Downloaded from http://jnis.bmj.com/ on February 13, 2016 - Published by group.bmj.com
Ischemic stroke
ORIGINAL RESEARCH
Risk of acute kidney injury associated with neuroimaging obtained during triage and treatment of patients with acute ischemic stroke symptoms Shelby L Hall,1,2 Stephan A Munich,1,2 Marshall C Cress,1,2 Leonardo Rangel-Castilla,1,2 Elad I Levy,1,2,3,4 Kenneth V Snyder,1,2,3,4,5 Adnan H Siddiqui1,2,3,4,6 For numbered affiliations see end of article. Correspondence to Dr Adnan H Siddiqui, University at Buffalo Neurosurgery, 100 High Street, Suite B4, Buffalo, NY 14203 USA; [email protected] Received 13 October 2015 Revised 4 January 2016 Accepted 11 January 2016
ABSTRACT Background Combining non-contrast CT (NCCT), CT angiography (CTA), and CT perfusion (CTP) imaging (referred to as a CT stroke study, CTSS) provides a rapid evaluation of the cerebrovascular axis during acute ischemic stroke. Iodinated contrast-enhanced CT imaging is not without risk, which includes renal injury. If a patient’s CTSS identifies vascular pathology, digital subtraction angiography (DSA) is often performed within 24–48 h. Such patients may receive multiple administrations of iodinated contrast material over a short time period. Objective We aimed to evaluate the incidence of acute kidney injury (AKI) in patients who underwent a CTSS and DSA for evaluation of acute ischemic symptoms or for stroke intervention within a 48 h period between August 2012 and December 2014. Methods We identified 84 patients for inclusion in the analysis. Patients fell into one of two cohorts: AKI, defined as a rise in the serum creatinine level of ≥0.5 mg/dL from baseline, or non-AKI. Clinical parameters included pre- and post-imaging serum creatinine level, time between CTSS and DSA, and type of angiographic procedure (diagnostic vs intervention) performed. Results Four patients (4.7%) experienced AKI, one of whom had baseline renal dysfunction (defined as baseline serum creatinine level ≥1.5 mg/dL). The mean difference between baseline and peak creatinine values was found to be significantly greater in patients with AKI than in non-AKI patients (1.65 vs −0.09, respectively; p=0.0008). Conclusions This study provides preliminary evidence of the safety and feasibility of obtaining CTSS with additional DSA imaging, whether for diagnosis or intervention, to identify possible acute ischemic stroke.
CT angiography (CTA) and perfusion imaging studies. By combining NCCT imaging with CTA from the aortic arch to skull vertex and CT perfusion (CTP) imaging, the entire cerebrovascular axis can be visualized during acute ischemic stroke events.7 Although rapid and effective, iodinated contrast-enhanced CT imaging is not without risk, the primary of which is renal injury. This may be of particular concern in patients who are elderly, diabetic, and those with baseline renal dysfunction.8 Recent studies suggest these imaging strategies to be safe (associated with a low incidence of contrast nephropathy) in the evaluation of acute ischemic stroke.7–9 Patients who present to our institution with symptoms suggestive of acute ischemic stroke routinely undergo investigation with a stroke CT protocol (herein referred to as CT stroke study (CTSS)), which consists of NCCT scan of the brain, CTP of the head, and CTA of the head and neck. If a favorable penumbral pattern is identified in conjunction with an occlusion site that is amenable to endovascular intervention, patients are taken immediately to the interventional suite for possible intervention. Patients in whom no acute occlusion is identified but whose CTSS is concerning for nonocclusive vascular pathology (eg, carotid stenosis or intracranial atherosclerotic disease) typically undergo further investigation with digital subtraction angiography (DSA) within the next 24–48 h. Therefore, at our institution, patients routinely receive multiple administrations of iodinated contrast material over a relatively short time period. In this study we aimed to evaluate the incidence of acute kidney injury (AKI) in patients who underwent a CTSS and a DSA within a 48 h period.
