Abstract 129: Clinical-imaging Mismatch versus Perfusion Imaging Mismatch Selection for Stroke Patients Undergoing Mechanical Thrombectomy

Stroke ◽  
2017 ◽  
Vol 48 (suppl_1) ◽  
Author(s):  
Mehdi Bouslama ◽  
Meredith Bowen ◽  
Diogo C Haussen ◽  
Seena Dehkharghani ◽  
Jonathan A Grossberg ◽  
...  
Keyword(s):  
Perfusion Imaging ◽  
Ct Perfusion ◽  
Tertiary Care ◽  
Significant Proportion ◽  
Information Criterion ◽  
Reperfusion Therapy ◽  
Anterior Circulation ◽  
Lesion Core ◽  
Good Discriminator ◽  
Core Infarct

Background and Purpose: The best approach to select patients for reperfusion therapy in acute ischemic stroke remains to be established. Different methodologies have been proposed using different clinical, vascular, and parenchymal imaging parameters. Our aim is to compare Perfusion-imaging Mismatch (PIM) and Clinical-Core Mismatch (CCM) patient selection and assess their ability to predict outcomes. Methods: We reviewed our prospectively collected endovascular database at a tertiary care academic institution for patients with acute anterior circulation strokes, adequate CT perfusion imaging maps and a National Institute of health Stroke Scale (NIHSS) ≥10 from September 2010 to March 2015. Patients were categorized according to the PIM and CCM definitions. PIM was defined as follows: Core Lesion ≤50cc; Tmax >10sec <100cc; Mismatch (Tmax> 6s lesion - core lesion) ≥15cc and ratio >1.8. CCM was defined as: NIHSS ≥ 10 and core infarct <31 cc (and age < 80) or NIHSS ≥ 20 and core infarct <51 cc (and age < 80) or NIHSS ≥ 10 and core infarct <21 cc (and age ≥ 80). The ability of PIM and CCM to predict good outcomes (modified Rankin scale 0-2) was evaluated using the area under the receiver operating characteristic curves (AUC), Akaike information criterion (AIC) and Bayesian information criterion (BIC). Results: A total of 368 patients qualified for the study. PIM had a lower number of qualifying patients compared to CCM (n=231, 62.8% vs n=303, 82.3%). The two groups were statistically different (p<0.001) with the following disagreement: 12 PIM+/CCM- and 84 PIM-/CCM+. There were no differences in good outcomes between PIM+ and PIM- patients (52% vs 48%, p=0.5). CCM+ patients had higher rates of good outcomes than CCM- (53% vs. 35%, p=0.015). There were no differences between PIM and CCM in predicting good outcomes as assessed by the AUC, AIC and BIC (0.82, 323.64 and 330.61 vs 0.82, 323.56 and 330.53 respectively) Conclusion: We were unable to demonstrate a difference between the PIM and CCM in predicting clinical outcomes. However, PIM seems to unjustifiably disqualify a significant proportion of patients that still benefit from reperfusion. In contrast with CCM, PIM does not seem to be a good discriminator of good outcomes. Future prospective studies are warranted.

scholarly journals Interpreting CT perfusion in stroke

2018 ◽  
Vol 19 (2) ◽  
pp. 136-142 ◽  
Author(s):  
Stevan Christopher Wing ◽  
Hugh S Markus
Keyword(s):  
Acute Stroke ◽  
Perfusion Imaging ◽  
Treatment Time ◽  
Ct Perfusion ◽  
Time Windows ◽  
Onset Time ◽  
Brain Perfusion ◽  
Reperfusion Therapy ◽  
Imaging Protocol ◽  
Stroke Imaging

CT perfusion images can be rapidly obtained on all modern CT scanners and easily incorporated into an acute stroke imaging protocol. Here we discuss the technique of CT perfusion imaging, how to interpret the data and how it can contribute to the diagnosis of acute stroke and selection of patients for treatment. Many patients with acute stroke are excluded from reperfusion therapy if the onset time is not known or if they present outside of traditional treatment time windows. There is a growing body of evidence supporting the use of perfusion imaging in these patients to identify patterns of brain perfusion that are favourable for recanalisation therapy.

