acute brain infarct:detection and delineation with ct angiographic source images versus nonenhanced
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7/30/2019 Acute Brain Infarct:Detection and Delineation with CT Angiographic Source Images versus Nonenhanced
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LOGO
Acute Brain Infarct:Detectionand Delineation with CTAngiographic Source Imagesversus Nonenhanced
Presented by : dr Rivani Kurniawan
Lecturer : dr Farhan Anwary .SpRad(K)MH.Kes
Erica C. S. Camargo, MD, PhD et all
RSNA, 2007 radiographics.rsnajnls.org
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Introduction
The Alberta Stroke Programme Early CT Score (ASPECTS) isan established scale for quantifying hypoattenuation fromacute stroke on non-enhanced computed tomographic (CT)scans and helps in the prediction of clinical outcome
ASPECTS has been used as a reliable and convenientsurrogate for visual interpretation of lesion volume not only onnon-enhanced CT scans but also on CT angiographic sourceimages and diffusion-weighted magnetic resonance (MR)
images
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The purpose of our study was to retrospectivelycompare the sensitivity and specificity of admissionnon enhanced CT scans with those of CT angiographicsource images in the detection of early ischemicchanges in middle cerebral artery (MCA) stroke and
to retrospectively compare admission non enhancedCT scans with CT angiographic source images in thedelineation of final infarct extent
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Material and methode
We analyzed data from 110 consecutive patientsenrolled in a prospective cohort study at twouniversity-based hospitals, part of the ScreeningTechnology and Outcomes Project in Stroke (alsoknown as STOPStroke), at which emergency CT
angiography for patients suspected of havingischemic stroke (stroke, transient ischemic attack, orstroke mimics) was performed
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Patients were excluded if iodinated contrast agentadministration was contraindicated (ie, history ofcontrast agent allergy, pregnancy, congestive heartfailure, increased creatinine level) or if there wasevidence of intracranial hemorrhage on non
enhanced CT scans
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Within our cohort, 82 patients had signs andsymptoms suggestive of MCA territory stroke andwere enrolled in the study from March throughAugust 2003. Of these, 51 patients who were imagedwithin 12 hours of symptom onset and who did not
have evidence of old strokes on admissionnonenhanced CT scans were included in the study.Mean patient age was 64.3 years (range, 2196years); 53% (27) were women and 47% (24)weremen
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Neuroimaging protocol
Non enhanced CT was
performed
120140 kVp, 170 mA,
2-second scan time,
and 5-mm section
thickness
Non enhanced CT and CT angiographic acquisitions were performed
according to standard departmental protocols with eight- or 16-section multi detector
CT angiography was performed
after a 25-second delay (40
seconds for patients in atrial
fibrillation) and administration of
100140 mL of a non ionic contrast
agent at an injection rate of 3mL/sec by using a power injector
via an 18-gauge intravenous
catheter. Parameters were 140 kVp,
220250 mA, 0.8 1.0-second
rotation time, 2.5-mm section
thickness.
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Follow-up neuroimaging as reference standard.1
All patients underwent follow-up neuroimaging studies within 10
days after stroke onset. The patients treating physicians
decided timing of follow-up imaging and the imaging modality to
be used
When available, preference was given to diffusion weighted MR images,
followed by fluid-attenuated inversion-recovery MR images, and finally
nonenhanced CT scans
When more than one appropriate follow-up image was available,we
selected for inclusion the follow-up image that most clearly confirmed the
presence or absence of a new ischemic stroke
.
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B
C
A
For non enhanced
CT scans, low-
attenuation regions in
the MCA territory that
were not suggestive
of encephalomalacia
and/ or chronic
infarction on the
admission non
enhanced CT scans
.
