Introduction: Early detection of large vessel occlusion (LVO) is essential to facilitate fast endovascular treatment. CT angiography (CTA) is used to detect LVO in suspected stroke patients. We... Show moreIntroduction: Early detection of large vessel occlusion (LVO) is essential to facilitate fast endovascular treatment. CT angiography (CTA) is used to detect LVO in suspected stroke patients. We aimed to assess the accuracy of CTA evaluations in daily clinical practice in a large cohort of suspected stroke patients. Patients and methods: We used data from the PRESTO study, a multicenter prospective observational cohort study that included suspected stroke patients between August 2018 and September 2019. Baseline CTAs were re-evaluated by an imaging core laboratory and compared to the local assessment. LVO was defined as an occlusion of the intracranial internal carotid artery, M1 segment, or basilar artery. Medium vessel occlusion (MeVO) was defined as an A1, A2, or M2 occlusion. We calculated the accuracy, sensitivity, and specificity to detect LVO and LVO+MeVO, using the core laboratory evaluation as reference standard. Results: We included 656 patients. The core laboratory detected 89 LVOs and 74 MeVOs in 155 patients. Local observers missed 6 LVOs (7%) and 28 MeVOs (38%), of which 23 M2 occlusions. Accuracy of LVO detection was 99% (95% CI: 98-100%), sensitivity 93% (95% CI: 86-97%), and specificity 100% (95% CI: 99-100%). Accuracy of LVO+MeVO detection was 95% (95% CI: 93-96%), sensitivity 79% (95% CI: 72-85%), and specificity 99% (95% CI: 98-100%). Discussion and Conclusion: CTA evaluations in daily clinical practice are highly accurate and LVOs are adequately recognized. The detection of MeVOs seems more challenging. The evolving EVT possibilities emphasize the need to improve CTA evaluations in the acute setting. Show less
Dewey, M.; Rochitte, C.E.; Ostovaneh, M.R.; Chen, M.Y.; George, R.T.; Niinuma, H.; ... ; Arbab-Zadeh, A. 2021
Background: Few data exist on long-term outcome in patients undergoing combined coronary CT angiography (CTA) and myocardial CT perfusion imaging (CTP) as well as invasive coronary angiography (ICA... Show moreBackground: Few data exist on long-term outcome in patients undergoing combined coronary CT angiography (CTA) and myocardial CT perfusion imaging (CTP) as well as invasive coronary angiography (ICA) and single photon emission tomography (SPECT). Methods: At 16 centers, 381 patients were followed for major adverse cardiac events (MACE) for the CORE320 study. All patients underwent coronary CTA, CTP, and SPECT before ICA within 60 days. Prognostic performance according binary results (normal/abnormal) was assessed by 5-year major cardiovascular events (MACE) free survival and area under the receiver-operating-characteristic curve (AUC). Results: Follow up beyond 2-years was available in 323 patients. MACE-free survival rate was greater among patients with normal combined CTA-CTP findings compared to ICA-SPECT: 85 vs. 80% (95% confidence interval [CI] for difference 0.1, 11.3) though event-free survival time was similar (4.54 vs. 4.37 years, 95% CI for dif-ference:-0.03, 0.36). Abnormal results by combined CTA-CTP was associated with 3.83 years event-free survival vs. 3.66 years after abnormal combined ICA-SPECT (95% CI for difference:-0.05, 0.39). Predicting MACE by AUC also was similar: 65 vs. 65 (difference 0.1; 95% CI-4.6, 4.9). When MACE was restricted to cardiovascular death, myocardial infarction, or stroke, AUC for CTA-CTP was 71 vs. 60 by ICA-SPECT (difference 11.2; 95% CI-1.0, 19.7). Conclusions: Combined CTA-CTP evaluation yields at least equal 5-year prognostic information as combined ICA-SPECT assessment in patients presenting with suspected coronary artery disease. Noninvasive cardiac CT assessment may eliminate the need for diagnostic cardiac catheterization in many patients. Clinical trial registration:NCT00934037. Show less
Objectives Coronary CT angiography (cCTA) has been used to non-invasively assess both the anatomical and hemodynamic significance of coronary stenosis. The current study investigated a new CFD... Show moreObjectives Coronary CT angiography (cCTA) has been used to non-invasively assess both the anatomical and hemodynamic significance of coronary stenosis. The current study investigated a new CFD-based method of evaluating pressure-flow curves across a stenosis to further enhance the diagnostic value of cCTA imaging. Methods Fifty-eight patients who underwent both cCTA imaging and invasive coronary angiography (ICA) with fractional flow reserve (FFR) within 2 weeks were enrolled. The pressure-flow curve-derived parameters, viscous friction (VF) and expansion loss (EL), were compared with conventional cCTA parameters including percent area stenosis (AS) and minimum lumen area (MLA) by receiver operating characteristic (ROC) curve