Tugas Critical Appraisal

The Use of Neurovascular Ultrasound Versus Digital

Subtraction Angiography in Acute Ischemic Stroke

Dosen Pembimbing :
Prof. Dr. dr. R.M. Suryadi Tjekyan, DTM&H.

Disusun Oleh :
Nama : Dr. M. Haryadi Ade Kurniadi
NIM : 04042711822006

PROGRAM STUDY ILMU PENYAKIT DALAM

RSUP Dr. MOHAMMAD HOESIN PALEMBANG
FAKULTAS KEDOKTERAN UNIVERSITAS SRIWIJAYA
2018
 Critical Appraisal Jurnal Uji Klinik

The use of neurovascular ultrasound versus digital subtraction angiography in acute

ischemic stroke

CRITICAL APPRAISAL WORKSHEET

(1) (2) (3)
Can you find this Is the way this was done a Does this problem threaten
information in the paper ? problem? the validity of the study ?

1. What is the research 1. Is it concerned with

question and/or the impact on an
hypothesis? intervention, No
casuality, or
“The aim of this study is to determining the
com-pare the use of NVUE magnitude of a health
(CVD+TCCS) with the problem? 2. If not, how useful are
gold-standard, digital the results produced
subtraction angiography Yes by this type of study?
(DSA), in diagnosing
significant extracranial “The importance of the “The importance of the
and intracranial NVUE in acute IS is related NVUE in acute IS is related
arteriopathy in acute IS to its capacity to identify the to its capacity to identify the
patients.” site of the clots, predict site of the clots, predict
patient out-come and patient out-come and
evaluate vessel evaluate vessel
2. What is the study recanalization6. The recanalization6. The
identification of tandem identification of tandem
type?
occlusion (ICA + MCA) occlusion (ICA + MCA)
could help in the decision to could help in the decision to
“Diagnostic study”
an interventional therapy an interventional therapy
because intravenous because intravenous
reperfusion treatments reperfusion treatments
demonstrated a low demonstrated a low
3. What is the reference recanalization pattern and a recanalization pattern and a
population? What poor outcome16. poor outcome16.
are the sampling
frame and sampling
methode? 2. Is the study type
appropriate to the 3. Do these threaten the
“The authors research question? internal validity of the
retrospectively evaluated study?
nonconsecutive patients Yes
with IS or TIA admitted to No
 the Emergency Room (The present study
between February 2010 demonstrated that in acute IS
and July 2011. or TIA patients, NVUE has a 4. Does this threaten the
high sensitivity and internal validity of the
Inclusion criteria were: (1) specificity com-pared to
fewer than 12 hours DSA for diagnoses of study?
between the symptoms
significant lesions in the No
onset and hospital
extra-cranial and intracranial
admission; (2) confirmed
symptomatic vessel.
diagnoses of IS or TIA
based on clinical,
neurological and
complementary 3. Is the sampling frame 5. Is measurement error
evaluations; (3) the NVUE appropriate for the an important source
(CVD + TCCS) must have reference population? of bias?
been performed within the Is there selection
first 12 hours of hospital bias? NO
admission;
Yes, the sampling frame is
(4) the presence of a appropriate.
bilateral temporal acoustic (total sampling) 6.
window and a complete a) How
extracranial and intracranial No, there is no bias important are
evaluation. omitted
selection. outcomes?
(5) the DSA exam must b) Is
have been performed within measurement
the first 120 hours of 4. Has bias been error an
hospital admission. DSA introduced? important
evaluation was considered source of
in the current clinical Yes. bias?
practice for the patient
evaluation as the presence of The current study has __
cortical symptoms and/or important limitations. It
non-lacunar lesion and evaluated a small, highly
negative selective group of patients, a
electrocardiography and large number of patients was
ecocardiography; and (6) excluded for incomplete
non-clinical or technical evaluation based on the
contrain-dication for DSA predefined criteria or a delay
evaluation. The hospital in the complementary
ethics committee authorized
method examination. The
this study.
present study selected
patients admitted to a tertiary
hospital within a relatively
4. In an experimental short per-iod of time after
study, how were symptoms onset, and this
subjects assigned to methodology could exclude
group? In a some patients that arrived
longitudinal study later in the hos-pital. Some
patients were submitted to
thrombolysis, and this could
 how many reached influence the findings in both
final follow up? techniques. The DSA was
done only in patients with
“Inclusion criteria were: clinical indication to perform
(1) fewer than 12 hours this methodology, and this
between the symptoms could select more critical
onset and hospital patients to the analysis. In our
admission; (2) confirmed hospital, at the moment of the
diagnoses of IS or TIA study, patients did not have
based on clinical, access to magnetic res-
neurological and onance angiography and
complementary computed tomography 7. Is confounding an
evaluations; (3) the NVUE angiogra-phy to be compared important source of
(CVD + TCCS) must have with DSA. Another bias?
been performed within the important limitation was the
first 12 hours of hospital
delay between procedures __
admission;
(NVUE and DSA), which
(6) the presence of a could increase the number of
bilateral temporal acoustic false positives found by the
window and a complete NVUE due to acute
extracranial and recanalization, a potential
intracranial evaluation; occlusion/stenosis in the
