title: Acute stroke assessment with CT: do we need multimodal evaluation?
abstract: OBJECTIVE
  To assess detection of stroke and prediction of extent of infarction with multimodal computed tomographic (CT) evaluation (unenhanced CT, perfusion CT, and CT angiography) in patients suspected of having acute stroke.
  
  
  METHODS
  Forty-four consecutive patients with a mean National Institutes of Health Stroke Scale score of 10.45 and suspected of having ischemic stroke of the anterior circulation were examined with multi-detector row CT within 8 hours (mean, 3.05 hours) of onset of symptoms. All evaluations were performed with the knowledge that acute stroke was suspected but without detailed clinical information. The extent of ischemia or final infarction on the baseline unenhanced CT scan and follow-up images was assessed with the Alberta Stroke Program Early CT score. Different perfusion maps and follow-up images were assessed to determine the percentage of the ischemia-affected hemisphere. Each component, as well as the multimodal CT evaluation, was compared with follow-up unenhanced CT scans or magnetic resonance images after a mean time of 2.32 days.
  
  
  RESULTS
  Multimodal CT revealed true-positive findings in 30 of 41 patients and true-negative findings in three, resulting in a sensitivity of 78.9%. Unenhanced CT, CT angiography, and perfusion CT showed sensitivities of 55.3%, 57.9%, and 76.3%, respectively. In eight patients, small infarctions (mean size, 1.47 cm) that were proved at follow-up were missed with all modalities at initial multimodal CT. With perfusion CT, four of these small infarctions were missed within the white matter of the section levels. Maps of cerebral blood flow showed the best correlation with the final size of infarction with an r(2) value of 0.71.
  
  
  CONCLUSIONS
  The presented multimodal CT evaluation improves detection rate and prediction of the final size of infarction in comparison with unenhanced CT, CT angiography, and perfusion CT alone.
authors.affiliation: Departments of Clinical Radiology and Neurology, University Hospital of Muenster, Albert-Schweitzer-Strasse 33, 48149 Muenster, Germany. kloska@uni-uenster.de
authors.forename: Stephan P
authors.initials: SP
authors.lastname: Kloska
authors.forename: Darius G
authors.initials: DG
authors.lastname: Nabavi
authors.forename: Christiane
authors.initials: C
authors.lastname: Gaus
authors.forename: Eun-Mi
authors.initials: EM
authors.lastname: Nam
authors.forename: Ernst
authors.initials: E
authors.lastname: Klotz
authors.forename: E Bernd
authors.initials: EB
authors.lastname: Ringelstein
authors.forename: Walter
authors.initials: W
authors.lastname: Heindel
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000792:Angiography / Q000379:methods; D002545:Brain Ischemia / Q000000981:diagnostic imaging; D002544:Cerebral Infarction / Q000000981:diagnostic imaging; D002560:Cerebrovascular Circulation / Q000502:physiology; D003287:Contrast Media; D005260:Female; D005500:Follow-Up Studies; D005544:Forecasting; D006801:Humans; D008279:Magnetic Resonance Imaging; D008297:Male; D008875:Middle Aged; D010477:Perfusion; D011237:Predictive Value of Tests; D011446:Prospective Studies; D011856:Radiographic Image Enhancement / Q000379:methods*; D020521:Stroke / Q000000981:diagnostic imaging*; D014057:Tomography, X-Ray Computed / Q000379:methods*
chemical_list: D003287:Contrast Media