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Wrona P, Wróbel D, Mizera P, Jóźwik J, Jakobschy K, Zdrojewska K, Homa T, Sawczyńska K, Popiela T, Słowik A, Turaj W. The benefit of optimizing recanalization during mechanical thrombectomy in patients with acute ischemic stroke depends on preprocedural tissue-level collateralization. Neuroradiology 2024:10.1007/s00234-024-03443-7. [PMID: 39153089 DOI: 10.1007/s00234-024-03443-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2024] [Accepted: 08/09/2024] [Indexed: 08/19/2024]
Abstract
PURPOSE Thrombolysis in Cerebral Infarction (TICI) 3 represents the optimal angiographic outcome following mechanical thrombectomy (MT) for acute ischemic stroke (AIS). Although it is known to yield better outcomes than TICI 2b, the influence of preprocedural cerebral hemodynamics on the clinical advantage of TICI 3 over TICI 2b remains unexplored. METHODS This single-center retrospective analysis involved patients with anterior circulation AIS who underwent successful recanalization during MT at the Comprehensive Stroke Center, University Hospital, Krakow between January 2019 and July 2023. We assessed the benefit of achieving TICI 2c/3 over TICI 2b on the basis of preprocedural computed perfusion imaging results, primarily focusing on early infarct volume (EIV) and tissue-level collaterals indicated by hypoperfusion intensity ratio (HIR). Good functional outcome (GFO) was defined as a modified Rankin Score < 3 on day 90. RESULTS The study comprised 612 patients, of whom 467 (76.3%) achieved TICI 2c/3. GFO was more frequent in the TICI 2c/3 group (54.5% vs 69.4%, p < 0.001). There was interaction between the recanalization status and both HIR (Pi = 0.042) and EIV (Pi = 0.012) in predicting GFO, with disproportionately higher impact of HIR and EIV in TICI 2b group. The benefit from TICI 2c/3 over TICI 2b was insignificant among patients with good collaterals, defined by HIR < 0.3 (odds ratio:1.36 [0.58-3.18], p = 0.483). CONCLUSION TICI 2c/3 improves patient functional outcomes compared to TICI 2b regardless of EIV. However, such angiographic improvement may be clinically futile in patients with good tissue-level collateralization. Our findings suggest that preprocedural HIR should be considered when optimization of recanalization is considered during MT.
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Affiliation(s)
- Paweł Wrona
- Department of Neurology, Jagiellonian University Medical College, Krakow, Poland
- Department of Neurology, University Hospital, Krakow, Poland
| | - Dominik Wróbel
- Faculty of Medicine, Student Scientific Group in Cerebrovascular Diseases, Jagiellonian University Medical College, Sw Anny 12 Street, Krakow, Poland.
| | - Paweł Mizera
- Faculty of Medicine, Student Scientific Group in Cerebrovascular Diseases, Jagiellonian University Medical College, Sw Anny 12 Street, Krakow, Poland
| | - Joanna Jóźwik
- Faculty of Medicine, Student Scientific Group in Cerebrovascular Diseases, Jagiellonian University Medical College, Sw Anny 12 Street, Krakow, Poland
| | - Klaudia Jakobschy
- Faculty of Medicine, Student Scientific Group in Cerebrovascular Diseases, Jagiellonian University Medical College, Sw Anny 12 Street, Krakow, Poland
| | - Kaja Zdrojewska
- Faculty of Medicine, Student Scientific Group in Cerebrovascular Diseases, Jagiellonian University Medical College, Sw Anny 12 Street, Krakow, Poland
| | - Tomasz Homa
- Department of Neurology, University Hospital, Krakow, Poland
| | - Katarzyna Sawczyńska
- Department of Neurology, Jagiellonian University Medical College, Krakow, Poland
- Department of Neurology, University Hospital, Krakow, Poland
| | - Tadeusz Popiela
- Department of Radiology, University Hospital, Krakow, Poland
- Department of Radiology, Jagiellonian University Medical College, Krakow, Poland
| | - Agnieszka Słowik
- Department of Neurology, Jagiellonian University Medical College, Krakow, Poland
- Department of Neurology, University Hospital, Krakow, Poland
| | - Wojciech Turaj
- Department of Neurology, Jagiellonian University Medical College, Krakow, Poland
- Department of Neurology, University Hospital, Krakow, Poland