NVUE could represent an
(7) the DSA exam evan-escent stenosis
must have been performed recanalyzed before the DSA.
within the first 120 hours A risk related to this delay
of hospital admission. might be the false negative
DSA evaluation was
result of NVUE, this was
considered in the current
observed only in a P2 PCA
clinical practice for the
stenosis that was not visua-
patient evaluation as the
presence of cortical lized by TCCS.
symptoms and/or non-
lacunar lesion and negative
electrocardiography and
ecocardiography; and (6) 5. Is there measurement
non-clinical or technical error?
contrain-dication for DSA
evaluation. The hospital Yes
ethics committee
authorized this study. In the present study, all false
negative by the CVD were
During the study period, observed in the vertebral
265 patients were admitted
arteries when considering
due to IS or TIA, 165 were
any stenosis/occlusion, but
submitted to NVUE and 81
to DSA. Sixty five (39.3%) this disappeared when
IS or TIA patients considering only the 9. Is the study useful or
underwent both evalua- symptomatic vessel. This is the result
tions, NVUE and DSA, for might be related to the inconclusive?
etiological diagnoses. stenosis criteria to the
From this group, 41 (63%) vertebral disease and the
patients were excluded for lower accu-racy to find the Yes, the study is useful.The
the following rea-sons: 25 vertebral artery by result is conclusive.
(38%) patients were ultrasound14.
submitted to NVUE 24 Result: In conclusion, the
hours after the onset of present study demonstrated
symptoms, eleven (17%) that a standardized NVUE
patients had no temporal evaluation has a high
window or an incomplete sensitivity and specificity
6.
evaluation and five (8%)
a) Are all for diagnosing cervical and
underwent the DSA after intracranial arterial
120 hours. relevant
abnormalities compared to
outcome
DSA. The NVUE protocol
assessed?
should be included in all
b) Is there stroke centers to improve
measurement stroke diagnosis and to
5. What are the study error? identify different prognosis
factors and how are patterns.
they measured? a) Yes, all relevant
outcome are assessed.
The present study
evaluated the sensitivity, b) Yes, there is no
specificity, negative measurement error.
predictive value (NPV),
positive predictive value In the present study, all false 10. Do you accept the
(PPV) and the accuracy of negative by the CVD were results of this study?
NVUE compared to DSA observed in the vertebral
(gold-standard) for arteries when considering Yes, I do.
extracranial and any stenosis/occlusion, but
intracranial evaluation. this disappeared when
The following variables considering only the
were analyzed: mean age, symptomatic vessel. This
gender, the median might be related to the
National Institute of Health stenosis criteria to the
Stroke Scale (NIHSS) on vertebral disease and the
admis-sion, the median lower accu-racy to find the
NIHSS at 24 hours, the vertebral artery by
median modified Rankin 14
ultrasound .
Score (mRS) after seven
days and three months, IS
or TIA etiology based in a
complementary evaluation, 7. Are potential
symp-tomatic stroke side, confounders
arterial stroke topography, controlled?
stroke risk fac-tors, time in
days between NVUE and No
DSA evaluation, the
concordance between
symptomatic NVUE and 8. Were the tests
DSA findings with the appropriate for the
extracranial evaluation, (ii) data? Are confidence
with the intracranial
evaluation, and (iii) with
the combined extracranial intervals given? Is the
and intra-cranial power given?
evaluation
Yes
6. What are the
outcome factors and
9. Was the sample size
how are they
measured? sufficient to detect a
clinically/socially
“Intracranial abnormalities significant result?
were identified when an
increased segmental flow Yes
velocity associated with
retrograde flow, vessel
occlusion signals or
turbulent flow patterns were
observed based on a fast- 10. Do the results apply
track neurovascular to the population in
ultrasound examination1.
which you would be
The flow velocity
measurements in the
interested?
intracranial evaluation were
not cor-rected according to Yes.
the incident angle1,9,10,11.
The stenosis and occlusion
of the extracranial vessels
were based on pre-vious
studies9,12,13,14. All the DSA
exams were performed by
two experienced
neuroradiologists (PCS, RP)
blinded to the NVUE results
and clinical data. The
presence of extracranial
stenosis, occlusion higher
than 50%, or any grade of
intracra-nial stenosis or
occlusion was considered to
be a significant abnormality.

7. What important
potential
confounders are
considered?

There were no potential

confounders.
 8. Are statistical tests
considered?

Yes it was considered

“Statistical analyses were

performed using Epi Info
6.04 software. Statistical
significance was assessed
by the Chi-square test for
categorical variables.
Statistical significance was
set at p , 0.05.

9. Are the results

clinically/socially
important?

Yes

10. What conclusions

did the authors reach
about the research
question? Did they
generate new
hypotheses? Do you
agree with the
conclusions?

“In conclusion, the present

study demonstrated that a
standardized NVUE
evaluation has a high
sensitivity and specificity
for diagnosing cervical and
intracranial arterial
abnormalities compared to
DSA. The NVUE protocol
should be included in all
stroke centers to improve
stroke diagnosis and to
identify different prognosis
patterns”
Yes, I agree with the
conclusions.