Does the Primary Imaging Modality-Computed Tomography or Magnetic Resonance Imaging-Influence Stroke Physicians' Certainty on Whether or Not to Give Thrombolysis to Randomized Acute Stroke Patients?

BACKGROUND: Door-to-needle time of 20 minutes to stroke patients with intravenous tissue plasminogen activator (iv-tPA) is feasible when computed tomography (CT) is used as first-line of brain imaging. Magnetic resonance imaging (MRI)-based assessment is more time-consuming but superior in detecting acute ischemia. The certainty with which stroke physicians prescribe or refrain from giving iv-tPA treatment to CT- versus MRI-examined patients has not previously been studied. The aim of the present study was to determine the effect of a primary imaging strategy of CT or MRI on clinicians' certainty to prescribe or refrain from giving iv-tPA to patients with suspected acute stroke. METHOD: Consecutive patients with suspected stroke were quasi-randomized to either CT- or MRI-based assessment before potential iv-tPA treatment. The influence of (1) the clinical findings and (2) the image findings, and (3) the certainty with which the stroke physician prescribed or refrained from giving iv-tPA treatment were assessed with visual analog scales (VAS). Predictors of treatment certainty were identified with a random-effect model. RESULTS: Four-hundred forty-four consecutive patients were quasi-randomized. MRI influenced the final treatment decision more than CT (P = .002). Compared with CT-examined patients (mean VAS score 8.6, SD ±1.6) stroke physicians were significantly more certain when prescribing or refraining from giving iv-tPA to MRI-examined patients (mean VAS score 9.0, SD ±1.2) (P = .014). No differences in modified Rankin scale or mortality were detected at 3 months in CT- versus MRI-examined iv-tPA-treated patients. CONCLUSIONS: Stroke physicians were significantly more certain when prescribing iv-tPA to MRI-examined stroke patients, and MRI influences the final treatment decision significantly more compared with CT, although no difference in mortality and functional outcome at 3 months was detected between CT- and MRI-examined patients treated with iv-tPA.

Showing no spot sign is a strong predictor of independent living after intracerebral haemorrhage.

BACKGROUND: A spot sign on computed tomography angiography (CTA) is a potentially strong predictor of poor outcome on ultra-early radiological imaging. The aim of this study was to assess the spot sign as a predictor of functional outcome at 3 months as well as long-term mortality, with a focus on the ability to identify patients with a spontaneous, acceptable outcome. METHODS: In a prospective, consecutive single-centre registry of acute stroke patients, we investigated patients with spontaneous intracerebral haemorrhage (ICH) admitted within 4.5 h after symptom onset from April 2009 to January 2013. The standard work-up in our centre included CTA for spot sign status, unless a contraindication was present. Modified Rankin Scale (mRS) scores were assessed at 3 months in the outpatient clinic or by telephone interviews. Long-term mortality was assessed by electronic chart follow-up for up to 1,500 days. RESULTS: Of the 128 patients, 37 (28.9%) had a spot sign on admission CTA. The presence of a spot sign was associated with larger median admission haematoma volume [38.0 ml (IQR 18.0-78.0) vs. 12.0 ml (5.0-24.0); p<0.0001] and higher median National Institutes of Health Stroke Scale score [19 (IQR 12-23) vs. 12 (6-16); p<0.0001]. Three months after stroke, the median functional outcome was considerably better in patients without spot sign [mRS score 3 (IQR 2-4) vs. 6 (4-6); p<0.0001]. The absence of a spot sign showed a sensitivity and specificity for good outcome (mRS scores 0-2) of 0.91 and 0.36, respectively. The presence of a spot sign was, in multivariate models, an independent inverse predictor of good 3-month outcome (OR 0.17; 95% CI: 0.03-0.88) as well as a prominent independent predictor of poor 3-month outcome (mRS scores 5-6; OR 3.40; 95% CI: 1.10-10.5) and death during follow-up (HR 3.04; 95% CI: 1.45-6.34). Patients with a spot sign surviving the acute phase had long-term survival comparable to patients with no spot sign. CONCLUSION: The absence or presence of a spot sign is a reliable ultra-early predictor of long-term mortality and functional outcome in patients with spontaneous ICH.

Prevalence of early neurological deterioration after I.V - thrombolysis in acute ischaemic stroke patients - A hospital-based cohort study.

