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Neuroradiology
Published in: Neuroradiology 4/2021

Open Access 01-04-2021 | Stroke | Diagnostic Neuroradiology

Prediction of long-term recurrent ischemic stroke: the added value of non-contrast CT, CT perfusion, and CT angiography

Authors: Frans Kauw, Jacoba P. Greving, Richard A. P. Takx, Hugo W. A. M. de Jong, Wouter J. Schonewille, Jan A. Vos, Marieke J. H. Wermer, Marianne A. A. van Walderveen, L. Jaap Kappelle, Birgitta K. Velthuis, Jan W. Dankbaar, On behalf of the Dutch acute stroke study (DUST) investigators

Published in: Neuroradiology | Issue 4/2021

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Abstract

Purpose

The aim of this study was to evaluate whether the addition of brain CT imaging data to a model incorporating clinical risk factors improves prediction of ischemic stroke recurrence over 5 years of follow-up.

Methods

A total of 638 patients with ischemic stroke from three centers were selected from the Dutch acute stroke study (DUST). CT-derived candidate predictors included findings on non-contrast CT, CT perfusion, and CT angiography. Five-year follow-up data were extracted from medical records. We developed a multivariable Cox regression model containing clinical predictors and an extended model including CT-derived predictors by applying backward elimination. We calculated net reclassification improvement and integrated discrimination improvement indices. Discrimination was evaluated with the optimism-corrected c-statistic and calibration with a calibration plot.

Results

During 5 years of follow-up, 56 patients (9%) had a recurrence. The c-statistic of the clinical model, which contained male sex, history of hyperlipidemia, and history of stroke or transient ischemic attack, was 0.61. Compared with the clinical model, the extended model, which contained previous cerebral infarcts on non-contrast CT and Alberta Stroke Program Early CT score greater than 7 on mean transit time maps derived from CT perfusion, had higher discriminative performance (c-statistic 0.65, P = 0.01). Inclusion of these CT variables led to a significant improvement in reclassification measures, by using the net reclassification improvement and integrated discrimination improvement indices.

