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Tu LH, Melnick E, Venkatesh AK, Sheth KN, Navaratnam D, Yaesoubi R, Forman HP, Mahajan A. Cost-Effectiveness of CT, CTA, MRI, and Specialized MRI for Evaluation of Patients Presenting to the Emergency Department With Dizziness. AJR Am J Roentgenol 2024; 222:e2330060. [PMID: 37937837 DOI: 10.2214/ajr.23.30060] [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] [Indexed: 11/09/2023]
Abstract
BACKGROUND. Underlying stroke is often misdiagnosed in patients presenting with dizziness. Although such patients are usually ineligible for acute stroke treatment, accurate diagnosis may still improve outcomes through selection of patients for secondary prevention measures. OBJECTIVE. The purpose of our study was to investigate the cost-effectiveness of differing neuroimaging approaches in the evaluation of patients presenting to the emergency department (ED) with dizziness who are not candidates for acute intervention. METHODS. A Markov decision-analytic model was constructed from a health care system perspective for the evaluation of a patient presenting to the ED with dizziness. Four diagnostic strategies were compared: noncontrast head CT, head and neck CTA, conventional brain MRI, and specialized brain MRI (including multiplanar high-resolution DWI). Differing long-term costs and outcomes related to stroke detection and secondary prevention measures were compared. Cost-effectiveness was calculated in terms of lifetime expenditures in 2022 U.S. dollars for each quality-adjusted life year (QALY); deterministic and probabilistic sensitivity analyses were performed. RESULTS. Specialized MRI resulted in the highest QALYs and was the most cost-effective strategy with US$13,477 greater cost and 0.48 greater QALYs compared with noncontrast head CT. Conventional MRI had the next-highest health benefit, although was dominated by extension with incremental cost of US$6757 and 0.25 QALY; CTA was also dominated by extension, with incremental cost of US$3952 for 0.13 QALY. Non-contrast CT alone had the lowest utility among the four imaging choices. In the deterministic sensitivity analyses, specialized MRI remained the most cost-effective strategy. Conventional MRI was more cost-effective than CTA across a wide range of model parameters, with incremental cost-effectiveness remaining less than US$30,000/QALY. Probabilistic sensitivity analysis yielded similar results as found in the base-case analysis, with specialized MRI being more cost-effective than conventional MRI, which in turn was more cost-effective than CTA. CONCLUSION. The use of MRI in patients presenting to the ED with dizziness improves stroke detection and selection for subsequent preventive measures. MRI-based evaluation leads to lower long-term costs and higher cumulative QALYs. CLINICAL IMPACT. MRI, incorporating specialized protocols when available, is the preferred approach for evaluation of patients presenting to the ED with dizziness, to establish a stroke diagnosis and to select patients for secondary prevention measures.
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Affiliation(s)
- Long H Tu
- Department of Radiology and Biomedical Imaging, Yale School of Medicine, 20 York St, New Haven, CT 06510
| | - Edward Melnick
- Department of Emergency Medicine, Yale School of Medicine, New Haven, CT
| | - Arjun K Venkatesh
- Department of Emergency Medicine, Yale School of Medicine, New Haven, CT
| | - Kevin N Sheth
- Department of Neurology, Yale School of Medicine, New Haven, CT
| | | | - Reza Yaesoubi
- Department of Health Policy and Management, Yale School of Public Health, New Haven, CT
| | - Howard P Forman
- Department of Radiology and Biomedical Imaging, Yale School of Medicine, 20 York St, New Haven, CT 06510
| | - Amit Mahajan
- Department of Radiology and Biomedical Imaging, Yale School of Medicine, 20 York St, New Haven, CT 06510
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Malhotra A, Khunte M, Wu X, Radmard M. Letter to the Editor Re "Endovascular thrombectomy or bridging therapy in minor ischemic stroke with large vessel occlusion". Thromb Res 2023; 232:145. [PMID: 36739257 DOI: 10.1016/j.thromres.2023.01.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2022] [Accepted: 01/06/2023] [Indexed: 01/26/2023]
Affiliation(s)
- Ajay Malhotra
- Department of Radiology and Biomedical Imaging, Yale School of Medicine, Box 208042, Tompkins East 2, 333 Cedar St, New Haven, CT 06520-8042, USA.
| | | | - Xiao Wu
- Department of Radiology and Biomedical Imaging, University of California at San Francisco, San Francisco, CA, USA
| | - Mahla Radmard
- Department of Radiology and Biomedical Imaging, Yale School of Medicine, New Haven, CT, USA
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Khunte M, Chen H, Khunte A, Payabvash S, Gandhi D, Malhotra A. Trends in Use of Intravenous Thrombolysis and Endovascular Thrombectomy in Patients With Acute Stroke With Large Vessel Occlusion 2016 to 2020 and Impact of COVID-19 Pandemic. J Am Heart Assoc 2023; 12:e029579. [PMID: 37889182 PMCID: PMC10727381 DOI: 10.1161/jaha.122.029579] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2023] [Accepted: 06/20/2023] [Indexed: 10/28/2023]
Affiliation(s)
- Mihir Khunte
- Warren Alpert Medical SchoolBrown UniversityProvidenceRIUSA
- Department of Radiology and Biomedical ImagingYale UniversityNew HavenCTUSA
| | - Huanwen Chen
- National Institute of Neurological Disorders and StrokeNational Institutes of HealthBethesdaMDUSA
- Division of Interventional Neuroradiology, Department of RadiologyUniversity of Maryland Medical CenterBaltimoreMDUSA
- Department of NeurologyGeorgetown University HospitalWashingtonDCUSA
| | - Akshay Khunte
- Department of Radiology and Biomedical ImagingYale UniversityNew HavenCTUSA
| | | | - Dheeraj Gandhi
- Division of Interventional Neuroradiology, Department of RadiologyUniversity of Maryland Medical CenterBaltimoreMDUSA
| | - Ajay Malhotra
- Department of Radiology and Biomedical ImagingYale UniversityNew HavenCTUSA
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Sanmartin MX, Katz JM, Wang J, Malhotra A, Sangha K, Bastani M, Martinez G, Sanelli PC. Cost-effectiveness of endovascular thrombectomy in acute stroke patients with large ischemic core. J Neurointerv Surg 2023; 15:e166-e171. [PMID: 36175016 DOI: 10.1136/jnis-2022-019460] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Accepted: 09/14/2022] [Indexed: 11/04/2022]
Abstract
BACKGROUND Evidence has shown that endovascular thrombectomy (EVT) treatment improves clinical outcomes. Yet, its benefit remains uncertain in patients with large established infarcts as defined by ASPECTS (Alberta Stroke Program Early CT Score) <6. This study evaluates the cost-effectiveness of EVT, compared with standard care (SC), in acute ischemic stroke (AIS) patients with ASPECTS 3-5. METHODS An economic evaluation study was performed combining a decision tree and Markov model to estimate lifetime costs (2021 US$) and quality-adjusted life years (QALYs) of AIS patients with ASPECTS 3-5. Incremental cost-effectiveness ratios (ICERs), net monetary benefits (NMBs), and deterministic one-way and two-way sensitivity analyses were performed. Probabilistic sensitivity analyses were also performed to evaluate the robustness of our model. RESULTS Compared with SC, the cost-effectiveness analyses revealed that EVT yields higher lifetime benefits (2.20 QALYs vs 1.41 QALYs) with higher lifetime healthcare cost per patient ($285 861 vs $272 954). The difference in health benefits between EVT and SC was 0.79 QALYs, equivalent to 288 additional days of healthy life per patient. Even though EVT is more costly than SC alone, it is still cost-effective given better outcomes with ICER of $16 239/QALY. The probabilistic sensitivity analyses indicated that EVT was the most cost-effective strategy in 98.8% (9882 of 10 000) of iterations at the willingness-to-pay threshold of $100 000 per QALY. CONCLUSIONS The results of this study suggest that EVT is cost-effective in AIS patients with a large ischemic core (ASPECTS 3-5), compared with SC alone over the patient's lifetime.
