Utility of Computed Tomographic Perfusion in Thrombolysis for Minor Stroke

Ng, Felix; Coote, Skye; Frost, Tanya; Bladin, Chris; Choi, Philip

doi:10.1161/strokeaha.116.013021

Cited by 16 publications

(16 citation statements)

References 13 publications

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“…This low rate is even more remarkable when one considers that it does not include the many patients who were excluded from thrombolysis based on small or absent perfusion lesions, who would be expected to have very low rates of sICH. A similar very low rate of sICH has also been seen in larger mCT cohorts . Comparing our network with other telestroke programs, our rate of independence of 55% compares favorably to published studies, with rates ranging from 34% to 49%.…”

Section: Discussionsupporting

confidence: 84%

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Implementation of multimodal computed tomography in a telestroke network: Five‐year experience

O’Brien

Evans

2019

CNS Neurosci Ther

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Aims Penumbral selection is best‐evidence practice for thrombectomy in the 6‐24 hour window. Moreover, it helps to identify the best responders to thrombolysis. Multimodal computed tomography (mCT) at the primary centre—including noncontrast CT, CT perfusion, and CT angiography—may enhance reperfusion therapy decision‐making. We developed a network with five spoke primary stroke sites and assessed safety, feasibility, and influence of mCT in rural hospitals on decision‐making for thrombolysis. Methods Consecutive patients assessed via telemedicine from April 2013 to June 2018. Clinical outcomes were measured, and decision‐making compared using theoretical models for reperfusion therapy applied without mCT guidance. Symptomatic intracranial hemorrhage (sICH) was assessed according to Safe Implementation of Treatments in Stroke Thrombolysis Registry criteria. Results A total of 334 patients were assessed, 240 received mCT, 58 were thrombolysed (24.2%). The mean age of thrombolysed patients was 70 years, median baseline National Institutes of Health Stroke Scale was 10 (IQR 7‐18) and 23 (39.7%) had a large vessel occlusion. 1.7% had sICH and 3.5% parenchymal hematoma. Three months poststroke, 55% were independent, compared with 70% in the non‐thrombolysed group. Conclusion Implementation of CTP in rural centers was feasible and led to high thrombolysis rates with low rates of sICH.

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Section: Discussionsupporting

confidence: 84%

“…A similar very low rate of sICH has also been seen in larger mCT cohorts. 7,17 Comparing our network with other telestroke programs, our rate of independence of 55% compares favorably to published studies, with rates ranging from 34% to 49%. Those studies reported similar baseline NIHSS (range from 10 to 12, versus 10 in our study).…”

Section: Discussionsupporting

confidence: 74%

Implementation of multimodal computed tomography in a telestroke network: Five‐year experience

O’Brien

Evans

2019

CNS Neurosci Ther

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“…We should note that we did not evaluate the clinical profile behind the NIHSS, and were not able to assess the impact of different clinical syndromes (mainly aphasia or hemiparesis) on the functional outcome at 3 months. Finally, although perfusion imaging has been shown to be of interest in the context of low NIHSS strokes and arterial occlusion [18], this modality was not available for enough number of patients in our cohort.…”

Section: Discussionmentioning

confidence: 99%

“…This threshold has been previously used to assess the functional outcome of minor or mild stroke patients [18,19]. …”

Section: Methodsmentioning

confidence: 99%

Is Reperfusion Useful in Ischaemic Stroke Patients Presenting with a Low National Institutes of Health Stroke Scale and a Proximal Large Vessel Occlusion of the Anterior Circulation?

et al. 2017

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Background: In population-based studies, patients presenting with minor or mild stroke symptoms represent about two-thirds of stroke patients, and almost one-third of these patients are unable to ambulate independently at the time of discharge. Although mechanical thrombectomy (MT) has become the standard of care for acute ischaemic stroke with proximal large vessel occlusion (LVO) in the anterior circulation, the management of patients harbouring proximal occlusion and minor-to-mild stroke symptoms has not yet been determined by recent trials. The purpose of this study was to evaluate the impact of reperfusion on clinical outcome in low National Institutes of Health Stroke Scale (NIHSS) patients treated with MT. Methods: We analysed 138 consecutive patients with acute LVO of the anterior circulation (middle cerebral artery M1 or M2 segment, internal carotid artery or tandem occlusion) with NIHSS <8, having undergone MT in 3 different centres. Reperfusion was graded using the modified thrombolysis in cerebral infarction (TICI) score and 3 grades were defined, ranging from failed or poor reperfusion (TICI 0, 1, 2A) to complete reperfusion (TICI 3). The primary clinical endpoint was an excellent outcome defined as a modified Rankin score (mRs) 0-1 at 3-months. The impact of reperfusion grade was assessed in univariate and multivariate analyses. The secondary endpoints included favourable functional outcome (90-day mRS 0-2), death and safety concerns. Results: Successful reperfusion was achieved in 81.2% of patients (TICI 2B, n = 47; TICI 3, n = 65). Excellent outcome (mRs 0-1) was achieved in 69 patients (65.0%) and favourable outcome (mRs ≤2) in 108 (78.3%). Death occurred in 7 (5.1%). Excellent outcome increased with reperfusion grades, with a rate of 34.6% in patients with failed/poor reperfusion, 61.7% in patients with TICI 2B reperfusion, and 78.5% in patients with TICI 3 reperfusion (p < 0.001). In multivariate analysis adjusted for patient characteristics associated with excellent outcome, the reperfusion grade remained significantly associated with an increase in excellent outcome; the OR (95% CI) was 3.09 (1.06-9.03) for TICI 2B and 6.66 (2.27-19.48) for TICI 3, using the failed/poor reperfusion grade as reference. Similar results were found regarding favourable outcome (90-day mRs 0-2) or overall mRS distribution (shift analysis). Conclusion: Successful reperfusion is strongly associated with better functional outcome among patients with proximal LVO in the anterior circulation and minor-to-mild stroke symptoms. Randomized controlled studies are mandatory to assess the benefit of MT compared with optimal medical management in this subset of patients.

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“…The early and frequent use of multi-model imaging is useful in identifying stroke mechanism and predicting patients likely to worsen following IS [35] or may benefit from thrombolysis. [36] A limitation of our study is that multi-model imaging was completed in approximately 50% of patients. Our work is similar to the report of Ali et al [26] In their series, older patients with higher NIHSS, larger stroke size on imaging and poor collaterals were more likely to show progression.…”

Section: Plos Onementioning

confidence: 99%

Progression of stroke deficits in patients presenting with mild symptoms: The underlying etiology determines outcome

et al. 2020

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Utility of Computed Tomographic Perfusion in Thrombolysis for Minor Stroke

Cited by 16 publications

References 13 publications

Implementation of multimodal computed tomography in a telestroke network: Five‐year experience

Implementation of multimodal computed tomography in a telestroke network: Five‐year experience

Is Reperfusion Useful in Ischaemic Stroke Patients Presenting with a Low National Institutes of Health Stroke Scale and a Proximal Large Vessel Occlusion of the Anterior Circulation?

Progression of stroke deficits in patients presenting with mild symptoms: The underlying etiology determines outcome

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