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Research ArticleBrainE

Clinical Stroke Penumbra: Use of National Institutes of Health Stroke Scale as a Surrogate for CT Perfusion in Patient Triage for Intra-Arterial Middle Cerebral Artery Stroke Therapy

J.L. Boxerman, M.V. Jayaraman, W.A. Mehan, J.M. Rogg and R.A. Haas
American Journal of Neuroradiology November 2012, 33 (10) 1893-1900; DOI: https://doi.org/10.3174/ajnr.A3102
J.L. Boxerman
aFrom the Department of Diagnostic Imaging (J.L.B., M.V.J., J.M.R., R.A.H.), Rhode Island Hospital and Alpert Medical School of Brown University, Providence, Rhode Island
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M.V. Jayaraman
aFrom the Department of Diagnostic Imaging (J.L.B., M.V.J., J.M.R., R.A.H.), Rhode Island Hospital and Alpert Medical School of Brown University, Providence, Rhode Island
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W.A. Mehan
bDepartment of Neuroradiology (W.A.M.), Massachusetts General Hospital, Boston, Massachusetts.
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J.M. Rogg
aFrom the Department of Diagnostic Imaging (J.L.B., M.V.J., J.M.R., R.A.H.), Rhode Island Hospital and Alpert Medical School of Brown University, Providence, Rhode Island
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R.A. Haas
aFrom the Department of Diagnostic Imaging (J.L.B., M.V.J., J.M.R., R.A.H.), Rhode Island Hospital and Alpert Medical School of Brown University, Providence, Rhode Island
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    Fig 1.

    Summary of the study design, highlighting independent and consensus analysis by neuroradiologists by using CTP (CTP group) and NIHSS with CTA (stroke scale group) to estimate infarct core and penumbra. Intragroup and intergroup consensus were determined (κ), as well as the significance of unblinding the stroke scale group to CTP (McNemar test).

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    Fig 2.

    A 76-year-old woman 5 hours 22 minutes after symptom onset (NIHSS score = 25). A, CTA demonstrates left M1 cutoff (white arrow). B, CTA source images demonstrate hypoattenuation in the left corona radiata, basal ganglia, and temporal lobe consistent with MCA infarct. C, Predominantly matched CBV and CBF defects corresponding to a portion of infarct core predicted on CTA source images, with peripheral prolonged TTP suggesting penumbra (Somatom 16). IAT recommendations for stroke scale (infarct core more than one-third of the MCA territory) and CTP (treatable penumbra) groups were discordant.

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    Fig 3.

    A 47-year-old man 3 hours 37 minutes after symptom onset (NIHSS score = 17). A, CTA demonstrates right M1 cutoff (white arrow). B, CTA source image demonstrates equivocal hypoattenuation in the right corona radiata (white arrow), suggesting a small infarct. C, Large mismatched CBF and MTT compared with CBV (white arrow), consistent with treatable penumbra (LightSpeed Qx/I). On the basis of NIHSS score, locus of M1 cutoff and size of infarct core, the stroke scale group also recommended IAT.

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    Fig 4.

    An 88-year-old woman 3 hours 1 minute after symptom onset (NIHSS score = 17). A, CTA demonstrates right M1 cutoff (white arrow). B, CTA source images demonstrate hypoattenuation in the posterior right MCA territory (white arrow), consistent with a small infarct. C, Matched CBV and CBF defects corresponding to the infarct core on CTA source images, with matched TTP defect predicting the absence of treatable penumbra (Somatom 16). On the basis of the NIHSS score, locus of M1 cutoff, and size of infarct core, the stroke scale group predicted a treatable penumbra and recommended IAT. The stroke scale group revised its recommendation to “no treat” when unblinded to CTP.

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    Fig 5.

    A 92-year-old woman 4 hours 11 minutes after symptom onset (NIHSS score = 9). A, CTA demonstrates a focal defect in the distal left M1 (white arrow). B, CTA source images demonstrate hypoattenuation in the left corona radiata (white arrow), consistent with a small infarct. C, Essentially matched CBV and CBF defects corresponding to the infarct core on CTA source images, with a matched TTP defect including a small peripheral region of prolonged TTP predicting the absence of substantial penumbra (Somatom 16). On the basis of the NIHSS score, the locus of M1 cutoff, and size of infarct core, the stroke scale group predicted a treatable penumbra and recommended IAT. The stroke scale group revised its recommendation to “no treat” when unblinded to CTP.

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    Fig 6.

    Summary of treatment decisions for the stroke scale and CTP groups. Of the 28 patients with accessible lesions, 17 were concluded by both groups to have treatable infarct core (less than one-third of the MCA territory), 15 of whom had treatable penumbra (>20% infarct core). There was 1 discrepancy regarding infarct core (asterisk), treated by the CTP but not the stroke scale group, and 2 discrepancies regarding penumbra (double asterisks), both treated by the stroke scale but not the CTP group but reversed by the stroke scale group on unblinding.

Tables

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  • Summary of intragroup and intergroup scores for the 3 IAT criteriaa

    Stroke Scale Group ConsensusCTP Group ConsensusIntergroup
    YesNoκ (SE)YesNoκ (SE)κ (SE)
    Lesion accessibility2881.02881.01.0
    Core infarct <1/3 MCA25110.94 (0.06)26100.66 (0.14)0.93 (0.07)
    Penumbra >20% core1840.64 (0.19)21150.83 (0.09)0.49 (0.22)
    Recommend IAT17190.83 (0.09)16200.78 (0.11)0.83 (0.09)
    • ↵a Stroke scale group used NCCT, CTA, and the NIHSS for IAT triage, and the CTP group used NCCT, CTA, and CTP.

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American Journal of Neuroradiology: 33 (10)
American Journal of Neuroradiology
Vol. 33, Issue 10
1 Nov 2012
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Cite this article
J.L. Boxerman, M.V. Jayaraman, W.A. Mehan, J.M. Rogg, R.A. Haas
Clinical Stroke Penumbra: Use of National Institutes of Health Stroke Scale as a Surrogate for CT Perfusion in Patient Triage for Intra-Arterial Middle Cerebral Artery Stroke Therapy
American Journal of Neuroradiology Nov 2012, 33 (10) 1893-1900; DOI: 10.3174/ajnr.A3102

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Clinical Stroke Penumbra: Use of National Institutes of Health Stroke Scale as a Surrogate for CT Perfusion in Patient Triage for Intra-Arterial Middle Cerebral Artery Stroke Therapy
J.L. Boxerman, M.V. Jayaraman, W.A. Mehan, J.M. Rogg, R.A. Haas
American Journal of Neuroradiology Nov 2012, 33 (10) 1893-1900; DOI: 10.3174/ajnr.A3102
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