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Affiliation(s)
- Maria X Sanmartin
- Siemens Healthineers USA, Malvern, Pennsylvania, USA
- Imaging Clinical Effectiveness and Outcomes Research, Center for Health Innovations and Outcomes Research, Feinstein Institute for Medical Research, Manhasset, New York, USA
| | - Jeffrey M Katz
- Department of Neurosurgery, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, New York, USA
- Department of Radiology, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, New York, USA
| | - Jason Wang
- Department of Radiology, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, New York, USA
| | - Ajay Malhotra
- Department of Radiology and Biomedical Imaging, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Kinpritma Sangha
- Siemens Healthineers USA, Malvern, Pennsylvania, USA
- Imaging Clinical Effectiveness and Outcomes Research, Center for Health Innovations and Outcomes Research, Feinstein Institute for Medical Research, Manhasset, New York, USA
| | - Mehrad Bastani
- Imaging Clinical Effectiveness and Outcomes Research, Center for Health Innovations and Outcomes Research, Feinstein Institute for Medical Research, Manhasset, New York, USA
| | - Gabriela Martinez
- Imaging Clinical Effectiveness and Outcomes Research, Center for Health Innovations and Outcomes Research, Feinstein Institute for Medical Research, Manhasset, New York, USA
| | - Pina C Sanelli
- Imaging Clinical Effectiveness and Outcomes Research, Center for Health Innovations and Outcomes Research, Feinstein Institute for Medical Research, Manhasset, New York, USA
- Department of Radiology, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, New York, USA
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Radmard M, Wu X, Khunte M, Malhotra A. Factors associated with door-in-door-out times in large vessel occlusion stroke patients undergoing endovascular therapy. Am J Emerg Med 2023:S0735-6757(23)00316-9. [PMID: 37393131 DOI: 10.1016/j.ajem.2023.06.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2023] [Accepted: 06/13/2023] [Indexed: 07/03/2023] Open
Affiliation(s)
- Mahla Radmard
- Department of Radiology and Biomedical Imaging, Yale University, New Haven, CT, USA
| | - Xiao Wu
- Department of Radiology and Biomedical Imaging, University of California at San Francisco, USA
| | - Mihir Khunte
- Department of Radiology and Biomedical Imaging, Yale School of Medicine, USA.
| | - Ajay Malhotra
- Department of Radiology and Biomedical Imaging, Yale School of Medicine, Box 208042, Tompkins East 2, 333 Cedar St, New Haven, CT 06520-8042, USA.
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Du M, Qin C, Liu M, Liu J. Cost-Effectiveness Analysis of COVID-19 Inactivated Vaccines in Reducing the Economic Burden of Ischaemic Stroke after SARS-CoV-2 Infection. Vaccines (Basel) 2023; 11:957. [PMID: 37243061 PMCID: PMC10224220 DOI: 10.3390/vaccines11050957] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2023] [Revised: 04/24/2023] [Accepted: 05/06/2023] [Indexed: 05/28/2023] Open
Abstract
Due to significant economic burden and disability from ischaemic stroke and the relationship between ischaemic stroke and SARS-CoV-2 infection, we aimed to explore the cost-effectiveness of the two-dose inactivated COVID-19 vaccination program in reducing the economic burden of ischaemic stroke after SARS-CoV-2 infection. We constructed a decision-analytic Markov model to compare the two-dose inactivated COVID-19 vaccination strategy to the no vaccination strategy using cohort simulation. We calculated incremental cost-effectiveness ratios (ICERs) to evaluate the cost-effectiveness and used number of the ischaemic stroke cases after SARS-CoV-2 infection and quality-adjusted life-years (QALYs) to assess effects. Both one-way deterministic sensitivity analysis and probabilistic sensitivity analysis were performed to assess the robustness of the results. We found that the two-dose inactivated vaccination strategy reduced ischaemic stroke cases after SARS-CoV-2 infection by 80.89% (127/157) with a USD 1.09 million as vaccination program cost, saved USD 3675.69 million as direct health care costs and gained 26.56 million QALYs compared with no vaccination strategy among 100,000 COVID-19 patients (ICER < 0 per QALY gained). ICERs remained robust in sensitivity analysis. The proportion of older patients and the proportion of two-dose inactivated vaccination among older people were the critical factors that affected ICER. This study suggests the importance of COVID-19 vaccination is not only in preventing the spread of infectious diseases, but also in considering its long-term value in reducing the economic burden of non-communicable diseases such as ischaemic stroke after SARS-CoV-2 infection.