METHODS INTRODUCTION
To cite: Hall SL, Munich SA, Cress MC, et al. J NeuroIntervent Surg Published Online First: [please include Day Month Year] doi:10.1136/ neurintsurg-2015-012118
In the routine diagnosis and treatment of acute ischemic stroke, basic imaging of the brain and cerebrovasculature has become common practice. Routine evaluation of patients presenting with stroke-like symptoms typically includes noncontrast CT (NCCT) of the head.1 With the recent publication of five trials2–6 comparing endovascular and routine medical treatment for patients with acute anterior circulation occlusion, the importance of precise identification of the occlusion site during initial patient triage was highlighted. This localization is efficiently obtained by performing contrast
This retrospective study was approved by the local Institutional Review Board. Patients who had received both a CTSS and DSA within the same 48 h period for evaluation of acute ischemia or for stroke intervention between August 2012 and December 2014 were identified from our clinical database. In accordance with the CTSS protocol, 130 mL of an iodinated contrast agent (80 mL for CTA and 50 mL for CTP) is administered. The typical agent used is Omnipaque 350 (GE Healthcare). If there is concern that the patient has compromised renal function, Visipaque 320 (GE Healthcare) is substituted. This is typically
Hall SL, et al. J NeuroIntervent Surg 2016;0:1–5. doi:10.1136/neurintsurg-2015-012118
1
Downloaded from http://jnis.bmj.com/ on February 13, 2016 - Published by group.bmj.com
Ischemic stroke considered to be the case at our institution if the patient has a glomerular filtration rate (GFR)
Ischemic stroke
ORIGINAL RESEARCH
Risk of acute kidney injury associated with neuroimaging obtained during triage and treatment of patients with acute ischemic stroke symptoms Shelby L Hall,1,2 Stephan A Munich,1,2 Marshall C Cress,1,2 Leonardo Rangel-Castilla,1,2 Elad I Levy,1,2,3,4 Kenneth V Snyder,1,2,3,4,5 Adnan H Siddiqui1,2,3,4,6 For numbered affiliations see end of article. Correspondence to Dr Adnan H Siddiqui, University at Buffalo Neurosurgery, 100 High Street, Suite B4, Buffalo, NY 14203 USA; [email protected] Received 13 October 2015 Revised 4 January 2016 Accepted 11 January 2016
ABSTRACT Background Combining non-contrast CT (NCCT), CT angiography (CTA), and CT perfusion (CTP) imaging (referred to as a CT stroke study, CTSS) provides a rapid evaluation of the cerebrovascular axis during acute ischemic stroke. Iodinated contrast-enhanced CT imaging is not without risk, which includes renal injury. If a patient’s CTSS identifies vascular pathology, digital subtraction angiography (DSA) is often performed within 24–48 h. Such patients may receive multiple administrations of iodinated contrast material over a short time period. Objective We aimed to evaluate the incidence of acute kidney injury (AKI) in patients who underwent a CTSS and DSA for evaluation of acute ischemic symptoms or for stroke intervention within a 48 h period between August 2012 and December 2014. Methods We identified 84 patients for inclusion in the analysis. Patients fell into one of two cohorts: AKI, defined as a rise in the serum creatinine level of ≥0.5 mg/dL from baseline, or non-AKI. Clinical parameters included pre- and post-imaging serum creatinine level, time between CTSS and DSA, and type of angiographic procedure (diagnostic vs intervention) performed. Results Four patients (4.7%) experienced AKI, one of whom had baseline renal dysfunction (defined as baseline serum creatinine level ≥1.5 mg/dL). The mean difference between baseline and peak creatinine values was found to be significantly greater in patients with AKI than in non-AKI patients (1.65 vs −0.09, respectively; p=0.0008). Conclusions This study provides preliminary evidence of the safety and feasibility of obtaining CTSS with additional DSA imaging, whether for diagnosis or intervention, to identify possible acute ischemic stroke.
CT angiography (CTA) and perfusion imaging studies. By combining NCCT imaging with CTA from the aortic arch to skull vertex and CT perfusion (CTP) imaging, the entire cerebrovascular axis can be visualized during acute ischemic stroke events.7 Although rapid and effective, iodinated contrast-enhanced CT imaging is not without risk, the primary of which is renal injury. This may be of particular concern in patients who are elderly, diabetic, and those with baseline renal dysfunction.8 Recent studies suggest these imaging strategies to be safe (associated with a low incidence of contrast nephropathy) in the evaluation of acute ischemic stroke.7–9 Patients who present to our institution with symptoms suggestive of acute ischemic stroke routinely undergo investigation with a stroke CT protocol (herein referred to as CT stroke study (CTSS)), which consists of NCCT scan of the brain, CTP of the head, and CTA of the head and neck. If a favorable penumbral pattern is identified in conjunction with an occlusion site that is amenable to endovascular intervention, patients are taken immediately to the interventional suite for possible intervention. Patients in whom no acute occlusion is identified but whose CTSS is concerning for nonocclusive vascular pathology (eg, carotid stenosis or intracranial atherosclerotic disease) typically undergo further investigation with digital subtraction angiography (DSA) within the next 24–48 h. Therefore, at our institution, patients routinely receive multiple administrations of iodinated contrast material over a relatively short time period. In this study we aimed to evaluate the incidence of acute kidney injury (AKI) in patients who underwent a CTSS and a DSA within a 48 h period.
METHODS INTRODUCTION
To cite: Hall SL, Munich SA, Cress MC, et al. J NeuroIntervent Surg Published Online First: [please include Day Month Year] doi:10.1136/ neurintsurg-2015-012118
In the routine diagnosis and treatment of acute ischemic stroke, basic imaging of the brain and cerebrovasculature has become common practice. Routine evaluation of patients presenting with stroke-like symptoms typically includes noncontrast CT (NCCT) of the head.1 With the recent publication of five trials2–6 comparing endovascular and routine medical treatment for patients with acute anterior circulation occlusion, the importance of precise identification of the occlusion site during initial patient triage was highlighted. This localization is efficiently obtained by performing contrast
This retrospective study was approved by the local Institutional Review Board. Patients who had received both a CTSS and DSA within the same 48 h period for evaluation of acute ischemia or for stroke intervention between August 2012 and December 2014 were identified from our clinical database. In accordance with the CTSS protocol, 130 mL of an iodinated contrast agent (80 mL for CTA and 50 mL for CTP) is administered. The typical agent used is Omnipaque 350 (GE Healthcare). If there is concern that the patient has compromised renal function, Visipaque 320 (GE Healthcare) is substituted. This is typically
Hall SL, et al. J NeuroIntervent Surg 2016;0:1–5. doi:10.1136/neurintsurg-2015-012118
1
Downloaded from http://jnis.bmj.com/ on February 13, 2016 - Published by group.bmj.com
Ischemic stroke considered to be the case at our institution if the patient has a glomerular filtration rate (GFR)
