Potential Influence of Acute CT on Inpatient Costs in Patients with Ischemic Stroke

Background and Purpose-In acute stroke patients, the presence of a hyperdense middle cerebral artery sign on unenhanced CT is a specific but insensitive indicator of acute thrombosis. Our purpose was to determine whether the hyperdense basilar artery (HDBA) sign has utility in detecting thrombosis and predicting outcome in patients presenting with signs and symptoms of posterior circulation stroke. Methods-Unenhanced CT scans obtained within 24 hours of symptom onset in 95 patients with suspected posterior circulation stroke were reviewed. Three neuroimagers blinded to clinical outcome and results of the concurrent CT angiography (which served as the reference standard) rated presence of HDBA sign on a 5-point scale for level of certainty (1ϭdefinitely absent; 5ϭdefinitely present). Receiver operating characteristic curve analysis was performed. Short-term outcome was measured by discharge National Institute of Health Stroke Scale (NIHSS) scores; long-term outcome was measured by 6-month modified Rankin score (dichotomized, poor outcome defined as modified Rankin score Ͼ2). The following variables were correlated with short-term and long-term outcome by univariate analysis: HDBA sign, age, sex, time from stroke onset to imaging, admission NIHSS, history of stroke/TIA, atrial fibrillation, coronary artery disease, hypertension, diabetes, hypercholesterolemia, tobacco use, and thrombolysis. Variables showing correlation with PϽ0.1 were included in multiple regression analysis. Results-Using a level of certainty cutoff score of Ն4 (probable, definite), HDBA sign had 71% sensitivity, 98% specificity, 94% accuracy, 83% positive predictive value, and 95% negative predictive value for basilar artery occlusion. In univariate analysis, factors significantly correlated with discharge NIHSS were: admission NIHSS (PϽ0.0001; rϭ0.77), HDBA sign (Pϭ0.01), and diabetes (Pϭ0.02). Factors showing significant correlation or association with poor long-term outcome were age (Pϭ0.02), admission NIHSS (Pϭ0.007), HDBA sign (Pϭ0.02), and history of stroke or TIA (Pϭ0.007). The odds ratio of HDBA sign for predicting poor long-term outcome was 5.3 (95% CI, 1.1-33.3). In multiple regression analysis, the only independent predictors of discharge NIHSS were admission NIHSS (PϽ0.0001) and HDBA sign (Pϭ0.004). Significant independent predictors of poor long-term outcome were age (Pϭ0.02), admission NIHSS (Pϭ0.008), history of stroke/TIA (Pϭ0.03), and HDBA sign (Pϭ0.05). Conclusion-In patients presenting with a high pretest probability of posterior circulation stroke based on clinical symptoms, the presence of the HDBA sign on unenhanced CT is a strong predictor of basilar artery thrombosis, and both short-and long-term outcome.

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“…13 Sensitivity, specificity, accuracy, positive predictive value, and negative predictive value for different certainty levels were calculated.…”

Section: Discussionmentioning

confidence: 99%

Hyperdense Basilar Artery Sign on Unenhanced CT Predicts Thrombus and Outcome in Acute Posterior Circulation Stroke

Goldmakher

Camargo

Furie

et al. 2009

Stroke

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“…218 Advantages of the multimodal CT approach over MRI include wider availability of emergency CT imaging, more rapid imaging, and fewer contraindications to CT versus MRI. [351][352][353] Perfusion CT parameters of cerebral blood volume, cerebral blood flow, and mean transit time can be more easily quantified than their perfusion-weighted MRI counterparts, owing in part to the linear relationship between iodinated CT contrast concentration and resulting CT image density, a relationship that does not hold for gadolinium concentration versus MRI signal intensity. Because of its availability and greater degree of quantification, perfusion CT has the potential to increase patient access to new treatments and imagingbased clinical trials.…”

Section: Perfusion Ct and Mrimentioning

confidence: 99%

Guidelines for the Early Management of Patients With Acute Ischemic Stroke

Jauch¹,

Saver²,

Adams³

et al. 2013

Stroke

5,374

1,801

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Background and Purpose-The authors present an overview of the current evidence and management recommendations for evaluation and treatment of adults with acute ischemic stroke. The intended audiences are prehospital care providers, physicians, allied health professionals, and hospital administrators responsible for the care of acute ischemic stroke patients within the first 48 hours from stroke onset. These guidelines supersede the prior 2007 guidelines and 2009 updates. Methods-Members of the writing committee were appointed by the American Stroke Association Stroke Council's Scientific Statement Oversight Committee, representing various areas of medical expertise. Strict adherence to the American Heart Association conflict of interest policy was maintained throughout the consensus process. Panel members were assigned topics relevant to their areas of expertise, reviewed the stroke literature with emphasis on publications since the prior guidelines, and drafted recommendations in accordance with the American Heart Association Stroke Council's Level of Evidence grading algorithm. Results-The goal of these guidelines is to limit the morbidity and mortality associated with stroke. The guidelines support the overarching concept of stroke systems of care and detail aspects of stroke care from patient recognition; emergency medical services activation, transport, and triage; through the initial hours in the emergency department and stroke unit. The guideline discusses early stroke evaluation and general medical care, as well as ischemic stroke, specific interventions such as reperfusion strategies, and general physiological optimization for cerebral resuscitation. The American Heart Association makes every effort to avoid any actual or potential conflicts of interest that may arise as a result of an outside relationship or a personal, professional, or business interest of a member of the writing panel. Specifically, all members of the writing group are required to complete and submit a Disclosure Questionnaire showing all such relationships that might be perceived as real or potential conflicts of interest. Guidelines for the Early Management of PatientsThis statement was approved by the American Heart Association Science Advisory and Coordinating Committee on December 12, 2012. A copy of the document is available at http://my.americanheart.org/statements by selecting either the "By Topic" link or the "By Publication Date" link. To purchase additional reprints, call 843-216-2533 or e-mail kelle.ramsay@wolterskluwer.com.The Executive Summary is available as an online-only Data Supplement with this article at http://stroke.ahajournals.org/lookup/suppl/ doi:10.1161/STR.0b013e318284056a/-/DC1.The American Heart Association requests that this document be cited as follows: Jauch EC, Saver JL, Adams HP Jr, Bruno A, Connors JJ, Demaerschalk BM, Khatri P, McMullan PW Jr, Qureshi AI, Rosenfield K, Scott PA, Summers DR, Wang DZ, Wintermark M, Yonas H; on behalf of the American Heart Association Stroke Council, Council on Cardio...

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“…Gleason et al considered the cost savings in the USA which would result from the implementation of a CT angiography-CT perfusion protocol. 331 While they did not include clinical outcomes, the main mechanism of incurring additional scanning cost in order to reduce length of inpatient stay was similar to that in the current study. Heller et al, in contrast, compared different CT scanning strategies in their paper but only considered death and dependency at 6 months and not the resource implications of the different strategies.…”

Section: Cost-effectiveness Of Ct In Strokementioning

confidence: 66%

What is the best imaging strategy for acute stroke?

Wardlaw

Keir

Seymour

et al. 2005

Int J Technol Assess Health Care

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Potential Influence of Acute CT on Inpatient Costs in Patients with Ischemic Stroke

Cited by 37 publications

References 13 publications

Hyperdense Basilar Artery Sign on Unenhanced CT Predicts Thrombus and Outcome in Acute Posterior Circulation Stroke

Hyperdense Basilar Artery Sign on Unenhanced CT Predicts Thrombus and Outcome in Acute Posterior Circulation Stroke

Guidelines for the Early Management of Patients With Acute Ischemic Stroke

What is the best imaging strategy for acute stroke?

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