Admission CT perfusion may overestimate initial infarct core: the ghost infarct core concept

2016 ◽  
Vol 9 (1) ◽  
pp. 66-69 ◽  
Author(s):  
Sandra Boned ◽  
Marina Padroni ◽  
Marta Rubiera ◽  
Alejandro Tomasello ◽  
Pilar Coscojuela ◽  
...  
Keyword(s):  
Cerebral Blood Volume ◽  
Time Window ◽  
Ct Perfusion ◽  
Early Time ◽  
Infarct Core ◽  
Vessel Occlusion ◽  
Endovascular Thrombectomy ◽  
Adjusted Logistic Regression ◽  
Contrast Ct

BackgroundIdentifying infarct core on admission is essential to establish the amount of salvageable tissue and indicate reperfusion therapies. Infarct core is established on CT perfusion (CTP) as the severely hypoperfused area, however the correlation between hypoperfusion and infarct core may be time-dependent as it is not a direct indicator of tissue damage. This study aims to characterize those cases in which the admission core lesion on CTP does not reflect an infarct on follow-up imaging.MethodsWe studied patients with cerebral large vessel occlusion who underwent CTP on admission but received endovascular thrombectomy based on a non-contrast CT Alberta Stroke Program Early CT Score (ASPECTS) >6. Admission infarct core was measured on initial cerebral blood volume (CBV) CTP and final infarct on follow-up CT. We defined ghost infarct core (GIC) as initial core minus final infarct >10 mL.Results79 patients were studied. Median National Institutes of Health Stroke Scale (NIHSS) score was 17 (11–20), median time from symptoms to CTP was 215 (87–327) min, and recanalization rate (TICI 2b–3) was 77%. Thirty patients (38%) presented with a GIC >10 mL. GIC >10 mL was associated with recanalization (TICI 2b–3: 90% vs 68%; p=0.026), admission glycemia (<185 mg/dL: 42% vs 0%; p=0.028), and time to CTP (<185 min: 51% vs >185 min: 26%; p=0.033). An adjusted logistic regression model identified time from symptom to CTP imaging <185 min as the only predictor of GIC >10 mL (OR 2.89, 95% CI 1.04 to 8.09). At 24 hours, clinical improvement was more frequent in patients with GIC >10 mL (66.6% vs 39%; p=0.017).ConclusionsCT perfusion may overestimate final infarct core, especially in the early time window. Selecting patients for reperfusion therapies based on the CTP mismatch concept may deny treatment to patients who might still benefit from reperfusion.

scholarly journals Ghost Infarct Core and Admission Computed Tomography Perfusion: Redefining the Role of Neuroimaging in Acute Ischemic Stroke

2018 ◽  
Vol 7 (6) ◽  
pp. 513-521 ◽  
Author(s):  
Nuno Martins ◽  
Ana Aires ◽  
Beatriz Mendez ◽  
Sandra Boned ◽  
Marta Rubiera ◽  
...  
Keyword(s):  
Computed Tomography ◽  
Cerebral Blood Volume ◽  
Time Window ◽  
Infarct Volume ◽  
Early Time ◽  
Infarct Core ◽  
Computed Tomography Perfusion ◽  
Noncontrast Ct ◽  
Adjusted Logistic Regression ◽  
Core Volume

