COVID-19 Stroke Apical Lung Examination Study: A Diagnostic and Prognostic Imaging Biomarker in Suspected Acute Stroke

Abstract

BACKGROUND AND PURPOSE: Diagnosis of coronavirus disease 2019 (COVID-19) relies on clinical features and reverse-transcriptase polymerase chain reaction testing, but the sensitivity is limited. Carotid CTA is a routine acute stroke investigation and includes the lung apices. We evaluated CTA as a potential COVID-19 diagnostic imaging biomarker. MATERIALS AND METHODS: This was a multicenter, retrospective study (n ¼ 225) including CTAs of patients with suspected acute stroke from 3 hyperacute stroke units (March-April 2020). We evaluated the reliability and accuracy of candidate diagnostic imaging biomarkers. Demographics, clinical features, and risk factors for COVID-19 and stroke were analyzed using univariate and multivariate statistics. RESULTS: Apical ground-glass opacification was present in 22.2% (50/225) of patients. Ground-glass opacification had high interrater reliability (Fleiss k ¼ 0.81; 95% CI, 0.68-0.95) and, compared with reverse-transcriptase polymerase chain reaction, had good diagnostic performance (sensitivity, 75% [95% CI, 56-87]; specificity, 81% [95% CI, 71-88]; OR ¼ 11.65 [95% CI, 4.14-32.78]; P , .001) on multivariate analysis. In contrast, all other contemporaneous demographic, clinical, and imaging features available at CTA were not diagnostic for COVID-19. The presence of apical ground-glass opacification was an independent predictor of increased 30-day mortality (18.0% versus 5.7%, P ¼ .017; hazard ratio ¼ 3.51; 95% CI, 1.42-8.66; P ¼ .006). CONCLUSIONS: We identified a simple, reliable, and accurate COVID-19 diagnostic and prognostic imaging biomarker obtained from CTA lung apices: the presence or absence of ground-glass opacification. Our findings have important implications in the management of patients presenting with suspected stroke through early identification of COVID-19 and the subsequent limitation of disease transmission. ABBREVIATIONS: BSTI ¼ British Society of Thoracic Imaging; COVID-19 ¼ coronavirus disease 2019; GGO ¼ ground-glass opacification; IRR ¼ interrater reliability; RT-PCR ¼ reverse-transcriptase polymerase chain reaction; SARS-CoV-2 ¼ Severe Acute Respiratory Syndrome coronavirus 2 T he Severe Acute Respiratory Syndrome coronavirus 2 (SARS-CoV-2) was given pandemic status by the World Health Organization in March 2020. 1,2 When symptomatic, coronavirus disease 2019 (COVID-19) typically causes mild, self-limiting respiratory features. However, a severe lower respiratory and multisystem disease may occur, necessitating hospitalization. 3 Approximately 6.0% of patients with COVID-19 die, and 12% require intensive care support. 4-7 Symptoms alone are insufficient for a diagnosis due to a high prevalence of asymptomatic carriers and a variable presymptomatic incubation period (2-14 days). 8,9 The diagnostic reference standard is the reverse-transcriptase polymerase chain reaction

Admission chest CT findings and risk assessment for stroke-associated pneumonia

“…While it is not unexpected to observe a close relationship between imaging and clinical signs of pneumonia, the role of other features observed in chest CT not considered as signs of overt infection is an unexplored field. Indeed, the recent COVID-19 pandemic has triggered a research interest for analyzing lung tissue that remains within the frame of standard stroke work-up and has shown that abnormal chest CT findings are not uncommon in stroke patients even when analyzed in just the apical segments of lungs, and do not always signify the presence of COVID-19 pneumonia or other infections [ 15 , 16 ]. Our study is a further effort in this arena and highlights that pulmonary pathologies other than overt signs of infections on chest CT can be predictive of SAP.…”

Epicardial adipose tissue in obesity with heart failure with preserved ejection fraction: Cardiovascular magnetic resonance biomarker study

“…Initial univariate analyses and stepwise multivariate linear regression analyses were executed to identify predictors of the odds of HFpEF in the obese population. Covariates with a univariate P value < 0.10 were included in the multivariate logistic regression analysis[ 24 , 25 ]. Pearson’s correlation coefficient was employed for correlation analyses.…”

COVID-19 Stroke Apical Lung Examination Study 2: a national prospective CTA biomarker study of the lung apices, in patients presenting with suspected acute stroke (COVID SALES 2)

“…Prior to the study, sites received training materials regarding the assessment of apical GGO for CTA and the Alberta Stroke Program Early CT score (ASPECTS) for NCCT ( Siddiqui et al, 2020 ). Fig.…”

“…Patients with suspected acute stroke caused by large vessel occlusion are potentially eligible for mechanical thrombectomy, and CTA from the aortic arch to cranial vertex is performed routinely in the imaging work up. Early in the pandemic, ground-glass opacification (GGO) in the lung apices on CTA, performed for patients with suspected acute stroke, was identified as a COVID-19 diagnostic biomarker with good sensitivity (75 %) and specificity (81 %) that was available before RT-PCR results ( Siddiqui et al, 2020 ). Furthermore, it was demonstrated that apical GGO seen on CTA could be used as a prognostic biomarker because the presence of GGO was an independent predictor of 30-day mortality ( Siddiqui et al, 2020 ).…”