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Rau A, Reisert M, Taschner CA, Demerath T, Elsheikh S, Frank B, Köhrmann M, Urbach H, Kellner E. Reducing False-Positives in CT Perfusion Infarct Core Segmentation Using Contralateral Local Normalization. AJNR Am J Neuroradiol 2024; 45:277-283. [PMID: 38302197 DOI: 10.3174/ajnr.a8111] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2023] [Accepted: 11/20/2023] [Indexed: 02/03/2024]
Abstract
BACKGROUND AND PURPOSE The established global threshold of rCBF <30% for infarct core segmentation can lead to false-positives, as it does not account for the differences in blood flow between GM and WM and patient-individual factors, such as microangiopathy. To mitigate this problem, we suggest normalizing each voxel not only with a global reference value (ie, the median value of normally perfused tissue) but also with its local contralateral counterpart. MATERIALS AND METHODS We retrospectively enrolled 2830 CTP scans with suspected ischemic stroke, of which 335 showed obvious signs of microangiopathy. In addition to the conventional, global normalization, a local normalization was performed by dividing the rCBF maps with their mirrored and smoothed counterpart, which sets each voxel value in relation to the contralateral counterpart, intrinsically accounting for GM and WM differences and symmetric patient individual microangiopathy. Maps were visually assessed and core volumes were calculated for both methods. RESULTS Cases with obvious microangiopathy showed a strong reduction in false-positives by using local normalization (mean 14.7 mL versus mean 3.7 mL in cases with and without microangiopathy). On average, core volumes were slightly smaller, indicating an improved segmentation that was more robust against naturally low blood flow values in the deep WM. CONCLUSIONS The proposed method of local normalization can reduce overestimation of the infarct core, especially in the deep WM and in cases with obvious microangiopathy. False-positives in CTP infarct core segmentation might lead to less-than-optimal therapy decisions when not correctly interpreted. The proposed method might help mitigate this problem.
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Affiliation(s)
- Alexander Rau
- From the Department of Neuroradiology (A.R., C.A.T., T.D., S.E., H.U.), Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
- Department of Diagnostic and Interventional Radiology (A.R.), Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Marco Reisert
- Medical Physics, Department of Diagnostic and Interventional Radiology (M.R., E.K.), Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
- Department of Stereotactic and Functional Neurosurgery (M.R.), Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Christian A Taschner
- From the Department of Neuroradiology (A.R., C.A.T., T.D., S.E., H.U.), Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Theo Demerath
- From the Department of Neuroradiology (A.R., C.A.T., T.D., S.E., H.U.), Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Samer Elsheikh
- From the Department of Neuroradiology (A.R., C.A.T., T.D., S.E., H.U.), Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Benedikt Frank
- Department of Neurology and Center for Translational Neuro- and Behavioral Sciences (B.F., M.K.), University Hospital Essen, Essen, Germany
| | - Martin Köhrmann
- Department of Neurology and Center for Translational Neuro- and Behavioral Sciences (B.F., M.K.), University Hospital Essen, Essen, Germany
| | - Horst Urbach
- From the Department of Neuroradiology (A.R., C.A.T., T.D., S.E., H.U.), Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Elias Kellner
- Medical Physics, Department of Diagnostic and Interventional Radiology (M.R., E.K.), Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
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Ballout AA, Oh SY, Huang B, Patsalides A, Libman RB. Ghost infarct core: A systematic review of the frequency, magnitude, and variables of CT perfusion overestimation. J Neuroimaging 2023; 33:716-724. [PMID: 37248074 DOI: 10.1111/jon.13127] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2023] [Revised: 05/16/2023] [Accepted: 05/18/2023] [Indexed: 05/31/2023] Open
Abstract