Background: Determining the size of infarct extent is crucial to elect patients for reperfusion therapies. Computed tomography perfusion (CTP) based on cerebral blood volume may overestimate infarct core on admission and consequently include ghost infarct core (GIC) in a definitive lesional area. Purpose: Our goal was to confirm and better characterize the GIC phenomenon using CTP cerebral blood flow (CBF) as the reference parameter to determine infarct core. Methods: We performed a retrospective, single-center analysis of consecutive thrombectomies of middle cerebral or intracranial internal carotid artery occlusions considering noncontrast CT Alberta Stroke Program Early CT Score ≥6 in patients with pretreatment CTP. We used the RAPID® software to measure admission infarct core based on initial CBF. The final infarct was extracted from follow-up CT. GIC was defined as initial core minus final infarct > 10 mL. Results: A total of 123 patients were included. The median National Institutes of Health Stroke Scale score was 18 (13–20), the median time from symptoms to CTP was 188 (67–288) min, and the recanalization rate (Thrombolysis in Cerebral Infarction score 2b, 2c, or 3) was 83%. Twenty patients (16%) presented with GIC. GIC was associated with shorter time to recanalization (150 [105–291] vs. 255 [163–367] min, p = 0.05) and larger initial CBF core volume (38 [26–59] vs. 6 [0–27] mL, p < 0.001). An adjusted logistic regression model identified time to recanalization < 302 min (OR 4.598, 95% CI 1.143–18.495, p = 0.032) and initial infarct volume (OR 1.01, 95% CI 1.001–1.019, p = 0.032) as independent predictors of GIC. At 24 h, clinical improvement was more frequent in patients with GIC (80 vs. 49%, p = 0.01). Conclusions: CTP CBF < 30% may overestimate infarct core volume, especially in patients imaged in the very early time window and with fast complete reperfusion. Therefore, the CTP CBF technique may exclude patients who would benefit from endovascular treatment.

Abstract WMP23: Likelihood of Undergoing Endovascular Stroke Therapy in Centers With High vs Low Utilization of CT Perfusion Imaging

Stroke ◽  
2020 ◽  
Vol 51 (Suppl_1) ◽  
Author(s):  
Songmi Lee ◽  
Victor Lopez-Rivera ◽  
James Fan ◽  
Sean I Savitz ◽  
Albert J Yoo ◽  
...  
Keyword(s):  
Logistic Regression ◽  
Ct Perfusion ◽  
Stroke Therapy ◽  
Infarct Core ◽  
Vessel Occlusion ◽  
Ct Perfusion Imaging ◽  
Adjusted Logistic Regression ◽  
Contrast Ct ◽  
Time Of Presentation ◽  
Endovascular Stroke Therapy

Introduction: CT Perfusion (CTP) is frequently used to evaluate patients with large vessel occlusion (LVO) acute ischemic stroke (AIS) for possible endovascular stroke therapy (EST). However, the accuracy of its infarct core and penumbral predictions are uncertain, and as such, may rule out patients who would otherwise have received EST without CTP-based selection. Methods: From our prospectively maintained multicenter registry, we identified AIS patients between January 2018 and February 2019. Data were collected from 4 comprehensive stroke centers - one center often performs CTP on nearly all AIS evaluations (CTP-H) and 3 centers perform CTP for uncertain findings on non-contrast CT (CTP-L). All 4 CSCs are covered by a single group of Vascular Neurologists and NeuroInterventionists with standardization of quality practices. Logistic regression adjusted for age, NIHSS, CT ASPECTS as ordinal variables, time of presentation (0-6 hrs. vs 6-24 hrs.), and occlusion location was used to assess the likelihood of undergoing EST. Results are provided as median [IQR] and OR [95% CI]. Results: Among 2,317 patients with AIS, median age was 67 [57-78], 48% were female and 48% were white. The CTP rates at the 3 CTP-L centers were 18%, 31%, and 36%, while CTP rate at CTP-H center was 74% among all AIS patients (p<0.0001). 309 (43%) patients with LVO presented to CTP-L centers and 404 (57%) to the CTP-H center. For LVO patients presenting at CTP-L centers, median age was 70 [60-80], 52% were female, and 42% were white, while at CTP-H center median age was 68 [59-78], 44% were female and 57% were white. ASPECTS scores (CTP-L 9 [7-10] vs CTP-H 8 [6-9], p>0.05) and proportion of ICA/MCA occlusions (72% vs 77%; p>0.05), were comparable among centers, but LVO patients presenting at CTP-L centers had a lower NIHSS (11[4-18] vs 14[7-20]; p<0.01). For patients presenting 0-6 hrs, a higher number presented at the CTP-H center (20% vs 27%; p<0.05). In adjusted logistic regression, patients presenting with LVO to the CTP-H center were less likely to undergo EST (OR 0.51 [0.29-0.89]; p<0.05). Conclusion: In this study of 4 CSCs staffed by the same group of physicians, routine utilization of CTP in EST patient selection was associated with reduced likelihood of EST in patients with LVO.

