Optimal thresholds for ischemic penumbra predicted by computed tomography perfusion in patients with acute ischemic stroke treated with mechanical thrombectomy

2017 ◽  
Vol 10 (3) ◽  
pp. 279-284 ◽  
Author(s):  
Katsuharu Kameda ◽  
Junji Uno ◽  
Ryosuke Otsuji ◽  
Nice Ren ◽  
Shintaro Nagaoka ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Cerebral Blood Volume ◽  
Mechanical Thrombectomy ◽  
Ct Perfusion ◽  
Characteristic Curve ◽  
Mean Transit Time ◽  
Area Under The Curve ◽  
Ischemic Penumbra ◽  
Optimal Thresholds

Background and purposeOptimal thresholds for ischemic penumbra detected by CT perfusion (CTP) in patients with acute ischemic stroke (AIS) have not been elucidated. In this study we investigated optimal thresholds for salvageable ischemic penumbra and the risk of hemorrhagic transformation (HT).MethodsA total of 156 consecutive patients with AIS treated with mechanical thrombectomy (MT) at our hospital were enrolled. Absolute (a) and relative (r) CTP parameters including cerebral blood flow (aCBF and rCBF), cerebral blood volume (aCBV and rCBV), and mean transit time (aMTT and rMTT) were evaluated for their value in detecting ischemic penumbra in each of seven arbitrary regions of interest defined by the major supplying blood vessel. Optimal thresholds were calculated by performing receiver operating characteristic curve analysis in 47 patients who achieved Thrombolysis In Cerebral Infarction (TICI) grade 3 recanalization. The risk of HT after MT was evaluated in 101 patients who achieved TICI grade 2b–3 recanalization.ResultsAbsolute CTP parameters for distinguishing ischemic penumbra from ischemic core were as follows: aCBF, 27.8 mL/100 g/min (area under the curve 0.82); aCBV, 2.1 mL/100 g (0.75); and aMTT, 7.30 s (0.70). Relative CTP parameters were as follows: rCBF, 0.62 (0.81); rCBV, 0.83 (0.87); and rMTT, 1.61 (0.73). CBF was significantly lower in areas of HT than in areas of infarction (aCBF, p<0.01; rCBF, p<0.001).ConclusionsCTP may be able to predict treatable ischemic penumbra and the risk of HT after MT in patients with AIS.

Abstract TP245: Prediction of Hemorrhagic Transformation in Patients With Acute Ischaemic Stroke and Atrial Fibrillation With Ct Perfusion Aspects Scores

Stroke ◽  
2017 ◽  
Vol 48 (suppl_1) ◽  
Author(s):  
Qiaoshu Wang ◽  
Yanyan Cao ◽  
Yongbo Zhao ◽  
Louis Caplan
Keyword(s):  
Atrial Fibrillation ◽  
Ischemic Stroke ◽  
Acute Stroke ◽  
Acute Ischemic Stroke ◽  
Roc Analysis ◽  
Cerebral Blood Volume ◽  
Ct Perfusion ◽  
Mean Transit Time ◽  
Operating Characteristics ◽  
Middle Cerebral Artery Infarction

Background and Purpose: Hemorrhage transformation (HT) is common in patients with acute cerebral infarction caused by atrial fibrillation. The prediction of HT is crucial after acute stroke, especially for the patients received vessel recanalization therapy. The Alberta Stroke program early CT score (ASPECTS) is used to estimate early ischemic changes within the MCA territory in the acute stroke setting. Several studies indicated that CT perfusion (CTP) and MR diffusion weighted imaging (DWI) ASPECTS scores was useful to quantify the degree of ischemic brain tissue. Hereby we did the study to explore the association of CT perfusion ASPECTS scores with HT in patients with acute ischemic stroke and atrial fibrillation. Methods: This was a single center retrospective study. All patients with middle cerebral artery infarction and atrial fibrillation from September 2008 to September 2013 were included. MR imaging including DWI and gradient echo sequence (GRE), and CTP were required to identify the HT and determine the scores of CTP- ASPECTS. Demographic and clinical characteristics of the HT positive and negative groups were explored. Results: Fifty-four patients were analyzed, among them twenty-four patients (44%) developed HT. According to logistic regression analysis, mean transit time (MTT), cerebral blood volume (CBV) and DWI-ASPECTS scores were associated with HT ( p = 0.035, 0.044, and 0.020 respectively). The following receiver operating characteristics (ROC) analysis revealed area under the curve of MTT, CBV, CBF and DWI were 0.588, 0.737, 0.687, and 0.841 respectively. CBV-ASPECTS score was found to have medium prediction value of HT among all CTP-ASPECTS parameters. ROC analysis also indicated that CBV-ASPECTS score < 7 was the optimal threshold. Conclusions: CTP-ASPECTS was useful to predict the HT of acute ischemic stroke caused by atrial fibrillation and CBV-ASPECTS score < 7 was the preferable parameter.

