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. 2017 Feb 24;12(2):e0172356.
doi: 10.1371/journal.pone.0172356. eCollection 2017.

4D-CTA improves diagnostic certainty and accuracy in the detection of proximal intracranial anterior circulation occlusion in acute ischemic stroke

Bart A J M Wagemans  1 , Wim H van Zwam  1 , Patricia J Nelemans  2 , Robert J van Oostenbrugge  3 , Alida A Postma  1
Affiliations

4D-CTA improves diagnostic certainty and accuracy in the detection of proximal intracranial anterior circulation occlusion in acute ischemic stroke

Bart A J M Wagemans et al. PLoS One. .

Abstract

Introduction: In acute ischemic stroke, imaging of the cranio-cervical vessels is essential for intra-arterial treatment selection. Fast, reliable and easy accessible imaging is necessary 24 hours a day, 7 days a week. Radiologists in training and non-expert readers often perform initial reviewing. In this pilot study, the potential benefit of adding 4Dimensional-CT Angiography (4D-CTA) to the patient selection protocol for intra-arterial therapy is investigated.

Materials and methods: Twenty-five datasets of prospectively recruited patients, eligible for intra-arterial treatment, were enrolled. Four radiologists-in-training consecutively reviewed CTA, CT-Perfusion and 4D-CTA (post-processed from CTP datasets) and scored: occlusion-presence and diagnostic certainty (scale 1-10). Time-to-diagnosis was registered.

Results: Arterial occlusion was present in 8 patients. Accuracy improved from 88-92% after CTA and CTP assessment to 96-100% after 4D-CTA assessment (P-values >0,05). Mean diagnostic certainty improved from 7,2-8,6 to 8,8-9,3 (P-values all < 0,05). Mean time to diagnosis increased from 3, 5, 5 and 4 minutes after CTA to 9, 14, 12, and 10 minutes after 4D-CTA.

Conclusion: 4D-CTA as an additive to regular CTA and CT-Perfusion in patients with acute ischemic stroke eligible for intra-arterial treatment shows a tendency to increase diagnostic accuracy and improves diagnostic certainty, when reviewed by radiologist in training, while only mildly prolonging time to diagnosis.

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Conflict of interest statement

Competing Interests: The authors have declared that no competing interests exist.

Figures

Fig 1
Fig 1. Reviewing example of a patient that presented to the ER with right-sided hemiplegia and dysarthria.
A difficult to read CTA due venous enhancement just siding the right MCA was performed, and intra-cranial vessels where initially declared patent. Only when reviewing the 4D-CTA data, the patient was transferred to the angio-suite for IA therapy. Below figs shows consecutively CTA, coronal MIP view, perfusion map and a freeze of the 4D-CTA.
Fig 2
Fig 2. ROC curves and area under the curve (AUC) for diagnostic performance.
Four different readers, comparing CTA alone, CTA + CTP, and CTA, CTP and 4DCTA.
Fig 3
Fig 3. Changes in sensitivity and specificity in relation to the experience of the different readers.
Sensitivity and specificity in %, experience in years.
Fig 4
Fig 4. Patient selection protocol.
See this image and copyright information in PMC

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