Multimodal CT Provides Improved Performance for Lacunar Infarct Detection

Das, Tilak; Settecase, Fabio; Boulos, Mark I.; Huynh, Thien; d’Esterre, Christopher D; Symons, Sean; Zhang, L.; Aviv, Richard I.

doi:10.3174/ajnr.a4255

Cited by 29 publications

(36 citation statements)

References 31 publications

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“…Our finding of a high frequency of perfusion deficits, in small subcortical infarcts is not surprising since the presence of ischemia should be associated with perfusion deficit (11–16). Several patterns of perfusion deficit with subcortical infarcts have been described including “inverse mismatch.” The inverse mismatch pattern has been described with infarcts involving the thalamus, PLIC, lentiform nucleus, and corona radiata (11–13).…”

Section: Discussionsupporting

confidence: 50%

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Examining Subcortical Infarcts in the Era of Acute Multimodality CT Imaging

Tan

Singhal

et al. 2016

Front. Neurol.

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BackgroundLacunar infarct has been characterized as small subcortical infarct. It is postulated to occur from “in situ microatheroma or lipohyalinosis” in small vessel or lacunar mechanism. Based on this idea, such infarcts by lacunar mechanism should not be associated with large area of perfusion deficits that extend beyond the subcortical region to the cortical region. By contrast, selected small subcortical infarcts, as defined by MR imaging in the subacute and chronic stage, may initially have large perfusion deficit or related large vessel occlusions. These infarcts with “lacunar” phenotype may also be caused by disease in the parent vessel and may have very different stroke mechanism from small vessel disease. Our aim is to describe differences in imaging characteristics between patients with small subcortical infarction with “lacunar phenotype” from those with lacunar mechanism.Materials and methodsPatients undergoing acute CT perfusion/angiography (CTP/CTA) within 6 h of symptom onset and follow-up magnetic resonance imaging (MRI) for ischemic stroke were included (2009–2013). Lacunar infarct was defined as a single subcortical infarct ≤20 mm on follow-up MRI. Presence of perfusion deficits, vessel occlusion, and infarct dimensions was compared between lacunar infarcts and other topographical infarct types.ResultsOverall, 182 patients (mean age 66.4 ± 15.3 years, 66% males) were included. Lacunar infarct occurred in 31 (17%) patients. Of these, 12 (39%) patients had a perfusion deficit compared with those with any cortical infarction (120/142, 67%), and the smallest lacunar infarct with a perfusion deficit had a diameter of <5 mm. The majority of patients with lacunar infarction (8/12, 66.7%) had a relevant vessel occlusion. A quarter of lacunar infarcts had a large artery stroke mechanism evident on acute CTP/CTA. Lacunar mechanism was present in 3/8 patients with corona radiata, 5/10 lentiform nucleus, 5/6 posterior limb of internal capsule (PLIC), 3/5 thalamic infarcts, 1/2 miscellaneous locations. There was a trend to significant with regards to finding lacunar mechanism among patients with thalamic and PLIC infarcts versus lentiform nucleus and corona radiata infarcts (p = 0.13).ConclusionDiverse stroke mechanisms were present among subcortical infarcts in different locations. When available acute CTP/CTA should be combined with subacute imaging of subcortical infarct to separate “lacunar phenotype” from those with lacunar mechanism.

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Section: Discussionsupporting

confidence: 50%

“…More recently, authors have described various patterns of perfusion deficits related to these small subcortical infarcts (11–16). These patterns are categorized as mismatch, matched, and inverse mismatch.…”

Section: Introductionmentioning

confidence: 99%

Examining Subcortical Infarcts in the Era of Acute Multimodality CT Imaging

Tan

Singhal

et al. 2016

Front. Neurol.

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“…We justified the inclusion of purely ischemic patterns (MTT prolongation/ CBF reduction in the absence of a visible CBV defect) in addition to overt infarction (CBV reduction) because even in the context of TIA (with clinical improvement), a perfusion abnormality (signifying ischemia) is associated with an increased probability of DWI/ ADC infarction at presentation or follow-up [18,19]. This approach has been used before in the supratentorium [7] in a recent study of lacunar infarction [15] and posterior fossa CTP [12]. For each posterior fossa AS-PECTS location a positive diagnosis required localization to right, left or midline and was scored individually for each modality (total scores 738 for 3 readers).…”

Section: Review Protocolmentioning

confidence: 97%

“…The review method simulated the clinical review process, beginning with NCCT, followed by CTA-SI and CTP color maps [7,15]. Therefore, three DICOM folders were prepared containing NCCT, NCCT + CTA-SI and NCCT + CTA-SI + CTP.…”

Section: Review Protocolmentioning

confidence: 99%

The predictive value of a targeted posterior fossa multimodal stroke protocol for the diagnosis of acute posterior ischemic stroke

Sharon¹,

Boyle

Yeung³

et al. 2016

Neurovasc Imaging

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Background: There is limited but growing research regarding the accuracy of CTP in diagnosing acute posterior ischemia stroke. We sought to evaluate the diagnostic accuracy of an incremental multimodal CT protocol in acute posterior ischemic stroke. Methods: Retrospective review of incremental NCCT, CTA-source images and CTP use in 82 consecutive patients with acute posterior ischemic stroke. Readers were blinded to infarct status on follow-up imaging (MRI or CT). Predictive effects of observed diagnostic accuracy and confidence score were quantified with the entropy r 2 value. Sensitivity, specificity, and CI were calculated accounting for multiple reader assessments. Receiver Operating Characteristic analyses, including Area Under the Curve, were conducted for the three modalities. Inter-reader agreement was established with Intraclass Correlation Coefficient.

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“…CT perfusion has been increasingly used in hyperacute stroke and has shown promise in improving detection of lacunar infarcts. 2 We present 4 patients in whom CT perfusion was performed using a 320-slice scanner (Aquilion ONE Vision, Toshiba, Japan) and Ultravist 370 (iopromide, Bayer, Switzerland) injected at 4 mL/s for 50 mL. Multiplanar reconstruction of perfusion data was performed using commercially available software (Vitrea 6.6.2036.1, Vital Images, Minnetonka, MN).…”

mentioning

confidence: 99%