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Mobile Stroke Unit Computed Tomography Angiography Substantially Shortens Door-to-Puncture Time.

ABSTRACT: Background and Purpose- Endovascular thrombectomy (ET) door-to-puncture time (DTPT) is a modifiable metric. One of the most important, yet time-consuming steps, is documentation of large vessel occlusion by computed tomography angiography (CTA). We hypothesized that obtaining CTA on board a Mobile Stroke Unit and direct alert of the ET team shortens DTPT by over 30 minutes. Methods- We compared DTPT between patients having CTA onboard the Mobile Stroke Unit then subsequent ET from September 2018 to November 2019 and patients in Mobile Stroke Unit from August 2014 to August 2018, when onboard CTA was not yet being used. We also correlated DTPT with change in National Institutes of Health Stroke Scale between baseline and 24 hours. Results- Median DTPT was 53.5 (95% CI, 35-67) minutes shorter with onboard CTA and direct ET team notification: 41 minutes (interquartile range, 30.0-63.5) versus 94.5 minutes (interquartile range, 69.8-117.3; P<0.001). Median on-scene time was 31.5 minutes (interquartile range, 28.8-35.5) versus 27.0 minutes (interquartile range, 23.0-31.0) (P<0.001). Shorter DTPT correlated with greater improvement of National Institutes of Health Stroke Scale (correlation=-0.2, P=0.07). Conclusions- Prehospital Mobile Stroke Unit management including on-board CTA and ET team alert substantially shortens DTPT. Registration- URL: https://clinicaltrials.gov; Unique identifier: NCT02190500.

SUBMITTER: Czap AL

PROVIDER: S-EPMC7188560 | biostudies-literature | 2020 May

REPOSITORIES: biostudies-literature

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Mobile Stroke Unit Computed Tomography Angiography Substantially Shortens Door-to-Puncture Time.

Czap Alexandra L AL Singh Noopur N Bowry Ritvij R Jagolino-Cole Amanda A Parker Stephanie A SA Phan Kenny K Wang Mengxi M Sheth Sunil A SA Rajan Suja S SS Yamal Jose-Miguel JM Grotta James C JC

Stroke 20200416 5

Background and Purpose- Endovascular thrombectomy (ET) door-to-puncture time (DTPT) is a modifiable metric. One of the most important, yet time-consuming steps, is documentation of large vessel occlusion by computed tomography angiography (CTA). We hypothesized that obtaining CTA on board a Mobile Stroke Unit and direct alert of the ET team shortens DTPT by over 30 minutes. Methods- We compared DTPT between patients having CTA onboard the Mobile Stroke Unit then subsequent ET from September 2018 ...[more]

PMID: 32295510

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Project description:AimTo improve delivery of acute therapies for acute ischaemic stroke (AIS).MethodWe identified factors influencing the speed of diagnosis and delivery of acute therapies in a prospective cohort of 21 children with suspected AIS (eight with AIS, 13 stroke mimics) and explored them in a retrospective cohort with confirmed AIS.ResultsApproximately half of the prospective and total AIS cohorts presented with acute, sustained hemiparesis, and were diagnosed relatively quickly. AIS was suspected and diagnosed more slowly in the half presenting with symptoms other than sustained hemiparesis. Thirty-one out of 51 patients with AIS (19 females, 32 males, mean age 8 years 6 months, SD 5 years 4 months) had arterial abnormalities identified by computed tomography angiography (CTA) or magnetic resonance angiography (MRA): 11 with large vessel occlusion, six with dissection, five with moyamoya disease, nine with other arteriopathies. Among these patients, those initially imaged with CTA were diagnosed more quickly than those with initial magnetic resonance imaging/angiography, which facilitated thrombectomy and thrombolytic therapy. Twenty out of 51 had AIS without arterial abnormalities on CTA or MRA: eight with lenticulostriate vasculopathy and 12 with other small-vessel AIS. Among these patients, 80% were ineligible for thrombolysis for reasons beyond delay to diagnosis, and all showed good outcomes with supportive treatments alone.InterpretationClinical features at presentation influence rapidity with which childhood AIS is suspected and diagnosed. Readily available CTA can direct thrombectomy in patients with large vessel occlusion and thrombolysis in most, but not all, eligible patients.What this paper addsChildren with acute ischaemic stroke (AIS) commonly present with symptoms other than sustained hemiparesis. Stroke is more slowly recognized in these patients, which limits potential therapies. Computed tomography angiography (CTA) accurately identifies AIS with large vessel occlusion, enabling timely endovascular thrombectomy. CTA is sufficient to direct thrombolytic therapy in most eligible children. Most childhood AIS without arterial abnormalities identified by CTA had good outcomes.

