Imaging, Intervention, and Workflow in Acute Ischemic Stroke: The Calgary Approach

Zerna, Charlotte; Assis, Zarina; d’Esterre, Christopher D; Menon, Bijoy K; Goyal, Mayank

doi:10.3174/ajnr.a4610

Cited by 35 publications

(31 citation statements)

References 23 publications

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“…Identifying the acute ischemic stroke patients with symptomatic vascular occlusions helps distinguish the most high-risk patients and has the potential to lead to more rapid institution of treatment. 7,8,13 Another explanation for pial vessel asymmetry without detection of occlusion is early recanalization without reperfusion. Identifying these patients is relevant because reperfusion has been shown to be a stronger predictor of good clinical and imaging outcome compared to recanalization.…”

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confidence: 99%

“…CT perfusion has shown potential to provide additional information, but it is currently limited by the lack of standardization of the imaging protocol, the absence of uniform definition for the ischemic core and penumbra, as well as its vulnerability to motion artifact and image processing delays. 13 Multiphase CTA is an innovative, user-friendly imaging tool that can improve diagnostic accuracy for anterior circulation intracranial occlusions, even when used by relatively inexperienced readers and even when occlusions are distal. The inclusion of the multiphase CTA in acute ischemic stroke imaging protocols has the potential to allow non-radiology trained physicians and trainees to rapidly and accurately determine anterior circulation occlusions, a crucial point in the clinical management of the patient for revascularization procedures.…”

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confidence: 99%

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Multiphase CT angiography increases detection of anterior circulation intracranial occlusion

Zerna

Assis

et al. 2016

Neurology

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Objective: To evaluate whether the use of multiphase CT angiography (CTA) improves interrater agreement for intracranial occlusion detection between stroke neurology trainees and an expert neuroradiologist.Methods: A neuroradiologist and 2 stroke neurology fellows independently reviewed 100 prospectively collected single-phase and multiphase CTA scans from acute ischemic stroke patients with mild symptoms (NIH Stroke Scale score #5). The presence and location of a vascular occlusion(s) were documented. Interrater agreement single-and multiphase CTA was quantified using unweighted k statistics. We assessed for any occlusions, anterior vs posterior occlusions, and pial vessel asymmetry.Results: Using multiphase CTA, the neuroradiologist detected 50 scans with anterior circulation occlusions and 15 scans with posterior circulation occlusions. Median reading time was 2 minutes per scan. Median reading time for the neurologists was 3 minutes per multiphase CTA scan. Interrater agreement was fair between the 2 neurologists and neuroradiologist when using single-phase CTA (k 5 0.45 and 0.32). Agreement improved minimally when stratified by anterior vs posterior circulation. When using multiphase CTA, agreement was high for detection of occlusion or asymmetry of pial vessels in the anterior circulation (k 5 0.80 and 0.84).Conclusions: Multiphase CTA improves diagnostic accuracy in minor ischemic stroke for detection of anterior circulation intracranial occlusion. Classification of evidence:This study provides Class II evidence that multiphase CTA, compared to single-phase CTA, improves the interrater agreement between stroke neurology trainees and an expert neuroradiologist for detecting anterior circulation intracranial vascular occlusion in patients with minor acute ischemic strokes.

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confidence: 99%

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confidence: 99%

Multiphase CT angiography increases detection of anterior circulation intracranial occlusion

Zerna

Assis

et al. 2016

Neurology

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“…11a), it is not clear whether this represents real extracranial occlusion (usually due to dissection) or pseudoocclusion caused by slow flow due to the intracranial occlusion. mCTA is the advanced imaging modality of choice in AIS [53][54][55] and can help distinguish these two entities: in pseudoocclusion, delayed contrast appearance in the affected ICA can usually be depicted in the delayed phases and the vessel lumen appears slightly hyperdense. 56 If this can be seen (►Fig.…”

Section: Pseudoocclusion At the Ica Originmentioning

confidence: 99%

Evolution of Stroke Thrombectomy Techniques to Optimize First-Pass Complete Reperfusion