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Affiliation(s)
- Min Du
- Department of Epidemiology and Biostatistics, School of Public Health, Peking University, No. 38, Xueyuan Road, Haidian District, Beijing 100191, China
| | - Chenyuan Qin
- Department of Epidemiology and Biostatistics, School of Public Health, Peking University, No. 38, Xueyuan Road, Haidian District, Beijing 100191, China
| | - Min Liu
- Department of Epidemiology and Biostatistics, School of Public Health, Peking University, No. 38, Xueyuan Road, Haidian District, Beijing 100191, China
| | - Jue Liu
- Department of Epidemiology and Biostatistics, School of Public Health, Peking University, No. 38, Xueyuan Road, Haidian District, Beijing 100191, China
- Institute for Global Health and Development, Peking University, No. 5, Yiheyuan Road, Haidian District, Beijing 100871, China
- Department of Global Health and Population, Harvard TH Chan School of Public Health, 677 Huntington Avenue Boston, Boston, MA 02115, USA
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Regenhardt RW, Potter CA, Huang SS, Lev MH. Advanced Imaging for Acute Stroke Treatment Selection: CT, CTA, CT Perfusion, and MR Imaging. Radiol Clin North Am 2023; 61:445-456. [PMID: 36931761 DOI: 10.1016/j.rcl.2023.01.003] [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] [Indexed: 03/17/2023]
Abstract
There is constant evolution in the diagnosis and treatment of acute ischemic stroke due to advances in treatments, imaging, and outreach. Two major revolutions were the advent of intravenous thrombolysis in the 1990s and endovascular thrombectomy in 2010s. Neuroimaging approaches have also evolved with key goals-detect hemorrhage, augment thrombolysis treatment selection, detect arterial occlusion, estimate infarct core, estimate viable penumbra, and augment thrombectomy treatment selection. The ideal approach to diagnosis and treatment may differ depending on the system of care and available resources. Future directions include expanding indications for these treatments, including a shift from time-based to tissue-based selection.
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Affiliation(s)
- Robert W Regenhardt
- Massachusetts General Hospital, 55 Fruit Street, WAC 7-745, Boston, MA 02114, USA. https://twitter.com/rwregen
| | | | - Samuel S Huang
- Albany Medical College, 438 Waltham Street, Lexington, MA 02421, USA
| | - Michael H Lev
- Massachusetts General Hospital, 55 Fruit Street, WAC 7-745, Boston, MA 02114, USA
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8
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Malhotra A, Khunte M, Wu X, Radmard M. Letter to the Editor Regarding "Drip and Ship versus Mothership Model in the MCA Stroke: A Propensity-Matched Real World Analysis Through NIS Data". World Neurosurg 2023; 170:266. [PMID: 36782423 DOI: 10.1016/j.wneu.2022.09.098] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2022] [Accepted: 09/23/2022] [Indexed: 02/11/2023]
Affiliation(s)
- Ajay Malhotra
- Department of Radiology and Biomedical Imaging, Yale School of Medicine, New Haven, Connecticut, USA.
| | | | - Xiao Wu
- Department of Radiology and Biomedical Imaging, University of California at San Francisco, San Francisco, California, USA
| | - Mahla Radmard
- Department of Radiology and Biomedical Imaging, Yale University, New Haven, Connecticut, USA
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9
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Khunte M, Wu X, Koo A, Payabvash S, Matouk C, Heit JJ, Wintermark M, Albers GW, Sanelli PC, Gandhi D, Malhotra A. Cost-effectiveness of thrombectomy in patients with minor stroke and large vessel occlusion: effect of thrombus location on cost-effectiveness and outcomes. J Neurointerv Surg 2023; 15:39-45. [PMID: 35022300 DOI: 10.1136/neurintsurg-2021-018375] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2021] [Accepted: 12/18/2021] [Indexed: 12/16/2022]
Abstract
BACKGROUND To evaluate the cost-effectiveness of endovascular thrombectomy (EVT) to treat large vessel occlusion (LVO) in patients with acute, minor stroke (National Institute of Health Stroke Scale (NIHSS) <6) and impact of occlusion site. METHODS A Markov decision-analytic model was constructed accounting for both costs and outcomes from a societal perspective. Two different management strategies were evaluated: EVT and medical management. Base case analysis was done for three different sites of occlusion: proximal M1, distal M1 and M2 occlusions. One-way, two-way and probabilistic sensitivity analyses were performed. RESULTS Base-case calculation showed EVT to be the dominant strategy in 65-year-old patients with proximal M1 occlusion and NIHSS <6, with lower cost (US$37 229 per patient) and higher effectiveness (1.47 quality-adjusted life years (QALYs)), equivalent to 537 days in perfect health or 603 days in modified Rankin score (mRS) 0-2 health state. EVT is the cost-effective strategy in 92.7% of iterations for patients with proximal M1 occlusion using a willingness-to-pay threshold of US$100 000/QALY. EVT was cost-effective if it had better outcomes in 2%-3% more patients than intravenous thrombolysis (IVT) in absolute numbers (base case difference -16%). EVT was cost-effective when the proportion of M2 occlusions was less than 37.1%. CONCLUSIONS EVT is cost-effective in patients with minor stroke and LVO in the long term (lifetime horizon), considering the poor outcomes and significant disability associated with non-reperfusion. Our study emphasizes the need for caution in interpreting previous observational studies which concluded similar results in EVT versus medical management in patients with minor stroke due to a high proportion of patients with M2 occlusions in the two strategies.
