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Conjugate Eye Deviation on CT Associated With Worse Outcomes Despite IV Thrombolysis
Nirav H Shah1, Nirav Bhatt2, Anita Tipirneni2
1Department of Neurology, University of California San Francisco, San Francisco, CA, USA.
Insights
Computed tomography conjugate eye deviation (CT-CED) in stroke patients predicts large vessel occlusion and atrial fibrillation. This finding may help identify stroke patients who could benefit from endovascular therapy.
Area of Science:
- Neurology
- Radiology
- Emergency Medicine
Background:
- Rapid stroke management is critical for patient outcomes.
- Ipsilateral computed tomography conjugate eye deviation (CT-CED) is linked to worse stroke outcomes.
- CT-CED has not been previously evaluated as a predictor of vascular occlusion.
Purpose of the Study:
- To test the hypothesis that CT-CED is a marker for vascular occlusion.
- To evaluate the association between CT-CED and vascular occlusion in patients receiving intravenous tissue plasminogen activator (IV tPA).
Main Methods:
- Retrospective analysis of 104 patients with acute ischemic stroke treated with IV tPA.
- Baseline CT scans were assessed for CT-CED by two blinded examiners.
- Follow-up imaging was used to identify infarct location and intracranial large vessel occlusion (LVO).
Main Results:
- CT-CED was present in 36 patients, with excellent inter-rater reliability (κ = 0.97).
- Patients with CT-CED had higher initial NIHSS, worse modified Rankin Scale scores, and longer hospital length of stay.
- Vascular occlusion was identified in 58% of patients with CT-CED versus 32% without (P < .01).
- Atrial fibrillation was diagnosed in 61% of patients with CT-CED versus 22% without (P < .01).
Conclusions:
- CT-CED is associated with higher initial NIHSS, large vessel occlusion, and atrial fibrillation.
- CT-CED may serve as a screening tool for endovascular therapy in stroke patients.
- Prospective studies are warranted to confirm the utility of CT-CED in guiding treatment decisions.
Introduction:
Rapid stroke management has significant implications in patient outcomes. Ipsilateral computed tomography conjugate eye deviation (CT-CED) has been associated with worse outcomes but has never been evaluated as predictive of vascular occlusion. To test the hypothesis that CT-CED is a marker for vascular occlusion, we evaluated patients treated with intravenous tissue plasminogen activator (IV tPA).
Methods:
We performed a retrospective analysis of patients with acute ischemic stroke treated with IV tPA at a large tertiary care hospital over an 18-month period. A waiver of informed consent was granted. Two examiners evaluated baseline brain CTs blinded to the location of infarct to assess the presence of CT-CED and follow-up imaging for the location of infarct and the presence of intracranial large vessel occlusion. Demographics, initial National Institutes of Health Stroke Scale (NIHSS), modified Rankin Scales (mRSs), and hospital length of stay (LOS) were collected.
Results:
Among 104 patients treated with IV tPA, 36 had CT-CED. Inter-rater reliability for CT-CED was excellent (κ = 0.97; 95% confidence interval: 0.98-1.0). The CT-CED group was older (69.8 vs 64 years; P = .038), had higher initial NIHSS (14.6 vs 11; P = .01), worse mRS (3.2 vs 2.4; P = .03), and longer LOS (8.4 vs 6.4; P = .05) compared with those without CT-CED. A vascular occlusion in the territory of the infarct was seen in 58% of patients with CT-CED versus 32% without CT-CED (P < .01). Atrial fibrillation (AF) was diagnosed in 61% patients with CT-CED versus 22% without (P < .01).
Conclusion:
The CT-CED is associated with higher initial NIHSS, large vessel occlusion, and AF. Prospective studies are needed to ascertain whether CT-CED may be utilized part of a screen for endovascular therapy.