BACKGROUND AND PURPOSE CT perfusion (CTP) imaging is now widely used to select patients with large vessel occlusions for mechanical thrombectomy. Ghost infarct core (GIC) phenomenon has been coined to describe CTP core overestimation and has been investigated in several retrospective studies. Our aim is to review the frequency, magnitude, and variables associated with this phenomenon. METHODS A primary literature search resulted in eight studies documenting median time from symptom onset to CTP, median estimated core size, median final infarct volume, median core overestimation of the GIC population, recanalization rates, good outcomes, and collateral status for this systematic review. RESULTS All the studies investigated patients who underwent CTP within 6 hours of symptom onset, ranging from median times of 105 to 309 minutes. The frequency of core overestimation varied from 6% to 58.4%, while the median estimated ischemic core and final infarction volume ranged from 7 to 27 mL and 12 to 31 mL, respectively. The median core overestimation ranged from 3.6 to 30 mL with upper quartile ranges up to 58 mL. GIC was found to be a highly time-and-collateral-dependent process that increases in frequency and magnitude as the time from symptom onset to imaging decreases and in the presence of poor collaterals. CONCLUSIONS CTP ischemic core overestimation appears to be a relatively common phenomenon that is most frequent in patients with poor collaterals imaged within the acute time window. Early perfusion imaging should be interpreted with caution to prevent the inadvertent exclusion of patients from highly effective reperfusion therapies.
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Affiliation(s)
- Ahmad A Ballout
- Department of Neurology, Zucker School of Medicine at Hofstra/Northwell, Manhasset, New York, USA
| | - Seok Yoon Oh
- Department of Neurology, Zucker School of Medicine at Hofstra/Northwell, Manhasset, New York, USA
| | - Brendan Huang
- Department of Neurology, Zucker School of Medicine at Hofstra/Northwell, Manhasset, New York, USA
| | - Athos Patsalides
- Department of Neurosurgery, Zucker School of Medicine at Hofstra/Northwell, Manhasset, New York, USA
| | - Richard B Libman
- Department of Neurology, Zucker School of Medicine at Hofstra/Northwell, Manhasset, New York, USA
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Doheim MF, Hagrass AI, Elrefaey M, Al-Bayati AR, Bhatt NR, Lang M, Starr M, Rocha M, Gross B, Nogueira RG. From therapeutic nihilism to armamentarium: A meta-analysis of randomized clinical trials assessing safety and efficacy of endovascular therapy for acute large ischemic strokes. Interv Neuroradiol 2023:15910199231170681. [PMID: 37082795 DOI: 10.1177/15910199231170681] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/22/2023] Open
Abstract
BACKGROUND Three recent randomized clinical trials (RCTs) investigated the potential benefit of endovascular therapy (EVT) in acute ischemic stroke patients presenting with large infarcts. We aimed to confirm the safety and efficacy of EVT in patients presenting with large infarcts and provide more precise estimations of the treatment effects using study-level meta-analysis. METHODS Comprehensive search of MEDLINE database through PubMed till February 2023 was performed including RCTs only. The data were then extracted from the selected studies and pooled as risk ratio (RR) with 95% confidence interval (95% CI). RESULTS There were a total of 1005 patients across the three qualifying RCTs. Regarding the functional outcomes assessed by modified Rankin Scale (mRS) score, the analyzed data demonstrated statistically significant differences in favor of thrombectomy for both independent ambulatory status (mRS 0-3: RR = 1.78, 95% CI [1.28, 2.48], p = 0.0006) and functional independence (mRS 0-2: RR = 2.54, 95% CI [1.85, 3.48], p < 0.001). The analyzed data did not demonstrate any statistically significant differences between EVT and medical management alone in terms of 90-day mortality (RR = 0.95, 95% CI [0.78, 1.16], p = 0.61), symptomatic intracranial hemorrhage (RR = 1.83, 95% CI [0.95, 3.55], p = 0.07), and need for hemicraniectomy (RR = 1.22, 95% CI [0.43, 3.41], p = 0.71). CONCLUSION This study confirms the benefit of EVT on functional outcomes of patients presenting with large ischemic infarcts without significant differences in the rates of symptomatic intracranial hemorrhage, hemicraniectomy, or 90-day mortality.