For diffusion-
weighted MR
images, hyperintense
regions in the MCA
territory, with
corresponding
restricted diffusion on
the apparentdiffusion coefficient
maps
For fluid-attenuated
inversion-recovery
MR images,
hyperintense regionsin the MCA territory
that were also not
suggestive of chronic
infarct and that
corresponded to
regions of restricteddiffusion on the
admission apparent
diffusion coefficient
maps
The criteria used to define the presence or
absence of an ischemic stroke on follow-upimages were as follows
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Image Review
Image review was independently on a picture archiving andcommunication system workstation by a board-certified
neuroradiologist and a clinical neurologist experienced in stroke
neuroimaging interpretation (M.H.L. and W.J.K., 15 and 25years of
neuroimaging review experience, respectively)
Reviewers were blinded to follow-up clinical and imaging
findings but had information in regard to the patientsage, sex,
and presenting clinical symptoms
Neither of the reviewers had participated in the selection of the
patients
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In all cases, non enhanced CT images obtained foracute stroke were reviewed first, followed by CTangio-graphic source images, and finally, follow-upimages for confirmation of true-positive or true-negative infarct regions.Disagreements in readings
were resolved in consensus
we reviewed each of 10 regions for the presence orabsence of ischemic lesions according to a five-pointlevel of certainty score (score 5,definitely present;
score 4, probably present; score 3, equivocal;score 2,probably absent; score 1, definitely absent)
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These regions included the insula (I), caudatenucleus (C), lentiform nucleus (L), internal capsule(IC), superior parietal lobe (M6), precentral and
superior frontal lobe (M5), anterior superior frontallobe (M4), inferior parietal and posterior temporallobe (M3), temporal lobe (M2), and anterior inferiorfrontal lobe (M1)
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Statistical analysis
Stroke detection: To compare stroke detection rates with non
enhancedCT and CT angiographic source images, weused standard receiver operating characteristic(ROC) curve analysis methods
The standard for the presence or absence of strokewas determined by using follow-up images
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Stroke delineation Standard linear regression coefficients were
calculated to determine the correlation of each of thenon enhanced CT scan and CT angiographic sourceimage ASPECTS with final infarct volumes on follow-up images by using the optimal level of certainty cutoff score
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Of the 33 patients with stroke, one had a top of theinternal carotid artery T lesion, three had internalcarotid artery and M1 MCA segment occlusions, sevenhad M1 MCA segment occlusions, two had M1 and M2MCA segment occlusions, and nine had M2 MCA
segment occlusions. No other arterial occlusionswere detected in the remaining 11 patients withstroke
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Stroke detection
With a level of certainty cutoff score of 4 or greater(probable, definite) for the presence of any acute
ASPECTS template ischemic hypo attenuation, strokedetection sensitivity was 48% (16 of 33) with nonenhanced CT scans and 70% (23 of 33) with CTangiographic source images
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Stroke delineation
For a cutoff score of 4 or greater, linear regressionanalysis revealed an R2 0.42 (P.001; slope1.53; 95%
CI: 1.01, 2.05) for correlation between admissionnon enhanced CT scan ASPECTS and follow-up imageASPECTS and an R 2 0.73 (P.001; slope 1.11; 95%CI: 0.91, 1.30) for correlation between admission CTangiographic source image ASPECTS and follow-up
image ASPECTS
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Discussion
CT angiographic source images were both
(a)more sensitive than non enhanced CT scansin the early detection of irreversible MCA
infarction within 12 hours of symptomonset
(b)more accurate than non enhanced CT scansin delineation of final infarct extent, as
measured by using ASPECTS
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The combination of vascular CT angiograms with
parenchymal CT angiographic source images,compared with admission non-enhanced CT scansalone, improves the overall accuracy of infarct
localization, vascular territory determination, vesselocclusion identification, stroke subtyping, andprediction of final stroke extent
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CT angiography with CT angiographic source imagesis typically more available, faster, affordable, andeasier to perform in critically ill patients than is MRimaging
When used in conjunction with quantitative first-pass
CT perfusion images, which provide a measure ofpenumbral tissue at risk, CT angiographic sourceimages compared with CT perfusion images forischemic lesion size mismatch have the potential toaid in the selection of patients for treatments in a
manner analogous to diffusion-weighted MR imagescompared with perfusion images for mismatch
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because non enhanced CT read-out was performed
prior to CT angiographic readout, this difference mayhave biased the detection of ischemic hypoattenuation with CT angiographic source images, as
readers were aware of the presence or absence ofintra- and ex-tra cranial arterial occlusions whenthey rated the CT angiographic source images
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This was a conscious intention of our study design,however, as the order of readout was chosen tosimulate the actual clinical scenario in which the nonenhanced CT scans are reviewed first. In-deed, thefact that readers were aware of pertinent presenting
signs and symptoms when they were interpreting thenon enhanced CT scans clearly influenced the pretestprobability that a given hypo attenuation was real orartifactual , although this knowledge should haveaffected the non enhanced CT scan and CTangiographic source image readouts equally
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awareness of the clinical history was intended to
simulate the clinical setting, and, if anything, the biasis toward favoring non enhanced CT scan sensitivity,as previous work has shown that knowledge of the
emergency clinical findings at presentation improvesdetection of stroke with nonenhanced CT scans (butnot with diffusion-weighted MR images)
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In conclusion, the results of our study support therole of CT angiographic source images, rather thannon enhanced CT scans alone, in improving both thedetection of early ischemic changes and theprediction of final infarct extent and, hence, favor the
use of CT angiography and CT angiographic sourceimages in the emergency setting for diagnosis andtri-age of patients with potential stroke.
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We analyzed data from 110
consecutive patients enrolled in aprospective cohortstudy at two
university-based hospitals
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