Abstract T MP4: Quality of CT Perfusion Imaging Thresholds for Infarct and Penumbra in the Acute Ischemic Stroke Setting: An Updated Systematic Review

Stroke ◽  
2015 ◽  
Vol 46 (suppl_1) ◽  
Author(s):  
Christopher d'Esterre ◽  
Jonathan Dykeman ◽  
Mohamed Al-mekhlafi ◽  
Petra Cimflova ◽  
Shivanand Patil ◽  
...  
Keyword(s):  
Systematic Review ◽  
At Risk ◽  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Perfusion Imaging ◽  
Cerebral Blood Volume ◽  
Ct Perfusion ◽  
Mean Transit Time ◽  
Infarct Core ◽  
Not At Risk

Background: CT Perfusion (CTP) may inform treatment decisions in acute ischemic stroke (AIS). We sought to determine extent of variability with CTP thresholds for infarct core and penumbra and reasons for such variability using an up-to-date systematic review. Methods: Search strategy combined the themes of AIS, perfusion imaging, and CT/MRI. Two independent reviewers screened at all levels; disagreements were settled through consensus. Inclusion criteria were CTP within 24hrs of stroke onset and reported perfusion thresholds for infarct core, penumbra, and/or normal/not at risk tissue for mixed grey/white matter. Study demographics, QUADAS assessment of quality, and mean thresholds of cerebral blood volume (CBV), cerebral blood flow (CBF), mean transit time (MTT), relative CBV (rCBV), relative CBF (rCBF), and relative MTT (rMTT) were collected. Thresholds were reported as median mean threshold (interquartile range). Results: The search resulted in a total of 11919 abstracts from EMBASE and MEDLINE. Of these, 711 studies were identified for full-text review, 134 met all eligibility criteria. 29 studies provided thresholds for CTP and were included in the review. For CBF, median mean threshold was 8.64 (7.94-13.92) ml/min/100g for core, 19.1 (17.1-31.9) ml/min/100g for penumbra and 47.4 (35.6-59.1) ml/min/100g for normal/not at risk tissue. For CBV, median mean threshold was 1.0 (0.68-1.88) ml/100g for core, 2.45 (2.0-3.0) ml/100g for penumbra, and 2.65 (2.0-3.3) ml/100g for normal/not at risk tissue. For MTT median mean threshold was 15.6 (15.3-17.7) seconds for core, 10.5 (7.1-46.2) seconds for penumbra, and 3.9 (3.65-4.15) seconds for normal/not at risk tissue. Median mean threshold for rCBF was 29% (22.5%-35.5%) for core. Sufficient TTP and Tmax data were not reported. Overall, quality was highly variable according QUADAS ranging from 20.7% to 93.1% across the 14 variables. Conclusions: Due to heterogeneity of vendor CTP algorithms, follow-up imaging to define infarct core (NCCT, DWI), unknown recanalization times/reperfusion status and differing onset to CT times, CTP thresholds for infarct core and penumbra are highly variable. As such, a single best threshold for core could not be derived from literature.

