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Improved Turnaround Times | Median time to first decision: 12 days

Research ArticleBrain

Multimodal CT Provides Improved Performance for Lacunar Infarct Detection

T. Das, F. Settecase, M. Boulos, T. Huynh, C.D. d'Esterre, S.P. Symons, L. Zhang and R.I. Aviv
American Journal of Neuroradiology June 2015, 36 (6) 1069-1075; DOI: https://doi.org/10.3174/ajnr.A4255
T. Das
aFrom the Department of Radiology (T.D.), Cambridge University Hospitals NHS Foundation Trust, Addenbrooke's Hospital, Cambridge, UK
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F. Settecase
cDepartments of Medical Imaging (F.S., T.H., R.I.A., S.P.S., L.Z.)
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M. Boulos
dNeurology (M.B.), Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
eUniversity of Toronto (M.B., T.H., S.P.S., R.I.A.), Toronto, Ontario, Canada.
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T. Huynh
cDepartments of Medical Imaging (F.S., T.H., R.I.A., S.P.S., L.Z.)
eUniversity of Toronto (M.B., T.H., S.P.S., R.I.A.), Toronto, Ontario, Canada.
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C.D. d'Esterre
bDepartment of Neurology (C.D.d.), University of Calgary, Calgary Stroke Program, Foothills Medical Centre, Calgary, Alberta, Canada
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S.P. Symons
cDepartments of Medical Imaging (F.S., T.H., R.I.A., S.P.S., L.Z.)
eUniversity of Toronto (M.B., T.H., S.P.S., R.I.A.), Toronto, Ontario, Canada.
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L. Zhang
cDepartments of Medical Imaging (F.S., T.H., R.I.A., S.P.S., L.Z.)
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R.I. Aviv
cDepartments of Medical Imaging (F.S., T.H., R.I.A., S.P.S., L.Z.)
eUniversity of Toronto (M.B., T.H., S.P.S., R.I.A.), Toronto, Ontario, Canada.
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  • Fig 1.
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    Fig 1.

    Receiver operating characteristic curves show the diagnostic performance of the incremental CT protocol in the detection of lacunar infarction, without adjusting for multiple readers. There is a statistically significant increase in the area under the curve with each incremental protocol (CTP versus CTA, P < .006, and CTP versus NCCT, P < .001). The dashed line indicates NCCT only; the dotted line, NCCT and CTA-SI; and the solid line, NCCT, CTA-SI, and CTP.

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    Fig 2.

    Images of a 72-year-old man who presented with left-sided weakness (NIHSS score, 9), scanned 85 minutes after symptom onset. NCCT (A) and CTA-SI (B) show subtle hypoattenuation, inconclusive for acute infarction (white arrows). C, The MTT map demonstrates a perfusion deficit in the right lentiform nucleus (black arrow). The patient received intravenous thrombolysis. D, Follow-up DWI confirms lacunar infarction in the right lentiform nucleus (white arrow).

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    Fig 3.

    Images of a 55-year-old man who presented with left-sided weakness. A, No abnormality is evident on NCCT. B, CTA-SI shows a possible hypoattenuation in the posterior limb of the right internal capsule or thalamus. C, MTT map demonstrates a focus of increased MTT in the region of the internal capsule (black arrow). The patient received intravenous thrombolysis. D, Follow-up DWI confirms focal hyperintensity consistent with recent lacunar infarction in the posterior limb of the right internal capsule (white arrow).

Tables

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    Table 1:

    Comparison of baseline demographic features of 88 patients presenting with acute stroke symptoms with and without lacunar infarcta

    Lacunar Infarct Present (n = 59)Lacunar Infarct Absent (n = 29)P Value
    Mean age (yr) (SD)72 (13.4)68 (17.5).30
    Median NIHSS (IQR)6.5 (5)2 (5).16
    Median days to follow-up (IQR)2.5 (3)2 (5.5).60
    Male sex33 (56%)11 (38%).17
    Cardiovascular risk factors
        Hypertension39 (66%)12 (41%).04b
        Diabetes15 (25%)1 (3%).02b
        Atrial fibrillation8 (14%)1 (3%).26
        Coronary artery disease13 (22%)4 (14%).40
        Hyperlipidemia23 (39%)6 (21%).10
        Smoking6 (10%)1 (3%).27
    • ↵a All values are No. (%) unless otherwise specified.

    • ↵b Statistically significant.