OBJECTIVES: Early Neurological Deterioration (END) occur in up to 25% of patients with ischaemic stroke receiving stroke-unit-care and in 11-13.8% of patients treated with iv-tissue-Plasmniogen-Activator (iv-tPA). The aim of the study was to establish and compare the prevalence of END and symptomatic Intracranial Hemorrhage (sICH) in a prospectively designed registry of consecutive patients treated with iv-tPA to a historic cohort of iv-tPA eligible patients whom were hospitalized prior to implementation of iv-tPA-treatment but receiving otherwise comparable acute stroke care. PATIENTS AND METHODS: Single center registry from a public Danish stroke-unit. Three-hundred-sixty-one unselected consecutive iv-tPA-treated patients admitted within 4.5 h from symptom-onset with symptoms of acute stroke and >17 years of age. The iv-tPA-treated cohort was compared to a pre-tPA cohort of 246 iv-tPA-eligible patients who were admitted to the same stroke center from 1998 to 2001. Acute stroke care apart from iv-tPA was comparable. Outcome measures was assessed on admission and at 24 h; END as any increase in National Institute of Health Stroke Scale (NIHSS) and symptomatic Intracranial Hemorrhage (sICH) with use of CT-head-scan. RESULTS: END was observed in 27 (7.5%) of the 361 patients in the tPA-cohort and 43 (17.5%) of 246 in the pre-tPA-cohort, p < 0.0001. Any ICH was detected in 23 (6.4%) and sICH in 3 (0.8%) of the iv-tPA-treated patients. CONCLUSION: END is significantly less frequent in acute stroke patients treated with iv-tPA. Deterioration due to ICH was rare and of limited severity in this population. END though remains a significant complication after stroke why more detailed knowledge on the various causes of END is needed to further improve patient outcome.

Hereditary cerebral small vessel disease and stroke.

Cerebral small vessel disease is considered hereditary in about 5% of patients and is characterized by lacunar infarcts and white matter hyperintensities on MRI. Several monogenic hereditary diseases causing cerebral small vessel disease and stroke have been identified. The purpose of this systematic review is to provide a guide for determining when to consider molecular genetic testing in patients presenting with small vessel disease and stroke. CADASIL, CARASIL, collagen type IV mutations (including PADMAL), retinal vasculopathy with cerebral leukodystrophy, Fabry disease, hereditary cerebral hemorrhage with amyloidosis, and forkhead box C1 mutations are described in terms of genetics, pathology, clinical manifestation, imaging, and diagnosis. These monogenic disorders are often characterized by early-age stroke, but also by migraine, mood disturbances, vascular dementia and often gait disturbances. Some also present with extra-cerebral manifestations such as microangiopathy of the eyes and kidneys. Many present with clinically recognizable syndromes. Investigations include a thorough family medical history, medical history, neurological examination, neuroimaging, often supplemented by specific examinations e.g of the of vision, retinal changes, as well as kidney and heart function. However molecular genetic analysis is the final gold standard of diagnosis. There are increasing numbers of reports on new monogenic syndromes causing cerebral small vessel disease. Genetic counseling is important. Enzyme replacement therapy is possible in Fabry disease, but treatment options remain overall very limited.

CT and MRI-based door-needle-times for acute stroke patients a quasi-randomized clinical trial.

OBJECTIVES: Door-Needle-times (DNT) of 20min are feasible when Computer Tomography (CT) is used for first-line brain-imaging to assess stroke-patients' eligibility for intravenous-tissue-Plasminogen-Activator (iv-tPA), but the more time-consuming Magnetic Resonance Imaging (MRI)-based-evaluation is superior in detecting acute ischaemia.

Prevalence and long-term clinical significance of intracranial atherosclerosis after ischaemic stroke or transient ischaemic attack: a cohort study.

OBJECTIVES: We investigated the prevalence and long-term risk associated with intracranial atherosclerosis identified during routine evaluation. DESIGN: This study presents data from a prospective cohort of patients admitted to our stroke unit for thrombolysis evaluation. SETTING AND PARTICIPANTS: We included 652 with a final diagnosis of ischaemic stroke or transient ischaemic attack (TIA) from April 2009 to December 2011. All patients were acutely evaluated with cerebral CT and CT angiography (CTA). Acute radiological examinations were screened for intracranial arterial stenosis (IAS) or intracranial arterial calcifications (IAC). Intracranial stenosis was grouped into 30-50%, 50-70% and >70% lumen reduction. The extent of IAC was graded as number of vessels affected. PRIMARY AND SECONDARY OUTCOME MEASURE: Patients were followed until July 2013. Recurrence of an ischaemic event (stroke, ischaemic heart disease (IHD) and TIA) was documented through the national chart system. Poor outcome was defined as death or recurrence of ischaemic event. RESULTS: 101 (15.5%) patients showed IAS (70: 30-50%, 29: 50-70% and 16: >70%). Two-hundred and fifteen (33%) patients had no IAC, 339 (52%) in 1-2 vessels and 102 (16%) in >2 vessels. During follow-up, 53 strokes, 20 TIA and 14 IHD occurred, and 95 patients died. The risk of poor outcome was significantly different among different extents of IAS as well as IAC (log-rank test p<0.01 for both). In unadjusted analysis IAS and IAC predicted poor outcome and recurrent ischaemic event. When adjusted, IAS and IAC independently increased the risk of a recurrent ischaemic event (IAS: HR 1.67; CI 1.04 to 2.64 and IAC: HR 1.22; CI 1.02 to 1.47). CONCLUSIONS: Intracranial atherosclerosis detected during acute evaluation predicts an increased risk of recurrent stroke.