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Affiliation(s)
- Mohamed F Doheim
- Department of Neurology, UPMC Stroke Institute, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | | | - Mohamed Elrefaey
- Department of Neurology, State University of New York Upstate Medical University, Syracuse, NY, USA
| | - Alhamza R Al-Bayati
- Department of Neurology, UPMC Stroke Institute, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Nirav R Bhatt
- Department of Neurology, UPMC Stroke Institute, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Michael Lang
- Department of Neurology, UPMC Stroke Institute, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
- Department of Neurosurgery, UPMC Stroke Institute, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Matthew Starr
- Department of Neurology, UPMC Stroke Institute, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Marcelo Rocha
- Department of Neurology, UPMC Stroke Institute, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Bradley Gross
- Department of Neurology, UPMC Stroke Institute, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
- Department of Neurosurgery, UPMC Stroke Institute, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Raul G Nogueira
- Department of Neurology, UPMC Stroke Institute, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
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Predictors of ghost infarct core on baseline computed tomography perfusion in stroke patients with successful recanalization after mechanical thrombectomy. Eur Radiol 2023; 33:1792-1800. [PMID: 36282310 DOI: 10.1007/s00330-022-09189-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Revised: 09/13/2022] [Accepted: 09/19/2022] [Indexed: 11/04/2022]
Abstract
OBJECTIVES To assess the predictors of ghost infarct core (GIC) in stroke patients achieving successful recanalization after mechanical thrombectomy (MT), based on final infarct volume (FIV) calculated from follow-up diffusion-weighted imaging (DWI). METHODS A total of 115 consecutive stroke patients who had undergone baseline computed tomography perfusion (CTP) scan, achieved successful recanalization after MT, and finished follow-up DWI evaluation were retrospectively enrolled. Ischemic core volume was automatically generated from baseline CTP, and FIV was determined manually based on follow-up DWI. Stroke-related risk factors and demographic, clinical, imaging, and procedural data were collected and assessed. Univariate and multivariate analyses were applied to identify the predictors of GIC. RESULTS Of the 115 included patients (31 women and 84 men; median age, 66 years), 18 patients (15.7%) showed a GIC. The GIC group showed significantly shorter time interval from stroke onset to CTP scan and that from stroke onset to recanalization (both p < 0.001), but higher ischemic core volume (p < 0.001), hypoperfused area volume (p < 0.001), mismatch area volume (p = 0.006), and hypoperfusion ratio (p = 0.001) than the no-GIC group. In multivariate analysis, time interval from stroke onset to CTP scan (odds ratio [OR], 0.983; p = 0.005) and ischemic core volume (OR, 1.073; p < 0.001) were independently associated with the occurrence of GIC. CONCLUSIONS In stroke patients achieving successful recanalization after MT, time interval from stroke onset to CTP and ischemic core volume are associated with the occurrence of GIC. Patients cannot be excluded from MT solely based on baseline CTP-derived ischemic core volume, especially for patients with a shorter onset time. KEY POINTS • Ghost infarct core (GIC) was found in 15.7% of patients with acute ischemic stroke (AIS) in our study cohort. • GIC was associated with stroke onset time, volumetric parameters derived from CTP, and collateral status indicated by HIR. • Time interval from stroke onset to CTP scan and ischemic core volume were independent predictors of GIC.
