Abstract Body: Introduction: Emerging technologies, such as Cone-Beam CT (CBCT), may improve workflows in acute ischemic stroke (AIS). Direct-to-angiography workflow relies on CBCT to exclude intracranial hemorrhage (ICH) to determine treatment eligibility for intravenous thrombolysis (IVT) and/or mechanical thrombectomy (MT). Prior studies evaluated CBCT for ICH detection using small, selected cohorts and variable diagnostic metrics yielding a wide range of sensitivity and specificity values. Our purpose was to synthesize available evidence to determine the diagnostic accuracy of CBCT for ICH detection, with particular focus on specific hemorrhage types: intraparenchymal (IPH), subarachnoid (SAH), and intraventricular (IVH).
Methods: We performed a systematic review and meta-analysis following the Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) guidelines. Our protocol was registered with the International Prospective Register of Systematic Reviews (PROSPERO). Systematic searches were last performed on April 1, 2024 in EMBASE, PubMed, Web-of-Science, Scopus, and CINAHL databases. Inclusion criteria: (1) Studies reporting diagnostic metrics of CBCT for ICH; (2) Studies using a reference standard to determine ICH. Exclusion criteria: (1) Case reports, abstracts, and reviews; (2) Studies without patient-level data. Pooled estimates and 95% confidence intervals (CI) were calculated for the Log diagnostic Odds ratio (DOR), sensitivity, and specificity for ICH and hemorrhage types using random-effects and common-effects models.
Results: Seven studies were included in the meta-analysis yielding 466 patients (Fig 1). Pooled Log DOR, sensitivity, and specificity (95%CI) for ICH were 5.28 (4.11,6.46), 0.88 (0.79,0.97), and 0.99 (0.98,1.0), respectively (Fig 2,3). Pooled sensitivity (95%CI) for IPH, SAH, and IVH were 0.98 (0.95,1.0), 0.82 (0.57,1.0), and 0.78 (0.55,1.0). Pooled specificity (95%CI) for IPH, SAH, and IVH were 0.99 (0.98,1.0), 0.99 (0.97,1.0), and 1.0 (0.98,1.0).
Conclusion: CBCT had high specificity for ICH and hemorrhage types. However, sensitivity was lower and varied with the highest sensitivity for IPH followed by SAH and IVH. These findings indicate that CBCT may be reliable for exclusion of ICH in determining MT eligibility in AIS patients who are not IVT candidates. However, the high false-negatives of CBCT for SAH and IVH requires caution for IVT decision-making, where missing a small hemorrhage could result in devastating outcomes.