Project description:OBJECTIVE:To compare assessment of collaterals by single-phase computed tomography (CT) angiography (CTA) and CT perfusion-derived 3-phase CTA, multiphase CTA and temporal maximum-intensity projection (tMIP) images to digital subtraction angiography (DSA), and relate collateral assessments to clinical outcome in patients with acute ischemic stroke. METHODS:Consecutive acute ischemic stroke patients who underwent CT perfusion, CTA, and DSA before thrombectomy with occlusion of the internal carotid artery, the M1 or the M2 segments were included. Two observers assessed all CT images and one separate observer assessed DSA (reference standard) with static and dynamic (modified American Society of Interventional and Therapeutic Neuroradiology) collateral grading methods. Interobserver agreement and concordance were quantified with Cohen-weighted ? and concordance correlation coefficient, respectively. Imaging assessments were related to clinical outcome (modified Rankin Scale, ? 2). RESULTS:Interobserver agreement (n = 101) was 0.46 (tMIP), 0.58 (3-phase CTA), 0.67 (multiphase CTA), and 0.69 (single-phase CTA) for static assessments and 0.52 (3-phase CTA) and 0.54 (multiphase CTA) for dynamic assessments. Concordance correlation coefficient (n = 80) was 0.08 (3-phase CTA), 0.09 (single-phase CTA), and 0.23 (multiphase CTA) for static assessments and 0.10 (3-phase CTA) and 0.27 (multiphase CTA) for dynamic assessments. Higher static collateral scores on multiphase CTA (odds ratio [OR], 1.7; 95% confidence interval [CI], 1.1-2.7) and tMIP images (OR, 2.0; 95% CI, 1.1-3.4) were associated with modified Rankin Scale of 2 or less as were higher modified American Society of Interventional and Therapeutic Neuroradiology scores on 3-phase CTA (OR, 1.5; 95% CI, 1.1-2.2) and multiphase CTA (OR, 1.7; 95% CI, 1.1-2.6). CONCLUSIONS:Concordance between assessments on CT and DSA was poor. Collateral status evaluated on 3-phase CTA and multiphase CTA, but not on DSA, was associated with clinical outcome.