Topographic correlation of infarct area on CT perfusion with functional outcome in acute ischemic stroke

2020 ◽  
Vol 132 (1) ◽  
pp. 33-41 ◽  
Author(s):  
Neil Haranhalli ◽  
Nnenna Mbabuike ◽  
Sanjeet S. Grewal ◽  
Tasneem F. Hasan ◽  
Michael G. Heckman ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Functional Outcome ◽  
Ct Perfusion ◽  
Multivariable Analysis ◽  
Reperfusion Therapy ◽  
Infarct Core ◽  
Anterior Circulation ◽  
Logistic Regression Models ◽  
Confounding Variables

OBJECTIVEThe role of CT perfusion (CTP) in the management of patients with acute ischemic stroke (AIS) remains a matter of debate. The primary aim of this study was to evaluate the correlation between the areas of infarction and penumbra on CTP scans and functional outcome in patients with AIS.METHODSThis was a retrospective review of 100 consecutively treated patients with acute anterior circulation ischemic stroke who underwent CT angiography (CTA) and CTP at admission between February 2011 and October 2014. On CTP, the volume of ischemic core and penumbra was measured using the Alberta Stroke Program Early CT Score (ASPECTS). CTA findings were also noted, including the site of occlusion and regional leptomeningeal collateral (rLMC) score. Functional outcome was defined by modified Rankin Scale (mRS) score obtained at discharge. Associations of CTP and CTA parameters with mRS scores at discharge were assessed using multivariable proportional odds logistic regression models.RESULTSThe median age was 67 years (range 19–95 years), and the median NIH Stroke Scale score was 16 (range 2–35). In a multivariable analysis adjusting for potential confounding variables, having an infarct on CTP scans in the following regions was associated with a worse mRS score at discharge: insula ribbon (p = 0.043), perisylvian fissure (p < 0.001), motor strip (p = 0.007), M2 (p < 0.001), and M5 (p = 0.023). A worse mRS score at discharge was more common in patients with a greater volume of infarct core (p = 0.024) and less common in patients with a greater rLMC score (p = 0.004).CONCLUSIONSThe results of this study provide evidence that several CTP parameters are independent predictors of functional outcome in patients with AIS and have potential to identify those patients most likely to benefit from reperfusion therapy in the treatment of AIS.

Abstract WMP15: A Simple Tool to Predict Target Mismatch in Ischemic Stroke Patients with Anterior Circulation Occlusion

Stroke ◽  
2017 ◽  
Vol 48 (suppl_1) ◽  
Author(s):  
Adam de Havenon ◽  
Steve O’Donnell ◽  
Alex Linn ◽  
Scott McNally ◽  
Bailey Dunleavy ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Perfusion Imaging ◽  
Time Window ◽  
Ct Perfusion ◽  
Volumetric Analysis ◽  
Stroke Patients ◽  
Anterior Circulation ◽  
Ct Angiogram

Introduction: The efficacy of endovascular thrombectomy in an extended time window for acute ischemic stroke patients with Target Mismatch (TM) on perfusion imaging was shown in a recent study and the ongoing DEFUSE-3 trial is studying thrombectomy in a 6-16 hour window for TM patients. A limitation of TM is that perfusion imaging is not widely available. We sought to identify a tool to predict TM based on clinical factors and CT angiogram (CTA) imaging, which is available at most hospitals. Methods: We reviewed acute ischemic stroke patients from 2010-2014 with proximal middle cerebral artery occlusion, CTA and CT perfusion (CTP) at hospital admission. TM was identified on CTP using the Olea Sphere volumetric analysis software with Bayesian deconvolution. TM was defined by the DEFUSE-3 criteria. ASPECTS was derived from the non-contrast CT head and the CTA source images (CTA-ASPECTS). Two collateral scores were derived from CTA source images. Results: 61 patients met inclusion criteria. The mean±SD age was 61±18 years and 61% were male. Mean NIH Stroke Scale (NIHSS) was 14.1±8.0 and median (IQR) follow-up modified Rankin Scale was 3 (1,6). TM was present in 35/61 (57%), who had lower mRS at follow-up (z=3.5, p<0.001). The predictor variables are shown in Table 1. The best combination of predictors was CTA-ASPECTS >4 and NIHSS <16, which had a sensitivity of 80% and specificity of 85% for TM (Figure 1). Discussion: We report a reliable, accessible, and clinically useful tool for predicting TM. This score warrants further study as a tool to guide transfer decisions from primary or secondary stroke centers to tertiary centers where endovascular intervention would be possible for selected patients.