scholarly journals Mobile Interventional Stroke Teams Improve Outcomes in the Early Time Window for Large Vessel Occlusion Stroke

Stroke ◽  
2021 ◽  
Author(s):  
Jacob R. Morey ◽  
Xiangnan Zhang ◽  
Naoum Fares Marayati ◽  
Stavros Matsoukas ◽  
Emily Fiano ◽  
...  
Keyword(s):  
Scale Score ◽  
Time Window ◽  
Early Time ◽  
National Institutes Of Health ◽  
Large Vessel ◽  
Late Time ◽  
Modified Rankin Scale ◽  
Large Vessel Occlusion ◽  
Vessel Occlusion ◽  
Endovascular Thrombectomy

Background and Purpose: Endovascular thrombectomy for large vessel occlusion stroke is a time-sensitive intervention. The use of a Mobile Interventional Stroke Team (MIST) traveling to Thrombectomy Capable Stroke Centers to perform endovascular thrombectomy has been shown to be significantly faster with improved discharge outcomes, as compared with the drip-and-ship (DS) model. The effect of the MIST model stratified by time of presentation has yet to be studied. We hypothesize that patients who present in the early window (last known well of ≤6 hours) will have better clinical outcomes in the MIST model. Methods: The NYC MIST Trial and a prospectively collected stroke database were assessed for patients undergoing endovascular thrombectomy from January 2017 to February 2020. Patients presenting in early and late time windows were analyzed separately. The primary end point was the proportion with a good outcome (modified Rankin Scale score of 0–2) at 90 days. Secondary end points included discharge National Institutes of Health Stroke Scale and modified Rankin Scale. Results: Among 561 cases, 226 patients fit inclusion criteria and were categorized into MIST and DS cohorts. Exclusion criteria included a baseline modified Rankin Scale score of >2, inpatient status, or fluctuating exams. In the early window, 54% (40/74) had a good 90-day outcome in the MIST model, as compared with 28% (24/86) in the DS model ( P <0.01). In the late window, outcomes were similar (35% versus 41%; P =0.77). The median National Institutes of Health Stroke Scale at discharge was 5.0 and 12.0 in the early window ( P <0.01) and 5.0 and 11.0 in the late window ( P =0.11) in the MIST and DS models, respectively. The early window discharge modified Rankin Scale was significantly better in the MIST model ( P <0.01) and similar in the late window ( P =0.41). Conclusions: The MIST model in the early time window results in better 90-day outcomes compared with the DS model. This may be due to the MIST capturing high-risk fast progressors at an earlier time point. REGISTRATION: URL: https://www.clinicaltrials.gov ; Unique identifier: NCT03048292.

Abstract WP57: Acute Carotid Stenting Following Intracranial Thrombectomy Has Comparable Safety and Efficacy in Early versus Late Time Window Stroke

Stroke ◽  
2020 ◽  
Vol 51 (Suppl_1) ◽  
Author(s):  
Amer Mitchelle ◽  
Fiona S Lau ◽  
Andrew Cheung ◽  
Jason Wenderoth ◽  
Alexander McQuinn ◽  
...  
Keyword(s):  
Symptom Onset ◽  
Time Window ◽  
Time Windows ◽  
Early Time ◽  
Carotid Stenting ◽  
Late Time ◽  
Extracranial Internal Carotid Artery ◽  
Anterior Circulation ◽  
Endovascular Thrombectomy

