Charlotte Zerna, MD, MSc
Mayer SA, Viarasilpa T, Panyavachiraporn N, Brady M, Scozzari D, Van Harn M, et al. CTA-for-All: Impact of Emergency Computed Tomographic Angiography for All Patients With Stroke Presenting Within 24 Hours of Onset. Stroke. 2019.
Mechanical thrombectomy for acute ischemic stroke in the anterior circulation due to large-vessel occlusion (LVO) has been established as the new standard of care. The ESCAPE trial found no evidence of treatment heterogeneity between subjects in the early and late windows, and treatment effect favoring intervention was seen across all clinical outcomes in the extended time window.1 The DAWN and DEFUSE 3 trials were then further able to show benefit of mechanical thrombectomy > 6 hours from onset for patients selected by clinical-core mismatch or perfusion-core mismatch via advanced neuroimaging.2, 3 But even though benefit clearly exists beyond 6 hours, fast mechanical thrombectomy is critical since an LVO acute ischemic stroke typically leads to destruction of 1.9 million neurons, 14 billion synapses, and 12 km (7.5 miles) of myelinated fibers per minute.4 Because LVO can only be diagnosed by time-efficient neurovascular imaging, the authors implemented a CTA-for-All stroke imaging policy in their regional health system for all patients presenting within 24 hours of last known well, regardless of baseline NIHSS scores and eliminating the requirement of obtaining baseline creatinine levels. The new policy applied to stroke codes in both the ED and on hospital floors, whereas before, an emergency CTA was reserved only for patients with acute ischemic stroke confirmed by non-contrast CT who presented within 6 hours of last known well and with an NIHSS score of at least 6 once serum creatinine levels were known.