Review Article
Cerebral CT angiography and CT perfusion in acute stroke detection: a systematic review of diagnostic value Akmal Sabarudin1, Cantiriga Subramaniam1, Zhonghua Sun2 1
Diagnostic Imaging and Radiotherapy Programme, School of Diagnostic and Applied Health Sciences, Faculty of Health Sciences, Universiti
Kebangsaan Malaysia, 50300, Kuala Lumpur, Malaysia; 2Discipline of Medical Imaging, Department of Imaging and Applied Physics, Curtin University, GPO Box U1987 Perth, Western Australia 6845, Australia Correspondence to: Akmal Sabarudin, PhD. Diagnostic Imaging & Radiotherapy Programme, School of Diagnostic & Applied Health Sciences, Faculty of Health Sciences, Universiti Kebangsaan Malaysia, 50300, Kuala Lumpur, Malaysia. Email: [email protected].
Abstract: The purpose of this study was to analyse the diagnostic value of cerebral CT angiography (CTA) and CT perfusion (CTP) examinations in the detection of acute stroke based on a systematic review of the current literature. The review was conducted based on searching of seven databases for articles published between 1993 and 2013. Diagnostic value in terms of sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) and accuracy was analysed from 21 articles which were found to meet selection criteria. The mean sensitivity, specificity, PPV, NPV and accuracy for CTA were significantly higher than those for CTP with 83.2% (95% CI: 57.9-100.0%), 95.0% (95% CI: 74.4-100%), 84.1% (95% CI: 50.0-100%), 97.1 (95% CI: 94.0-100%) and 94.0% (95% CI: 83.0-99.0) versus 69.9% (95% CI: 20.0-97.0%), 87.4 (95% CI: 61.0-100.0%), 76.4% (95% CI: 48.0-95.4%), 78.2% (95% CI: 55.8-93.9%) and 89.8% (95% CI: 75.7-97.1%), respectively. This analysis shows that CTA has high diagnostic value in detecting high degree of cerebral arterial stenosis (>70%) whereas CTP provides high specificity in the detection of ischemia and infarct tissue of brain. Keywords: Cerebral CT angiography; CT perfusion (CTP); acute stroke; diagnostic accuracy Submitted Mar 05, 2014. Accepted for publication Jul 03, 2014. doi: 10.3978/j.issn.2223-4292.2014.07.10 View this article at: http://dx.doi.org/10.3978/j.issn.2223-4292.2014.07.10
Introduction Early detection of acute stroke helps to reduce mortality rate since rapid treatment decision can be made by clinicians (1). Computed tomography angiography (CTA) and CT perfusion (CTP) of the brain are two imaging procedures which are reported to be of paramount importance in the evaluation of acute stroke apart from unenhanced CT for emergency situation (2-7). With the introduction of intravenous contrast material, the exact site of occlusion in the cerebral vessels can be determined clearly through the vascular assessment of CTA (5,8,9). Reconstructed CTA images are available in various formats for visualization of anatomical details such as maximum intensity projection (MIP), shaded surface display (SSD), multi-planar
© AME Publishing Company. All rights reserved.
