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Research ArticleBrain
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The Triple Rule-Out for Acute Ischemic Stroke: Imaging the Brain, Carotid Arteries, Aorta, and Heart

A.D. Furtado, D.D. Adraktas, N. Brasic, S.-C. Cheng, K. Ordovas, W.S. Smith, M.R. Lewin, K. Chun, J.D. Chien, S. Schaeffer and M. Wintermark
American Journal of Neuroradiology August 2010, 31 (7) 1290-1296; DOI: https://doi.org/10.3174/ajnr.A2075
A.D. Furtado
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D.D. Adraktas
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N. Brasic
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S.-C. Cheng
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K. Ordovas
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W.S. Smith
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M.R. Lewin
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K. Chun
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J.D. Chien
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S. Schaeffer
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M. Wintermark
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    Fig 1.

    Stroke CT protocol design. A bolus of 30 cc of contrast was injected into the right or left cubital vein, followed by a 15 cc saline flush, both at an injection rate of 5 cc per second. The first acquisition (1) (not ECG gated) ascends from the aortic arch origin to the vertex of the head, taking place after a delay determined from perfusion CT used as a bolus test, typically 15 seconds. A second bolus (2) of 60 cc of contrast was injected 3 seconds later and followed by a 60 cc saline flush, again at an injection rate of 5 cc per second. The second acquisition descends from the aortic arch origin to the diaphragm and is ECG gated.

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    Fig 2.

    Study participants. One hundred twenty consecutive patients receiving standard-of-care stroke CT evaluation were prospectively enrolled in our study. Five patients were excluded because of CABGs. In 79 patients, both the carotid and cardiac portions of the CTA succeeded. In 36 patients, the carotid portion succeeded, but the cardiac portion failed. Fifteen of these 36 failures were directly related to our protocol, 7 were related to patient size, and 14, to technical issues. The 21 cases in which failure was unrelated to our protocol were excluded, and our image-quality analysis was performed on the remaining 94 patients.

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    Fig 3.

    A, Segment-level analysis of coronary artery image quality. Each coronary artery segment was given an image-quality score (0 = excellent, 1 = good, and 2 = nondiagnostic). The nondiagnostic segments were separated into 3 categories: motion artifacts, poor contrast, and streak artifacts. Those segments that were nondiagnostic due to tiny vessel size, heavy calcification, or pacemaker artifacts were excluded because they were nondiagnostic for reasons not directly related to our protocol. B, Vessel-level analysis of coronary artery image quality. A coronary artery was considered excellent if the entire artery was diagnostic, good if 1 or 2 segments were diagnostic, and nondiagnostic if no segments were diagnostic. Those segments that were nondiagnostic for reasons unrelated to our protocol (ie, tiny vessel size, heavy calcification, or pacemaker artifacts) were omitted from this analysis. C, Patient-level analysis of coronary artery image quality. Cardiac examinations that were 75%–100% diagnostic were considered excellent, cardiac examinations that were 50%–74% diagnostic were considered good, and cardiac examinations that were 0%–49% diagnostic were considered failed. Most patients (65%, n = 61) had cardiac examinations that were 75%–100% diagnostic. Nondiagnostic segments in the failed cases were primarily due to motion artifacts.

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American Journal of Neuroradiology: 31 (7)
American Journal of Neuroradiology
Vol. 31, Issue 7
1 Aug 2010
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A.D. Furtado, D.D. Adraktas, N. Brasic, S.-C. Cheng, K. Ordovas, W.S. Smith, M.R. Lewin, K. Chun, J.D. Chien, S. Schaeffer, M. Wintermark
The Triple Rule-Out for Acute Ischemic Stroke: Imaging the Brain, Carotid Arteries, Aorta, and Heart
American Journal of Neuroradiology Aug 2010, 31 (7) 1290-1296; DOI: 10.3174/ajnr.A2075

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The Triple Rule-Out for Acute Ischemic Stroke: Imaging the Brain, Carotid Arteries, Aorta, and Heart
A.D. Furtado, D.D. Adraktas, N. Brasic, S.-C. Cheng, K. Ordovas, W.S. Smith, M.R. Lewin, K. Chun, J.D. Chien, S. Schaeffer, M. Wintermark
American Journal of Neuroradiology Aug 2010, 31 (7) 1290-1296; DOI: 10.3174/ajnr.A2075
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