analysis. FFR <= 0.80 was used to indicate ischemia-causing stenosis. Correlations between FFR and other measurements were calculated by Spearman's rank correlation coefficient (rho). Results Sixty-eight stenoses from 58 patients were analyzed. VF, EL, and AS were significantly larger in the group of FFR <= 0.8 while smaller MLA values were observed. The ROC-AUC of VF (0.91, 95% CI 0.81-0.96) was better than that of AS (change in AUC (Delta AUC) 0.27, p < 0.05) and MLA (Delta AUC 0.17, p < 0.05), and ROC-AUC of EL (0.90, 95%CI 0.80-0.96) was also better than that of AS (Delta AUC 0.26, p < 0.05) and MLA (Delta AUC 0.16, p < 0.05). FFR values correlated well with VF (rho = - 0.74 (95% CI - 0.83 to - 0.61, p < 0.0001) and EL (rho = - 0.74 (95% CI - 0.83 to - 0.61, p < 0.0001). Conclusion Pressure-flow curve-derived parameters enhance the diagnostic value of cCTA examination. Show less
Rubeis, G. de; Napp, A.E.; Schlattmann, P.; Geleijns, J.; Laule, M.; Dreger, H.; ... ; DISCHARGE Trial Grp 2020
Objective To implement detailed EU cardiac computed tomography angiography (CCTA) quality criteria in the multicentre DISCHARGE trial (FP72007-2013, EC-GA 603266), we reviewed image quality and... Show moreObjective To implement detailed EU cardiac computed tomography angiography (CCTA) quality criteria in the multicentre DISCHARGE trial (FP72007-2013, EC-GA 603266), we reviewed image quality and adherence to CCTA protocol and to the recommendations of invasive coronary angiography (ICA) in a pilot study. Materials and methods From every clinical centre, imaging datasets of three patients per arm were assessed for adherence to the inclusion/exclusion criteria of the pilot study, predefined standards for the CCTA protocol and ICA recommendations, image quality and non-diagnostic (NDX) rate. These parameters were compared via multinomial regression and ANOVA. If a site did not reach the minimum quality level, additional datasets had to be sent before entering into the final accepted database (FADB). Results We analysed 226 cases (150 CCTA/76 ICA). The inclusion/exclusion criteria were not met by 6 of the 226 (2.7%) datasets. The predefined standard was not met by 13 of 76 ICA datasets (17.1%). This percentage decreased between the initial CCTA database and the FADB (multinomial regression, 53 of 70 vs 17 of 75 [76%] vs [23%]). The signal-to-noise ratio and contrast-to-noise ratio of the FADB did not improve significantly (ANOVA, p = 0.20; p = 0.09). The CTA NDX rate was reduced, but not significantly (initial CCTA database 15 of 70 [21.4%]) and FADB 9 of 75 [12%]; p = 0.13). Conclusion We were able to increase conformity to the inclusion/exclusion criteria and CCTA protocol, improve image quality and decrease the CCTA NDX rate by implementing EU CCTA quality criteria and ICA recommendations. Show less
In patients with acute headache who present to the emergency room the yield of a CTA is highest in patients with an abnormality on head NCCT. The yield in patients with normal NCCT is low. A... Show moreIn patients with acute headache who present to the emergency room the yield of a CTA is highest in patients with an abnormality on head NCCT. The yield in patients with normal NCCT is low. A multivariable prediction model showed that clinical symptoms have no added value over the variable ‘normal NCCT’ alone. In patients with acute headache and a normal NCCT the yield of CTA is higher than in the general population, but findings consist mainly of unruptured intracranial aneurysms that do not always have treatment implications and may generate anxiety. The sporadically found cervical dissection, CVT or RCVS may justify performing CTA. At the moment there are no clinical factors, which can predict which patients will have an abnormality on CTA after a normal NCCT. In patients who are suspected of CVT but who have no additional risk factors besides headache, CT venography is unnecessary if the D-dimer level in serum is normal. The negative predictive value of D-dimer in this group is very high for excluding CVT. If CSF testing for the presence of bilirubin is required, the Leiden method, an iterative calculation model, is 100% sensitive. Specificity can be increased if the UK NEQAS method is applied on the CSF’s that test positive with the Leiden method. This workflow assures both highest specificity and highest laboratory workforce efficiency. In patients suspected of bacterial meningitis procalcitonin determination in CSF may become a valuable marker particularly in patients with confounding factors such as recent neurosurgical intervention. The differentiation from aseptic or septic meningitis in this group is difficult and an additional marker would be valuable to avoid unnecessary antibiotic treatment. Show less
Stenstrom, I.; Maaniitty, T.; Uusitalo, V.; Pietila, M.; Ukkonen, H.; Kajander, S.; ... ; Saraste, A. 2017