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Garcia-Tornel Garcia-Camba A, Ribo M. Reader Response: Accuracy of CT Perfusion-Based Core Estimation of Follow-up Infarction: Effects of Time Since Last Known Well. Neurology 2022; 99:632-633. [PMID: 36192184 DOI: 10.1212/wnl.0000000000201279] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2022] [Accepted: 08/05/2022] [Indexed: 11/15/2022] Open
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Kremenova K, Lukavsky J, Holesta M, Peisker T, Lauer D, Weichet J, Malikova H. CT Brain Perfusion in the Prediction of Final Infarct Volume: A Prospective Study of Different Software Settings for Acute Ischemic Core Calculation. Diagnostics (Basel) 2022; 12:diagnostics12102290. [PMID: 36291979 PMCID: PMC9601142 DOI: 10.3390/diagnostics12102290] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2022] [Revised: 09/14/2022] [Accepted: 09/19/2022] [Indexed: 11/16/2022] Open
Abstract
CT perfusion (CTP) is used for the evaluation of brain tissue viability in patients with acute ischemic stroke (AIS). We studied the accuracy of three different syngo.via software (SW) settings for acute ischemic core estimation in predicting the final infarct volume (FIV). The ischemic core was defined as follows: Setting A: an area with cerebral blood flow (CBF) < 30% compared to the contralateral healthy hemisphere. Setting B: CBF < 20% compared to contralateral hemisphere. Setting C: area of cerebral blood volume (CBV) < 1.2 mL/100 mL. We studied 47 AIS patients (aged 68 ± 11.2 years) with large vessel occlusion in the anterior circulation, treated in the early time window (up to 6 h), who underwent technically successful endovascular thrombectomy (EVT). FIV was measured on MRI performed 24 ± 2 h after EVT. In general, all three settings correlated with each other; however, the absolute agreement between acute ischemic core volume on CTP and FIV on MRI was poor; intraclass correlation for all three settings was between 0.64 and 0.69, root mean square error of the individual observations was between 58.9 and 66.0. Our results suggest that using CTP syngo.via SW for prediction of FIV in AIS patients in the early time window is not appropriate.
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Affiliation(s)
- Karin Kremenova
- Radiology Department, Third Faculty of Medicine, Charles University, Faculty Hospital Kralovske Vinohrady, 100 34 Prague, Czech Republic
- Correspondence:
| | - Jiri Lukavsky
- Institute of Psychology, Czech Academy of Sciences, 110 00 Prague, Czech Republic
| | - Michal Holesta
- Radiology Department, Third Faculty of Medicine, Charles University, Faculty Hospital Kralovske Vinohrady, 100 34 Prague, Czech Republic
| | - Tomas Peisker
- Neurology Department, Third Faculty of Medicine, Charles University, Faculty Hospital Kralovske Vinohrady, 100 34 Prague, Czech Republic
| | - David Lauer
- Neurology Department, Third Faculty of Medicine, Charles University, Faculty Hospital Kralovske Vinohrady, 100 34 Prague, Czech Republic
| | - Jiri Weichet
- Radiology Department, Third Faculty of Medicine, Charles University, Faculty Hospital Kralovske Vinohrady, 100 34 Prague, Czech Republic
| | - Hana Malikova
- Radiology Department, Third Faculty of Medicine, Charles University, Faculty Hospital Kralovske Vinohrady, 100 34 Prague, Czech Republic
- Institute of Anatomy, Second Faculty of Medicine, Charles University, 150 00 Prague, Czech Republic
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Abrams K, Dabus G. Perfusion Scotoma: A Potential Core Underestimation in CT Perfusion in the Delayed Time Window in Patients with Acute Ischemic Stroke. AJNR Am J Neuroradiol 2022; 43:813-816. [PMID: 35618426 DOI: 10.3174/ajnr.a7524] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Accepted: 04/07/2022] [Indexed: 11/07/2022]
Abstract
With the growing rise in utilization of CT perfusion for selecting patients for thrombectomy in acute ischemic stroke from large vessel occlusion, some potential pitfalls are becoming more commonly seen particularly when it comes to estimating the core infarct size on CT perfusion. Ghost infarct core has been described to account for overestimating core infarct size in the early time period (<3 hours). Herein, we describe the phenomenon of underestimating core infarct size on CT perfusion in the later time period (>6 hours), which we have termed perfusion scotoma.
