Alberta Stroke Program Early CT Score (ASPECTS) in real time: A prospective study of its interobserver variation among radiologists in a training hospital from a low-resource setting

Background and Objectives@#The Alberta Stroke Program Early CT Score (ASPECTS) is a standardized system used to quantify the extent of ischemic involvement in cases of acute middle cerebral artery (MCA) infarct. It aids in clinical decision-making to identify patients who are more likely to benefit from thrombolytic therapy. This study aimed to determine the interobserver variation of ASPECTS among training and expert radiologists in a real-time, low-resource setting.

Inter-observer variation of the Alberta Stoke Program Early CT Score (ASPECTS) among radiologists in the Philippine General Hospital

@#<p style="text-align: justify;"><strong>Objective:</strong> To determine the inter-observer variation of ASPECTS among radiologists in the Philippine General Hospital (PGH), particularly between trainee radiologists and an expert reader.</p><p style="text-align: justify;"><strong>Methods:</strong> Thirty (30) cranial CT scan studies of clinically-diagnosed, non-hemorrhagic stroke patients were analyzed by 9 trainee radiologists (3 fellows, and 3 senior and 3 junior residents) and one expert reader. Data analysis involved determining the levels of agreement within and across groups, and against the expert reader.</p><p style="text-align: justify;"><strong>Results and Conclusion:</strong> There was moderate agreement (kappa = 0.60) between the junior residents and the expert reader, and substantial agreement between the senior residents and the expert reader (kappa = 0.70), as well as between the fellows and the expert reader (kappa = 0.63). Over-all, there was a substantial agreement between the trainee radiologists and the expert reader (kappa = 0.63). It can be concluded that the interpretation of trainee radiologists in PGH, particularly that of a senior resident or a fellow, is comparable with that of an expert reader, and can, thus, be useful in cases where an interpretation of a CT scan procedure in a clinically-diagnosed stroke patient is needed.</p>

Surgical Management of Acute Stroke

Stroke is a most common neurological disease leading to mortality and morbidity. Many clinical evidences confirm that medical treatment including thrombolytic and antithrombotic therapy may improve the clinical outcome in patients with acute ischemic stroke. However, little information exists about effectiveness and safety of reperfusion surgery such as emergency carotid endarterectomy and extracranial-intracranial bypass surgery in patients with acute ischemic stroke and limits its wide application. Recent pooled analysis of three randomized controlled clinical trials-DECIMAL (decompressive craniectomy in malignant middle cerebral artery infarcts) trial; DESTINY (decompressive surgery for the treatment of malignant infarction of the middle cerebral artery) trial; and HAMLET (hemicraniectomy after middle cerebral artery infarction with life-threatening edema trial) reported decompressive surgery undertaken within 48 hours of stroke onset in patients with malignant middle cerebral artery infarction reduced mortality and morbidity. However, decompressive surgery in patients with malignant middle cerebral artery infarction should be done according to the clinical conditions of individual patients. No clear evidences are present on that craniotomy, minimally invasive surgery, and early clot evacuation are effective on functional outcome of patients with spontaneous intracerebral hemorrhage compared with initial conservative therapy. In conclusion, a lot of well-designed studies are needed to recommend appropriate surgical management in patients with acute ischemic and hemorrhagic stroke.

A Case of Middle Cerebral Artery Infarct Developed Immediately After Head Injury

Cerebral infarcts rarely occur following head injury. Carotid artery dissection is usually proposed mechanism in such cases. We experienced a case of middle cerebral artery (MCA) infarct occurred just after head trauma without evidence of vascular abnormality. A 59-year-old male was transported to the emergency room immediately after traffic accident. He had right zygomatic fracture without neck injury. Left hemiparesis was noticed, and brain CT revealed hyperdense MCA sign in the right side. His neurologic status deteriorated over 2 days, and brain MRI showed total right MCA infarct with midline shift. Cerebral angiography was unremarkable. Two months later he had improved so much, but left hemiparesis with right MCA infarction re-developed. We suggest head trauma immediately can induce cerebral infarct without neck vessel injury, and in differential diagnosis of focal neurologic deficit after trauma, cerebral infarct as well as hemorrhage or contusion must be considered.