reformation (MRP) and volume rendering technique (VRT) (5,10-12). Moreover, reconstructed images of CTA provide sufficient diagnostic information which enables the CTA to replace MRI, and this could be an advantage for patients unfit for the MRI examination (9). Studies have reported that the grade of stenosis at a vessel lumen over 50% was likely to cause mild stroke (13-15). In addition, it is also confirmed that at least 30% of patients with more than 70% occluded vessel lumens were detected with stroke (15). Several studies had reported that the multimodal CT evaluation of cerebral vasculature such as a combination of unenhanced CT with CTP and CTA will increase the diagnostic accuracy in the detection of infarction, ischemia and the origin of occluded vessels’ lumen in stroke patients (5,6,16). Kloska et al. stated that the
www.amepc.org/qims
Quant Imaging Med Surg 2014;4(4):282-290
Quantitative Imaging in Medicine and Surgery, Vol 4, No 4 August 2014
multimodal CT provides sensitivity of 78.9% which is much higher than that of single CT approach with unenhanced CT (55.3%), CTA (57.9%) and CTP (76.3%) (16). Although multimodal CT techniques offer better evaluation of ischemia, infarction and site of occlusion, the radiation dose received by the patient during the procedure is a major concern. Since the diagnostic value of CTA and CTP in the detection of acute stroke has not been systematically studied, therefore, the purpose of this review was to analyse the diagnostic performance of CTA and CTP in terms of sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) and accuracy based on a systematic review of the current literature. Materials and methods Seven databases were searched to identify studies of CTA and CTP which were used in the diagnosis of stroke over a period of 20 years (from 1993 to 2013). The search was completely done only on English literature which was included in Highwire, PubMed, Science Direct, Ovid, SpringerLink, Mdconsult and Oxfords journals. The keywords used for identification of references were ‘CTA stroke accuracy’, ‘cerebral CTA in detecting acute stroke’, ‘CTP stroke and accuracy’, ‘CTA brain scan and accuracy’, ‘CTP brain scan and accuracy’ and ‘cerebral CTP in detecting acute stroke’. The search was limited to human subjects, severity of stenosis more than 50% and the value of sensitivity, specificity, PPV, NPV and accuracy must also be reported. Studies conducted on phantom or animals, reported in foreign languages, case reports and review articles were excluded from this study. Data extraction and analysis The data were recorded and extracted independently by two authors based on the selection criteria. Information included (I) year of publication; (II) patient demographics such as number of patients and age; (III) types of scanners and (IV) technical parameters such as scan duration and scan delay time were extracted. The other parameters such as sensitivity, specificity, PPV, NPV and accuracy were also extracted in order to analyse the diagnostic value of cerebral CTA and CTP. Relevant results were further assessed with Quality Assessment of Diagnostic Accuracy Studies (QUADAS) tool which is a validated consensus method containing
© AME Publishing Company. All rights reserved.
283
14 checklists for study characteristics investigation of the diagnostic accuracy of the selected chosen studies (Table S1) (17). QUADAS is a screening tool used in the assessment of systematic reviews to avoid the potential for bias, lack of applicability in order to sustain the quality literature report (17). Statistical analysis Data were analysed using the Statistical Package for Social Sciences for window version 19.0 (SPSS Inc, Chicago, IL, USA). The diagnostic values in each study was extracted and analysed using multivariate analysis for multifactorial mean comparisons in CTA and CTP. A P value of 70%) was significantly lower than that in the lower degree of stenosis ( or = 50% symptomatic vertebral or basilar artery stenosis: prospective population-based study. Brain 2009;132:982-8. Buskens E, Nederkoorn PJ, Buijs-Van Der Woude T, Mali WP, Kappelle LJ, Eikelboom BC, Van Der Graaf Y, Hunink MG. Imaging of carotid arteries in symptomatic patients: cost-effectiveness of diagnostic strategies. Radiology 2004;233:101-12. North American Symptomatic Carotid Endarterectomy Trial Collaborators. Beneficial effect of carotid endarterectomy in symptomatic patients with high-grade carotid stenosis. N Engl J Med 1991;325:445-53. Kloska SP, Nabavi DG, Gaus C, Nam EM, Klotz E, Ringelstein EB, Heindel W. Acute stroke assessment with CT: do we need multimodal evaluation? Radiology 2004;233:79-86. Whiting P, Rutjes AW, Reitsma JB, Bossuyt PM, Kleijnen J. The development of QUADAS: a tool for the quality assessment of studies of diagnostic accuracy included in systematic reviews. BMC Med Res Methodol 2003;3:25. Anderson GB, Ashforth R, Steinke DE, Ferdinandy R, Findlay JM. CT angiography for the detection and characterization of carotid artery bifurcation disease.
© AME Publishing Company. All rights reserved.