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Affiliation(s)
- K Abrams
- From the Department of Radiology (K.A.), Baptist Hospital of Miami, Miami Neuroscience Institute, Miami, Florida
| | - G Dabus
- Department of Neuroendovascular Surgery (G.D.), Miami Cardiac and Vascular Institute, Miami Neuroscience Institute, Miami, Florida
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Carrera E, Baron JC. Patient Selection for Thrombectomy Using Brain Imaging: Does Time Still Matter? Neurology 2022; 98:867-868. [PMID: 35450965 DOI: 10.1212/wnl.0000000000200719] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Affiliation(s)
- Emmanuel Carrera
- From the Stroke Center, Department of Clinical Neurosciences (E.C.), Geneva University Hospital; Faculty of Medicine (E.C.), Geneva, Switzerland; Department of Neurology (J.-C.B.), Hôpital Sainte-Anne and Université de Paris; INSERM U1266 (J.-C.B.), Institut de Psychiatrie et Neurosciences de Paris, France
| | - Jean-Claude Baron
- From the Stroke Center, Department of Clinical Neurosciences (E.C.), Geneva University Hospital; Faculty of Medicine (E.C.), Geneva, Switzerland; Department of Neurology (J.-C.B.), Hôpital Sainte-Anne and Université de Paris; INSERM U1266 (J.-C.B.), Institut de Psychiatrie et Neurosciences de Paris, France
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Sarraj A, Campbell BCV, Christensen S, Sitton CW, Khanpara S, Riascos RF, Pujara D, Shaker F, Sharma G, Lansberg MG, Albers GW. Accuracy of CT Perfusion-Based Core Estimation of Follow-up Infarction: Effects of Time Since Last Known Well. Neurology 2022; 98:e2084-e2096. [PMID: 35450966 PMCID: PMC9169942 DOI: 10.1212/wnl.0000000000200269] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2021] [Accepted: 02/08/2022] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND AND OBJECTIVES To assess the accuracy of baseline CT perfusion (CTP) ischemic core estimates. METHODS From SELECT (Optimizing Patient Selection for Endovascular Treatment in Acute Ischemic Stroke), a prospective multicenter cohort study of imaging selection, patients undergoing endovascular thrombectomy who achieved complete reperfusion (modified Thrombolysis In Cerebral Ischemia score 3) and had follow-up diffusion-weighted imaging (DWI) available were evaluated. Follow-up DWI lesions were coregistered to baseline CTP. The difference between baseline CTP core (relative cerebral blood flow [rCBF] <30%) volume and follow-up infarct volume was classified as overestimation (core ≥10 mL larger than infarct), adequate, or underestimation (core ≥25 mL smaller than infarct) and spatial overlap was evaluated. RESULTS Of 101 included patients, median time from last known well (LKW) to imaging acquisition was 138 (82-244) minutes. The median baseline ischemic core estimate was 9 (0-31.9) mL and median follow-up infarct volume was 18.4 (5.3-68.7) mL. All 6/101 (6%) patients with overestimation of the subsequent infarct volume were imaged within 90 minutes of LKW and achieved rapid reperfusion (within 120 minutes of CTP). Using rCBF <20% threshold to estimate ischemic core in patients presenting within 90 minutes eliminated overestimation. Volumetric correlation between the ischemic core estimate and follow-up imaging improved as LKW time to imaging acquisition increased: Spearman ρ <90 minutes 0.33 (p = 0.049), 90-270 minutes 0.63 (p < 0.0001), >270 minutes 0.86 (p < 0.0001). Assessment of the spatial overlap between baseline CTP ischemic core lesion and follow-up infarct demonstrated that a median of 3.2 (0.0-9.0) mL of estimated core fell outside the subsequent infarct. These regions were predominantly in white matter. DISCUSSION Significant overestimation of irreversibly injured ischemic core volume was rare, was only observed in patients who presented within 90 minutes of LKW and achieved reperfusion within 120 minutes of CTP acquisition, and occurred primarily in white matter. Use of a more conservative (rCBF <20%) threshold for estimating ischemic core in patients presenting within 90 minutes eliminated all significant overestimation cases. TRIAL REGISTRATION INFORMATION ClinicalTrials.gov: NCT03876457.
