Background: Large vessel occlusion (LVO) leads to debilitating stroke and responds modestly to recombinant tissue plasminogen activator (rt-TPA). Early thrombectomy improves functional outcomes in selected patients with proximal occlusion but it is not available in all medical facilities. The best imaging modality for triage in an acute stroke setting in drip-and-ship models is still the subject of debate. Objectives: We aimed to assess the diagnostic value of millimeter-sliced noncontrast computed tomography (NCCT) hyperdense middle cerebral artery sign (HMCAS) in itself or associated with clinical data for early detection of LVO in drip-and-ship models of acute stroke management. Methods: NCCT of patients admitted to the Erasme Hospital, ULB, Brussels, Belgium, for suspicion of acute ischemic stroke between January 1 and July 31, 2017, were collected. Patients with brain hemorrhages were excluded, leading to 122 cases. The presence of HMCAS on NCCT was determined via visual assessment by 6 raters blinded to all other data. An independent rater assessed the presence of LVO on digital subtraction angiography imaging or contrast-enhanced CT angiography (CTA). The sensitivity, false-positive rate (FPR), and accuracy of HMCAS and the dot sign to detect LVO were calculated. The interobserver agreement of HMCAS was assessed using Gwet’s AC1 coefficient. Then, on a separate occasion, the first 2 observers rereviewed all NCCT provided with clinical clues. The sensitivity, FPR, and accuracy of HMCAS were recalculated. Results: HMCAS was found in 21% of the cases and a dot sign was found in 9%. The mean HMCAS sensitivity was 62% (95% CI 45–79%) and its accuracy was 86% (95% CI 79–92%) for detecting LVO. The interobserver reliability coefficient was 80% for HMCAS. Combined with clinical information, HMCAS sensitivity increased to 81% (95% CI 68–94; p = 0.041) and accuracy increased to 91% (95% CI 86–96%). Conclusion: When clinical data are provided, detection of HMCAS on thinly sliced NCCT could be enough to decide on transfer for thrombectomy in drip-and-ship models of acute stroke management, especially in situations where CTA is less available and referral centers for thrombectomy fewer and further apart.
Cerebrovasc Dis Extra 2020;10:36–43

中文翻译：

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急性中风管理滴灌模型中的高密度脑中动脉信号。

背景：大血管闭塞（LVO）会导致中风虚弱，并对重组组织纤溶酶原激活剂（rt-TPA）产生适度反应。早期血栓切除术可改善部分近端闭塞患者的功能结局，但并非在所有医疗机构中都可用。在滴水和运输模型中，在急性中风情况下进行分类的最佳成像方式仍是争论的话题。目的：我们旨在评估毫米波切片无造影计算机断层扫描（NCCT）高密度脑中动脉体征（HMCAS）本身或与临床数据相关的诊断价值，以便在急性中风管理的滴灌和船运模型中早期检测LVO 。方法：收集2017年1月1日至2017年7月31日期间因怀疑患有急性缺血性中风而入住比利时布鲁塞尔大学伊拉斯梅医院的患者的NCCT。脑出血患者被排除在外，导致122例。HMCAS在NCCT上的存在是由6位不了解所有其他数据的评估者通过视觉评估确定的。一个独立的评估者在数字减影血管造影成像或对比增强CT血管造影（CTA）上评估了LVO的存在。计算了HMCAS的灵敏度，假阳性率（FPR）和准确性以及检测LVO的点号。使用Gwet的AC1系数评估HMCAS的观察者间一致性。然后，在另外一个场合，最初的2位观察者对所有提供临床线索的NCCT进行了复查。重新计算了HMCAS的灵敏度，FPR和准确性。结果：在21％的病例中发现了HMCAS，在9％的病例中发现了点符号。HMCAS的平均灵敏度为62％（95％CI 45–79％），其检测LVO的准确度为86％（95％CI 79–92％）。HMCAS的观察者间可靠性系数为80％。结合临床信息，HMCAS的敏感性提高到81％（95％CI 68-94； p = 0.041），准确性提高到91％（95％CI 86-96％）。结论：当提供临床数据时，在急性卒中治疗的滴灌和船运模型中，薄切片NCCT上的HMCAS检测足以决定血栓切除术的转移，尤其是在CTA较少且血栓切除术转诊中心较少的情况下并进一步分开。
Cerebrovasc Dis Extra 2020; 10：36–43