CT perfusion and angiographic assessment of pial collateral reperfusion in acute ischemic stroke: the CAPRI study

2016 ◽  
Vol 8 (12) ◽  
pp. 1211-1216 ◽  
Author(s):  
Arturo Consoli ◽  
Tommy Andersson ◽  
Ake Holmberg ◽  
Luca Verganti ◽  
Andrea Saletti ◽  
...  
Keyword(s):  
Multivariate Analysis ◽  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Cerebral Blood Volume ◽  
Ct Perfusion ◽  
Mean Transit Time ◽  
Univariate Analysis ◽  
Infarct Core ◽  
Intravenous Tissue Plasminogen Activator ◽  
Dichotomous Variable

BackgroundThe purpose of this study was to evaluate the correlation between a novel angiographic score for collaterals and CT perfusion (CTP) parameters in patients undergoing endovascular treatment for acute ischemic stroke (AIS).Methods103 patients (mean age 66.7±12.7; 48.5% men) with AIS in the anterior circulation territory, imaged with non-contrast CT, CT angiography, and CTP, admitted within 8 h from symptom onset and treated with any endovascular approach, were retrospectively included in the study. Clinical, neuroradiological data, and all time intervals were collected. Careggi Collateral Score (CCS) was used for angiographic assessment of collaterals and the Alberta Stroke Program Early CT Score (ASPECTS) for semiquantitative analysis of CTP maps. Two centralized core laboratories separately reviewed angiographic data, whereas CT findings were evaluated by an expert neuroradiologist. Univariate and multivariate analysis were performed considering CCS both as an ordinal and a dichotomous variable.Results37/103 patients (35.9%) received intravenous tissue plasminogen activator. Median (IQR) ASPECTS was 9 (6–10) for admission CT, 9 (5–10) for cerebral blood volume (CBV) maps, 3 (2–3) for mean transit time maps, 3 (2–4), for cerebral blood flow maps, and 5 (3–7) for CTP mismatch. Univariate analysis showed a significant correlation between CCS and ASPECTS for all CTP parameters. Multivariate analysis confirmed an independent association only between CCS and CBV (p=0.020 when CCS was considered as a dichotomous variable, p=0.026 with ordinal CCS).ConclusionsA correlation between angiographic assessment of the collateral circulation and CTP seems to be present, suggesting that CCS may provide an indirect evaluation of the infarct core volume to consider for patient selection in AIS.

scholarly journals Assessing the Relative Value of CT Perfusion Compared to Non-contrast CT and CT Angiography in Prognosticating Reperfusion-Eligible Acute Ischemic Stroke Patients

2021 ◽  
Vol 12 ◽  
Author(s):  
Andrew Bivard ◽  
Christopher Levi ◽  
Longting Lin ◽  
Xin Cheng ◽  
Richard Aviv ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Ct Angiography ◽  
Predictive Accuracy ◽  
Ct Perfusion ◽  
Imaging Modality ◽  
Characteristic Curve ◽  
Treatment Decision ◽  
Receiver Operator Characteristic Curve ◽  
Stroke Patients

In the present study we sought to measure the relative statistical value of various multimodal CT protocols at identifying treatment responsiveness in patients being considered for thrombolysis. We used a prospectively collected cohort of acute ischemic stroke patients being assessed for IV-alteplase, who had CT-perfusion (CTP) and CT-angiography (CTA) before a treatment decision. Linear regression and receiver operator characteristic curve analysis were performed to measure the prognostic value of models incorporating each imaging modality. One thousand five hundred and sixty-two sub-4.5 h ischemic stroke patients were included in this study. A model including clinical variables, alteplase treatment, and NCCT ASPECTS was weak (R2 0.067, P &lt; 0.001, AUC 0.605) at predicting 90 day mRS. A second model, including dynamic CTA variables (collateral grade, occlusion severity) showed better predictive accuracy for patient outcome (R2 0.381, P &lt; 0.001, AUC 0.781). A third model incorporating CTP variables showed very high predictive accuracy (R2 0.488, P &lt; 0.001, AUC 0.899). Combining all three imaging modalities variables also showed good predictive accuracy for outcome but did not improve on the CTP model (R2 0.439, P &lt; 0.001, AUC 0.825). CT perfusion predicts patient outcomes from alteplase therapy more accurately than models incorporating NCCT and/or CT angiography. This data has implications for artificial intelligence or machine learning models.