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Affiliation(s)
- Mihir Khunte
- Department of Radiology and Biomedical Imaging, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Xiao Wu
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, California, USA
| | - Andrew Koo
- Department of Neurosurgery, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Seyedmehdi Payabvash
- Department of Radiology and Biomedical Imaging, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Charles Matouk
- Department of Neurosurgery, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Jeremy J Heit
- Radiology, Neuroadiology and Neurointervention Division, Stanford University, Stanford, California, USA
| | - Max Wintermark
- Department of Neuroradiology, MD Anderson, Houston, TX, USA
| | - Gregory W Albers
- Department of Neurology and Neurosurgery, Stanford University, Stanford, California, USA
| | - Pina C Sanelli
- Hofstra Northwell School of Medicine at Hofstra University, Hempstead, New York, USA
| | - Dheeraj Gandhi
- Department of Interventional Neuroradiology, University of Maryland, Baltimore, Maryland, USA
| | - Ajay Malhotra
- Department of Radiology and Biomedical Imaging, Yale University School of Medicine, New Haven, Connecticut, USA
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10
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Malhotra A, Khunte M, Wu X, Radmard M. Letter to the editor re "Minor stroke in large vessel occlusion: A matched analysis of patients from the German Stroke Registry-Endovascular Treatment and patients from the Safe Implementation of Treatments in Stroke-International Stroke Thrombolysis Register". Eur J Neurol 2023; 30:290-291. [PMID: 36260371 DOI: 10.1111/ene.15598] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2022] [Accepted: 10/07/2022] [Indexed: 01/02/2023]
Affiliation(s)
- Ajay Malhotra
- Department of Radiology and Biomedical Imaging, Yale University, New Haven, Connecticut, USA
| | | | - Xiao Wu
- Department of Radiology and Biomedical Imaging, University of California at San Francisco, San Francisco, California, USA
| | - Mahla Radmard
- Department of Radiology and Biomedical Imaging, Yale University, New Haven, Connecticut, USA
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Tu LH, Malhotra A, Venkatesh AK, Taylor RA, Sheth KN, Yaesoubi R, Forman HP, Sureshanand S, Navaratnam D. Clinical criteria to exclude acute vascular pathology on CT angiogram in patients with dizziness. PLoS One 2023; 18:e0280752. [PMID: 36893103 PMCID: PMC9997874 DOI: 10.1371/journal.pone.0280752] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2022] [Accepted: 01/06/2023] [Indexed: 03/10/2023] Open
Abstract
BACKGROUND Patients presenting to the emergency department (ED) with dizziness may be imaged via CTA head and neck to detect acute vascular pathology including large vessel occlusion. We identify commonly documented clinical variables which could delineate dizzy patients with near zero risk of acute vascular abnormality on CTA. METHODS We performed a cross-sectional analysis of adult ED encounters with chief complaint of dizziness and CTA head and neck imaging at three EDs between 1/1/2014-12/31/2017. A decision rule was derived to exclude acute vascular pathology tested on a separate validation cohort; sensitivity analysis was performed using dizzy "stroke code" presentations. RESULTS Testing, validation, and sensitivity analysis cohorts were composed of 1072, 357, and 81 cases with 41, 6, and 12 instances of acute vascular pathology respectively. The decision rule had the following features: no past medical history of stroke, arterial dissection, or transient ischemic attack (including unexplained aphasia, incoordination, or ataxia); no history of coronary artery disease, diabetes, migraines, current/long-term smoker, and current/long-term anti-coagulation or anti-platelet medication use. In the derivation phase, the rule had a sensitivity of 100% (95% CI: 0.91-1.00), specificity of 59% (95% CI: 0.56-0.62), and negative predictive value of 100% (95% CI: 0.99-1.00). In the validation phase, the rule had a sensitivity of 100% (95% CI: 0.61-1.00), specificity of 53% (95% CI: 0.48-0.58), and negative predictive value of 100% (95% CI: 0.98-1.00). The rule performed similarly on dizzy stroke codes and was more sensitive/predictive than all NIHSS cut-offs. CTAs for dizziness might be avoidable in 52% (95% CI: 0.47-0.57) of cases. CONCLUSIONS A collection of clinical factors may be able to "exclude" acute vascular pathology in up to half of patients imaged by CTA for dizziness. These findings require further development and prospective validation, though could improve the evaluation of dizzy patients in the ED.
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Affiliation(s)
- Long H. Tu
- Department of Radiology and Biomedical Imaging, Yale School of Medicine, New Haven, CT, United States of America
- * E-mail:
| | - Ajay Malhotra
- Department of Radiology and Biomedical Imaging, Yale School of Medicine, New Haven, CT, United States of America
| | - Arjun K. Venkatesh
- Department of Emergency Medicine, Yale School of Medicine, New Haven, CT, United States of America
| | - Richard A. Taylor
- Department of Emergency Medicine, Yale School of Medicine, New Haven, CT, United States of America
| | - Kevin N. Sheth
- Department of Neurology, Yale School of Medicine, New Haven, CT, United States of America
| | - Reza Yaesoubi
- Health Policy and Management, Yale School of Public Health, New Haven, CT, United States of America
| | - Howard P. Forman
- Department of Radiology and Biomedical Imaging, Yale School of Medicine, New Haven, CT, United States of America
| | - Soundari Sureshanand
- Yale Center for Clinical Investigation, Yale School of Medicine, New Haven, CT, United States of America
| | - Dhasakumar Navaratnam
- Department of Neurology, Yale School of Medicine, New Haven, CT, United States of America
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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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13
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Khunte M, Wu X, Avery EW, Gandhi D, Payabvash S, Matouk C, Heit JJ, Wintermark M, Albers GW, Sanelli P, Malhotra A. Impact of collateral flow on cost-effectiveness of endovascular thrombectomy. J Neurosurg 2022; 137:1801-1810. [PMID: 35535841 DOI: 10.3171/2022.2.jns212887] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2021] [Accepted: 02/07/2022] [Indexed: 01/29/2023]
Abstract
OBJECTIVE Acute ischemic stroke patients with large-vessel occlusion and good collateral blood flow have significantly better outcomes than patients with poor collateral circulation. The purpose of this study was to evaluate the cost-effectiveness of endovascular thrombectomy (EVT) based on collateral status and, in particular, to analyze its effectiveness in ischemic stroke patients with poor collaterals. METHODS A decision analysis study was performed with Markov modeling to estimate the lifetime quality-adjusted life-years (QALYs) and associated costs of EVT based on collateral status. The study was performed over a lifetime horizon with a societal perspective in the US setting. Base-case analysis was done for good, intermediate, and poor collateral status. One-way, two-way, and probabilistic sensitivity analyses were performed. RESULTS EVT resulted in greater effectiveness of treatment compared to no EVT/medical therapy (2.56 QALYs in patients with good collaterals, 1.88 QALYs in those with intermediate collaterals, and 1.79 QALYs in patients with poor collaterals), which was equivalent to 1050, 771, and 734 days, respectively, in a health state characterized by a modified Rankin Scale (mRS) score of 0-2. EVT also resulted in lower costs in patients with good and intermediate collaterals. For patients with poor collateral status, the EVT strategy had higher effectiveness and higher costs, with an incremental cost-effectiveness ratio (ICER) of $44,326/QALY. EVT was more cost-effective as long as it had better outcomes in absolute numbers in at least 4%-8% more patients than medical management. CONCLUSIONS EVT treatment in the early time window for good outcome after ischemic stroke is cost-effective irrespective of the quality of collateral circulation, and patients should not be excluded from thrombectomy solely on the basis of collateral status. Despite relatively lower benefits of EVT in patients with poor collaterals, even smaller differences in better outcomes have significant long-term financial implications that make EVT cost-effective.