Ospel

McTaggart

Kashani

et al. 2020

Semin intervent Radiol

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Since 2015, endovascular therapy (EVT) has become the standard of care for acute ischemic stroke (AIS) due to large vessel occlusion. It is a safe and highly effective treatment, and its number needed to treat of 2.6 is one of the highest throughout medicine. The ultimate goal when performing EVT is to maximize chances of good outcome through achievement of fast first-pass complete reperfusion, as incomplete and delayed reperfusion increases complication rates and negatively affects outcome. Since EVT has been established as standard of care, new devices have been developed and treatment techniques have been refined. This review provides a brief overview about the rationale for and history of EVT, followed by a detailed step-by-step description of how to perform EVT using the BADDASS (BAlloon guide with large bore Distal access catheter with Dual Aspiration with Stent-retriever as Standard approach), a combined technique, which is in our opinion the safest and most effective way to achieve fast first-pass complete reperfusion. We also discuss treatment strategies for patients with simultaneous high-grade carotid stenosis/pseudoocclusion/occlusion and gaining carotid access in challenging arch anatomy, as these are commonly encountered situations in AIS, and conclude with an outlook on new technologies and future directions of EVT.

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“…Routine use of a pre-prepared stroke kit (BRISK), 55) which contains the basic equipment that is needed for EVT Waiting times for anesthesia Waiting for an anesthesiologist to initiate general anesthesia often leads to delays in EVT initiation. 56) Use of conscious sedation instead of general anesthesia whenever possible All-time available anesthesiologist in the angiography suite EVT: endovascular treatment Table 3 expanded thrombolysis in cerebral infarction (eTICI) score 42,57) eTICI score Definition…”

Section: Improving Stroke Care Through Simulation Trainingmentioning

confidence: 99%

Optimizing Stroke Care for Patients with Large Vessel Occlusions: Current State of the Art and Future Directions

Ospel

Mayank

Yoshimura

et al. 2020

JNET

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Acute ischemic stroke (AIS) is a severely disabling disease. Endovascular therapy is a powerful and highly effective treatment option for these patients and has recently become standard of care. The benefits of endovascular treatment (EVT) are tremendous both from a patient and from an economic perspective, since it dramatically improves individual patient outcomes while reducing long-term healthcare costs at the same time. The effect of EVT is highly time-dependent. Thus, the overarching goal in AIS is to quickly transport and diagnose the patient to minimize treatment delays. In this review, we provide an overview about the current state of stroke care, propose a fast and simplified imaging protocol and management approach for AIS patients. We also highlight the challenges we are currently facing in endovascular stroke treatment and suggest possible solutions to overcome these. Keywords▶ acute ischemic stroke, endovascular therapy, mechanical thrombectomy, stroke imaging, multiphase CT angiography therapeutic window (within 4.5 hours from symptom onset). 2) It is estimated that only 3%-5% of AIS patients ultimately receive intravenous alteplase. 3) Clearly, there was a need for another alternative treatment strategy to reduce the morbidity and mortality in AIS. Therefore, endovascular treatment techniques (EVT), which rely on mechanical clot retrieval rather than pharmacological recanalization, have been developed. In 2015, ischemic stroke treatment has fundamentally changed. Five major randomized controlled trials have proven the superiority of EVT compared to medical management in patients with LVO strokes. 4) EVT is now considered standard of care for these patients. 2) Why Offering Endovascular Therapy for AIS? Benefit from a patient perspective There are several reasons why EVT should be performed for LVO strokes. First and foremost, the benefit of EVT compared to best medical care from a patient perspective is overwhelming: The number needed to treat for reduction of disability by at least one point on the modified Rankin Scale (mRS) is 2.6, one of the lowest throughout the history of medicine. 4) This translates into a substantial increase in quality-adjusted life years (QALYs). 5) The safety profile of EVT is excellent, with no significant differences in mortality and symptomatic intracranial Background: Natural History of Acute Ischemic Stroke Acute ischemic stroke (AIS) is a severely disabling disease, particularly when there is an underlying large vessel occlusion (LVO). Until recently, intravenous alteplase was the only available treatment option for LVO patients, but its efficacy was limited, as recanalization of the occluded vessel was only achieved in 7%-30% of patients, 1) and many patients were not eligible for alteplase treatment at all because of the numerous contraindications and narrow This work is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives International License.

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Imaging, Intervention, and Workflow in Acute Ischemic Stroke: The Calgary Approach

Cited by 35 publications

References 23 publications

Multiphase CT angiography increases detection of anterior circulation intracranial occlusion

Multiphase CT angiography increases detection of anterior circulation intracranial occlusion

Evolution of Stroke Thrombectomy Techniques to Optimize First-Pass Complete Reperfusion

Optimizing Stroke Care for Patients with Large Vessel Occlusions: Current State of the Art and Future Directions

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