Initial Experience with Upfront Arterial and Perfusion Imaging among Ischemic Stroke Patients Presenting within the 4.5-hour Time Window

• Published in: Journal of stroke and cerebrovascular diseases 2014-02, Vol.23 (2), p.220-224
• Main Authors: Noorian, Ali Reza, MD, Bryant, Katja, RN, Aiken, Ashley, MD, Nicholson, Andrew D., MD, Edwards, Adam B., MD, Markowski, Mason P., MD, PhD, Dehkharghani, Seena, MD, Bouloute, Jemisha C., RN, Abney, Jacquelyn, RN, Nahab, Fadi, MD
• Format: Article
• Language: English
• Subjects: Acute stroke; Aged; Aged, 80 and over; Brain Ischemia - diagnostic imaging; Brain Ischemia - physiopathology; Brain Ischemia - therapy; Cardiovascular; Cerebral Angiography - methods; Cerebral Revascularization; Cerebrovascular Circulation; Clinical Competence; computed tomographic perfusion; Coronary Vessels - diagnostic imaging; Coronary Vessels - physiopathology; Decision Support Techniques; Female; Georgia; Hospitals, University; Humans; Learning Curve; Male; Middle Aged; Neurology; Patient Selection; Perfusion Imaging - methods; Predictive Value of Tests; Retrospective Studies; revascularization; Stroke - diagnostic imaging; Stroke - physiopathology; Stroke - therapy; Time Factors; Time-to-Treatment; tissue plasminogen activator; Tomography, X-Ray Computed; Treatment Outcome
• ISSN: 1052-3057; 1532-8511
• DOI: 10.1016/j.jstrokecerebrovasdis.2012.12.008

Background Although perfusion imaging is being evaluated as a tool to select acute ischemic stroke patients who are most likely to benefit from reperfusion therapies beyond the standard time windows, there are limited data on the utility of perfusion imaging within the intravenous (IV) thrombolytic time window. Methods A new stroke imaging protocol was initiated at Emory University Hospital including computed tomographic angiography (CTA) and computed tomographic perfusion (CTP). All patients presenting within 4.5 hours from last known normal time with suspected stroke were prospectively identified. Impact of CTA and CTP on the clinical management was recorded prospectively by stroke team members. Results During the study period, 87 patients met eligibility criteria for the CTA/CTP protocol, of which 83 (95%) underwent this upfront comprehensive imaging protocol and 30 (34%) received IV thrombolytics. Overall, stroke team members reported that CTA and/or CTP aided their clinical management in 39 (47%) cases, including aiding in identification of a nonstroke diagnosis (n = 18), triage to the neurologic intensive care unit (n = 9), early triage to endovascular therapy (n = 4), and initiation of IV thrombolytic for low National Institutes of Health Stroke Scale score with large vessel occlusion (n = 3). Door to needle time ≤60 minutes was achieved in only 18% of patients receiving IV thrombolysis during the study period, but had improved to 44% in the subsequent 6-month period. Conclusions An upfront CTA/CTP protocol aided stroke team decision-making in nearly half of cases. Implementation of a CTA/CTP protocol was associated with a learning curve of 6 months before door to needle time ≤60 minutes returned to similar rates as the pre-CTA/CTP protocol.