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Affiliation(s)
- Mihir Khunte
- 1Department of Radiology and Biomedical Imaging, Yale University, New Haven, Connecticut
| | - Xiao Wu
- 2Department of Radiology and Biomedical Imaging, University of California, San Francisco, California
| | - Emily W Avery
- 1Department of Radiology and Biomedical Imaging, Yale University, New Haven, Connecticut
| | - Dheeraj Gandhi
- 3Department of Radiology, University of Maryland Medical Center, Baltimore, Maryland
| | - Seyedmehdi Payabvash
- 1Department of Radiology and Biomedical Imaging, Yale University, New Haven, Connecticut
| | - Charles Matouk
- 1Department of Radiology and Biomedical Imaging, Yale University, New Haven, Connecticut.,4Department of Neurosurgery, Yale University, New Haven, Connecticut
| | - Jeremy J Heit
- 5Department of Radiology.,6Department of Neurosurgery, and
| | | | - Gregory W Albers
- 6Department of Neurosurgery, and.,7Department of Neurology, Stanford University, Stanford, California; and
| | - Pina Sanelli
- 8Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Long Island, New York
| | - Ajay Malhotra
- 1Department of Radiology and Biomedical Imaging, Yale University, New Haven, Connecticut
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14
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The Value of CTA Based on Gold Nanorod Contrast Agent in Coronary Artery Diagnosis and Plaque Property Analysis. COMPUTATIONAL AND MATHEMATICAL METHODS IN MEDICINE 2021; 2021:5799133. [PMID: 34819991 PMCID: PMC8608500 DOI: 10.1155/2021/5799133] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/01/2021] [Accepted: 10/18/2021] [Indexed: 11/29/2022]
Abstract
Coronary CT angiography (CTA) with the characteristics of noninvasive and simple operation is widely used in the diagnosis of coronary artery stenosis. The choice of contrast agent exerts an important impact on the imaging quality of CTA. Conventional iodine contrast agents are easily excreted by the kidneys, from which the imaging window is short, and the imaging quality is poor. Metal nanomaterials have unique optical properties and have broad application prospects in imaging. Our aim is to explore the value of gold nanorod contrast agent in the diagnosis of coronary heart disease. A gold nanorod suspension was first prepared, and the prepared gold nanorod was uniform and had good dispersibility. It can be seen from the light absorption curve that there are two obvious peaks on the UV absorption peak of the gold nanorods. The gold nanorods were cultured in different solutions, and it was found that the particle size of the gold nanorods did not change significantly within 72 hours, indicating that the prepared gold nanorods had good stability. When observing the damage degree of mouse kidney tissue, it was shown that the damage degree of gold nanorod contrast agent to mouse kidney tissue was less than that of iodine contrast agent. The above results indicate that the gold nanorod contrast agent has good stability and safety. Therefore, our study demonstrated that the gold nanorod contrast agent has high value in the diagnosis of coronary arteries and the analysis of plaque properties.
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Head and Neck CTA Utilization: Analysis of Ordering Frequency and Nonroutine Results Communication, With Focus on the Fifty Most Common Emergency Department Clinical Presentations. AJR Am J Roentgenol 2021; 218:544-551. [PMID: 34585611 DOI: 10.2214/ajr.21.26543] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Background: Utilization of head and neck CTA in the emergency department (ED) has grown disproportionately to other neuroimaging examinations. Objective: To characterize utilization of head and neck CTA in the ED, comparing utilization and frequency of nonroutine results communication among patients' chief concerns. Methods: All adult ED visits for a single healthcare system from January 2014 to December 2017 were retrospectively reviewed. Variables recorded included chief concerns, whether head and neck CTA was performed, and, if so, whether the report documented nonroutine results communication. The fifty chief concerns resulting in the highest number of head and neck CTA examinations were identified. Frequencies of head and neck CTA ordering and of nonroutine results communication were calculated. A subset of reports documenting nonroutine communication were manually reviewed. Results: Head and neck CTA was ordered in 2.5% (17,903) of 708,145 ED visits in 236,476 patients (mean age 48.9±20.5 years; 110,952 male, 125,521 female, 3 unknown sex). Head and neck CTA was ordered for 833 distinct chief concerns. Nonroutine results communication was documented for 17.6% (31,55/17,903) of examinations. Among the fifty chief concerns associated with the highest number of examinations, frequency of ordering head and neck CTA ranged from <0.5% (five concerns) to 55.2% (stroke code), and frequency of nonroutine communication ranged from 5.6% (transient ischemic attack) to 67.5% (unresponsive). Chief concerns not among the fifty most common accounted for 50.0% (8956/17903) of examinations; these exhibited a collective frequency of nonroutine communication of 4.8% (429/8956). Manual review of 11.1% (350/3155) of reports with a nonroutine communication indicated an acute finding related to the indication in 51.1%, non-emergent but potentially explanatory finding in 28.0%, incidental finding in 28.0%, and communication of negative results in 6.9%. Conclusion: Head and neck CTA is ordered in 2.5% of ED visits for a wide range of chief concerns. Frequencies of ordering and of nonroutine results communication are highly variable among chief concerns. Acute indication-related findings account for half of nonroutine radiologist communications. Clinical Impact: Insight into patterns regarding head and neck CTA ordering and nonroutine results may help optimize patient selection and radiologist communications in the ED setting.
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Khunte M, Wu X, Payabvash S, Zhu C, Matouk C, Schindler J, Sanelli P, Gandhi D, Malhotra A. Cost-effectiveness of endovascular thrombectomy in patients with acute stroke and M2 occlusion. J Neurointerv Surg 2021; 13:784-789. [PMID: 33077578 DOI: 10.1136/neurintsurg-2020-016765] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2020] [Revised: 09/14/2020] [Accepted: 09/15/2020] [Indexed: 12/19/2022]
Abstract
BACKGROUND The cost-effectiveness of endovascular thrombectomy (EVT) in patients with acute ischemic stroke due to M2 branch occlusion remains uncertain. OBJECTIVE To evaluate the cost-effectiveness of EVT compared with medical management in patients with acute stroke presenting with M2 occlusion using a decision-analytic model. METHODS A decision-analytic study was performed with Markov modeling to estimate the lifetime quality-adjusted life years and associated costs of EVT-treated patients compared with no-EVT/medical management. The study was performed over a lifetime horizon with a societal perspective in the Unites States setting. Base case, one-way, two-way, and probabilistic sensitivity analyses were performed. RESULTS EVT was the long-term cost-effective strategy in 93.37% of the iterations in the probabilistic sensitivity analysis, and resulted in difference in health benefit of 1.66 QALYs in the 65-year-old age groups, equivalent to 606 days in perfect health. Varying the outcomes after both strategies shows that EVT was more cost-effective when the probability of good outcome after EVT was only 4-6% higher relative to medical management in clinically likely scenarios. EVT remained cost-effective even when its cost exceeded US$200 000 (threshold was US$209 111). EVT was even more cost-effective for 55-year-olds than for 65-year-old patients. CONCLUSION Our study suggests that EVT is cost-effective for treatment of acute M2 branch occlusions. Faster and improved reperfusion techniques would increase the relative cost-effectiveness of EVT even further in these patients.