289
Stroke 2000;31:2168-74. 19. Bash S, Villablanca JP, Jahan R, Duckwiler G, Tillis M, Kidwell C, Saver J, Sayre J. Intracranial vascular stenosis and occlusive disease: evaluation with CT angiography, MR angiography, and digital subtraction angiography. AJNR Am J Neuroradiol 2005;26:1012-21. 20. Bucek RA, Puchner S, Kanitsar A, Rand T, Lammer J. Automated CTA quantification of internal carotid artery stenosis: a pilot trial. J Endovasc Ther 2007;14:70-6. 21. Duffis EJ, Jethwa P, Gupta G, Bonello K, Gandhi CD, Prestigiacomo CJ. Accuracy of computed tomographic angiography compared to digital subtraction angiography in the diagnosis of intracranial stenosis and its impact on clinical decision-making. J Stroke Cerebrovasc Dis 2013;22:1013-7. 22. Frölich AM, Psychogios MN, Klotz E, Schramm R, Knauth M, Schramm P. Angiographic reconstructions from whole-brain perfusion CT for the detection of large vessel occlusion in acute stroke. Stroke 2012;43:97-102. 23. Nguyen-Huynh MN, Wintermark M, English J, Lam J, Vittinghoff E, Smith WS, Johnston SC. How accurate is CT angiography in evaluating intracranial atherosclerotic disease? Stroke 2008;39:1184-8. 24. Shrier DA, Tanaka H, Numaguchi Y, Konno S, Patel U, Shibata D. CT angiography in the evaluation of acute stroke. AJNR Am J Neuroradiol 1997;18:1011-20. 25. Tholen AT, de Monyé C, Genders TS, Buskens E, Dippel DW, van der Lugt A, Hunink MG. Suspected carotid artery stenosis: cost-effectiveness of CT angiography in work-up of patients with recent TIA or minor ischemic stroke. Radiology 2010;256:585-97. 26. Toepker M, Mahabadi AA, Heinzle G, Hofmann W, Mathies R, Schuster A, Cejna M. Accuracy of MDCT in the determination of supraaortic artery stenosis using DSA as the reference standard. Eur J Radiol 2011;80:e351-5. 27. Campbell BC, Weir L, Desmond PM, Tu HT, Hand PJ, Yan B, Donnan GA, Parsons MW, Davis SM. CT perfusion improves diagnostic accuracy and confidence in acute ischaemic stroke. J Neurol Neurosurg Psychiatry 2013;84:613-8. 28. Ho CY, Hussain S, Alam T, Ahmad I, Wu IC, O’Neill DP. Accuracy of CT cerebral perfusion in predicting infarct in the emergency department: lesion characterization on CT perfusion based on commercially available software. Emerg Radiol 2013;20:203-12. 29. Huisa BN, Neil WP, Schrader R, Maya M, Pereira B, Bruce NT, Lyden PD. Clinical use of computed tomographic perfusion for the diagnosis and prediction
www.amepc.org/qims
Quant Imaging Med Surg 2014;4(4):282-290
Sabarudin et al. Cerebral CT angiography and CT perfusion
290
30.
31.
32.
33.
of lesion growth in acute ischemic stroke. J Stroke Cerebrovasc Dis 2014;23:114-22. Hunter GJ, Silvennoinen HM, Hamberg LM, Koroshetz WJ, Buonanno FS, Schwamm LH, Rordorf GA, Gonzalez RG. Whole-brain CT perfusion measurement of perfused cerebral blood volume in acute ischemic stroke: probability curve for regional infarction. Radiology 2003;227:725-30. Lin K, Rapalino O, Law M, Babb JS, Siller KA, Pramanik BK. Accuracy of the Alberta Stroke Program Early CT Score during the first 3 hours of middle cerebral artery stroke: comparison of noncontrast CT, CT angiography source images, and CT perfusion. AJNR Am J Neuroradiol 2008;29:931-6. Mayer TE, Hamann GF, Baranczyk J, Rosengarten B, Klotz E, Wiesmann M, Missler U, Schulte-Altedorneburg G, Brueckmann HJ. Dynamic CT perfusion imaging of acute stroke. AJNR Am J Neuroradiol 2000;21:1441-9. Murphy BD, Fox AJ, Lee DH, Sahlas DJ, Black SE, Hogan
MJ, Coutts SB, Demchuk AM, Goyal M, Aviv RI, Symons S, Gulka IB, Beletsky V, Pelz D, Hachinski V, Chan R, Lee TY. Identification of penumbra and infarct in acute ischemic stroke using computed tomography perfusionderived blood flow and blood volume measurements. Stroke 2006;37:1771-7. 34. Wintermark M, Fischbein NJ, Smith WS, Ko NU, Quist M, Dillon WP. Accuracy of dynamic perfusion CT with deconvolution in detecting acute hemispheric stroke. AJNR Am J Neuroradiol 2005;26:104-12. 35. Lev MH, Nichols SJ. Computed tomographic angiography and computed tomographic perfusion imaging of hyperacute stroke. Top Magn Reson Imaging 2000;11:273-87. 36. Koenig M, Kraus M, Theek C, Klotz E, Gehlen W, Heuser L. Quantitative assessment of the ischemic brain by means of perfusion-related parameters derived from perfusion CT. Stroke 2001;32:431-7.