scholarly journals Leukoaraiosis May Confound the Interpretation of CT Perfusion in Patients Treated with Mechanical Thrombectomy for Acute Ischemic Stroke

2019 ◽  
Vol 40 (8) ◽  
pp. 1323-1329 ◽  
Author(s):  
S. Rudilosso ◽  
C. Laredo ◽  
C. Vivancos ◽  
X. Urra ◽  
L. Llull ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Mechanical Thrombectomy ◽  
Ct Perfusion

Leukoaraiosis and acute ischemic stroke: 90-day clinical outcome following endovascular recanalization, with proposed “L-ASPECTS”

2020 ◽  
pp. neurintsurg-2020-015957 ◽  
Author(s):  
John Benson ◽  
Seyed Mohammad Seyedsaadat ◽  
Ian Mark ◽  
Deena M Nasr ◽  
Alejandro A Rabinstein ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Mechanical Thrombectomy ◽  
Area Under The Curve ◽  
Primary Outcome Measure ◽  
Anterior Circulation ◽  
Vessel Occlusion ◽  
Endovascular Thrombectomy ◽  
Endovascular Recanalization ◽  
Poor Outcomes

BackgroundTo assess if leukoaraiosis severity is associated with outcome in patients with acute ischemic stroke (AIS) following endovascular thrombectomy, and to propose a leukoaraiosis-related modification to the ASPECTS score.MethodsA retrospective review was completed of AIS patients that underwent mechanical thrombectomy for anterior circulation large vessel occlusion. The primary outcome measure was 90-day mRS. A proposed Leukoaraiosis-ASPECTS (“L-ASPECTS”) was calculated by subtracting from the traditional ASPECT based on leukoaraiosis severity (1 point subtracted if mild, 2 if moderate, 3 if severe). L-ASEPCTS score performance was validated using a consecutive cohort of 75 AIS LVO patients.Results174 patients were included in this retrospective analysis: average age: 68.0±9.1. 28 (16.1%) had no leukoaraiosis, 66 (37.9%) had mild, 62 (35.6%) had moderate, and 18 (10.3%) had severe. Leukoaraiosis severity was associated with worse 90-day mRS among all patients (P=0.0005). Both L-ASPECTS and ASPECTS were associated with poor outcomes, but the area under the curve (AUC) was higher with L-ASPECTS (P<0.0001 and AUC=0.7 for L-ASPECTS; P=0.04 and AUC=0.59 for ASPECTS). In the validation cohort, the AUC for L-ASPECTS was 0.79 while the AUC for ASPECTS was 0.70. Of patients that had successful reperfusion (mTICI 2b/3), the AUC for traditional ASPECTS in predicting good functional outcome was 0.80: AUC for L-ASPECTS was 0.89.ConclusionsLeukoaraiosis severity on pre-mechanical thrombectomy NCCT is associated with worse 90-day outcome in patients with AIS following endovascular recanalization, and is an independent risk factor for worse outcomes. A proposed L-ASPECTS score had stronger association with outcome than the traditional ASPECTS score.

Collateral Circulation Predicts the Size of the Infarct Core and the Proportion of Salvageable Penumbra in Hyperacute Ischemic Stroke Patients Treated with Intravenous Thrombolysis

2015 ◽  
Vol 40 (3-4) ◽  
pp. 182-190 ◽  
Author(s):  
Harri Rusanen ◽  
Jukka T. Saarinen ◽  
Niko Sillanpää
Keyword(s):  
Ischemic Stroke ◽  
Clinical Outcome ◽  
Collateral Circulation ◽  
Cerebral Blood Volume ◽  
Treatment Time ◽  
Ct Perfusion ◽  
Mean Transit Time ◽  
Intravenous Thrombolysis ◽  
Stroke Patients ◽  
The Impact

