Rujimas Khumtong1,2, Timo Krings1, Vitor M Pereira1, Aleksandra Pikula3, Joanna D Schaafsma4. 1. Division of Neuroradiology, Department of Medical Imaging, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, Canada. 2. Division of Diagnostic Radiology, Department of Radiology, Songklanagarind Hospital, Prince of Songkhla University, Songkhla, Thailand. 3. Division of Neurology, Department of Medicine, Toronto Western Hospital, University Health Network, University of Toronto, 5WW-425, Toronto Western Hospital, 399 Bathurst Street, Toronto, ON, M5T 2S8, Canada. 4. Division of Neurology, Department of Medicine, Toronto Western Hospital, University Health Network, University of Toronto, 5WW-425, Toronto Western Hospital, 399 Bathurst Street, Toronto, ON, M5T 2S8, Canada. joanna.schaafsma@uhn.ca.
Abstract
PURPOSE: Different CT-based protocols are being used in acute ischemic stroke. We aimed to assess the added value of delayed-phase CT angiography (CTA) and CT perfusion (CTP) to a basic protocol using non-contrast computerized tomography (NCCT) with arterial-phase CTA in patient selection for mechanical thrombectomy. METHODS: We retrospectively included consecutive acute ischemic stroke patients with a symptomatic intracranial arterial occlusion between January 2015 and November 2016 who underwent NCCT, arterial and delayed-phase CTA, and CTP. These imaging studies were grouped into five protocols: (1) NCCT and arterial-phase CTA; (2) NCCT, arterial-phase CTA, and CTP; (3) NCCT, arterial- and delayed-phase CTA; (4) NCCT, arterial- and delayed-phase CTA, and CTP; and (5) NCCT and delayed-phase CTA. Two interventional neuro-radiologists independently decided on mechanical thrombectomy for each patient based on the protocols. They reached consensus for discrepant decisions. We assessed the raters' confidence level, inter-rater agreement, and compared treatment decisions for the different protocols. RESULTS: We included 73 patients (44% male, mean age 74). The inter-rater agreement was substantial for protocols with three or more modalities (ҡ = 0.613-0.704) and moderate for two-modality protocols (ҡ = 0.506-0.529). The highest agreement and confidence level was achieved for the combination of NCCT, arterial-phase CTA, and CTP. Adding CTP to NCCT and arterial-phase CTA resulted in a 10% increase of recommendations for mechanical thrombectomy and adding delayed-phase CTA resulted in a 4% increase. These management changes did not reach statistical significance (p = 0.07; p = 0.25, respectively). CONCLUSION: Adding CTP and/or a delayed-phase CTA to NCCT with arterial-phase CTA improves the decision-maker's confidence level and creates a trend towards a lower threshold for mechanical thrombectomy.
PURPOSE: Different CT-based protocols are being used in acute ischemic stroke. We aimed to assess the added value of delayed-phase CT angiography (CTA) and CT perfusion (CTP) to a basic protocol using non-contrast computerized tomography (NCCT) with arterial-phase CTA in patient selection for mechanical thrombectomy. METHODS: We retrospectively included consecutive acute ischemic strokepatients with a symptomatic intracranial arterial occlusion between January 2015 and November 2016 who underwent NCCT, arterial and delayed-phase CTA, and CTP. These imaging studies were grouped into five protocols: (1) NCCT and arterial-phase CTA; (2) NCCT, arterial-phase CTA, and CTP; (3) NCCT, arterial- and delayed-phase CTA; (4) NCCT, arterial- and delayed-phase CTA, and CTP; and (5) NCCT and delayed-phase CTA. Two interventional neuro-radiologists independently decided on mechanical thrombectomy for each patient based on the protocols. They reached consensus for discrepant decisions. We assessed the raters' confidence level, inter-rater agreement, and compared treatment decisions for the different protocols. RESULTS: We included 73 patients (44% male, mean age 74). The inter-rater agreement was substantial for protocols with three or more modalities (ҡ = 0.613-0.704) and moderate for two-modality protocols (ҡ = 0.506-0.529). The highest agreement and confidence level was achieved for the combination of NCCT, arterial-phase CTA, and CTP. Adding CTP to NCCT and arterial-phase CTA resulted in a 10% increase of recommendations for mechanical thrombectomy and adding delayed-phase CTA resulted in a 4% increase. These management changes did not reach statistical significance (p = 0.07; p = 0.25, respectively). CONCLUSION: Adding CTP and/or a delayed-phase CTA to NCCT with arterial-phase CTA improves the decision-maker's confidence level and creates a trend towards a lower threshold for mechanical thrombectomy.
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