Cite this article as: Sabarudin A, Subramaniam C, Sun Z. Cerebral CT angiography and CT perfusion in acute stroke detection: a systematic review of diagnostic value. Quant Imaging Med Surg 2014;4(4):282-290. doi: 10.3978/ j.issn.2223-4292.2014.07.10
© AME Publishing Company. All rights reserved.
www.amepc.org/qims
Quant Imaging Med Surg 2014;4(4):282-290
Table S1 Quality Assessment of Diagnostic Accuracy Studies (QUADAS) tool No. Items
Yes No Unclear
1
Was the spectrum of patients’ representative of the patients who will receive the test in practice?
( ) ( )
( )
2
Were selection criteria clearly described?
( ) ( )
( )
3
Is the reference standard likely to correctly classify the target condition?
( ) ( )
( )
4
Is the time period between reference standard and index test short enough to be reasonably sure that the ( ) ( )
( )
5
Did the whole sample or a random selection of the sample, receive verification using a reference standard ( ) ( )
target condition did not change between the two tests? ( )
of diagnosis? 6
Did patients receive the same reference standard regardless of the index test result?
( ) ( )
( )
7
Was the reference standard independent of the index test (i.e., the index test did not form part of the
( ) ( )
( )
8
Was the execution of the index test described in sufficient detail to permit replication of the test?
( ) ( )
( )
reference standard)? 9
Was the execution of the reference standard described in sufficient detail to permit its replication?
( ) ( )
( )
10
Were the index test results interpreted without knowledge of the results of the reference standard?
( ) ( )
( )
11
Were the reference standard results interpreted without knowledge of the results of the index test?
( ) ( )
( )
12
Were the same clinical data available when test results were interpreted as would be available when the
( ) ( )
( )
13
Were uninterpretable/intermediate test results reported?
( ) ( )
( )
14
Were withdrawals from the study explained?
( ) ( )
( )
test is used in practice?
Source: Whiting et al. 2003 (17).
Cerebral CT angiography and CT perfusion in acute stroke detection: a systematic review of diagnostic value Akmal Sabarudin1, Cantiriga Subramaniam1, Zhonghua Sun2 1
Diagnostic Imaging and Radiotherapy Programme, School of Diagnostic and Applied Health Sciences, Faculty of Health Sciences, Universiti
Kebangsaan Malaysia, 50300, Kuala Lumpur, Malaysia; 2Discipline of Medical Imaging, Department of Imaging and Applied Physics, Curtin University, GPO Box U1987 Perth, Western Australia 6845, Australia Correspondence to: Akmal Sabarudin, PhD. Diagnostic Imaging & Radiotherapy Programme, School of Diagnostic & Applied Health Sciences, Faculty of Health Sciences, Universiti Kebangsaan Malaysia, 50300, Kuala Lumpur, Malaysia. Email: [email protected].
Abstract: The purpose of this study was to analyse the diagnostic value of cerebral CT angiography (CTA) and CT perfusion (CTP) examinations in the detection of acute stroke based on a systematic review of the current literature. The review was conducted based on searching of seven databases for articles published between 1993 and 2013. Diagnostic value in terms of sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) and accuracy was analysed from 21 articles which were found to meet selection criteria. The mean sensitivity, specificity, PPV, NPV and accuracy for CTA were significantly higher than those for CTP with 83.2% (95% CI: 57.9-100.0%), 95.0% (95% CI: 74.4-100%), 84.1% (95% CI: 50.0-100%), 97.1 (95% CI: 94.0-100%) and 94.0% (95% CI: 83.0-99.0) versus 69.9% (95% CI: 20.0-97.0%), 87.4 (95% CI: 61.0-100.0%), 76.4% (95% CI: 48.0-95.4%), 78.2% (95% CI: 55.8-93.9%) and 89.8% (95% CI: 75.7-97.1%), respectively. This analysis shows that CTA has high diagnostic value in detecting high degree of cerebral arterial stenosis (>70%) whereas CTP provides high specificity in the detection of ischemia and infarct tissue of brain. Keywords: Cerebral CT angiography; CT perfusion (CTP); acute stroke; diagnostic accuracy Submitted Mar 05, 2014. Accepted for publication Jul 03, 2014. doi: 10.3978/j.issn.2223-4292.2014.07.10 View this article at: http://dx.doi.org/10.3978/j.issn.2223-4292.2014.07.10
Introduction Early detection of acute stroke helps to reduce mortality rate since rapid treatment decision can be made by clinicians (1). Computed tomography angiography (CTA) and CT perfusion (CTP) of the brain are two imaging procedures which are reported to be of paramount importance in the evaluation of acute stroke apart from unenhanced CT for emergency situation (2-7). With the introduction of intravenous contrast material, the exact site of occlusion in the cerebral vessels can be determined clearly through the vascular assessment of CTA (5,8,9). Reconstructed CTA images are available in various formats for visualization of anatomical details such as maximum intensity projection (MIP), shaded surface display (SSD), multi-planar
© AME Publishing Company. All rights reserved.