Background: We studied the impact of collateral circulation on CT perfusion (CTP) parametric maps and the amount of salvaged brain tissue, the imaging and clinical outcome at 24 h and at 3 months in a retrospective acute (<3 h) stroke cohort (105 patients) with anterior circulation thrombus treated with intravenous thrombolysis. Methods: Baseline clinical and imaging information were collected and groups with different collateral scores (CS) were compared. Binary logistic regression analyses using good CS (CS ≥2) as the dependent variable were calculated. Results: CTP Alberta Stroke Program Early CT Score (ASPECTS) was successfully assessed in 58 cases. Thirty patients displayed good CS. Poor CS were associated with more severe strokes according to National Institutes of Health Stroke Scale (NIHSS) at arrival (15 vs. 7, p = 0.005) and at 24 h (10 vs. 3, p = 0.003) after intravenous thrombolysis. Good CS were associated with a longer mean onset-to-treatment time (141 vs. 121 min, p = 0.009) and time to CTP (102 vs. 87 min, p = 0.047), better cerebral blood volume (CBV) ASPECTS (9 vs. 6, p < 0.001), better mean transit time (MTT) ASPECTS (6 vs. 3, p < 0.001), better noncontrast CT (NCCT) ASPECTS (10 vs. 8, p < 0.001) at arrival and with favorable clinical outcome at 3 months (modified Rankin Scale ≤2, p = 0.002). The fraction of penumbra that was salvageable at arrival and salvaged at 24 h was higher with better CS (p < 0.001 and p = 0.035, respectively). In multivariate analysis, time from the onset of symptoms to imaging (p = 0.037, OR 1.04 per minute, 95% CI 1.00-1.08) and CBV ASPECTS (p = 0.001, OR 2.11 per ASPECTS point, 95% CI 1.33-3.34) predicted good CS. In similar multivariable models, MTT ASPECTS (p = 0.04, OR 1.46 per ASPECTS point, 95% CI 1.02-2.10) and NCCT ASPECTS predicted good CS (p = 0.003, OR 4.38 per CT ASPECTS point, 95% CI 1.66-11.55) along with longer time from the onset of symptoms to imaging (p = 0.045, OR 1.03 per minute, 95% CI 1.00-1.06 and p = 0.02, OR 1.05 per minute, 95% CI 1.00-1.09, respectively). CBV ASPECTS had a larger area under the receiver operating characteristic curve for good CS (0.837) than NCCT ASPECTS (0.802) or MTT ASPECTS (0.752) at arrival. Conclusions: Favorable CBV ASPECTS, NCCT ASPECTS and MTT ASPECTS are associated with good CS along with more salvageable tissue and longer time from the onset of symptoms to imaging in ischemic stroke patients treated with intravenous thrombolysis.

scholarly journals Factors Associated with Procedural Thromboembolisms after Mechanical Thrombectomy for Acute Ischemic Stroke

Medicina ◽  
2020 ◽  
Vol 56 (7) ◽  
pp. 353
Author(s):  
Taek Min Nam ◽  
Ji Hwan Jang ◽  
Young Zoon Kim ◽  
Kyu Hong Kim ◽  
Seung Hwan Kim
Keyword(s):  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Odds Ratio ◽  
Adjusted Odds Ratio ◽  
Mechanical Thrombectomy ◽  
Area Under The Curve ◽  
Multivariable Logistic Regression Analysis ◽  
Cutoff Value ◽  
Factors Associated ◽  
Procedural Time

