Clinical Stroke Penumbra: Use of National Institutes of Health Stroke Scale as a Surrogate for CT Perfusion in Patient Triage for Intra-Arterial Middle Cerebral Artery Stroke Therapy

Boxerman, Jerrold L.; Jayaraman, Mahesh; Mehan, William A.; Rogg, Jeffrey; Haas, Richard

doi:10.3174/ajnr.a3102

Cited by 17 publications

(7 citation statements)

References 35 publications

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“…In all of the above discussions, the concept of penumbra is evaluated using a combination of the severity of the clinical deficit and location of the LVO. This concept is the ‘clinical penumbra’, or ‘clinical–diffusion mismatch’ 65. When this approach is used, no additional physiologic imaging is used to categorize the volume of tissue at risk.…”

Section: Methodsmentioning

confidence: 99%

“…CT perfusion is at a greater disadvantage, since both core infarct and penumbral volumes depend on post-processing calculations, as opposed to MR-DWI, which preserves a sensitive physiological marker of irreversible infarction (restricted diffusion of water in infarcted tissue). Owing to these drawbacks of perfusion imaging (CTP or MR-PWI), some have postulated that a surrogate for the penumbra may simply be reflected by the patient's clinical examination or NIHSS 65. At this time, the clinical penumbra may be the best indicator to select patients for embolectomy as long as an accurate and small core infarct estimate is available.…”

Section: Methodsmentioning

confidence: 99%

See 1 more Smart Citation

Initial hospital management of patients with emergent large vessel occlusion (ELVO): report of the standards and guidelines committee of the Society of NeuroInterventional Surgery

McTaggart

Ansari

Goyal

et al. 2015

J NeuroIntervent Surg

137

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ObjectiveTo summarize the current literature regarding the initial hospital management of patients with acute ischemic stroke (AIS) secondary to emergent large vessel occlusion (ELVO), and to offer recommendations designed to decrease the time to endovascular treatment (EVT) for appropriately selected patients with stroke.MethodsUsing guidelines for evidenced-based medicine proposed by the Stroke Council of the American Heart Association, a critical review of all available medical literature supporting best initial medical management of patients with AIS secondary to ELVO was performed. The purpose was to identify processes of care that most expeditiously determine the eligibility of a patient with an acute stroke for interventions including intravenous fibrinolysis with recombinant tissue plasminogen activator (IV tPA) and EVT using mechanical embolectomy.ResultsThis review identifies four elements that are required to achieve timely revascularization in ELVO. (1) In addition to non-contrast CT (NCCT) brain scan, CT angiography should be performed in all patients who meet an institutional threshold for clinical stroke severity. The use of any advanced imaging beyond NCCT should not delay the administration of IV tPA in eligible patients. (2) Activation of the neurointerventional team should occur as soon as possible, based on either confirmation of large vessel occlusion or a prespecified clinical severity threshold. (3) Additional imaging techniques, particularly those intended to physiologically select patients for EVT (CT perfusion and diffusion–perfusion mismatch imaging), may provide additional value, but should not delay EVT. (4) Routine use of general anesthesia during EVT procedures, should be avoided if possible. These workflow recommendations apply to both primary and comprehensive stroke centers and should be tailored to meet the needs of individual institutions.ConclusionsPatients with ELVO are at risk for severe neurologic morbidity and mortality. To achieve the best possible clinical outcomes stroke centers must optimize their triage strategies. Strategies that provide patients with ELVO with the fastest access to reperfusion depend upon detail-oriented process improvement.

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Section: Methodsmentioning

confidence: 99%

Section: Methodsmentioning

confidence: 99%

Initial hospital management of patients with emergent large vessel occlusion (ELVO): report of the standards and guidelines committee of the Society of NeuroInterventional Surgery

McTaggart

Ansari

Goyal

et al. 2015

J NeuroIntervent Surg

137

View full text Add to dashboard Cite

show abstract

“…One investigation found no combination of CT ASPECTS and NIHSS predicted perfusion–diffusion mismatch ( 97 ) and another study found no relationship between “clinical–CT mismatch” and likelihood of responding to IV tPA ( 98 ). Researchers have also shown that EVT decisions were changed rarely (5.6%) when including CTP in addition to NIHSS, non-contrast CT and CTA ( 99 ).…”

Section: Moving Beyond the Clock: Shifting The Paradigm From “Time Ismentioning

confidence: 99%

Neuroimaging Paradigms to Identify Patients for Reperfusion Therapy in Stroke of Unknown Onset

et al. 2018

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Despite the proven efficacy of intravenous alteplase or endovascular thrombectomy for the treatment of patients with acute ischemic stroke, only a minority receive these treatments. This low treatment rate is due in large part to delay in hospital arrival or uncertainty as to the exact time of onset of ischemic stroke, which renders patients outside the current guideline-recommended window of eligibility for receiving these therapeutics. However, recent pivotal clinical trials of late-window thrombectomy now force us to rethink the value of a simplistic chronological formulation that “time is brain.” We must recognize a more nuanced concept that the rate of tissue death as a function of time is not invariant, that still salvageable tissue at risk of infarction may be present up to 24 h after last-known well, and that those patients may strongly benefit from reperfusion. Multiple studies have sought to address this clinical dilemma using neuroimaging methods to identify a radiographic time-stamp of stroke onset or evidence of salvageable ischemic tissue and thereby increase the number of patients eligible for reperfusion therapies. In this review, we provide a critical analysis of the current state of neuroimaging techniques to select patients with unwitnessed stroke for revascularization therapies and speculate on the future direction of this clinically relevant area of stroke research.

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“…Patients arriving at the authors' hospital within 4.5 hours of symptom onset are candidates for IV thrombolysis. 8,9 IV therapies must be initiated within a strict time limit to avoid unacceptable rates of intracranial hemorrhage. The therapeutic window for administration of IV rt-PA was extended from 3 to 4.5 hours based on the outcome of European Cooperative Acute Stroke Study III (ECASS III).…”

Section: Algorithmic Approach To Ischemic Strokementioning

confidence: 99%

Intra-arterial Stroke Management

Prince

Ahn

Soares

2013

Semin intervent Radiol

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Acute ischemic stroke is a leading cause of death and the leading cause of disability in the United States. Cerebral neuronal death begins within minutes after threshold values of blood oxygen saturation are crossed. Prompt restoration of oxygenated blood flow into ischemic tissue remains the common goal of reperfusion strategies. This article provides a brief overview of acute ischemic stroke, a summary of the major intra-arterial stroke therapy trials, and comments on current training requirements for the performance of intra-arterial therapies.

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Clinical Stroke Penumbra: Use of National Institutes of Health Stroke Scale as a Surrogate for CT Perfusion in Patient Triage for Intra-Arterial Middle Cerebral Artery Stroke Therapy

Cited by 17 publications

References 35 publications

Initial hospital management of patients with emergent large vessel occlusion (ELVO): report of the standards and guidelines committee of the Society of NeuroInterventional Surgery

Initial hospital management of patients with emergent large vessel occlusion (ELVO): report of the standards and guidelines committee of the Society of NeuroInterventional Surgery

Neuroimaging Paradigms to Identify Patients for Reperfusion Therapy in Stroke of Unknown Onset

Intra-arterial Stroke Management

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