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Affiliation(s)
- Amrou Sarraj
- From the Department of Neurology (A.S.), Case Western Reserve University-University Hospitals Cleveland Medical Center, OH; Department of Neurology (B.C.V.C., G.S.), The Royal Melbourne Hospital, University of Melbourne, Parkville, Australia; Department of Neurology (S.C., M.G.L., G.W.A.), Stanford University Medical Center, CA; Departments of Diagnostic and Interventional Imaging (C.W.S., S.K., R.F.R.) and Neurology (F.S.), UTHealth McGovern Medical School, Houston, TX; and Department of Neurology (D.P.), University Hospitals Cleveland Medical Center, OH
| | - Bruce C V Campbell
- From the Department of Neurology (A.S.), Case Western Reserve University-University Hospitals Cleveland Medical Center, OH; Department of Neurology (B.C.V.C., G.S.), The Royal Melbourne Hospital, University of Melbourne, Parkville, Australia; Department of Neurology (S.C., M.G.L., G.W.A.), Stanford University Medical Center, CA; Departments of Diagnostic and Interventional Imaging (C.W.S., S.K., R.F.R.) and Neurology (F.S.), UTHealth McGovern Medical School, Houston, TX; and Department of Neurology (D.P.), University Hospitals Cleveland Medical Center, OH
| | - Soren Christensen
- From the Department of Neurology (A.S.), Case Western Reserve University-University Hospitals Cleveland Medical Center, OH; Department of Neurology (B.C.V.C., G.S.), The Royal Melbourne Hospital, University of Melbourne, Parkville, Australia; Department of Neurology (S.C., M.G.L., G.W.A.), Stanford University Medical Center, CA; Departments of Diagnostic and Interventional Imaging (C.W.S., S.K., R.F.R.) and Neurology (F.S.), UTHealth McGovern Medical School, Houston, TX; and Department of Neurology (D.P.), University Hospitals Cleveland Medical Center, OH
| | - Clark W Sitton
- From the Department of Neurology (A.S.), Case Western Reserve University-University Hospitals Cleveland Medical Center, OH; Department of Neurology (B.C.V.C., G.S.), The Royal Melbourne Hospital, University of Melbourne, Parkville, Australia; Department of Neurology (S.C., M.G.L., G.W.A.), Stanford University Medical Center, CA; Departments of Diagnostic and Interventional Imaging (C.W.S., S.K., R.F.R.) and Neurology (F.S.), UTHealth McGovern Medical School, Houston, TX; and Department of Neurology (D.P.), University Hospitals Cleveland Medical Center, OH
| | - Shekhar Khanpara
- From the Department of Neurology (A.S.), Case Western Reserve University-University Hospitals Cleveland Medical Center, OH; Department of Neurology (B.C.V.C., G.S.), The Royal Melbourne Hospital, University of Melbourne, Parkville, Australia; Department of Neurology (S.C., M.G.L., G.W.A.), Stanford University Medical Center, CA; Departments of Diagnostic and Interventional Imaging (C.W.S., S.K., R.F.R.) and Neurology (F.S.), UTHealth McGovern Medical School, Houston, TX; and Department of Neurology (D.P.), University Hospitals Cleveland Medical Center, OH
| | - Roy F Riascos