scholarly journals Predictive Value of CT Perfusion Imaging on the Basis of Automatic Segmentation Algorithm to Evaluate the Collateral Blood Flow Status on the Outcome of Reperfusion Therapy for Ischemic Stroke

2021 ◽  
Vol 2021 ◽  
pp. 1-8
Author(s):  
Qingsong Gong ◽  
Botao Yu ◽  
Mengjie Wang ◽  
Min Chen ◽  
Haowen Xu ◽  
...  
Keyword(s):  
Blood Flow ◽  
Ischemic Stroke ◽  
Perfusion Imaging ◽  
Ct Perfusion ◽  
Automatic Segmentation ◽  
Reperfusion Therapy ◽  
Segmentation Algorithm ◽  
Collateral Flow ◽  
Collateral Blood Flow ◽  
Ct Perfusion Imaging

Our objective was to study the predictive value of CT perfusion imaging based on automatic segmentation algorithm for evaluating collateral blood flow status in the outcome of reperfusion therapy for ischemic stroke. All data of 30 patients with ischemic stroke reperfusion in our hospital were collected and examined by CT perfusion imaging. Convolutional neural network (CNN) algorithm was used to segment perfusion imaging map and evaluate the results. The patients were grouped by regional leptomeningeal collateral score (rLMCs). Binary logistic regression was used to analyze the independent influencing factors of collateral blood flow on brain CT perfusion. The modified Scandinavian Stroke Scale was used to evaluate the prognosis of patients, and the effects of different collateral flow conditions on prognosis were obtained. The accuracy of CNN segmentation image is 62.61%, the sensitivity is 87.42%, the similarity coefficient is 93.76%, and the segmentation result quality is higher. Blood glucose (95% CI = 0.943, P = 0.028 ) and ischemic stroke history (95% CI = 0.855, P = 0.003 ) were independent factors affecting the collateral blood flow status of stroke patients. CBF (95% CI = 0.818, P = 0.008 ) and CBV (95% CI = 0.796, P = 0.016 ) were independent influencing factors of CT perfusion parameters. After 3 weeks of onset, the prognostic function defect score of the good collateral flow group (11.11%) was lower than that of the poor group (41.67%) ( P < 0.05 ). The automatic segmentation algorithm has more accurate segmentation ability for stroke CT perfusion imaging and plays a good auxiliary role in the diagnosis of clinical stroke reperfusion therapy. The collateral blood flow state based on CT perfusion imaging is helpful to predict the treatment outcome of patients with ischemic stroke and further predict the prognosis of patients.

Endovascular reperfusion outcomes in patients with a stroke and low ASPECTS is highly dependent on baseline infarct volumes

2021 ◽  
pp. neurintsurg-2020-017184
Author(s):  
Mehdi Bouslama ◽  
Clara M Barreira ◽  
Diogo C Haussen ◽  
Gabriel Martins Rodrigues ◽  
Leonardo Pisani ◽  
...  
Keyword(s):  
Ct Perfusion ◽  
Infarct Volume ◽  
Care Center ◽  
Tertiary Care ◽  
Multivariable Analysis ◽  
Functional Independence ◽  
Primary Outcome Measure ◽  
Modified Rankin Scale ◽  
Anterior Circulation ◽  
Vessel Occlusion