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Affiliation(s)
- Mihir Khunte
- Department of Radiology and Biomedical Imaging, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Xiao Wu
- Department of Radiology and Biomedical Imaging, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Sam Payabvash
- Department of Radiology and Biomedical Imaging, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Chengcheng Zhu
- University of Washington School of Medicine, Seattle, Washington, USA
| | - Charles Matouk
- Department of Neurosurgery, Yale University, New Haven, Connecticut, USA
| | - Joseph Schindler
- Department of Neurology, Yale University, New Haven, Connecticut, USA
| | - Pina Sanelli
- Hofstra Northwell School of Medicine at Hofstra University, Hempstead, New York, USA
| | - Dheeraj Gandhi
- Department of Interventional Neuroradiology, University of Maryland, Baltimore, Maryland, USA
| | - Ajay Malhotra
- Department of Radiology and Biomedical Imaging, Yale University School of Medicine, New Haven, Connecticut, USA
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Minor Non-Disabling Stroke Patients with Large Vessel Severe Stenosis or Occlusion Might Benefit from Thrombolysis. Brain Sci 2021; 11:brainsci11070945. [PMID: 34356179 PMCID: PMC8306755 DOI: 10.3390/brainsci11070945] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2021] [Revised: 06/24/2021] [Accepted: 07/11/2021] [Indexed: 11/17/2022] Open
Abstract
Background: The benefit of alteplase in minor non-disabling acute ischemic stroke (AIS) is unknown. We aimed to explore the clinical efficacy of alteplase-treatment in minor non-disabling stroke in clinical practice. Methods: We used a prospectively collected database of AIS patients who were being assessed for thrombolysis with alteplase. Minor non-disabling AIS was identified as patients with baseline National Institutes of Health Stroke Scale (NIHSS) score ≤ 5 and a score 0 or 1 on each baseline NIHSS score item (items 1a to 1c being 0). Results: A total of 461 patients with minor non-disabling AIS were included and among them 240 (52.1%) patients were treated with alteplase and 113 (24.5%) patients had severe stenosis/occlusion of large vessels. No significant association of 90-day excellent outcome was found with alteplase-treatment (77.1% vs. 80.5%, p 1 = 0.425; OR 0.911, 95% CI 0.428 to 1.940; p 2 = 0.808). However, among patients with severe stenosis/occlusion of large vessels, alteplase-treatment was independently associated with excellent outcome (74.4% vs. 45.7%, p 1 = 0.005; OR 4.709, 95% CI 1.391 to 11.962; p 2 = 0.010). Conclusion: Although alteplase-treatment did not result in an excellent outcome in general minor non-disabling stroke patients, it may work in those specific patients who had severe stenosis/occlusion of large vessels.
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Controversies in Imaging of Patients with Acute Ischemic Stroke: AJR Expert Panel Narrative Review. AJR Am J Roentgenol 2021; 217:1027-1037. [PMID: 34106758 DOI: 10.2214/ajr.21.25846] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
The development of reperfusion therapies has profoundly impacted stroke care, initially with the advent of IV thrombolytic (IVT) treatment and, more recently, with the development and refinement of endovascular treatment (EVT). Progress in neuroimaging has supported the paradigm shift of stroke care, and advanced neuroimaging now has a fundamental role in triaging patients for both IVT and EVT. As the standard of care for acute ischemic stroke (AIS) evolves, controversies remain in certain clinical scenarios. This article explores the use of multimodality imaging for treatment selection of AIS in the context of recent guidelines, highlighting controversial topics and providing guidance for clinical practice. Results of major randomized trials supporting EVT are reviewed. Advantages and disadvantages of CT, CTA, MRI, and MRA in stroke diagnosis are summarized, with attention to level 1 evidence supporting the role of vascular imaging and perfusion imaging. Patient selection is compared between approaches based on time thresholds and physiologic approaches based on infarct core measurement using imaging. Moreover, various imaging approaches to core measurement are described. As ongoing studies push treatment boundaries, advanced imaging is expected to help identify a widening range of patients who may benefit from therapy.
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Liberman AL, Zhang H, Rostanski SK, Cheng NT, Esenwa CC, Haranhalli N, Singh P, Labovitz DL, Lipton RB, Prabhakaran S. Cost-Effectiveness of Advanced Neuroimaging for Transient and Minor Neurological Events in the Emergency Department. J Am Heart Assoc 2021; 10:e019001. [PMID: 34056914 PMCID: PMC8477874 DOI: 10.1161/jaha.120.019001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background Accurate diagnosis of patients with transient or minor neurological events can be challenging. Recent studies suggest that advanced neuroimaging can improve diagnostic accuracy in low-risk patients with transient or minor neurological symptoms, but a cost-effective emergency department diagnostic evaluation strategy remains uncertain. Methods and Results We constructed a decision-analytic model to evaluate 2 diagnostic evaluation strategies for patients with low-risk transient or minor neurological symptoms: (1) obtain advanced neuroimaging (magnetic resonance imaging brain and magnetic resonance angiography head and neck) on every patient or (2) current emergency department standard-of-care clinical evaluation with basic neuroimaging. Main probability variables were: proportion of patients with true ischemic events, strategy specificity and sensitivity, and recurrent stroke rate. Direct healthcare costs were included. We calculated incremental cost-effectiveness ratios, conducted sensitivity analyses, and evaluated various diagnostic test parameters primarily using a 1-year time horizon. Cost-effectiveness standards would be met if the incremental cost-effectiveness ratio was less than willingness to pay. We defined willingness to pay as $100 000 US dollars per quality-adjusted life year. Our primary and sensitivity analyses found that the advanced neuroimaging strategy was more cost-effective than emergency department standard of care. The incremental effectiveness of the advanced neuroimaging strategy was slightly less than the standard-of-care strategy, but the standard-of-care strategy was more costly. Potentially superior diagnostic approaches to the modeled advanced neuroimaging strategy would have to be >92% specific, >70% sensitive, and cost less than or equal to standard-of-care strategy's cost. Conclusions Obtaining advanced neuroimaging on emergency department patient with low-risk transient or minor neurological symptoms was the more cost-effective strategy in our model.