- From the Department of Neurology (A.S.), Case Western Reserve University-University Hospitals Cleveland Medical Center, OH; Department of Neurology (B.C.V.C., G.S.), The Royal Melbourne Hospital, University of Melbourne, Parkville, Australia; Department of Neurology (S.C., M.G.L., G.W.A.), Stanford University Medical Center, CA; Departments of Diagnostic and Interventional Imaging (C.W.S., S.K., R.F.R.) and Neurology (F.S.), UTHealth McGovern Medical School, Houston, TX; and Department of Neurology (D.P.), University Hospitals Cleveland Medical Center, OH
| | - Deep Pujara
- From the Department of Neurology (A.S.), Case Western Reserve University-University Hospitals Cleveland Medical Center, OH; Department of Neurology (B.C.V.C., G.S.), The Royal Melbourne Hospital, University of Melbourne, Parkville, Australia; Department of Neurology (S.C., M.G.L., G.W.A.), Stanford University Medical Center, CA; Departments of Diagnostic and Interventional Imaging (C.W.S., S.K., R.F.R.) and Neurology (F.S.), UTHealth McGovern Medical School, Houston, TX; and Department of Neurology (D.P.), University Hospitals Cleveland Medical Center, OH
| | - Faris Shaker
- From the Department of Neurology (A.S.), Case Western Reserve University-University Hospitals Cleveland Medical Center, OH; Department of Neurology (B.C.V.C., G.S.), The Royal Melbourne Hospital, University of Melbourne, Parkville, Australia; Department of Neurology (S.C., M.G.L., G.W.A.), Stanford University Medical Center, CA; Departments of Diagnostic and Interventional Imaging (C.W.S., S.K., R.F.R.) and Neurology (F.S.), UTHealth McGovern Medical School, Houston, TX; and Department of Neurology (D.P.), University Hospitals Cleveland Medical Center, OH
| | - Gagan Sharma
- From the Department of Neurology (A.S.), Case Western Reserve University-University Hospitals Cleveland Medical Center, OH; Department of Neurology (B.C.V.C., G.S.), The Royal Melbourne Hospital, University of Melbourne, Parkville, Australia; Department of Neurology (S.C., M.G.L., G.W.A.), Stanford University Medical Center, CA; Departments of Diagnostic and Interventional Imaging (C.W.S., S.K., R.F.R.) and Neurology (F.S.), UTHealth McGovern Medical School, Houston, TX; and Department of Neurology (D.P.), University Hospitals Cleveland Medical Center, OH
| | - Maarten G Lansberg
- From the Department of Neurology (A.S.), Case Western Reserve University-University Hospitals Cleveland Medical Center, OH; Department of Neurology (B.C.V.C., G.S.), The Royal Melbourne Hospital, University of Melbourne, Parkville, Australia; Department of Neurology (S.C., M.G.L., G.W.A.), Stanford University Medical Center, CA; Departments of Diagnostic and Interventional Imaging (C.W.S., S.K., R.F.R.) and Neurology (F.S.), UTHealth McGovern Medical School, Houston, TX; and Department of Neurology (D.P.), University Hospitals Cleveland Medical Center, OH
| | - Gregory W Albers
- From the Department of Neurology (A.S.), Case Western Reserve University-University Hospitals Cleveland Medical Center, OH; Department of Neurology (B.C.V.C., G.S.), The Royal Melbourne Hospital, University of Melbourne, Parkville, Australia; Department of Neurology (S.C., M.G.L., G.W.A.), Stanford University Medical Center, CA; Departments of Diagnostic and Interventional Imaging (C.W.S., S.K., R.F.R.) and Neurology (F.S.), UTHealth McGovern Medical School, Houston, TX; and Department of Neurology (D.P.), University Hospitals Cleveland Medical Center, OH
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