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      Reliability of visual assessment of non-contrast CT, CT angiography source images and CT perfusion in patients with suspected ischemic stroke.

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          Abstract

          Good reliability of methods to assess the extent of ischemia in acute stroke is important for implementation in clinical practice, especially between observers with varying experience. Our aim was to determine inter- and intra-observer reliability of the 1/3 middle cerebral artery (MCA) rule and the Alberta Stroke Program Early CT Score (ASPECTS) for different CT modalities in patients suspected of acute ischemic stroke.

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          Perfusion-CT assessment of infarct core and penumbra: receiver operating characteristic curve analysis in 130 patients suspected of acute hemispheric stroke.

          Max Wintermark, Adam Flanders, Birgitta K. Velthuis … (2006)
          Different definitions have been proposed to define the ischemic penumbra from perfusion-CT (PCT) data, based on parameters and thresholds tested only in small pilot studies. The purpose of this study was to perform a systematic evaluation of all PCT parameters (cerebral blood flow, volume [CBV], mean transit time [MTT], time-to-peak) in a large series of acute stroke patients, to determine which (combination of) parameters most accurately predicts infarct and penumbra. One hundred and thirty patients with symptoms suggesting hemispheric stroke < or =12 hours from onset were enrolled in a prospective multicenter trial. They all underwent admission PCT and follow-up diffusion-weighted imaging/fluid-attenuated inversion recovery (DWI/FLAIR); 25 patients also underwent admission DWI/FLAIR. PCT maps were assessed for absolute and relative reduced CBV, reduced cerebral blood flow, increased MTT, and increased time-to-peak. Receiver-operating characteristic curve analysis was performed to determine the most accurate PCT parameter, and the optimal threshold for each parameter, using DWI/FLAIR as the gold standard. The PCT parameter that most accurately describes the tissue at risk of infarction in case of persistent arterial occlusion is the relative MTT (area under the curve=0.962), with an optimal threshold of 145%. The PCT parameter that most accurately describes the infarct core on admission is the absolute CBV (area under the curve=0.927), with an optimal threshold at 2.0 ml x 100 g(-1). In a large series of 130 patients, the optimal approach to define the infarct and the penumbra is a combined approach using 2 PCT parameters: relative MTT and absolute CBV, with dedicated thresholds.
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            Systematic comparison of perfusion-CT and CT-angiography in acute stroke patients.

            Songling Liu, Felix Adler, Eric Tan … (2007)
            To systematically evaluate the accuracy of noncontrast computed tomography (NCT), perfusion computed tomography (PCT), and computed tomographic angiography (CTA) in determining site of occlusion, infarct core, salvageable brain tissue, and collateral flow in a large series of patients suspected of acute stroke. We retrospectively identified all consecutive patients with signs and symptoms suggesting hemispheric stroke of < 48 hours in duration who were evaluated on admission by NCT, PCT, and CTA, and underwent a follow-up CT/CTA or magnetic resonance imaging (MRI) and magnetic resonance angiography (MRA) within 6 months of initial imaging. Two neuroradiologists evaluated NCT for hypodensity, PCT for infarct core and salvageable brain tissue, and CTA source images and maximal intensity projections for site of occlusion, infarct core, and collateral flow. Follow-up CTA and MRA were assessed for persistent arterial occlusion or recanalization. Follow-up CT and MRI were reviewed for final infarct location and volume, and used as a gold standard to calculate sensitivity (SE) and specificity (SP) of initial imaging. A total of 113 patients were considered for analysis, including 55 patients with a final diagnosis of stroke. CTA source images were the most accurate technique in the detection of the site of occlusion (SE = 95%; SP = 100%). Decreased cerebral blood volume on PCT was the most accurate predictor of final infarct volume (SE = 80%; SP = 97%), Increased mean transit time on PCT was predictive of the tissue at risk for infarction in patients with persistent arterial occlusion. CTA maximal intensity projections was the best technique to quantify the degree of collateral circulation. The most accurate assessment of the site of occlusion, infarct core, salvageable brain tissue, and collateral circulation in patients suspected of acute stroke is afforded by a combination of PCT and CTA.
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              Acute stroke: usefulness of early CT findings before thrombolytic therapy.

              R Holle, E Bluhmki, C Manelfe … (1997)
              To determine whether the extent of subtle parenchymal hypoattenuation detected on computed tomographic (CT) scans obtained within 6 hours of ischemic stroke is a factor in predicting patients' response to thrombolytic treatment. The baseline CT scans of 620 patients, who received either recombinant tissue plasminogen activator (rt-PA) or a placebo, in a double-blind, randomized multicenter trial were prospectively evaluated and assigned to one of three categories according to the extent of parenchymal hypoattenuation: none, 33% or less (small), or more than 33% (large) of the middle cerebral artery territory. The association between the extent of hypoattenuation on the baseline CT scans and the clinical outcome in the placebo-treated and the rt-PA-treated groups after 3 months was analyzed. In 215 patients with a small hypoattenuating area, treatment increased the chance of good outcome. In 336 patients with a normal CT scan and in 52 patients with a large hypoattenuating area, rt-PA had no beneficial effect but increased the risk for fatal brain hemorrhage. The response to rt-PA in patients with ischemic stroke can be predicted on the basis of initial CT findings of the extent of parenchymal hypoattenuation in the territory of the middle cerebral artery.
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                Author and article information

                Journal
                Journal ID (iso-abbrev): PLoS ONE
                Title: PloS one
                Publisher: Public Library of Science (PLoS)
                ISSN (Electronic): 1932-6203
                ISSN (Print): 1932-6203
                Publication date (Electronic): 2013
                Volume: 8
                Issue: 10
                Affiliations
                [1 ] Department of Radiology, University Medical Center Utrecht, Utrecht, The Netherlands.
                Article
                Publisher Item ID: PONE-D-13-22346
                DOI: 10.1371/journal.pone.0075615
                PMC ID: 3792960
                PubMed ID: 24116061
                SO-VID: 3672fc57-8468-4a25-a29c-e4a1c1c452b7
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