Background: Determining the size of infarct extent is crucial to elect patients for reperfusion therapies. Computed tomography perfusion (CTP) based on cerebral blood volume may overestimate infarct core on admission and consequently include ghost infarct core (GIC) in a definitive lesional area. Purpose: Our goal was to confirm and better characterize the GIC phenomenon using CTP cerebral blood flow (CBF) as the reference parameter to determine infarct core. Methods: We performed a retrospective, single-center analysis of consecutive thrombectomies of middle cerebral or intracranial internal carotid artery occlusions considering noncontrast CT Alberta Stroke Program Early CT Score ≥6 in patients with pretreatment CTP. We used the RAPID® software to measure admission infarct core based on initial CBF. The final infarct was extracted from follow-up CT. GIC was defined as initial core minus final infarct > 10 mL. Results: A total of 123 patients were included. The median National Institutes of Health Stroke Scale score was 18 (13–20), the median time from symptoms to CTP was 188 (67–288) min, and the recanalization rate (Thrombolysis in Cerebral Infarction score 2b, 2c, or 3) was 83%. Twenty patients (16%) presented with GIC. GIC was associated with shorter time to recanalization (150 [105–291] vs. 255 [163–367] min, p = 0.05) and larger initial CBF core volume (38 [26–59] vs. 6 [0–27] mL, p < 0.001). An adjusted logistic regression model identified time to recanalization < 302 min (OR 4.598, 95% CI 1.143–18.495, p = 0.032) and initial infarct volume (OR 1.01, 95% CI 1.001–1.019, p = 0.032) as independent predictors of GIC. At 24 h, clinical improvement was more frequent in patients with GIC (80 vs. 49%, p = 0.01). Conclusions: CTP CBF < 30% may overestimate infarct core volume, especially in patients imaged in the very early time window and with fast complete reperfusion. Therefore, the CTP CBF technique may exclude patients who would benefit from endovascular treatment.

Background and Purpose— Time to reperfusion is fundamental in reducing morbidity and mortality in acute stroke. We aimed to demonstrate that direct transfer to angio-suite (DTAS) of patients with suspected large vessel occlusion stroke improves workflow times and outcomes. Methods— A case-control matched study of the first 79 DTAS patients with confirmed large vessel occlusion (cases) and 145 no-DTAS patients (controls). DTAS protocol included a cone beam computed tomography in the angio-suite to rule out intracerebral hemorrhage for those patients with no prior neuroimaging in a referring center. Cases and controls were matched by location of vessel occlusion, age, baseline National Institutes of Health Stroke Scale (NIHSS) score and time from symptoms onset to Comprehensive Stroke Center arrival. Dramatic clinical improvement was defined as a decrease in NIHSS score of >10 points or final NIHSS score of ≤2. Favorable outcome was defined as modified Rankin Scale score of ≤2 at 90 days. Results— During an 18 months period a total of 97 patients were directly transferred to the angio-suite after admission: 11 (11.6%) showed an intracerebral hemorrhage on cone beam computed tomography, 7 (7.2%) did not have a large vessel occlusion on initial angiogram, and 79 (76.3%) had a large vessel occlusion and received endovascular treatment (cases). There were no differences in age, baseline NIHSS score, level of occlusion and time from onset-to-door between cases and controls. The median door-to-groin time (16 [12–20] versus 70 [45–105] minutes; P <0.01) and onset-to-groin times (222 [152–282] versus 259 [190–345] minutes; P <0.01) were shorter in the DTAS group. At 24 hours, DTAS patients presented lower NIHSS score (7 [4–16] versus 14 [4–20]; P =0.01), higher rate of dramatic improvement (50.6% Vs. 31.7%; P =0.04), and higher rate of favorable clinical outcome at 90 days (41% versus 28%; P =0.05). A logistic regression model adjusting for all matching variables showed that DTAS protocol was independently associated with 3 months favorable outcome (odds ratio, 2.5; 95% CI, 1.2–5.3; P =0.01). Conclusions— DTAS is an effective strategy to reduce workflow time which may significantly increase the odds of achieving a favorable outcome.

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Background: Stroke is a leading cause of death and disability worldwide, particularly in low- and middle-income countries. We aimed to identify the main barriers to optimal acute management of stroke in a referral center.Methods: Demographic data was collected from patients assessed with acute stroke in the emergency department of the Instituto Nacional de Neurología y Neurocirugía (INNN) from January to June 2019. Additionally, a telephone interview was conducted with patients/primary caregiver to know which they considered the main reason for the delay in arrival at INNN since the onset of stroke.Results: 116 patients were assessed [age 65 ± 15 years, 67 (57.8%) men]. Patients consulted other facilities prior to arrival at INNN in 59 (50.9%) cases (range of hospitals visited 1–4), 83 (71.6%) arrived in a private car, with prenotification in only 4 (3.4%) of the total sample. The mean onset-to-door time was 17 h (45 min−10 days). Telephone interviews were done in 61 patients/primary caregivers, stating that they consider the multiple evaluations in other facilities [n = 26/61 (42.6%)] as the main reason for delay in arrival at the ED, followed by ignorance of stroke symptoms and treatment urgency [n = 21/61 (34.4%)].Conclusion: In this small, retrospective, single center study, the main prehospital barrier to optimal acute management of stroke in a developing country is multiple medical evaluations prior to the patient's transport to a specialized stroke hospital, who mostly arrived in a private car and without prenotification. These barriers can be overcome by strengthening public education and improving patient transfer networks and telemedicine.

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