Magnetic resonance imaging and computed tomography in emergency assessment of patients with suspected acute stroke: a prospective comparison

Chalela, Julio A.; Kidwell, Chelsea S.; Nentwich, Lauren M.; Luby, Marie; Butman, John A.; Demchuk, Andrew M.; Hill, Michael D.; Patronas, Nicholas J.; Latour, Lawrence L.; Warach, Steven

doi:10.1016/s0140-6736(07)60151-2

Cited by 1,085 publications

(750 citation statements)

References 24 publications

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“…Other strategies risk high rates of diagnostic error (58% to 84% missed by CT, 15,16 13.3% [n = 15/113] missed by MRI) and low cost-effectiveness. 37 <24 hours for all subjects ED presentation to neuroimaging <24 hours for all subjects (MRI n = 186; CT n = 4) Complications of testing ABCD2, HINTS-none CT-none; MRI-one claustrophobic reaction False negative initial MRI-DWI 14.3% of ischemic strokes (n = 15/105) ‖ • 2-24 hours after onset of symptoms (n = 9)…”

Section: Discussionmentioning

confidence: 99%

“…8 Although patients with brainstem or cerebellar (posterior fossa) hemorrhages also present with vertigo or dizziness, these rarely mimic benign dizziness presentations. 14 Brain computed tomography (CT) scans are very sensitive for detecting acute intracranial hemorrhages (93% 15 ), but cannot "rule out" ischemic stroke, as CTs detect only about 16% 15 to 42% 16 of early ischemic strokes. Brain magnetic resonance imaging (MRI) scans are costly, not always available, and in the first 24 hours after posterior fossa stroke symptom onset may be falsely negative in up to 20%.…”

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confidence: 99%

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HINTS Outperforms ABCD2 to Screen for Stroke in Acute Continuous Vertigo and Dizziness

Newman‐Toker

Kerber

Hsieh

et al. 2013

Academic Emergency Medicine

314

351

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ObjectivesDizziness and vertigo account for about 4 million emergency department (ED) visits annually in the United States, and some 160,000 to 240,000 (4% to 6%) have cerebrovascular causes. Stroke diagnosis in ED patients with vertigo/dizziness is challenging because the majority have no obvious focal neurologic signs at initial presentation. The authors sought to compare the accuracy of two previously published approaches purported to be useful in bedside screening for possible stroke in dizziness: a clinical decision rule (head impulse, nystagmus type, test of skew [HINTS]) and a risk stratification rule (age, blood pressure, clinical features, duration of symptoms, diabetes [ABCD2]).MethodsThis was a cross‐sectional study of high‐risk patients (more than one stroke risk factor) with acute vestibular syndrome (AVS; acute, persistent vertigo or dizziness with nystagmus, plus nausea or vomiting, head motion intolerance, and new gait unsteadiness) at a single academic center. All underwent neurootologic examination, neuroimaging (97.4% by magnetic resonance imaging [MRI]), and follow‐up. ABCD2 risk scores (0–7 points), using the recommended cutoff of ≥4 for stroke, were compared to a three‐component eye movement battery (HINTS). Sensitivity, specificity, and positive and negative likelihood ratios (LR+, LR–) were assessed for stroke and other central causes, and the results were stratified by age. False‐negative initial neuroimaging was also assessed.ResultsA total of 190 adult AVS patients were assessed (1999–2012). Median age was 60.5 years (range = 18 to 92 years; interquartile range [IQR] = 52.0 to 70.0 years); 60.5% were men. Final diagnoses were vestibular neuritis (34.7%), posterior fossa stroke (59.5% [105 infarctions, eight hemorrhages]), and other central causes (5.8%). Median ABCD2 was 4.0 (range = 2 to 7; IQR = 3.0 to 4.0). ABCD2 ≥ 4 for stroke had sensitivity of 61.1%, specificity of 62.3%, LR+ of 1.62, and LR– of 0.62; sensitivity was lower for those younger than 60 years old (28.9%). HINTS stroke sensitivity was 96.5%, specificity was 84.4%, LR+ was 6.19, and LR– was 0.04 and did not vary by age. For any central lesion, sensitivity was 96.8%, specificity was 98.5%, LR+ was 63.9, and LR– was 0.03 for HINTS, and sensitivity was 99.2%, specificity was 97.0%, LR+ was 32.7, and LR– was 0.01 for HINTS “plus” (any new hearing loss added to HINTS). Initial MRIs were falsely negative in 15 of 105 (14.3%) infarctions; all but one was obtained before 48 hours after onset, and all were confirmed by delayed MRI.ConclusionsHINTS substantially outperforms ABCD2 for stroke diagnosis in ED patients with AVS. It also outperforms MRI obtained within the first 2 days after symptom onset. While HINTS testing has traditionally been performed by specialists, methods for empowering emergency physicians (EPs) to leverage this approach for stroke screening in dizziness should be investigated.

