Diagnostic Yield and Therapeutic Implications of Vascular Imaging in Acute Ischemic Stroke: Prospective and Consecutive Study of Small Vessel versus Large Vessel Ischemia.

Abstract

To evaluate patients acute cerebral ischemia in order to assess for factors which may help to differentiate patients with small vessel involvement from those with large vessel involvement in an effort to determine diagnostic yield of vascular imaging. We prospectively and consecutively evaluated all acute ischemic stroke patients at our medical center from May 16, 2021 to December 10, 2021. Distinction between small vessel and large vessel involvement was based upon clinical presentation, the results of brain imaging and either computed tomographic angiography, in the vast majority, or magnetic resonance angiography. Patient demographics and risk factors for stroke as well as therapeutic intervention was assessed. Of the 90 patients studied, 59 had large vessel ischemia (66%) with 26 (44%) having large vessel occlusion and one had symptomatic high-grade middle cerebral artery stenosis. Conversely, none of the 31 patients with small vessel presentation (34%) had large vessel occlusion or high-grade stenosis. In addition, 19 out of 59 (32%) large vessel patients compared to 2 of 31 (6%) of the small vessel patients had atrial fibrillation identified as a potential mechanism with a p-value of 0.01 by univariate analysis and 0.17 by multivariate analysis. The routine use of vascular imaging in acute ischemic stroke is of very low yield in small vessel presentation with the presence of potential cardiogenic emboli is also relatively low. Efforts at accelerated identification of a small vessel mechanism, to avoid unnecessary testing, should provide significant value from both a patient management and cost standpoint.