Introduction: Endovascular thrombectomy (EVT) is beneficial in late time window stroke. However, patients with tandem extracranial carotid and intracranial occlusions are under-represented in previous trials. We analysed our acute anterior circulation strokes with tandem occlusions treated with EVT and extracranial internal carotid artery stenting. Methods: A prospectively maintained database of EVT patients treated in two Australian comprehensive stroke centres between January 2016 and May 2019 was screened for acute anterior circulation ischaemic stroke patients treated with EVT and extracranial internal carotid artery stenting. The cohort was divided into patients treated in early ( < 6 hours from symptom onset) and late (>6 hours from symptom onset) time windows. Results: Endovascular thrombectomy with acute carotid stenting was performed in 96 patients (mean age 71years, 78.3% male, mean time to reperfusion 13.5 +/- 10.1 hours, median NIHSS 15). Treatment >6hours after symptom onset occurred in 61 (63.5%) patients. No significant difference was seen between the two groups with respect to age, sex, presenting NIHSS, or mTICI score. At 90-day follow-up, good functional outcome (mRS 0-2) was similar for patients treated in the late versus early time windows, 19 (54.3%) vs 34 (55.7%), p=0.89 respectively. No difference was seen for symptomatic intracranial haemorrhage, 5 (7.2%) vs 3 (8.1%) p=0.87, or mortality at 90-day follow-up, 15 (24.6%) vs 6 (17.1%) p=0.40. Conclusion: Carotid stenting in late time window has comparable safety and efficacy to early time window stroke.

scholarly journals MRI software for diffusion-perfusion mismatch analysis may impact on patients’ selection and clinical outcome

2021 ◽  
Author(s):  
Silvia Pistocchi ◽  
Davide Strambo ◽  
Bruno Bartolini ◽  
Philippe Maeder ◽  
Reto Meuli ◽  
...  
Keyword(s):  
Clinical Outcome ◽  
Time Window ◽  
Early Time ◽  
Functional Independence ◽  
Late Time ◽  
Anterior Circulation ◽  
Vessel Occlusion ◽  
Endovascular Thrombectomy ◽  
Automated Method ◽  
Key Points

Abstract Objective Impact of different MR perfusion software on selection and outcome of patients with acute ischemic stroke (AIS) and large vessel occlusion (LVO) treated by endovascular thrombectomy (EVT) is unclear. We aimed at comparing two commercial MRI software, semi-automated with unadjusted (method A) and adjusted mask (method B), and fully automated (method C) in this setting. Methods MRI from 144 consecutive AIS patients with anterior circulation LVO was retrospectively analysed. All diffusion- and perfusion-weighted images (DWI-PWI) were post-processed with the three methods using standard thresholds. Concordance for core and hypoperfusion volumes was assessed with Lin’s test. Clinical outcome was compared between groups in patients who underwent successful EVT in the early and late time window. Results Mean core volume was higher and mean hypoperfusion volume was lower in method C than in methods A and B. In the early time window, methods A and B found fewer patients with a mismatch ratio ≤ 1.2 than method C (1/67 [1.5%] vs. 12/67 [17.9%], p = 0.0013). In the late time window, methods A and B found fewer patients with a mismatch ratio < 1.8 than method C (3/46 [6.5%] and 2/46 [4.3%] vs. 18/46 [39.1%], p ≤ 0.0002). More patients with functional independence at 3 months would not have been treated using method C versus methods A and B in the early (p = 0.0063) and late (p ≤ 0.011) time window. Conclusions MRI software for DWI-PWI analysis may influence patients’ selection before EVT and clinical outcome. Key Points • Method C detects fewer patients with favourable mismatch profile. • Method C might underselect more patients with functional independence at 3 months. • Software used before thrombectomy may influence patients’ outcome.

scholarly journals Non-contrast dual-energy CT virtual ischemia maps accurately estimate ischemic core size in large-vessel occlusive stroke

2021 ◽  
Vol 11 (1) ◽  
Author(s):  
Dylan N. Wolman ◽  
Fasco van Ommen ◽  
Elizabeth Tong ◽  
Frans Kauw ◽  
Jan Willem Dankbaar ◽  
...  
Keyword(s):  
Primary Outcome ◽  
Ct Perfusion ◽  
Primary Outcome Measure ◽  
Dual Energy ◽  
Large Vessel ◽  
Dual Energy Ct ◽  
Vessel Occlusion ◽  
Ischemic Core ◽  
Contrast Ct

