Early detection of small volume stroke and thromboembolic sources with computed tomography: Rationale and design of the ENCLOSE study

Frans Kauw, Fasco van Ommen, Edwin Bennink, Maarten J Cramer, L Jaap Kappelle, Richard Ap Takx, Birgitta K Velthuis, Max A Viergever, H Wouter van Es, Wouter J Schonewille, Jonathan M Coutinho, Charles Blm Majoie, Henk A Marquering, Hugo Wam de Jong, Jan W Dankbaar, Frans Kauw, Fasco van Ommen, Edwin Bennink, Maarten J Cramer, L Jaap Kappelle, Richard Ap Takx, Birgitta K Velthuis, Max A Viergever, H Wouter van Es, Wouter J Schonewille, Jonathan M Coutinho, Charles Blm Majoie, Henk A Marquering, Hugo Wam de Jong, Jan W Dankbaar

Abstract

Background: Computed tomography is the most frequently used imaging modality in acute stroke imaging protocols. Detection of small volume infarcts in the brain and cardioembolic sources of stroke is difficult with current computed tomography protocols. Furthermore, the role of computed tomography findings to predict recurrent ischemic stroke is unclear. With ENCLOSE, we aim to improve (1) the detection of small volume infarcts with thin slice computed tomography perfusion (CTP) images and thromboembolic source with cardiac computed tomography techniques in the acute stage of ischemic stroke and (2) prediction of recurrent ischemic stroke with computed tomography-derived predictors.Methods/design: ENCLOSE is a prospective multicenter observational cohort study, which will be conducted in three Dutch stroke centers (ClinicalTrials.gov Identifier: NCT04019483). Patients (≥18 years) with suspected acute ischemic stroke who undergo computed tomography imaging within 9 h after symptom onset are eligible. Computed tomography imaging includes non-contrast CT, CTP, and computed tomography angiography (CTA) from base of the heart to the top of the brain. Dual-energy CT data will be acquired when possible, and thin-slice CTP reconstructions will be obtained in addition to standard 5 mm CTP data. CTP data will be processed with commercially available software and locally developed model-based methods. The post-processed thin-slice CTP images will be compared to the standard CTP images and to magnetic resonance diffusion-weighted imaging performed within 48 h after admission. Detection of cardioembolic sources of stroke will be evaluated on the CTA images. Recurrence will be evaluated 90 days and two years after the index event. The added value of imaging findings to prognostic models for recurrent ischemic stroke will be evaluated.

Conclusion: The aim of ENCLOSE is to improve early detection of small volume stroke and thromboembolic sources and to improve prediction of recurrence in patients with acute ischemic stroke.

Keywords: Acute ischemic stroke; cardiac thrombus; computed tomography; detection; lacunar stroke; magnetic resonance imaging; prediction model; recurrent stroke.

Conflict of interest statement

Declaration of Conflicting Interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

© European Stroke Organisation 2020.

Figures

Figure 1.
Figure 1.
Flowchart of patient selection, study procedures, and outcome evaluations. Distal occlusion on admission CTA is defined as an occlusion distal to the A2 segment of the anterior cerebral artery, distal to the M1–M2 bifurcation of the middle cerebral artery, or an occlusion of the posterior circulation excluding basilar and vertebral artery occlusions. CT: computed tomography; MRI: magnetic resonance imaging; A2: A2 segment of anterior cerebral artery; M1–M2: junction between M1 and M2 segments of the middle cerebral artery; CTA: computed tomography angiography; FLAIR: fluid-attenuated inversion recovery; DWI: diffusion-weighted imaging; MRA: magnetic resonance angiography; SNAP: simultaneous non-contrast angiography and intraplaque hemorrhage.

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