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Background and Purpose The purpose of this study is to evaluate the frequency and clinical utility of repeat cerebrovascular imaging with computed tomography angiography (CTA) of the head after contrast-enhanced magnetic resonance angiography (CE-MRA) of the head in acute stroke patients. Materials and Methods All stroke patients admitted to 2 academic medical centers from January 1, 2012 through December 31, 2014 were identified as part of prospective radiology database if they underwent CE-MRA of the head followed by subsequent CTA of the head within 7 days. Two vascular neurologists blinded to CTA results retrospectively reviewed medical records including documented indications for imaging studies and clinical changes in patients to determine necessity of CTA. Results Of 1355 acute stroke patients who underwent CE-MRA of the head, 195 (14%) patients underwent subsequent CTA of the head within 7 days, including 33 patients with nondiagnostic CE-MRA because of motion artifact. Of the remaining 162 (12%) patients, 69 (43%) were considered to have an unnecessary CTA of the head. Multivariable logistic regression analysis identified (1) absence of new neurologic examination changes [OR 7.29; 95% CI 1.92-27.63] and (2) same documented indication for both studies [OR 6.47; 95% CI 3.04-13.78] as significant predictors of an unnecessary CTA. Changes in clinical management after CTA were significantly more common in necessary CTAs compared with studies determined to be unnecessary (42% versus 7%, P Conclusion The utility of repeat cerebrovascular imaging with CTA of the head following a diagnostic CE-MRA is low when there is no change in neurologic examination or when ordered for the same indication.

Background: There are limited data on the frequency of repeat non-invasive imaging performed in the evaluation of stroke patients and its utility in patient care. Hypothesis: Stroke patients frequently undergo repeat intracranial arterial imaging with limited change in clinical management. Methods: All stroke patients admitted to a comprehensive stroke center from January 1, 2012 through December 31, 2014 were identified as part of a prospective radiology database if they underwent contrast-enhanced MR angiography (CE-MRA) of the head and subsequent CT angiography (CTA) of the head within 7 days. Two vascular neurologists reviewed medical records to confirm the diagnosis of stroke and subtype, determine the indications of the two studies, evaluate if any neurologic change occurred prompting the subsequent CTA, new findings seen on CTA and identification of any change in clinical management based on the CTA results. Results: Of 1355 stroke patients who underwent CE-MRA of the head during the study period, 195 (14%) patients underwent subsequent CTA within 7 days, including 33 patients who had non-diagnostic CE-MRA due to patient motion. Of the 162 (12%) patients with diagnostic CE-MRA who underwent subsequent CTA head (mean age 59 ± 15 years, 52% female, 61% ischemic stroke, 11% ICH, 28% SAH), 69 (43%) patients were considered to have an unnecessary CTA of the head. In multivariable analysis, factors associated with an unnecessary CTA head included no new neurological exam changes [OR 7.29; 95% CI 1.92 to 27.63] and same documented indication for CE-MRA and CTA [OR 6.47; 95% CI 3.04 to 13.78]. Changes in clinical management after CTA of the head were seen in 42% of patients who had a clinically indicated CTA versus 7% of patients with a CTA considered unnecessary (p Conclusions: Approximately 1 in 8 stroke patients who underwent a diagnostic CE-MRA underwent a subsequent CTA of the head within 7 days and nearly half of these CTA studies were considered unnecessary. The utility of repeat cerebrovascular head imaging with CTA of the head after a diagnostic CE-MRA is low when there is no evidence of a change in neurological exam or when the same indication is documented for both studies.

Background: Early cognitive screening of stroke patients may identify unmet rehabilitative needs during stroke recovery but validated tools are lacking. We report our experience with the Six Item Screener (SIS) compared to the Montreal Cognitive Assessment (MOCA) and attempt to improve upon its shortcomings in stroke patients. Hypothesis: Low sensitivity of the SIS for cognitive impairment (CI) in stroke patients can be improved by incorporating visuoexecutive dimensions. Methods: Patients admitted with ischemic stroke (IS), transient ischemic attack (TIA), intracerebral (ICH) or subarachnoid hemorrhage (SAH) between December 2014 and June 2015 underwent inpatient screening for CI using SIS and MOCA, administered by speech-pathologists if they were alert and not aphasic. Predictive value and sensitivity/specificity cut-offs of SIS for CI (MOCA≤23) were determined. A screening tool, created by adding a clock-drawing task and dropping least important SIS components was developed. Results: Of 110 (IS/TIA: 56, ICH: 17, SAH: 26) patients who had MOCA and SIS performed at the same visit, 79 patients had CI; other patient characteristics including stroke severity, are described (Fig 1A). The AUC of SIS for CI was 0.78 and comparable across stroke types (AUC for IS: 0.81 ICH: 0.79 SAH: 0.95). SIS≤4 had 46.6% sensitivity for CI while SIS≤5 had 72.6% sensitivity and 80.6% specificity for CI. Excluding ‘year’ and ‘month’ questions of the SIS had no effect on the performance of the screening test (AUC=0.78 without). A 7-item tool (CISS) that included the clock drawing task (3 points) and omitted “year/month” SIS questions had excellent predictive power for CI (AUC=0.89) and comparable across stroke types (AUC 0.89-0.93) (Fig 1B,C). CISS≤6 had 94.5% sensitivity and 49.4% specificity for CI. Conclusions: The CISS improves upon the low sensitivity of the SIS for CI in stroke patients. A validation study using 3-month neuropsychological testing as the gold-standard is underway.