BackgroundPatients with large vessel occlusion stroke (LVOS) and a low Alberta Stroke Program Early CT Score (ASPECTS) are often not offered endovascular therapy (ET) as they are thought to have a poor prognosis.ObjectiveTo compare the outcomes of patients with low and high ASPECTS undergoing ET based on baseline infarct volumes.MethodsReview of a prospectively collected endovascular database at a tertiary care center between September 2010 and March 2020. All patients with anterior circulation LVOS and interpretable baseline CT perfusion (CTP) were included. Subjects were divided into groups with low ASPECTS (0–5) and high ASPECTS (6-10) and subsequently into limited and large CTP-core volumes (cerebral blood flow 30% >70 cc). The primary outcome measure was the difference in rates of 90-day good outcome as defined by a modified Rankin Scale (mRS) score of 0 to 2 across groups.Results1248 patients fit the inclusion criteria. 125 patients had low ASPECTS, of whom 16 (12.8%) had a large core (LC), whereas 1123 patients presented with high ASPECTS, including 29 (2.6%) patients with a LC. In the category with a low ASPECTS, there was a trend towards lower rates of functional independence (90-day modified Rankin Scale (mRS) score 0-2) in the LC group (18.8% vs 38.9%, p=0.12), which became significant after adjusting for potential confounders in multivariable analysis (aOR=0.12, 95% CI 0.016 to 0.912, p=0.04). Likewise, LC was associated with significantly lower rates of functional independence (31% vs 51.9%, p=0.03; aOR=0.293, 95% CI 0.095 to 0.909, p=0.04) among patients with high ASPECTS.ConclusionsOutcomes may vary significantly in the same ASPECTS category depending on infarct volume. Patients with ASPECTS ≤5 but baseline infarct volumes ≤70 cc may achieve independence in nearly 40% of the cases and thus should not be excluded from treatment.

scholarly journals Relationship between the degree of recanalization and functional outcome in acute ischemic stroke is mediated by penumbra salvage volume

2021 ◽  
Author(s):  
Gabriel Broocks ◽  
Hashim Jafarov ◽  
Rosalie McDonough ◽  
Friederike Austein ◽  
Lukas Meyer ◽  
...  
Keyword(s):  
Functional Outcome ◽  
Ct Perfusion ◽  
Reperfusion Therapy ◽  
Anterior Circulation ◽  
Vessel Occlusion ◽  
Important Mediator ◽  
Flow Restoration ◽  
Relationship Of ◽  
The Relationship

Abstract Background The presence of metabolically viable brain tissue that may be salvageable with rapid cerebral blood flow restoration is the fundament rationale for reperfusion therapy in patients with large vessel occlusion stroke. The effect of endovascular treatment (EVT) on functional outcome largely depends on the degree of recanalization. However, the relationship of recanalization degree and penumbra salvage has not yet been investigated. We hypothesized that penumbra salvage volume mediates the effect of thrombectomy on functional outcome. Methods 99 acute anterior circulation stroke patients who received multimodal CT and underwent thrombectomy with resulting partial to complete reperfusion (modified thrombolysis in cerebral infarction scale (mTICI) ≥ 2a) were retrospectively analyzed. Penumbra volume was quantified on CT perfusion and penumbra salvage volume (PSV) was calculated as difference of penumbra and net infarct growth from admission to follow-up imaging. Results In patients with complete reperfusion (mTICI ≥ 2c), the median PSV was significantly higher than the median PSV in patients with partial or incomplete (mTICI 2a–2b) reperfusion (median 224 mL, IQR: 168–303 versus 158 mL, IQR: 129–225; p < 0.01). A higher degree of recanalization was associated with increased PSV (+ 63 mL per grade, 95% CI: 17–110; p < 0.01). Higher PSV was also associated with improved functional outcome (OR/mRS shift: 0.89; 95% CI: 0.85–0.95, p < 0.0001). Conclusions PSV may be an important mediator between functional outcome and recanalization degree in EVT patients and could serve as a more accurate instrument to compare treatment effects than infarct volumes.