    • View popup
    Table 2:

    Distribution of confidence scores for infarct presence by modality for 2 readers for a total of 352 observations

    Confidence ScoreNCCTNCCT + CTA-SINCCT + CTA-SI + CTP
    1Definitely present5 (1.4%)16 (4.5%)42 (11.9%)
    2Probably present25 (7.1%)26 (7.4%)27 (7.7%)
    3Equivocal, possibly present83 (23.6%)68 (19.3%)18 (5.1%)
    4Equivocal, possibly absent4 (1.1%)2 (0.6%)18 (5.1%)
    5Probably absent78 (22.2%)89 (25.3%)131 (37.2%)
    6Definitely absent157 (44.6%)151 (42.9%)116 (33.0%)
    • View popup
    Table 3:

    Progressive increase of multiple entropy r2 value and decrease of AIC with the incremental protocola

    Logistic Regression ModelGEEs Method
    r2AICP ValueOdds Ratio (95% CI)AICP Value
    NCCT
        Model fit statistics0.015451.1451.3
        Observed diagnosis (yes vs no).281.68 (0.65–4.41).29
        Observed confidence score.901.03 (0.67–1.58).90
    NCCT + CTA-SI
        Model fit statistics0.170409.2408.7
        Observed diagnosis (yes vs no).590.78 (0.31–1.94).57
        Observed confidence score<.001b0.46 (0.31–0.68)<.001b
    NCCT + CTA-SI + CTP
        Model fit statistics0.329357.3357.1
        Observed diagnosis (yes vs no).04b0.33 (0.11–0.95).05
        Observed confidence score<.001b0.30 (0.20–0.44)<.001b
    • Note:—GEEs indicates generalized estimating equations.

    • ↵a With logistic regression analysis and the GEEs method, the actual stroke diagnosis was modelled on different observed diagnoses (NCCT alone, NCCT + CTA-SI, NCCT + CTA-SI + CTP) when adjusting for the corresponding confidence score. OR < 1 indicates that patients with a positive diagnosis on MRI are more likely to have a lower level of confidence (1 = definitely present, 2 = probably present, 3 = possibly present, 4 = possibly absent, 5 = probably absent, 6 = definitely absent).

    • ↵b Statistically significant.

    • View popup
    Table 4:

    Diagnostic performance for stroke detection with incremental study review using receiver operating characteristic–determined thresholds for level of confidence

    SensitivitySpecificity
    Se% (95% CI)P ValueaSp% (95% CI)P Valuea
    Level of confidence ≥5 vs <5
        1) NCCT40.7 (30.8–50.6)1 vs 2: .17470.5 (64.4–76.7)1 vs 2: .088
        2) NCCT + CTA-SI51.7 (40.9–62.5)1 vs 3: .048b78.2 (72.2–84.2)1 vs 3: .002b
        3) NCCT + CTA-SI + CTP55.9 (45.6–66.3)2 vs 3: .53683.3 (78.3–88.3)2 vs 3: .155
    Level of confidence ≤2 vs <2
        1) NCCT9.3 (4.3–14.3)1 vs 2: .009b91.9 (88.5–95.2)1 vs 2: .130
        2) NCCT + CTA-SI26.3 (17.3–35.3)1 vs 3: <.001b95.3 (92.5–98.1)1 vs 3: .691
        3) NCCT + CTA-SI + CTP42.4 (30.6–54.2)2 vs 3: .030b91.9 (88.4–95.4)2 vs 3: .264
    • Note:—Se indicates sensitivity; Sp, specificity.

    • ↵a P value was obtained by a linear regression model of natural log(Se) or log(Sp) for each modality.

    • ↵b Statistically significant.

    • View popup
    Table 5:

    Interobserver variability between 2 readers for lacunar infarction detection with incremental protocol

    Cohen κ (95% CI) for Each Sequence
    NCCTNCCT + CTA-SINCCT + CTA-SI + CTP
    Reader 1 vs 20.25 (0.11–0.39)0.47 (0.34–0.61)0.50 (0.35–0.64)
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American Journal of Neuroradiology: 36 (6)
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T. Das, F. Settecase, M. Boulos, T. Huynh, C.D. d'Esterre, S.P. Symons, L. Zhang, R.I. Aviv
Multimodal CT Provides Improved Performance for Lacunar Infarct Detection
American Journal of Neuroradiology Jun 2015, 36 (6) 1069-1075; DOI: 10.3174/ajnr.A4255

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Multimodal CT Provides Improved Performance for Lacunar Infarct Detection
T. Das, F. Settecase, M. Boulos, T. Huynh, C.D. d'Esterre, S.P. Symons, L. Zhang, R.I. Aviv
American Journal of Neuroradiology Jun 2015, 36 (6) 1069-1075; DOI: 10.3174/ajnr.A4255
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