Demaerschalk, Bart

Introduction: AI-driven software has been recommended as a means of triaging suspected large vessel occlusions (LVOs) on CT angiography (CTA), and different solutions are now commercially available. This study compared the performance of two software packages, Brainomix 360 Triage LVO and Rapid LVO, in prospective, real-world use. Methods: Consecutive patients scanned for suspected stroke at 3 comprehensive stroke centres from May to July 2024 (3 months) were included in the study. CTA, where available, was processed in real time by both Rapid and Brainomix software. Ground truth on vessel occlusion was ascertained using clinical review of electronic medical records. Occlusion location was coded as intracranial internal carotid artery terminus (ICA-T), middle cerebral artery (MCA) M1 or MCA M2. If more than one occlusion was observed, the most proximal of these was taken as the primary vessel affected. Results: There were 561 suspected stroke patients scanned during the study period across the three sites. Of these, CTA was sent for processing by both Rapid LVO and Brainomix 360 Triage LVO for 359 cases. Cases were excluded if no contrast was detected (n=17), leaving 342 cases (Table 1). Of these, proximal LVO (ICA-T or MCA M1) was confirmed in 14 cases and MCA M2 occlusions were present in 6 cases. Table 2 shows the LVO detection results for all cases from the two software packages. For both devices, sensitivity was higher when considering only proximal occlusions (ICA-T or M1). Performance was similar overall, but there was a trend towards differing sensitivity for more distal occlusions. As a composite measure, area under the curve (AUC) was higher for Brainomix than Rapid (Figure 1) but this difference was not significant. The positive predictive value (PPV) was low for both software packages due to the low incidence of LVO in the patient population. Conclusions: This study demonstrated consistent performance of two AI software devices, Brainomix 360 Triage LVO and Rapid LVO, for detection of LVO on CTA imaging, in prospective, real-world use. The low number of positive cases in the dataset (N=21) is a limitation of the study. There was a trend towards different performance for more distal vessel occlusion locations. Overall, the sensitivity observed in this dataset was in line with reports from previous retrospective studies for both software packages and underlines the importance of prospective evaluation to understand real-world performance.

Background: Stroke is a frequent manifestation of non-bacterial thrombotic endocarditis (NBTE), yet current knowledge largely stems from case reports and small series. This systematic review aimed to comprehensively describe stroke presentation, imaging features, management, and outcomes in NBTE patients. Methods: A comprehensive search of EMBASE, PubMed, MEDLINE, Web of Science and PsycINFO databases was conducted through September 2023. Studies reporting individual cases or case series of NBTE-related stroke were included. Extracted data included demographics, vascular risk factors, stroke presentation, imaging features, NBTE etiology, treatment modalities (unfractionated heparin/low molecular weight heparin (UFH/LMWH), warfarin, direct oral anticoagulants (DOACs), and valvular intervention), stroke recurrence, and mortality. Multivariate regression was performed to identify predictors of recurrent stroke and mortality. Results: A total of 129 patients from 118 studies were included (median age 56 [IQR:44-64], 62% females). Right (28%) and left (26%) hemispheric stroke syndromes accounted for the majority of clinical presentation, and multivessel ischemic infarcts (>2 territories) were observed in 66%. Conventional vascular risk factors were infrequent (1%-21%), while deep vein thrombosis and systemic embolism occurred in 59% and 38% of patients, respectively, either preceding or coinciding with stroke onset. Malignancy and autoimmune diseases were identified in 72% and 22%, respectively. Anticoagulation was initiated in 66% and 21% underwent valvular treatment. Over a median follow-up of 1.3 months, stroke recurrence and death occurred in 48% and 50%, respectively. Malignancy significantly increased mortality risk (OR 16.8, P<0.001), while autoimmune-related NBTE (OR 0.2, P=0.029), and anticoagulation with UFH/LMWH (OR 0.3, P=0.011) and VKA (OR 0.09, P=0.002) reduced mortality. Recurrent stroke was more likely in patients with malignancy (OR 16.8, P=0.001) and those receiving DOACs (OR 6.2, P=0.057) Conclusion: NBTE should be considered in stroke patients lacking conventional risk factors, particularly with underlying malignancy or autoimmune disease. Malignancy and DOAC use may increase the risk of recurrent strokes in this patient population.

Background and Purpose— Intravenous alteplase (tissue-type plasminogen activator) has been shown to be cost-effective because of savings in long-term disability. In October of 2005, an increased DRG payment to hospitals for alteplase-treated stroke patients was introduced. We sought to describe the trends in the cost of alteplase over time, in comparison to trends in hospital reimbursement in the United States. Methods— Using publicly available information on the Centers for Medicare and Medicaid Services (CMS) website ( www.cms.gov ), we obtained CMS quarterly payment amounts between January 1, 2005, and October 1, 2014, for alteplase, listed as alteplase recombinant, per mg. CMS payment amounts are the manufacturer’s average sales price+6% until April 2014, when it was lowered to +4.3%. Estimates for DRG base payments were calculated within the Medicare Provider and Analysis Review (MEDPAR) for fiscal years 2006 (DRG 559) and 2013 (MS DRGs 61, 62, and 63) as (DRG relative weights)×(standardized operating and capital amount). The consumer price index was also queried for all prescription drugs, urban areas, during the same study period as reference. Results— The CMS payment amount for alteplase per milligram was $30.50 in January 2005 and $64.30 in October 2014. Trends in the CMS payment amounts for alteplase increased by 111% between 2005 and 2014. The consumer price index for all prescription drugs increased by 30.2% in the same time frame. The base payment for alteplase-treated stroke admissions was $11 173 in 2006 and $12 064 in 2013, an 8% increase. Conclusions— We found a striking increase in the cost of alteplase over the last decade, with a 100 mg vial now with a CMS payment of ≈$6400, a >100% increase over 10 years. During the same time frame, the DRG base payment to hospitals increased by only 8%, and alteplase cost increased from 27% of the payment in 2006 to 53% in 2013. Researchers and stroke physicians should be aware of these changes in drug costs and their impact on cost-effectiveness analyses.