022] Open
Abstract
Posterior circulation stroke (PCS), caused by infarction within the vertebrobasilar arterial system, is a potentially life-threatening condition and accounts for about 20–25% of all ischemic strokes. Diagnosing PCS can be challenging due to the vast area of brain tissue supplied by the posterior circulation and, as a consequence, the wide range of—frequently non-specific—symptoms. Commonly used prehospital stroke scales and triage systems do not adequately represent signs and symptoms of PCS, which may also escape detection by cerebral imaging. All these factors may contribute to causing delay in recognition and diagnosis of PCS in the emergency context. This narrative review approaches the issue of diagnostic error in PCS from different perspectives, including anatomical and demographic considerations as well as pitfalls and problems associated with various stages of prehospital and emergency department assessment. Strategies and approaches to improve speed and accuracy of recognition and early management of PCS are outlined.
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Affiliation(s)
- Carolin Hoyer
- Department of Neurology and Mannheim Center for Translational Neuroscience, University Medical Center Mannheim, Mannheim, Germany
| | - Kristina Szabo
- Department of Neurology and Mannheim Center for Translational Neuroscience, University Medical Center Mannheim, Mannheim, Germany
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25
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Turner AC, Zachrison KS. Utilization of Advanced Imaging for Acute Ischemic Stroke: The Ongoing Quest for Optimized Stroke Systems of Care. Circ Cardiovasc Qual Outcomes 2021; 14:e007845. [PMID: 33757309 DOI: 10.1161/circoutcomes.121.007845] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Ashby C Turner
- Departments of Neurology (A.C.T.), Massachusetts General Hospital, Harvard Medical School, Boston
| | - Kori S Zachrison
- Emergency Medicine (K.S.Z.), Massachusetts General Hospital, Harvard Medical School, Boston
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26
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Ranliang Hu, Kadom N. Radiology Operations-The Role of Cost-Effectiveness Studies in Decision Making. J Am Coll Radiol 2021; 18:841-842. [PMID: 33508226 DOI: 10.1016/j.jacr.2021.01.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2020] [Revised: 01/04/2021] [Accepted: 01/04/2021] [Indexed: 10/22/2022]
Affiliation(s)
- Ranliang Hu
- Associate Neuroradiology Fellowship Program Director, Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, Georgia
| | - Nadja Kadom
- Director of Quality, the Department of Radiology, Children's Healthcare of Atlanta, Atlanta, Georgia.
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