Prediction of long-term recurrent ischemic stroke: the added value of non-contrast CT, CT perfusion, and CT angiography

Purpose: The aim of this study was to evaluate whether the addition of brain CT imaging data to a model incorporating clinical risk factors improves prediction of ischemic stroke recurrence over 5 years of follow-up. Methods: A total of 638 patients with ischemic stroke from three centers were selected from the Dutch acute stroke study (DUST). CT-derived candidate predictors included findings on non-contrast CT, CT perfusion, and CT angiography. Five-year follow-up data were extracted from medical records. We developed a multivariable Cox regression model containing clinical predictors and an extended model including CT-derived predictors by applying backward elimination. We calculated net reclassification improvement and integrated discrimination improvement indices. Discrimination was evaluated with the optimism-corrected c-statistic and calibration with a calibration plot. Results: During 5 years of follow-up, 56 patients (9%) had a recurrence. The c-statistic of the clinical model, which contained male sex, history of hyperlipidemia, and history of stroke or transient ischemic attack, was 0.61. Compared with the clinical model, the extended model, which contained previous cerebral infarcts on non-contrast CT and Alberta Stroke Program Early CT score greater than 7 on mean transit time maps derived from CT perfusion, had higher discriminative performance (c-statistic 0.65, P = 0.01). Inclusion of these CT variables led to a significant improvement in reclassification measures, by using the net reclassification improvement and integrated discrimination improvement indices. Conclusion: Data from CT imaging significantly improved the discriminatory performance and reclassification in predicting ischemic stroke recurrence beyond a model incorporating clinical risk factors only

Association of right ventricular functional parameters with adverse cardiopulmonary outcomes - a meta-analysis

Aims We aimed to confirm that three-dimensional echocardiography (3DE)-derived right ventricular (RV) ejection fraction (EF) is better associated with adverse cardiopulmonary outcomes than the conventional echocardiographic parameters. Methods We performed a meta-analysis of studies reporting the impact of unit change of RVEF, tricuspid annular plane systolic excursion (TAPSE), fractional area change (FAC), and free-wall longitudinal strain (FWLS) on clinical outcomes (all-cause mortality and/or adverse cardiopulmonary outcomes). Hazard ratios (HR) were rescaled by the within-study standard deviations (SD) to represent standardized changes. Within each study, we calculated the ratio of HRs related to 1 SD reduction in RVEF versus TAPSE, or FAC, or FWLS, to quantify the association of RVEF with adverse outcomes relative to the other metrics. These ratios of HRs were pooled using random-effects models. Results Ten independent studies were identified as suitable, including data on 1,928 patients with various cardiopulmonary conditions. Overall, 1 SD reduction in RVEF was robustly associated with adverse outcomes (HR: 2.64 [95% CI: 2.18 to 3.20], p<0.001; heterogeneity: I2=65%, p=0.002). In studies reporting HRs for RVEF and TAPSE, FAC, or FWLS in the same cohort, head-to-head comparison revealed that RVEF showed significantly stronger association with adverse outcomes per SD reduction versus the other three parameters (vs. TAPSE, HR: 1.54 [95% CI: 1.04 to 2.28], p=0.031; vs. FAC, HR: 1.45 [95% CI: 1.15 to 1.81], p=0.001; vs. FWLS, HR: 1.44 [95% CI: 1.07 to 1.95], p=0.018). Conclusion Reduction in 3DE-derived RVEF shows stronger association with adverse clinical outcomes than conventional RV functional indices, therefore, it might further refine the risk stratification of patients with cardiopulmonary diseases