Background and Purpose CT perfusion (CTP) mapping in research centers correlates well with diffusion weighted imaging (DWI) lesions and may accurately differentiate the infarct core from ischemic penumbra. The value of CTP in real-world clinical practice has not been fully established. We investigated the yield of CTP– derived cerebral blood volume (CBV) and mean transient time (MTT) for the detection of cerebral ischemia and ischemic penumbra in a sample of acute ischemic stroke (AIS) patients. Methods We studied 165 patients with initial clinical symptoms suggestive of AIS. All patients had an initial non-contrast head CT, CT Perfusion (CTP), CT angiogram (CTA) and follow up brain MRI. The obtained perfusion images were used for image processing. CBV, MTT and DWI lesion volumes were visually estimated and manually traced. Statistical analysis was done using R-2.14.and SAS 9.1. Results All normal DWI sequences had normal CBV and MTT studies (N=89). Seventy-three patients had acute DWI lesions. CBV was abnormal in 23.3% and MTT was abnormal in 42.5% of these patients. There was a high specificity (91.8%)but poor sensitivity (40.0%) for MTT maps predicting positive DWI. Spearman correlation was significant between MTT and DWI lesions (ρ=0.66, p>0.0001) only for abnormal MTT and DWI lesions>0cc. CBV lesions did not correlate with final DWI. Conclusions In real-world use, acute imaging with CTP did not predict stroke or DWI lesions with sufficient accuracy. Our findings argue against the use of CTP for screening AIS patients until real-world implementations match the accuracy reported from specialized research centers.

Opinion statementIntravenous alteplase or tissue plasminogen activator (tPA) has been the standard of care with proven efficacy for acute ischemic stroke for over a decade. Despite this, only a small fraction of potentially eligible stroke patients receive this medication. There seems to be a fear among practitioners of legal repercussions as a result of an increased risk of intracerebral hemorrhage due to tPA. This review of legal cases involving tPA will show that instead, physicians are often found liable as a result of not treating with tPA.

Background: It is well recognized that time to treatment inversely affects good outcome in acute stroke patients. The sooner patients are evaluated by a trained stroke physician, the more likely they will receive approved acute stroke treatments and interventions. At our Comprehensive Stroke Center, the code stroke team is made up of individuals and providers from multiple disciplines and in the activation of a code stroke, timing is the key element and we sought to improve this notification process through the use of a unifying single, alert system. Purpose: The goal of this project was to reduce our team activation time. We introduced an application called PerfectServe which allows for the entire stroke team to be alerted and the immediate notification of the neuro-interventional radiology team, when a suitable candidate is identified, without having to rely on a multistep process. Methods: Implementation of interventional radiology stroke intervention team using PerfectServe application notifications alongside our neurology and neuro-interventional radiology providers and enabling them to see real time updates of stroke patients and communicate plans of care. Retrospective analysis using a T-test analysis technique analyzed the data related to a one step process (PerfectServe application) and a previously utilized multiple step process (Everbridge application) times in minutes. Results: The one-step PerfectServe application significantly decreased the team notification alert to response confirmation by 10 minutes ( p =0.05). Conclusions: The one-step PerfectServe application activation process provided more effective communication, team activation times, and better door to treatment times.

Aim Head Injury is a common presentation in our DGH, which covers a large rural area and is now a regional trauma centre. We audited our management of head injuries against current guidelines and planned a new pathway to ensure patients receive the correct advice and follow up on discharge. Method Data was requested from IT for all head injury episodes in 2019, to reflect usual numbers pre-pandemic. Electronic letters, radiology and notes were used to identify whether imaging criteria was met/carried out, discharge destinations, re-presentations, specialty discussions, and head injury advice on discharge. Results 307 individual patients identified. 13 re-presentations. 10 required neurosurgical discussions Destinations 226 (73.6%) discharged direct from ED. Admissions: Surgical - 37 (12%), Medical - 6 (2%), Paeds – 14 (4.5%), ITU 2 (0.7%), Did not wait – 2 (0.7%), Not Recorded – 7 (2.3%) Imaging 100 patients met NICE criteria for CT, 100% were documented in notes and had CT. 76% reported normal, 18% had a bleed, contusion, or haematoma. HI advice 90% of ED discharges, 16% of Surgical and 16% of medical discharges had head injury discharge advice documented Conclusions Guidelines were met for 100% of patients requiring imaging. Head injury advice was well documented in ED but fell down in ward paperwork. We have written a robust pathway where all inpatients have a proforma completed during admission with prompts for discharge advice and rehab referral where appropriate, this is currently undergoing a re-audit to ensure improvement and if successful will become an established part of the trauma pathway in our hospital.

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