Conclusion

Data from CT imaging significantly improved the discriminatory performance and reclassification in predicting ischemic stroke recurrence beyond a model incorporating clinical risk factors only.
Appendix
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Literature
1.
Benjamin EJ, Blaha MJ, Chiuve SE et al (2017) Heart disease and stroke statistics-2017 update: a report from the American Heart Association. Circulation 135:e146–e603CrossRef
2.
Dhamoon MS, Sciacca RR, Rundek T et al (2006) Recurrent stroke and cardiac risks after first ischemic stroke: the Northern Manhattan Study. Neurology 66:641–646CrossRef
3.
Buenaflor FGB, Navarro JC, Lara KJAVN (2017) Recurrence rate of ischemic stroke: a single center experience. Austin J Cerebrovasc Dis Stroke 4:1057
4.
Kauw F, Takx RAP, de Jong HWAM et al (2018) Clinical and imaging predictors of recurrent ischemic stroke: a systematic review and meta-analysis. Cerebrovasc Dis 45:279–287CrossRef
5.
Wintermark M, Luby M, Bornstein NM et al (2015) International survey of acute stroke imaging used to make revascularization treatment decisions. Int J Stroke 10:759–762CrossRef
6.
Coutts SB, Modi J, Patel SK et al (2012) CT/CT angiography and MRI findings predict recurrent stroke after transient ischemic attack and minor stroke: results of the prospective CATCH study. Stroke 43:1013–1017CrossRef
7.
Liebeskind DS, Cotsonis GA, Saver JL et al (2011) Collaterals dramatically alter stroke risk in intracranial atherosclerosis. Ann Neurol 69:963–974CrossRef
8.
Ay H, Gungor L, Arsava EM et al (2010) A score to predict early risk of recurrence after ischemic stroke. Neurology 74:128–135CrossRef
9.
Nam K-W, Kwon H-M, Lim J-S et al (2017) Clinical relevance of abnormal neuroimaging findings and long-term risk of stroke recurrence. Eur J Neurol 24:1348–1354CrossRef
10.
Thompson DD, Murray GD, Dennis M et al (2014) Formal and informal prediction of recurrent stroke and myocardial infarction after stroke: a systematic review and evaluation of clinical prediction models in a new cohort. BMC Med 12:58CrossRef
11.
Edwards JD, Kapral MK, Fang J, Swartz RH (2017) Long-term morbidity and mortality in patients without early complications after stroke or transient ischemic attack. CMAJ 189:E954–E961CrossRef
12.
van Seeters T, Biessels GJ, van der Schaaf IC et al (2014) Prediction of outcome in patients with suspected acute ischaemic stroke with CT perfusion and CT angiography: the Dutch acute stroke trial (DUST) study protocol. BMC Neurol 14:37CrossRef
13.
van Seeters T, Biessels GJ, Kappelle LJ et al (2015) The prognostic value of CT angiography and CT perfusion in acute ischemic stroke. Cerebrovasc Dis 40:258–269CrossRef
14.
Adams HPJ, Bendixen BH, Kappelle LJ et al (1993) Classification of subtype of acute ischemic stroke. Definitions for use in a multicenter clinical trial. TOAST. Trial of Org 10172 in Acute Stroke Treatment. Stroke 24:35–41CrossRef
15.
Barber PA, Demchuk AM, Zhang J, Buchan AM (2000) Validity and reliability of a quantitative computed tomography score in predicting outcome of hyperacute stroke before thrombolytic therapy. ASPECTS Study Group. Alberta Stroke Programme Early CT Score. Lancet 355:1670–1674CrossRef
16.
Puetz V, Sylaja PN, Coutts SB et al (2008) Extent of hypoattenuation on CT angiography source images predicts functional outcome in patients with basilar artery occlusion. Stroke 39:2485–2490CrossRef
17.
Tan IY, Demchuk AM, Hopyan J et al (2009) CT angiography clot burden score and collateral score: correlation with clinical and radiologic outcomes in acute middle cerebral artery infarct. AJNR Am J Neuroradiol 30:525–531CrossRef
18.
van Seeters T, Biessels GJ, Niesten JM et al (2013) Reliability of visual assessment of non-contrast CT, CT angiography source images and CT perfusion in patients with suspected ischemic stroke. PLoS One 8:e75615CrossRef
19.
Tan JC, Dillon WP, Liu S et al (2007) Systematic comparison of perfusion-CT and CT-angiography in acute stroke patients. Ann Neurol 61:533–543CrossRef
20.
Kim JJ, Fischbein NJ, Lu Y et al (2004) Regional angiographic grading system for collateral flow: correlation with cerebral infarction in patients with middle cerebral artery occlusion. Stroke 35:1340–1344CrossRef
21.
Pencina MJ, D’Agostino RBS, D’Agostino RBJ, Vasan RS (2008) Evaluating the added predictive ability of a new marker: from area under the ROC curve to reclassification and beyond. Stat Med 27:112–157
22.
Pencina MJ, D’Agostino RBS, Steyerberg EW (2011) Extensions of net reclassification improvement calculations to measure usefulness of new biomarkers. Stat Med 30:11–21CrossRef
23.
Dunkler D, Sauerbrei W, Heinze G (2016) Global, Parameterwise and Joint Shrinkage Factor Estimation. J Stat Softw Mar;69(8):1–19
24.
Collins GS, Reitsma JB, Altman DG, Moons KGM (2015) Transparent reporting of a multivariable prediction model for individual prognosis or diagnosis (TRIPOD): the TRIPOD statement. J Clin Epidemiol 68:134–143CrossRef
25.
Baek JH, Kim K, Lee Y-B et al (2015) Predicting stroke outcome using clinical- versus imaging-based scoring system. J Stroke Cerebrovasc Dis 24:642–648CrossRef
26.
Madden KP, Karanjia PN, Adams HPJ, Clarke WR (1995) Accuracy of initial stroke subtype diagnosis in the TOAST study. Trial of ORG 10172 in Acute Stroke Treatment. Neurology 45:1975–1979CrossRef
27.
Gupta A, Giambrone AE, Gialdini G et al (2016) Silent brain infarction and risk of future stroke: a systematic review and meta-analysis. Stroke 47:719–725CrossRef
28.
Sillanpaa N, Saarinen JT, Rusanen H et al (2011) CT perfusion ASPECTS in the evaluation of acute ischemic stroke: thrombolytic therapy perspective. Cerebrovasc Dis Extra 1:6–16CrossRef
29.
Kernan WN, Viscoli CM, Brass LM et al (2000) The stroke prognosis instrument II (SPI-II): a clinical prediction instrument for patients with transient ischemia and nondisabling ischemic stroke. Stroke 31:456–462CrossRef
30.
Putaala J, Haapaniemi E, Metso AJ et al (2010) Recurrent ischemic events in young adults after first-ever ischemic stroke. Ann Neurol 68:661–671CrossRef
Metadata
Title
Prediction of long-term recurrent ischemic stroke: the added value of non-contrast CT, CT perfusion, and CT angiography
Authors
Frans Kauw
Jacoba P. Greving
Richard A. P. Takx
Hugo W. A. M. de Jong
Wouter J. Schonewille
Jan A. Vos
Marieke J. H. Wermer
Marianne A. A. van Walderveen
L. Jaap Kappelle
Birgitta K. Velthuis
Jan W. Dankbaar
On behalf of the Dutch acute stroke study (DUST) investigators
Publication date
01-04-2021
Publisher
Springer Berlin Heidelberg
Published in
Neuroradiology / Issue 4/2021
Print ISSN: 0028-3940
Electronic ISSN: 1432-1920
DOI
https://doi.org/10.1007/s00234-020-02526-5

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