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Affiliation(s)
- Ava L Liberman
- Department of Neurology Albert Einstein College of MedicineMontefiore Medical Center Bronx NY
| | - Hui Zhang
- The Center for Health and the Social Sciences University of Chicago Chicago IL
| | - Sara K Rostanski
- Department of Neurology New York University Grossman School of Medicine New York NY
| | - Natalie T Cheng
- Department of Neurology Albert Einstein College of MedicineMontefiore Medical Center Bronx NY
| | - Charles C Esenwa
- Department of Neurology Albert Einstein College of MedicineMontefiore Medical Center Bronx NY
| | - Neil Haranhalli
- Department of Neurosurgery and Radiology Albert Einstein College of MedicineMontefiore Medical Center Bronx NY
| | - Puneet Singh
- Department of Medicine Albert Einstein College of MedicineMontefiore Medical Center Bronx NY
| | - Daniel L Labovitz
- Department of Neurology Albert Einstein College of MedicineMontefiore Medical Center Bronx NY
| | - Richard B Lipton
- Department of Neurology Albert Einstein College of MedicineMontefiore Medical Center Bronx NY
| | - Shyam Prabhakaran
- Department of Neurology University of Chicago School of Medicine Chicago IL
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Amukotuwa SA, Dehkharghani S. Letter by Amukotuwa and Dehkharghani Regarding Article, "Deep Learning Based Software to Identify Large Vessel Occlusion on Noncontrast Computed Tomography". Stroke 2021; 52:e61-e62. [PMID: 33493047 DOI: 10.1161/strokeaha.120.032604] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Shalini A Amukotuwa
- Diagnostic Imaging, Monash Health, Clayton, Australia (S.A.S).,Department of Radiology, Barwon Health, Geelong, Australia (S.A.S.)
| | - Seena Dehkharghani
- Department of Radiology, New York University Langone Medical Center (S.D.)
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Fasen BACM, Heijboer RJJ, Hulsmans FJH, Kwee RM. Diagnostic performance of single-phase CT angiography in detecting large vessel occlusion in ischemic stroke: A systematic review. Eur J Radiol 2020; 134:109458. [PMID: 33302028 DOI: 10.1016/j.ejrad.2020.109458] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2020] [Revised: 09/24/2020] [Accepted: 11/30/2020] [Indexed: 11/17/2022]
Abstract
PURPOSE To systematically review the diagnostic performance of single-phase CT angiography (CTA) in detecting intracranial large vessel occlusion (LVO). METHOD MEDLINE and Embase were searched for studies investigating the diagnostic performance of single-phase CTA in detecting LVO. Study quality was assessed. Sensitivity and specificity were calculated and meta-analyzed with a bivariate random-effects model. Heterogeneity was assessed with a chi-squared test. RESULTS Eleven studies were included. High risk of bias with regard to "patient selection", "reference standard", and "flow and timing" was present in 4, 1, and 2 studies, respectively. In 7 studies, it was unclear whether reference tests were interpreted blinded to CTA readings. There was variability in types of vessel segments analyzed, resulting in heterogeneous sensitivity and specificity (P < 0.05). Two studies provided data for the proximal anterior circulation (distal intracranial carotid artery, A1-, A2-, M1- and M2-segments), with pooled sensitivity of 88.4 % (95 % CI: 62.2-97.2 %) and pooled specificity of 98.5 % (95 % CI: 33.2-100 %). One study suggested that multiphase CTA improved agreement between nonexperts and an expert in detecting A1-, A2-, M1-, M2-, and M3-segment occlusions compared to single-phase CTA (ĸ = 0.72-0.76 vs. ĸ = 0.32-0.45). No other included study reported added value of advanced CTA (CT perfusion, 4D-CTA, or multiphase CTA) compared to single-phase CTA in detecting proximal anterior circulation LVO. CONCLUSION There is lack of high-quality studies on the diagnostic performance of single-phase CTA for LVO detection in the proximal anterior circulation. The added value of advanced CTA techniques in detecting proximal anterior circulation LVO is not completely clear yet.
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Affiliation(s)
- Bram A C M Fasen
- Department of Radiology, Zuyderland Medical Center, Heerlen/Sittard/Geleen, the Netherlands
| | - Roeland J J Heijboer
- Department of Radiology, Zuyderland Medical Center, Heerlen/Sittard/Geleen, the Netherlands
| | - Frans-Jan H Hulsmans
- Department of Radiology, Zuyderland Medical Center, Heerlen/Sittard/Geleen, the Netherlands
| | - Robert M Kwee
- Department of Radiology, Zuyderland Medical Center, Heerlen/Sittard/Geleen, the Netherlands.
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22
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Reddy ST, Friedman E, Wu TC, Arevalo O, Zhang J, Rahbar MH, Ankrom C, Indupuru HKR, Savitz SI. Rapid Infarct Progression in Anterior Circulation Large Vessel Occlusion Ischemic Stroke Patients During Inter-Facility Transfer. J Stroke Cerebrovasc Dis 2020; 29:105308. [PMID: 32992188 DOI: 10.1016/j.jstrokecerebrovasdis.2020.105308] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2020] [Revised: 08/21/2020] [Accepted: 09/06/2020] [Indexed: 11/30/2022] Open
Abstract
INTRODUCTION We aimed to identify factors associated with rapid infarct progression during inter-facility transfer for endovascular thrombectomy evaluation and its impact on clinical outcomes. METHODS Patients with anterior circulation large artery occlusion within 24 h of onset transferred within our 17 hospital tele-stroke network were retrospectively analyzed. Patients were divided into fast progressors and slow progressors. Fast progressors were defined as CT ASPECTS score of ≥6 at the referring hospital (RH) and <6 at the hub hospital. Good clinical outcomes were defined as modified Rankin Scale score (mRS) 0-2 at 90 days. Demographic, clinical and radiologic variables associated with fast progressors and good clinical outcomes were identified using multivariable regression models. RESULTS Among the 190 patients, 44 (23%) patients underwent rapid infarct progression. Higher stroke severity at presentation [aOR, 1.096, 95% CI,1.023, 1.174; p = 0.009], presence of early ischemic changes (CT ASPECT 6-9) at the RH [aOR, 2.721, 95% CI, 1.22, 6.071; p = 0.014] were positively associated, whereas prior ischemic stroke [aOR, 0.272, 95% CI, 0.078, 0.948; p = 0.04] and higher collateral score (2,3,4) [aOR, 0.138, 95%CI, 0.059, 0.324, p=<0.0001] were negatively associated with rapid infarct progression. Fifty-eight (31%) transferred patients had good outcomes. After adjusting for reperfusion status, age [aOR, 0.96, 95% CI, 0.93, 0.98; p=<0.001], initial stroke severity [aOR, 0.87, 95% CI, 0.81, 0.93; p=<0.001], absolute rate of decrease in CT ASPECTS [aOR, 0.38, 95% CI, 0.19, 0.77; p = 0.007] and internal carotid artery (ICA) occlusion [aOR, 0.34, 95 %CI, 0.12, 0.94; p = 0.038] were negatively associated with good outcome. CONCLUSION Higher stroke severity, presence of early ischemic changes at the referring facility, absence of prior stroke, and poor collateral scores (CS 0-1) are the factors associated with rapid infarct progression in the telemedicine transfer cohort. Increasing age, higher stroke severity, higher absolute decrease in CT ASPECTS and ICA occlusion determine poor clinical outcomes.