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Section: Discussionmentioning

confidence: 99%

mentioning

confidence: 99%

HINTS Outperforms ABCD2 to Screen for Stroke in Acute Continuous Vertigo and Dizziness

Newman‐Toker

Kerber

Hsieh

et al. 2013

Academic Emergency Medicine

314

351

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“…First, all but one study included a very narrow spectrum of patients with typical anterior circulation stroke and limited severity. Moreover, the study with a wider spectrum of patients still only included mostly mild strokes (median National Institutes of Health Stroke Scale [NIHSS = 3], scale ranges from 0 to 42, maximal severity) [6]. Patients with severe stroke who often do not tolerate MRI were not eligible [6].…”

Section: The Cochrane Point Of View: a Systematic Reviewmentioning

confidence: 99%

“…Moreover, the study with a wider spectrum of patients still only included mostly mild strokes (median National Institutes of Health Stroke Scale [NIHSS = 3], scale ranges from 0 to 42, maximal severity) [6]. Patients with severe stroke who often do not tolerate MRI were not eligible [6]. Second, the information on other patients who were excluded because they either could not tolerate MRI or had contraindications (e.g., pacemakers and metal implants), was provided in only three studies [4].…”

Section: The Cochrane Point Of View: a Systematic Reviewmentioning

confidence: 99%

“…Second, the information on other patients who were excluded because they either could not tolerate MRI or had contraindications (e.g., pacemakers and metal implants), was provided in only three studies [4]. About 11% of the patients initially screened for inclusion were subsequently excluded in the largest study [6]. Third, in most studies, patients with stroke mimicking diseases (for example cerebral neoplasms or systemic infections) were also not included in the spectrum of interest [4].…”

Section: The Cochrane Point Of View: a Systematic Reviewmentioning

confidence: 99%

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Diagnosing acute stroke with magnetic resonance imaging (MRI) calls for caution: computed tomography (CT) is preferable for standard care

et al. 2011

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Fluid-Attenuated Inversion Recovery Vascular Hyperintensity

Olindo

Chausson²,

Joux³

et al. 2012

Arch Neurol

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Background: Few data are available on the relationship between fluid-attenuated inversion recovery vascular hyperintensities and proximal middle cerebral artery occlusion prognosis. Objectives: To assess a fluid-attenuated inversion recovery vascular hyperintensities score (FVHS) and explore its relationship with recanalization status and clinical outcomes after intravenous thrombolysis. Design: Retrospective study. Setting: Stroke unit in a university hospital. Patients: Consecutive patients with proximal middle cerebral artery occlusion, thrombolysed within 6 hours, were selected from our prospective database. The FVHS (range, 0-10; divided into low, medium, and high thirds) was quantified on the magnetic resonance image obtained at admission. Recanalization rates, infarction size (Alberta Stroke Program Early CT Score applied to diffusionweighted imaging [ASPECTS-DWI]), and 3-month functional outcomes (modified Rankin Scale score) were determined. Poor outcomes and large infarctions were defined as a modified Rankin Scale score higher than 2 and an ASPECTS-DWI score of 5 or lower, respectively. Main Outcome Measures: Interaction among FVHS, recanalization status, and outcomes. Results: Thirty-four patients had a low FVHS (Յ4), 32 had a medium FVHS (5 or 6), and 39 had a high FVHS (Ն7). The rate of poor functional outcome (modified Rankin Scale score Ͼ2) was higher for the group with low FVHSs than those with medium FVHSs and high FVHSs (82.3% vs 43.7% and 43.5%, respectively; PϽ.001). The rate of 24-hour large infarctions (ASPECTS-DWI score Յ5) was higher for those with low FVHSs than those with medium and high FVHSs (88.2% vs 56.2% and 51.3%, respectively; P=.002). The recanalization rate was not associated with FVHS. Multivariate analysis retained low FVHS as an independent early predictor of poor clinical outcome (odds ratio=9.91; 95% CI, 2.01-48.93; P=.004) and large infarction (odds ratio = 6.99; 95% CI, 1.78-27.46; P=.005). Low FVHS remained associated with poor outcomes regardless of recanalization status. Early recanalization in patients with a low FVHS decreased the poor functional outcome rate from 100% to 64.7% (P=.02). Conclusions: The FVHS is an early independent prognostic marker for patients with proximal middle cerebral artery occlusion. Synergy between FVHS and recanalization status appears to be a critical determinant of final outcomes, supporting intensive reperfusion treatment for patients with a low FVHS.

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Magnetic resonance imaging and computed tomography in emergency assessment of patients with suspected acute stroke: a prospective comparison

Cited by 1,085 publications

References 24 publications

HINTS Outperforms ABCD2 to Screen for Stroke in Acute Continuous Vertigo and Dizziness

HINTS Outperforms ABCD2 to Screen for Stroke in Acute Continuous Vertigo and Dizziness

Diagnosing acute stroke with magnetic resonance imaging (MRI) calls for caution: computed tomography (CT) is preferable for standard care

Fluid-Attenuated Inversion Recovery Vascular Hyperintensity

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