AbstractDual-energy CT (DECT) material decomposition techniques may better detect edema within cerebral infarcts than conventional non-contrast CT (NCCT). This study compared if Virtual Ischemia Maps (VIM) derived from non-contrast DECT of patients with acute ischemic stroke due to large-vessel occlusion (AIS-LVO) are superior to NCCT for ischemic core estimation, compared against reference-standard DWI-MRI. Only patients whose baseline ischemic core was most likely to remain stable on follow-up MRI were included, defined as those with excellent post-thrombectomy revascularization or no perfusion mismatch. Twenty-four consecutive AIS-LVO patients with baseline non-contrast DECT, CT perfusion (CTP), and DWI-MRI were analyzed. The primary outcome measure was agreement between volumetric manually segmented VIM, NCCT, and automatically segmented CTP estimates of the ischemic core relative to manually segmented DWI volumes. Volume agreement was assessed using Bland–Altman plots and comparison of CT to DWI volume ratios. DWI volumes were better approximated by VIM than NCCT (VIM/DWI ratio 0.68 ± 0.35 vs. NCCT/DWI ratio 0.34 ± 0.35; P < 0.001) or CTP (CTP/DWI ratio 0.45 ± 0.67; P < 0.001), and VIM best correlated with DWI (rVIM = 0.90; rNCCT = 0.75; rCTP = 0.77; P < 0.001). Bland–Altman analyses indicated significantly greater agreement between DWI and VIM than NCCT core volumes (mean bias 0.60 [95%AI 0.39–0.82] vs. 0.20 [95%AI 0.11–0.30]). We conclude that DECT VIM estimates the ischemic core in AIS-LVO patients more accurately than NCCT.

Endovascular treatment beyond 24 hours from the onset of acute ischemic stroke: the Italian Registry of Endovascular Thrombectomy in Acute Stroke (IRETAS)

2021 ◽  
pp. neurintsurg-2021-018045
Author(s):  
Ilaria Casetta ◽  
Enrico Fainardi ◽  
Giovanni Pracucci ◽  
Valentina Saia ◽  
Stefano Vallone ◽  
...  
Keyword(s):  
Acute Stroke ◽  
Ct Perfusion ◽  
Case Fatality ◽  
Functional Independence ◽  
Primary Outcome Measure ◽  
Stroke Patients ◽  
Infarct Core ◽  
Endovascular Thrombectomy ◽  
Symptomatic Intracranial Hemorrhage ◽  
Contrast Ct

BackgroundClinical trials and observational studies have demonstrated the benefit of thrombectomy up to 16 or 24 hours after the patient was last known to be well. This study aimed to evaluate the outcome of stroke patients treated beyond 24 hours from onset.MethodsWe analyzed the outcome of 34 stroke patients (mean age 70.7±12.3 years; median National Institutes of Health Stroke Scale (NIHSS) score 13) treated with endovascular thrombectomy beyond 24 hours from onset who were recruited in the Italian Registry of Endovascular Thrombectomy in Acute Stroke. Selection criteria for patients were: pre-stroke modified Rankin scale (mRS) score of ≤2, non-contrast CT Alberta Stroke Program Early CT score of ≥6, good collaterals on single phase CT angiography (CTA) or multiphase CTA, and CT perfusion mismatch with an infarct core size ≤50% of the total hypoperfusion extent or involving less than one-third of the extent of the middle cerebral artery territory evaluated by visual inspection. The primary outcome measure was functional independence assessed by the mRS at 90 days after onset. Safety outcomes were 90 day mortality and the occurrence of symptomatic intracranial hemorrhage (sICH).ResultsSuccessful recanalization (Thrombolysis in Cerebral Infarction score of 2b or 3) was present in 76.5% of patients. Three month functional independence (mRS score 0–2) was observed in 41.1% of patients. The case fatality rate was 26.5%. and the incidence of sICH was 8.8%.ConclusionsThese findings suggest that, in a real world setting, very late endovascular therapy is feasible in appropriately selected patients.

