Abstract
BackgroundPatients with acute stroke are often transferred to tertiary care centers for advanced interventional services. We hypothesized that the presence of a proximal cerebral artery occlusion on CT angiography (CTA) is an independent predictor of the use of these services.MethodsWe performed a historical cohort study of consecutive ischemic stroke patients presenting within 24 h of symptom onset to an academic emergency department who underwent emergent CTA. Use of tertiary care interventions including intra-arterial (IA) thrombolysis, mechanical clot retrieval, and neurosurgery were captured.ResultsDuring the study period, 207/290 (71%) of patients with acute ischemic stroke underwent emergent CTA. Of the patients, 74/207 (36%) showed evidence of a proximal cerebral artery occlusion, and 22/207 (11%) underwent an interventional procedure. Those with proximal occlusions were more likely to receive a neurointervention (26% vs. 2%, p < 0.001). They were more likely to undergo IA thrombolysis (9% vs. 0%, p = 0.001) or a mechanical intervention (19% vs. 0%, p < 0.0001), but not more likely to undergo neurosurgery (5% vs. 2%, p = 0.2). After controlling for the initial NIH stroke scale (NIHSS) score, proximal occlusion remained an independent predictor of the use of neurointerventional services (OR 8.5, 95% CI 2.2-33). Evidence of proximal occlusion on CTA predicted use of neurointervention with sensitivity of 82% (95% CI 59-94%), specificity of 71% (95% CI 64%-77%), positive predictive value (PPV) of 25% (95% CI 16%-37%), and negative predictive value (NPV) of 97% (95% CI 92%-99%).ConclusionProximal cerebral artery occlusion on CTA predicts the need for advanced neurointerventional services.
Highlights
Patients with acute stroke are often transferred to tertiary care centers for advanced interventional services
MR angiography (MRA) can identify proximal vessel occlusion, we did not include these studies because magnetic resonance imaging (MRI) is not available in the emergency department at most hospitals [17] and is not a required emergent service for primary stroke center (PSC)
25% of patients received IV recombinant tissue plasminogen activator (rtPA), 2.4% received IA thrombolysis, 6.8% received a mechanical intervention, 3.3% underwent surgery (4 decompressive hemicraniectomies and 3 carotid endarterectomies), and 52% were admitted to the neuroscience intensive care unit (ICU)
Summary
Patients with acute stroke are often transferred to tertiary care centers for advanced interventional services. A rapidly available tool that predicts which patients are interventional candidates would help emergency physicians determine who might benefit from transfer to a CSC. One candidate for such a tool is CT angiography (CTA), which can reliably detect large occlusive thrombi in proximal cerebral arteries [5]. As intravenous (IV) recombinant tissue plasminogen activator (rtPA) is less effective in recanalizing proximally occluded vessels [8], these individuals may preferentially benefit from advanced therapies at tertiary care centers. Since multislice CT scanners are available 24/7 in the majority of US emergency departments [17], it may be that this technology can be harnessed to select patients for transfer
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