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Affiliation(s)
- Sujan T Reddy
- Department of Neurology, Institute for Stroke and Cerebrovascular Disease, University of Texas Health Science Center at Houston, United States; Institute for Stroke and Cerebrovascular Disease, University of Texas Health Science Center at Houston, United States.
| | - Elliott Friedman
- Department of Neuroradiology, University of Texas Health Science Center at Houston, United States
| | - Tzu-Ching Wu
- Department of Neurology, Institute for Stroke and Cerebrovascular Disease, University of Texas Health Science Center at Houston, United States; Institute for Stroke and Cerebrovascular Disease, University of Texas Health Science Center at Houston, United States
| | - Octavio Arevalo
- Department of Neuroradiology, University of Texas Health Science Center at Houston, United States
| | - Jing Zhang
- Department of Biostatistics and Data Science, University of Texas Health Science Center at Houston, United States
| | - Mohammad H Rahbar
- Department of Biostatistics and Data Science, University of Texas Health Science Center at Houston, United States
| | - Christy Ankrom
- Department of Neurology, Institute for Stroke and Cerebrovascular Disease, University of Texas Health Science Center at Houston, United States
| | - Hari Kishan Reddy Indupuru
- Institute for Stroke and Cerebrovascular Disease, University of Texas Health Science Center at Houston, United States
| | - Sean I Savitz
- Department of Neurology, Institute for Stroke and Cerebrovascular Disease, University of Texas Health Science Center at Houston, United States; Institute for Stroke and Cerebrovascular Disease, University of Texas Health Science Center at Houston, United States
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Reidler P, Puhr-Westerheide D, Rotkopf L, Fabritius MP, Feil K, Kellert L, Tiedt S, Rémi J, Liebig T, Kunz WG. Cerebral attenuation on single-phase CT angiography source images: Automated ischemia detection and morphologic outcome prediction after thrombectomy in patients with ischemic stroke. PLoS One 2020; 15:e0236956. [PMID: 32790766 PMCID: PMC7425881 DOI: 10.1371/journal.pone.0236956] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2020] [Accepted: 07/16/2020] [Indexed: 11/26/2022] Open
Abstract
Objectives Stroke triage using CT perfusion (CTP) or MRI gained importance after successful application in recent trials on late-window thrombectomy but is often unavailable and time-consuming. We tested the clinical value of software-based analysis of cerebral attenuation on Single-phase CT angiography source images (CTASI) as CTP surrogate in stroke patients. Methods Software-based automated segmentation and Hounsfield unit (HU) measurements for all regions of the Alberta Stroke Program Early CT Score (ASPECTS) on CTASI were performed in patients with large vessel occlusion stroke who underwent thrombectomy. To normalize values, we calculated relative HU (rHU) as ratio of affected to unaffected hemisphere. Ischemic regions, regional ischemic core and final infarction were determined on simultaneously acquired CTP and follow-up imaging as ground truth. Receiver operating characteristics analysis was performed to calculate the area-under-the-curve (AUC). Resulting cut-off values were used for comparison with visual analysis and to calculate an 11-point automated CTASI ASPECTS. Results Seventy-nine patients were included. rHU values enabled significant classification of ischemic involvement on CTP in all ten regions of the ASPECTS (each p<0.001, except M4-cortex p = 0.002). Classification of ischemic core and prediction of final infarction had best results in subcortical regions but produced lower AUC values with significant classification for all regions except M1, M3 and M5. Relative total hemispheric attenuation provided strong linear correlation with CTP total ischemic volume. Automated classification of regional ischemia on CTASI was significantly more accurate in most regions and provided better agreement with CTP cerebral blood flow ASPECTS than visual assessment. Conclusions Automated attenuation measurements on CTASI provide excellent performance in detecting acute ischemia as identified on CTP with improved accuracy compared to visual analysis. However, value for the approximation of ischemic core and morphologic outcome in large vessel occlusion stroke after thrombectomy was regionally dependent and limited. This technique has the potential to facilitate stroke imaging as sensitive surrogate for CTP-based ischemia.
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Affiliation(s)
- Paul Reidler
- Department of Radiology, University Hospital, LMU Munich, Munich, Germany
- * E-mail:
| | | | - Lukas Rotkopf
- Department of Radiology, University Hospital, LMU Munich, Munich, Germany
| | | | - Katharina Feil
- Department of Neurology, University Hospital, LMU Munich, Munich, Germany
- German Center for Vertigo and Balance Disorders, LMU Munich, Munich, Germany
| | - Lars Kellert
- Department of Neurology, University Hospital, LMU Munich, Munich, Germany
| | - Steffen Tiedt
- Institute for Stroke and Dementia Research, LMU Munich, Munich, Germany
| | - Jan Rémi
- Department of Neurology, University Hospital, LMU Munich, Munich, Germany
| | - Thomas Liebig
- Department of Neuroradiology, University Hospital, LMU Munich, Munich, Germany
| | - Wolfgang G. Kunz
- Department of Radiology, University Hospital, LMU Munich, Munich, Germany
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Yousem DM, Zhou A, Alvin MD. CT Angiography for Triage of Minor Stroke: Controversial Analysis. Radiology 2020; 296:E124-E125. [DOI: 10.1148/radiol.2020200755] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- David M. Yousem
- Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins University School of Medicine, 600 N Wolfe St, Phipps Basement B112D, Baltimore MD 21287
| | - Alice Zhou
- Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins University School of Medicine, 600 N Wolfe St, Phipps Basement B112D, Baltimore MD 21287
| | - Matthew D. Alvin
- Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins University School of Medicine, 600 N Wolfe St, Phipps Basement B112D, Baltimore MD 21287
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