reformation (MRP) and volume rendering technique (VRT) (5,10-12). Moreover, reconstructed images of CTA provide sufficient diagnostic information which enables the CTA to replace MRI, and this could be an advantage for patients unfit for the MRI examination (9). Studies have reported that the grade of stenosis at a vessel lumen over 50% was likely to cause mild stroke (13-15). In addition, it is also confirmed that at least 30% of patients with more than 70% occluded vessel lumens were detected with stroke (15). Several studies had reported that the multimodal CT evaluation of cerebral vasculature such as a combination of unenhanced CT with CTP and CTA will increase the diagnostic accuracy in the detection of infarction, ischemia and the origin of occluded vessels’ lumen in stroke patients (5,6,16). Kloska et al. stated that the
www.amepc.org/qims
Quant Imaging Med Surg 2014;4(4):282-290
Quantitative Imaging in Medicine and Surgery, Vol 4, No 4 August 2014
multimodal CT provides sensitivity of 78.9% which is much higher than that of single CT approach with unenhanced CT (55.3%), CTA (57.9%) and CTP (76.3%) (16). Although multimodal CT techniques offer better evaluation of ischemia, infarction and site of occlusion, the radiation dose received by the patient during the procedure is a major concern. Since the diagnostic value of CTA and CTP in the detection of acute stroke has not been systematically studied, therefore, the purpose of this review was to analyse the diagnostic performance of CTA and CTP in terms of sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) and accuracy based on a systematic review of the current literature. Materials and methods Seven databases were searched to identify studies of CTA and CTP which were used in the diagnosis of stroke over a period of 20 years (from 1993 to 2013). The search was completely done only on English literature which was included in Highwire, PubMed, Science Direct, Ovid, SpringerLink, Mdconsult and Oxfords journals. The keywords used for identification of references were ‘CTA stroke accuracy’, ‘cerebral CTA in detecting acute stroke’, ‘CTP stroke and accuracy’, ‘CTA brain scan and accuracy’, ‘CTP brain scan and accuracy’ and ‘cerebral CTP in detecting acute stroke’. The search was limited to human subjects, severity of stenosis more than 50% and the value of sensitivity, specificity, PPV, NPV and accuracy must also be reported. Studies conducted on phantom or animals, reported in foreign languages, case reports and review articles were excluded from this study. Data extraction and analysis The data were recorded and extracted independently by two authors based on the selection criteria. Information included (I) year of publication; (II) patient demographics such as number of patients and age; (III) types of scanners and (IV) technical parameters such as scan duration and scan delay time were extracted. The other parameters such as sensitivity, specificity, PPV, NPV and accuracy were also extracted in order to analyse the diagnostic value of cerebral CTA and CTP. Relevant results were further assessed with Quality Assessment of Diagnostic Accuracy Studies (QUADAS) tool which is a validated consensus method containing
© AME Publishing Company. All rights reserved.