Background and objective: Procedural thromboembolisms after mechanical thrombectomy (MT) for acute ischemic stroke has rarely been studied. We retrospectively evaluated factors associated with procedural thromboembolisms after MT using diffusion-weight imaging (DWI) within 2 days of MT. Materials and Methods: From January 2018 to March 2020, 78 patients with acute ischemic stroke who underwent MT were evaluated using DWI. Procedural thromboembolisms were defined as new cerebral infarctions in other territories from the occluded artery on DWI after MT. Results: Procedural thromboembolisms were observed on DWI in 16 patients (20.5%). Procedural thromboembolisms were associated with old age (73.8 ± 8.18 vs. 66.8 ± 11.2 years, p = 0.021), intravenous (IV) thrombolysis (12 out of 16 (75.0%) vs. 25 out of 62 (40.3%), p = 0.023), heparinization (4 out of 16 (25.0%) vs. 37 out of 62 (59.7%), p = 0.023), and longer procedural time (90.9 ± 35.6 vs. 64.4 ± 33.0 min, p = 0.006). Multivariable logistic regression analysis revealed that procedural thromboembolisms were independently associated with procedural time (adjusted odds ratio (OR); 1.020, 95% confidence interval (CI); 1.002–1.039, p = 0.030) and IV thrombolysis (adjusted OR; 4.697, 95% CI; 1.223–18.042, p = 0.024). The cutoff value of procedural time for predicting procedural thromboembolisms was ≥71 min (area under the curve; 0.711, 95% CI; 0.570–0.851, p = 0.010). Conclusions: Procedural thromboembolisms after MT for acute ischemic stroke are significantly associated with longer procedural time and IV thrombolysis. This study suggests that patients with IV thrombolysis and longer procedural time (≥71 min) are at a higher risk of procedural thromboembolisms after MT for acute ischemic stroke.

Abstract 3048: Real-World Clinical Use of CT Perfusion for Diagnosis and Prediction of Lesion Growth in Acute Ischemic Stroke

Stroke ◽  
2012 ◽  
Vol 43 (suppl_1) ◽  
Author(s):  
Branko N Huisa ◽  
William P Neil ◽  
Nhu T Bruce ◽  
Marcel Maya ◽  
Benedict Pereira ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Real World ◽  
Cerebral Blood Volume ◽  
Ct Perfusion ◽  
Medical Center ◽  
Brain Mri ◽  
Academic Medical Center ◽  
Acute Ischemia ◽  
Perfusion Maps

Background: Diffusion-weighted imaging (DWI) detects acute ischemia with a high sensitivity. In research centers, qualitative CT perfusion (CTP) mapping correlates well with DWI and may accurately differentiate the infarct core from ischemic penumbra. The value of the CTP in real-world clinical practice, however, has not been fully established. We investigated the yield of CTP - derived cerebral blood volume (CBV) and mean transient time (MTT) for the detection of cerebral ischemia in a sample of acute ischemic stroke (AIS) patients. Methods: In a large metropolitan academic medical center that is a certified Primary Stroke Center (PSC) we retrospectively studied 162 patients who presented between January 2008 and July 2010 with symptoms suggestive of AIS. All patients had an initial Code Brain protocol including non-contrast head CT, CTP, and CTA. As clinically indicated, some patients underwent follow up brain MRI within 48 hours. Acute perfusion maps were derived in real time by a trained operator. From the obtained images CBV, MTT and DWI lesion volumes were manually traced using planimetry (ImageJ v1.42) by two stroke neurologists blinded to clinical information. Volumes were calculated using the Cavaleri theorem. Sensitivity, specificity and statistical analysis were calculated using Graph Pad 5.0. Results: Of 162 patients with acute stroke-like symptoms, 73 had DWI lesions. The sensitivity and specificity to detect abnormal DWI signals were 23% and 100%, for CBV; and 43.8% and 98.9% for MTT. For DWI lesions ≥5ml the yield was 59.3% for CVB and 77.8% for MTT. For lesions ≥10ml the yield was 68.4% for CBV and 89.5% for MTT. In patients with NIHSS ≥5, CBV predicted abnormal DWI in 22.6% and MTT in 35.5%. In patients with NIHSS ≥10, CBV and MTT, both had a yield of 50.0%. A CBV - MTT mismatch of >25% predicted MRI lesion extension in 81.25% of the cases. There were small but significant correlations for DWI versus CBV lesion volumes ( r 2 0.32, P= 0.0001), and for DWI versus MTT lesion volumes ( r 2 0.29, P <0.0001). Correlation between DWI and perfusion maps for MCA territory infarcts were CBV ( r 2 0.3, P <0.0001) and MTT ( r 2 0.45, P <0.0001). Conclusions: In real-world deployment during a Code Brain protocol in a busy PSC, acute imaging with CTP did not predict DWI lesions on brain MRI with sufficient accuracy. In patients with large lesions the predictive value was better.

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