Abstract TP68: Predictive Value of CT Perfusion in Hyper Acute Ischemic Stroke Patients

Stroke ◽  
2020 ◽  
Vol 51 (Suppl_1) ◽  
Author(s):  
Varun Kumar Pala ◽  
Rahul Chandra ◽  
Aaron Ravelo ◽  
Christopher Hackett ◽  
Russell Cerejo
Keyword(s):  
Perfusion Imaging ◽  
Symptom Onset ◽  
Time Window ◽  
Ct Perfusion ◽  
Infarct Volume ◽  
Early Time ◽  
Imaging Data ◽  
Anterior Circulation ◽  
Vessel Occlusion ◽  
Core Volume

Introduction: Perfusion imaging has been an integral part in patient selection for Endovascular Thrombectomy (EVT) in the extended window. In studies evaluating perfusion imaging in the early window, the mean time from symptom onset to perfusion imaging was greater than 90 minutes. Objective: To determine the accuracy of perfusion imaging core volume compared to final infarct volume in patients presenting in the hyper acute period. Methods: We performed a retrospective analysis on a prospectively collected stroke data base from January 2018 to July 2019. We included patients with intracranial large vessel occlusion (anterior circulation) who presented within 90 minutes of symptom onset and underwent perfusion imaging with CT-perfusion (CT-P) with subsequent EVT. We collected demographics, clinical and imaging data as well as procedural variables. Final infarct volume on CTH or MRI brain (done> 24hr post EVT) was calculated manually using PACS volume analysis software. RAPID CT-P Software was used for core measurement and CBF<30% was used to predict core. Results: Out of 242 patients who underwent EVT, 22 (9%) patients met inclusion criteria. Of these, 32% (7/22) were males and 68 %( 15/22) were females. Median age was 79 yrs (interquartile range (IQR) 66.7 - 85.2) and median NIHSS was 16 (IQR 14 - 21). M1 occlusion was seen in 59% while, 27% had ICA terminus occlusion and 14% had proximal M2 occlusion. Median core volume pre EVT was 14.5ml (IQR 6.7 - 36.7) and final median infarct volume was 9.6ml (IQR 1.2 - 24.3). Most patients, had final infarct volume calculated on MRI 73 %( 16/22) while 27% (6/22) had follow up CTH. CT- P overestimated the final stroke volume in 55% (12/22 patients) of patients. In a subgroup of 5 patients who presented within 60 minutes of symptoms onset, 80% (4/5 patients) had an over estimated core on CT-P with a median predicted core of 29 ml (IQR 13 - 35) and median final infarct volume of 0.2ml (IQR 0.1 - 3.7). Conclusion: CT-P using CBF < 30% may overestimate the core infarct volume in patients presented in the hyper acute window (<90min). Caution is advised when utilizing CTP in the early time window.

Abstract WP69: Does CBF Below 30% Actually Represent Infarct Core in Acute Ischemic Stroke? Proof of Mis-Concept

Stroke ◽  
2020 ◽  
Vol 51 (Suppl_1) ◽  
Author(s):  
Marta Rubiera ◽  
Alvaro Garcia-Tornel ◽  
Ludovico Ciolli ◽  
Marta Olive ◽  
Alejandro Tomasello ◽  
...  
Keyword(s):  
Functional Outcome ◽  
Ct Perfusion ◽  
Infarct Volume ◽  
Time Windows ◽  
Early Time ◽  
Exclusion Criterion ◽  
Infarct Core ◽  
Hemodynamic State ◽  
Contrast Ct ◽  
Over Time