283
14 checklists for study characteristics investigation of the diagnostic accuracy of the selected chosen studies (Table S1) (17). QUADAS is a screening tool used in the assessment of systematic reviews to avoid the potential for bias, lack of applicability in order to sustain the quality literature report (17). Statistical analysis Data were analysed using the Statistical Package for Social Sciences for window version 19.0 (SPSS Inc, Chicago, IL, USA). The diagnostic values in each study was extracted and analysed using multivariate analysis for multifactorial mean comparisons in CTA and CTP. A P value of 70%) was significantly lower than that in the lower degree of stenosis ( or = 50% symptomatic vertebral or basilar artery stenosis: prospective population-based study. Brain 2009;132:982-8. Buskens E, Nederkoorn PJ, Buijs-Van Der Woude T, Mali WP, Kappelle LJ, Eikelboom BC, Van Der Graaf Y, Hunink MG. Imaging of carotid arteries in symptomatic patients: cost-effectiveness of diagnostic strategies. Radiology 2004;233:101-12. North American Symptomatic Carotid Endarterectomy Trial Collaborators. Beneficial effect of carotid endarterectomy in symptomatic patients with high-grade carotid stenosis. N Engl J Med 1991;325:445-53. Kloska SP, Nabavi DG, Gaus C, Nam EM, Klotz E, Ringelstein EB, Heindel W. Acute stroke assessment with CT: do we need multimodal evaluation? Radiology 2004;233:79-86. Whiting P, Rutjes AW, Reitsma JB, Bossuyt PM, Kleijnen J. The development of QUADAS: a tool for the quality assessment of studies of diagnostic accuracy included in systematic reviews. BMC Med Res Methodol 2003;3:25. Anderson GB, Ashforth R, Steinke DE, Ferdinandy R, Findlay JM. CT angiography for the detection and characterization of carotid artery bifurcation disease.
© AME Publishing Company. All rights reserved.
289
Stroke 2000;31:2168-74. 19. Bash S, Villablanca JP, Jahan R, Duckwiler G, Tillis M, Kidwell C, Saver J, Sayre J. Intracranial vascular stenosis and occlusive disease: evaluation with CT angiography, MR angiography, and digital subtraction angiography. AJNR Am J Neuroradiol 2005;26:1012-21. 20. Bucek RA, Puchner S, Kanitsar A, Rand T, Lammer J. Automated CTA quantification of internal carotid artery stenosis: a pilot trial. J Endovasc Ther 2007;14:70-6. 21. Duffis EJ, Jethwa P, Gupta G, Bonello K, Gandhi CD, Prestigiacomo CJ. Accuracy of computed tomographic angiography compared to digital subtraction angiography in the diagnosis of intracranial stenosis and its impact on clinical decision-making. J Stroke Cerebrovasc Dis 2013;22:1013-7. 22. Frölich AM, Psychogios MN, Klotz E, Schramm R, Knauth M, Schramm P. Angiographic reconstructions from whole-brain perfusion CT for the detection of large vessel occlusion in acute stroke. Stroke 2012;43:97-102. 23. Nguyen-Huynh MN, Wintermark M, English J, Lam J, Vittinghoff E, Smith WS, Johnston SC. How accurate is CT angiography in evaluating intracranial atherosclerotic disease? Stroke 2008;39:1184-8. 24. Shrier DA, Tanaka H, Numaguchi Y, Konno S, Patel U, Shibata D. CT angiography in the evaluation of acute stroke. AJNR Am J Neuroradiol 1997;18:1011-20. 25. Tholen AT, de Monyé C, Genders TS, Buskens E, Dippel DW, van der Lugt A, Hunink MG. Suspected carotid artery stenosis: cost-effectiveness of CT angiography in work-up of patients with recent TIA or minor ischemic stroke. Radiology 2010;256:585-97. 26. Toepker M, Mahabadi AA, Heinzle G, Hofmann W, Mathies R, Schuster A, Cejna M. Accuracy of MDCT in the determination of supraaortic artery stenosis using DSA as the reference standard. Eur J Radiol 2011;80:e351-5. 27. Campbell BC, Weir L, Desmond PM, Tu HT, Hand PJ, Yan B, Donnan GA, Parsons MW, Davis SM. CT perfusion improves diagnostic accuracy and confidence in acute ischaemic stroke. J Neurol Neurosurg Psychiatry 2013;84:613-8. 28. Ho CY, Hussain S, Alam T, Ahmad I, Wu IC, O’Neill DP. Accuracy of CT cerebral perfusion in predicting infarct in the emergency department: lesion characterization on CT perfusion based on commercially available software. Emerg Radiol 2013;20:203-12. 29. Huisa BN, Neil WP, Schrader R, Maya M, Pereira B, Bruce NT, Lyden PD. Clinical use of computed tomographic perfusion for the diagnosis and prediction
www.amepc.org/qims
Quant Imaging Med Surg 2014;4(4):282-290
Sabarudin et al. Cerebral CT angiography and CT perfusion
290
30.
