Prince of Wales Clinical School, University of New South Wales, Clinical Neurosciences, Randwick, Australia (K.A., A.G., K.S.B.).
Gosford Hospital, Department of Neurosciences, Australia (J.E., W.O.B., L.S.E.).
Stroke. 2022 Sep;53(9):2917-2925. doi: 10.1161/STROKEAHA.122.038798. Epub 2022 Jun 2.
Definitive diagnosis of acute ischemic stroke is challenging, particularly in telestroke settings. Although the prognostic utility of CT perfusion (CTP) has been questioned, its diagnostic value remains under-appreciated, especially in cases without an easily visible intracranial occlusion. We assessed the diagnostic accuracy of routine CTP in the acute telestroke setting.
Acute and follow-up data collected prospectively from consecutive suspected patients with stroke assessed by a state-wide telestroke service between March 2020 and August 2021 at 12 sites in Australia were analyzed. All patients in the final analysis had been assessed with multimodal CT, including CTP, which was post-processed with automated volumetric software. Diagnostic sensitivity and specificity were calculated for multimodal CT and each individual component (noncontrast CT [NCCT], CT angiogram [CTA], and CTP). Final diagnosis determined by consensus review of follow-up imaging and clinical data was used as the reference standard.
During the study period, complete multimodal CT examination was obtained in 831 patients, 457 of whom were diagnosed with stroke. Diagnostic sensitivity for ischemic stroke increased by 19.5 percentage points when CTP was included with NCCT and CTA compared with NCCT and CTA alone (73.1% positive with NCCT+CTA+CTP [95% CI, 68.8-77.1] versus 53.6% positive with NCCT+CTA alone [95% CI, 48.9-58.3], <0.001). No difference was observed between specificities of NCCT+CTA and NCCT+CTA+CTP (98.7% [95% CI, 98.5-100] versus 98.7% [95% CI, 96.9-99.6], =0.13). Multimodal CT, including CTP, demonstrated the highest negative predictive value (75.0% [95% CI, 72.1-77.7]). Patients with stroke not evident on CTP had small volume infarcts on follow-up (1.2 mL, interquartile range 0.5-2.7mL).
Acquisition of CTP as part of a telestroke imaging protocol permits definitive diagnosis of cerebral ischemia in 1 in 5 patients with normal NCCT and CTA.
急性缺血性脑卒中的明确诊断具有挑战性，尤其是在远程卒中环境中。虽然 CT 灌注（CTP）的预后价值受到质疑，但它的诊断价值仍未被充分认识，尤其是在没有明显颅内闭塞的情况下。我们评估了常规 CTP 在急性远程卒中环境中的诊断准确性。
2020 年 3 月至 2021 年 8 月期间，在澳大利亚 12 个地点由全州远程卒中服务评估的连续疑似卒中患者前瞻性收集急性和随访数据。对最终分析中的所有患者均进行了多模态 CT 检查，包括 CTP，其使用自动容积软件进行后处理。计算了多模态 CT 和每个单独组件（非对比 CT [NCCT]、CT 血管造影 [CTA] 和 CTP）的诊断敏感性和特异性。使用随访影像学和临床数据的共识审查确定最终诊断作为参考标准。
在研究期间，831 例患者获得了完整的多模态 CT 检查，其中 457 例被诊断为卒中。与 NCCT 和 CTA 单独相比，当 CTP 与 NCCT 和 CTA 联合使用时，缺血性卒中的诊断敏感性增加了 19.5 个百分点（NCCT+CTA+CTP 阳性率为 73.1%[95%CI，68.8-77.1]，而 NCCT+CTA 单独阳性率为 53.6%[95%CI，48.9-58.3]，<0.001）。NCCT+CTA 和 NCCT+CTA+CTP 的特异性无差异（NCCT+CTA 为 98.7%[95%CI，98.5-100]，NCCT+CTA+CTP 为 98.7%[95%CI，96.9-99.6]，=0.13）。多模态 CT，包括 CTP，显示出最高的阴性预测值（75.0%[95%CI，72.1-77.7]）。在 CTP 上未见卒中的患者在随访时有小体积梗死（1.2mL，四分位距 0.5-2.7mL）。
在远程卒中成像方案中获取 CTP 可使 1/5 的 NCCT 和 CTA 正常的患者明确诊断为脑缺血。