On CT perfusion (CTP), cerebral blood flow < 30% than the contralateral hemisphere (CBF<30) is considered a marker of infarct core. Our hypothesis is that CBF<30 defines a reversible poor hemodynamic area rather than core and aimed to study CBF<30 evolution over time, its relationship with leptomeningeal collateral circulation (CC) and outcome parameters. Methods: Retrospective analysis of a prospective database of acute ischemic strokes who underwent CTP on admission and immediately after endovascular thrombectomy (EVT). CC was graded on CT angiography (CTA) by the modified Tan scale (good CC: 2-3 grades). Complete recanalization was defined by modified Thrombolysis in Cerebral Ischemia ≥ 2B. Final infarct volume (FIV) was semi-automatically measured on 48-72h CT; ghost core was defined as: admission CBF<30 - FIV > 10cc. Results: We included 494 patients; median time from onset to CT: 137 min (IQR 68-238). Median CBF<30 volume on admission: 8 cc (0-28). With longer onset-to-CT times ischemic changes progressively increased on non-contrast CT (ASPECTS decay r=-0.21, p<0.01), however CBF<30 progressively decreased (r=-0.13, p<0.01). 294 patients (60.6%) presented good CC. Good CC was associated with lower admission CBF<30 (median CBF<30 on good CC: 0 cc (0-12) vs 28.5 (7-57) on poor CC, p<0.01). In recanalized patients (419, 84.8%), CBF<30 virtually disappeared in CTP post-EVT (n=103) (median CBF<30: 0ml (IQR 0) (88%= 0 cc) despite that most patients developed established infarcts (median FIV 16 (4-50), 59% FIV>10cc)). Even in recanalized patients, baseline CBF<30 only moderately correlates with FIV (r=0.55, p<0.01). A ghost core was identified in 13.7% (34.5% if CT was performed <90min from onset). 46.6% patients had good functional outcome (mRS<3 at 3 months). A multivariate analysis of recanalized patients showed that CC (OR 0.43, CI 0.27-0.69, p<0.01) but not CBF<30 was an independent predictor of functional outcome. Conclusion: CBF<30 represents an hemodynamic state rather than established infarct core, evolving over time inversely as it should physiologically (increase of infarct core over time). CBF<30 should be considered as an outcome predictor but not used as exclusion criterion for EVT, especially in early time-windows.

scholarly journals Novel selection paradigms for endovascular stroke treatment in the extended time window

2021 ◽  
pp. jnnp-2020-325284
Author(s):  
Mehdi Bouslama ◽  
Diogo C Haussen ◽  
Gabriel Rodrigues ◽  
Clara Barreira ◽  
Michael Frankel ◽  
...  
Keyword(s):  
Time Window ◽  
Ct Perfusion ◽  
Clinical Aspects ◽  
Anterior Circulation ◽  
Stroke Treatment ◽  
Good Outcome ◽  
Potential Alternative ◽  
The Right ◽  
Contrast Ct ◽  
Selection Methodology

Background and purposeThe optimal selection methodology for stroke thrombectomy beyond 6 hours remains to be established.MethodsReview of a prospectively collected database of thrombectomy patients with anterior circulation strokes, adequate CT perfusion (CTP) maps, National Institute of Health Stroke Scale (NIHSS)≥10 and presenting beyond 6 hours from January 2014 to October 2018. Patients were categorised according to five selection paradigms: DAWN clinical-core mismatch (DAWN-CCM): between age-adjusted NIHSS and CTP core, DEFUSE 3 perfusion imaging mismatch (DEFUSE-3-PIM): between CTP-derived perfusion defect (Tmax >6 s lesion) and ischaemic core volumes and three non-contrast CT Alberta Stroke Program Early CT Score (ASPECTS)-based criteria: age-adjusted clinical-ASPECTS mismatch (aCAM): between age-adjusted NIHSS and ASPECTS, eloquence-adjusted clinical ASPECTS mismatch (eCAM): ASPECTS 6–10 and non-involvement of the right M6 and left M4 areas and standard clinical ASPECTS mismatch (sCAM): ASPECTS 6–10.Results310 patients underwent analysis. DEFUSE-3-PIM had the highest proportion of qualifying patients followed by sCAM, eCAM, aCAM and DAWN-CCM (93.5%, 92.6%, 90.6%, 90% and 84.5%, respectively). Patients meeting aCAM, eCAM, sCAM and DAWN-CCM criteria had higher rates of 90-day good outcome compared with their non-qualifying counterparts(43.2% vs 12%,p=0.002; 42.4% vs 17.4%, p=0.02; 42.4% vs 11.2%, p=0.009; and 43.7% vs 20.5%, p=0.007, respectively). There was no difference between patients meeting DEFUSE-3-PIM criteria versus not(40.8% vs 31.3%,p=0.45). In multivariate analysis, all selection modalities except for DEFUSE-3-PIM were independently associated with 90-day good outcome.ConclusionsASPECTS-based selection paradigms for late presenting and wake-up strokes ET have comparable proportions of qualifying patients and similar 90-day functional outcomes as DAWN-CCM and DEFUSE-3-PIM. They also might lead to better outcome discrimination. These could represent a potential alternative for centres where access to advanced imaging is limited.

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