Stroke Clinical Trial
Official title:
Feasibility and Reliability of Pulmonary Computed Tomography as a Radiological Reference Standard for Evaluating Chest X-ray and Candidate Biomarkers in Suspected Pneumonia Complicating Stroke
Pneumonia commonly complicates stroke and has a profound impact on clinical outcomes.
Accurate and timely diagnosis of pneumonia complicating stroke remains a major challenge as
several issues potentially confound diagnosis. Chest X-ray (CXR), a central component in the
diagnostic work-up, may have limited utility in the early stages as they are often of
suboptimal quality, and infrequently confirm typical diagnostic infiltrates. Blood biomarkers
of the stress-immune response have received considerable attention, but interpretation has
been limited by differing methodologies, including definition of pneumonia. Bacterial
organisms in the oral cavity may also be of relevance as biomarkers of post-stroke pneumonia.
Major challenges facing frontline clinicians are therefore whether to initiate antibiotics;
if so, when and for how long. These issues have antibiotic stewardship implications for
clinicians in terms of potential for under-treatment or over-treatment with antibiotics based
on CXR appearances.
Pulmonary Computed Tomography (CT) could be of value as a radiological reference standard
when pneumonia is suspected after stroke, and enable more rigorous evaluation of the
diagnostic performance of CXR (and other candidate biomarkers) to inform decision-making when
pneumonia is suspected.
The overall primary aim is therefore to investigate the feasibility and reliability of using
pulmonary CT as a radiological reference standard for evaluating suspected pneumonia
complicating stroke. The secondary aims are to explore the diagnostic accuracy of CXR and
blood biomarkers (index tests) when pneumonia is suspected during hospital admission after
stroke using pulmonary CT as a reference standard.
Pneumonia is a frequent complication of stroke, particularly within the first few days. The
risk of pneumonia is increased in patients who are older, have a more severe stroke and in
those who have swallowing problems as a result of their stroke. Patients who develop
pneumonia have a higher risk of death and longer hospital stay. The diagnosis of pneumonia is
not always easy, but it is important to identify pneumonia early in order to begin the most
appropriate treatment in a timely fashion and avoid giving antibiotics unnecessarily. Chest
x-ray, the standard test undertaken when pneumonia is suspected, infrequently shows changes
and is of limited value.
Pulmonary Computed Tomography (CT) scans can be used to image the lungs in more detail than a
standard chest xray. The Investigators plan to assess if it is feasible to perform pulmonary
CT imaging in stroke patients within 48 hours of symptoms and who may be acutely unwell. The
Investigators will also investigate how reliable CT is at diagnosing pneumonia by asking
different x-ray doctors to review the scans. Comparing the result of the pulmonary CT imaging
to the chest x-ray will allow assessment of their utility for the diagnosis of pneumonia. The
Investigators will also record whether the CT informs clinical management e.g. stopping
antibiotics if pneumonia is excluded.
Blood samples will be collected for measurement of inflammatory markers and mouth swabs will
measure types of bacteria. The analysis will be conducted at Salford Royal NHS Foundation
Trust (SRFT) and using new cutting-edge techniques performed by collaborators at ThermoFisher
and Manchester Collaborative Centre for Inflammation Research. The Investigators will assess
how useful these inflammatory proteins are in pneumonia diagnosis compared to the pulmonary
CT scans. This research will help the Investigating team design larger studies to diagnose
pneumonia earlier and more accurately, enabling more effective use of antibiotics.
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