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Role of CT angiography in patient selection for thrombolytic therapy in acute hemispheric stroke
S Wildermuth1, M Knauth, T Brandt
1Department of Neurology, University of Heidelberg, Germany. susannevwildermuth@krzmail.krz.uni-heidelberg.de
Insights
CT angiography (CTA) is feasible for assessing acute hemispheric ischemia. It helps identify patients who may not benefit from thrombolytic therapy, guiding treatment decisions.
Area of Science:
- Neurology
- Radiology
- Cardiovascular Medicine
Background:
- Thrombolytic therapy improves outcomes in select acute cerebral ischemia patients.
- Patient selection for thrombolysis can be enhanced by vascular imaging.
- Current rtPA trials do not mandate pre-treatment vascular imaging.
Purpose of the Study:
- To assess the feasibility of CT angiography (CTA) in acute hemispheric ischemia.
- To evaluate CTA's relevance in guiding thrombolytic therapy decisions.
Main Methods:
- CTA was performed on 40 patients with moderate to severe acute hemispheric ischemia (NIHSS ≥ 8).
- CTA findings were compared with Doppler ultrasonography (n=22) and digital subtraction angiography (n=7).
- Twenty patients received thrombolytic therapy; others received heparin.
Main Results:
- Diagnostic quality CTA images and 3D reconstructions were obtained in all patients.
- Thirty-four patients presented with vessel occlusion.
- Leptomeningeal collateral extent significantly correlated with thrombolytic therapy outcome (rs=0.46, P<0.05).
- CTA demonstrated high diagnostic accuracy compared to US (22/22) and DSA (6/7).
Conclusions:
- CTA is feasible and provides crucial information for initiating therapy in acute hemispheric ischemia.
- CTA can identify patients with autolyzed thrombi, internal carotid artery bifurcation occlusions, and poor leptomeningeal collaterals.
- These identified patient subgroups may have limited benefit from thrombolytic therapy.
Background And Purpose:
It has been shown that thrombolytic therapy can improve clinical outcome in a subgroup of patients with acute cerebral ischemia. This subgroup was characterized by certain clinical and imaging findings (eg, moderate to severe neurological deficit for less than 3 to 6 hours, occlusion of the middle cerebral artery, lack of extended infarct signs on CT, and efficient leptomeningeal collaterals). Although not part of published prospective randomized rtPA trials, information about the status of the brain vessels would be helpful in the selection of patients who may benefit the most. Our purpose was to determine the feasibility of CT angiography (CTA) in patients with acute hemispheric ischemia and to evaluate its relevance for thrombolytic therapy.
Methods:
CTA was performed in 40 consecutive patients (11 women and 29 men; age range, 19 to 80 years) with moderate or severe symptoms (National Institutes of Health Stroke Scale score of > or =8) of acute hemispheric ischemia. CTA findings were compared with Doppler ultrasonography (US; n=22) and intra-arterial digital subtraction angiography (DSA; n=7). Twenty patients received thrombolytic therapy, the remaining patients received intravenous heparin.
Results:
Images and 3-dimensional reconstructions of diagnostic quality could be obtained in all patients. Thirty-four patients had a vessel occlusion. The extent of leptomeningeal collaterals correlated significantly with the outcome after thrombolytic therapy (rs=0.46, P<0.05). The evaluation of diagnostic accuracy showed a high agreement with US (22 of 22) and DSA (6 of 7).
Conclusions:
CTA can provide important information for the initiation of therapy in patients with acute hemispheric ischemia. Identification of patients with autolyzed thrombi, occlusion of the internal carotid artery bifurcation, and poor leptomeningeal collaterals is feasible with the use of CTA. These patients may have little potential for benefit from thrombolytic therapy.