Project description:BackgroundIdentifying cardioembolic stroke is important for the decision-making of endovascular treatment and anticoagulation therapy. We aimed to explore the features of cardioembolic stroke on 4-dimensional (4D) computed tomography angiography (4D-CTA) and assess whether these features can assist in classifying stroke etiology.MethodsIn this retrospective study, we analyzed the images of 294 patients with acute ischemic stroke (AIS) from July 2020 to February 2022 at the First Affiliated Hospital of Chongqing Medical University, which had been consecutively collected. The data of 110 patients with occlusion of the M1/M2 segment of the middle cerebral artery (MCA) with/without intracranial internal carotid artery (ICA) occlusion were analyzed to calculate the clot burden score (CBS) and collateral score (CS), and the data of 88 patients with a clear origin and distal part were analyzed to measure clot length. Maximum intensity projection (MIP) and time MIP (tMIP) post-processing were used to assess the clot features. The Mann-Whitney U test was used to compare the clot characteristics between the 2 groups. Binary logistic regression was performed to assess the association between the image characteristics and cardioembolic stroke. Moreover, the receiver operating characteristic (ROC) curve was used to test the diagnostic efficacy of MIP/tMIP clot features in classifying cardioembolic stroke.ResultsAge, high-risk factors for cerebrovascular disease, high/medium-risk sources of cardioembolic stroke, clot length, CBS, and CS were significantly different between the cardioembolic stroke group and non-cardioembolic stroke group (P<0.05). In the cardioembolic stroke group, the median MIP and tMIP clot length was 12 mm [interquartile range (IQR), 8.3-17.4 mm] and 9.3 mm (IQR, 6.8-14.3 mm), respectively. In the non-cardioembolic stroke group, the median MIP and tMIP clot length was 6.5 mm (IQR, 4.7-11.5 mm) and 5.8 mm (IQR, 3.9-10.6 mm), respectively. Binary logistic regression showed that cardioembolic stroke was significantly associated with MIP-clot length [odds ratio (OR), 1.15; 95% confidence interval (CI): 1.02-1.29; P<0.05], tMIP-clot length (OR, 1.18; 95% CI: 1.02-1.36; P<0.05), and tMIP-CBS (OR, 3.96; 95% CI: 1.08-14.58; P<0.05). The area under the ROC curve (AUC) values of MIP clot length for identifying cardioembolic stroke were 0.75 (95% CI: 0.65-0.84, P<0.05), with a cut-off value of >7.4 mm [sensitivity: 84.62% (95% CI: 69.50-94.10%); specificity: 59.18% (95% CI: 44.20-73.00%)]. The AUC value of tMIP clot length was 0.72 (95% CI: 0.61-0.81, P<0.05), with a cut-off value of >5.4 mm [sensitivity: 92.31% (95% CI: 79.10-98.40%); specificity: 48.98% (95% CI: 34.40-63.70%)].ConclusionsClot length and CBS were overestimated on MIP images. Among the clot characteristics, clot length could identify cardioembolic stroke.

Project description:Background and Purpose- Cervicocerebral vascular calcification on computed tomography angiography is a known sign of advanced atherosclerosis. However, the clinical significance of calcification pattern remains unclear. In this study, we aimed to investigate the potential association between spotty calcium and acute ischemic stroke. Methods- This study included patients with first-time nonlacunar ischemic stroke (N=50) confirmed by brain magnetic resonance imaging or nonenhanced head computed tomography, as well as control subjects with asymptomatic carotid atherosclerosis (N=50) confirmed by carotid ultrasonography. Subjects in both groups underwent contrast-enhanced cervicocerebral computed tomography angiography within a week after the initial imaging examination. Spotty calcification was evaluated at 11 arterial segments commonly affected by atherosclerosis along the carotid and vertebrobasilar circulation. Statistical analysis was performed comparing the frequency and spatial pattern of spotty calcification between the 2 groups. Results- Spotty calcification in the Stroke group was markedly more prevalent than that in the Control group (total SC count: 8.74±4.96 versus 1.84±1.82, P<0.001). The odds ratio (95% CI) for stroke was 2.49 (1.55-4.00) for spotty calcification at bilateral carotid bifurcation, 1.52 (1.13-2.04) at carotid siphon, and 1.98 (1.45-2.69) at all evaluated locations. A total number of 3 spotty calcifications were determined as the optimal cutoff threshold for increased risk of stroke. Spotty calcium showed significantly greater area under the receiver operating characteristics curve than total calcium volume irrespective of size (0.88 versus 0.77). Within the Stroke group, ipsilateral lateral side showed significantly more spotty calcium than the contralateral side (5.18±3.05 versus 3.56±2.67, P<0.001). Conclusions- Nonlacunar ischemia stroke was associated with markedly increased incidence of spotty calcification with a distinct spatial pattern on cervicocerebral computed tomography compared with subclinical atherosclerosis, suggesting the potential role of spotty calcification for improving the risk stratification for ischemic stroke.

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Mobile Stroke Unit Computed Tomography Angiography Substantially Shortens Door-to-Puncture Time.

Publications

Mobile Stroke Unit Computed Tomography Angiography Substantially Shortens Door-to-Puncture Time.

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