31.
32.
33.
of lesion growth in acute ischemic stroke. J Stroke Cerebrovasc Dis 2014;23:114-22. Hunter GJ, Silvennoinen HM, Hamberg LM, Koroshetz WJ, Buonanno FS, Schwamm LH, Rordorf GA, Gonzalez RG. Whole-brain CT perfusion measurement of perfused cerebral blood volume in acute ischemic stroke: probability curve for regional infarction. Radiology 2003;227:725-30. Lin K, Rapalino O, Law M, Babb JS, Siller KA, Pramanik BK. Accuracy of the Alberta Stroke Program Early CT Score during the first 3 hours of middle cerebral artery stroke: comparison of noncontrast CT, CT angiography source images, and CT perfusion. AJNR Am J Neuroradiol 2008;29:931-6. Mayer TE, Hamann GF, Baranczyk J, Rosengarten B, Klotz E, Wiesmann M, Missler U, Schulte-Altedorneburg G, Brueckmann HJ. Dynamic CT perfusion imaging of acute stroke. AJNR Am J Neuroradiol 2000;21:1441-9. Murphy BD, Fox AJ, Lee DH, Sahlas DJ, Black SE, Hogan
MJ, Coutts SB, Demchuk AM, Goyal M, Aviv RI, Symons S, Gulka IB, Beletsky V, Pelz D, Hachinski V, Chan R, Lee TY. Identification of penumbra and infarct in acute ischemic stroke using computed tomography perfusionderived blood flow and blood volume measurements. Stroke 2006;37:1771-7. 34. Wintermark M, Fischbein NJ, Smith WS, Ko NU, Quist M, Dillon WP. Accuracy of dynamic perfusion CT with deconvolution in detecting acute hemispheric stroke. AJNR Am J Neuroradiol 2005;26:104-12. 35. Lev MH, Nichols SJ. Computed tomographic angiography and computed tomographic perfusion imaging of hyperacute stroke. Top Magn Reson Imaging 2000;11:273-87. 36. Koenig M, Kraus M, Theek C, Klotz E, Gehlen W, Heuser L. Quantitative assessment of the ischemic brain by means of perfusion-related parameters derived from perfusion CT. Stroke 2001;32:431-7.
Cite this article as: Sabarudin A, Subramaniam C, Sun Z. Cerebral CT angiography and CT perfusion in acute stroke detection: a systematic review of diagnostic value. Quant Imaging Med Surg 2014;4(4):282-290. doi: 10.3978/ j.issn.2223-4292.2014.07.10
© AME Publishing Company. All rights reserved.
www.amepc.org/qims
Quant Imaging Med Surg 2014;4(4):282-290
Table S1 Quality Assessment of Diagnostic Accuracy Studies (QUADAS) tool No. Items
Yes No Unclear
1
Was the spectrum of patients’ representative of the patients who will receive the test in practice?
( ) ( )
( )
2
Were selection criteria clearly described?
( ) ( )
( )
3
Is the reference standard likely to correctly classify the target condition?
( ) ( )
( )
4
Is the time period between reference standard and index test short enough to be reasonably sure that the ( ) ( )
( )
5
Did the whole sample or a random selection of the sample, receive verification using a reference standard ( ) ( )
target condition did not change between the two tests? ( )
of diagnosis? 6
Did patients receive the same reference standard regardless of the index test result?
( ) ( )
( )
7
Was the reference standard independent of the index test (i.e., the index test did not form part of the
( ) ( )
( )
8
Was the execution of the index test described in sufficient detail to permit replication of the test?
( ) ( )
( )
reference standard)? 9
Was the execution of the reference standard described in sufficient detail to permit its replication?
( ) ( )
( )
10
Were the index test results interpreted without knowledge of the results of the reference standard?
( ) ( )
( )
11
Were the reference standard results interpreted without knowledge of the results of the index test?
( ) ( )
( )
12
Were the same clinical data available when test results were interpreted as would be available when the
( ) ( )
( )
13
Were uninterpretable/intermediate test results reported?
( ) ( )
( )
14
Were withdrawals from the study explained?
( ) ( )
( )
test is used in practice?
Source: Whiting et al. 2003 (17).