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.

Selection Paradigms for Large Vessel Occlusion Acute Ischemic Stroke Endovascular Therapy

2017 ◽  
Vol 44 (5-6) ◽  
pp. 277-284 ◽  
Author(s):  
Mehdi Bouslama ◽  
Meredith T. Bowen ◽  
Diogo C. Haussen ◽  
Seena Dehkharghani ◽  
Jonathan A. Grossberg ◽  
...  
Keyword(s):  
Ct Perfusion ◽  
Information Criterion ◽  
Large Vessel ◽  
Selection Combining ◽  
Clinical Aspects ◽  
Large Vessel Occlusion ◽  
Anterior Circulation ◽  
Vessel Occlusion ◽  
C Statistic ◽  
Inclusion Rate

Background: Optimal patient selection methods for thrombectomy in large vessel occlusion stroke (LVOS) are yet to be established. We sought to evaluate the ability of different selection paradigms to predict favorable outcomes. Methods: Review of a prospectively collected database of endovascular patients with anterior circulation LVOS, adequate CT perfusion (CTP), National Institutes of Health Stroke Scale (NIHSS) ≥10 from September 2010 to March 2016. Patients were retrospectively assessed for thrombectomy eligibility by 4 mismatch criteria: Perfusion-Imaging Mismatch (PIM): between CTP-derived perfusion defect and ischemic core volumes; Clinical-Core Mismatch (CCM): between age-adjusted NIHSS and CTP core; Clinical-ASPECTS Mismatch (CAM-1): between age-adjusted NIHSS and ASPECTS; Clinical-ASPECTS Mismatch (CAM-2): between NIHSS and ASPECTS. Outcome measures were inclusion rates for each paradigm and their ability to predict good outcomes (90-day modified Rankin Scale 0-2). Results: Three hundred eighty-four patients qualified. CAM-2 and CCM had higher inclusion (89.3 and 82.3%) vs. CAM-1 (67.7%) and PIM (63.3%). Proportions of selected patients were statistically different except for PIM and CAM-1 (p = 0.19), with PIM having the highest disagreement. There were no differences in good outcome rates between PIM(+)/PIM(-) (52.2 vs. 48.5%; p = 0.51) and CAM-2(+)/CAM-2(-) (52.4 vs. 38.5%; p = 0.12). CCM(+) and CAM-1(+) had higher rates compared to nonselected counterparts (53.4 vs. 38.7%, p = 0.03; 56.6 vs. 38.6%; p = 0.002). The abilities of PIM, CCM, CAM-1, and CAM-2 to predict outcomes were similar according to the c-statistic, Akaike and Bayesian information criterion. Conclusions: For patients with NIHSS ≥10, PIM appears to disqualify more patients without improving outcomes. CCM may improve selection, combining a high inclusion rate with optimal outcome discrimination across (+) and (-) patients. Future studies are warranted.

scholarly journals Late Thrombectomy in Clinical Practice

2021 ◽  
Author(s):  
Moriz Herzberg ◽  
Korbinian Scherling ◽  
Robert Stahl ◽  
Steffen Tiedt ◽  
Frank A. Wollenweber ◽  
...  
Keyword(s):  
Clinical Practice ◽  
Clinical Outcome ◽  
Perfusion Imaging ◽  
Time Window ◽  
Ct Perfusion ◽  
Large Trial ◽  
Real World Data ◽  
Baseline Trial ◽  
Good Outcome ◽  
Number Of Patients

Abstract Background and Purpose To provide real-world data on outcome and procedural factors of late thrombectomy patients. Methods We retrospectively analyzed patients from the multicenter German Stroke Registry. The primary endpoint was clinical outcome on the modified Rankin scale (mRS) at 3 months. Trial-eligible patients and the subgroups were compared to the ineligible group. Secondary analyses included multivariate logistic regression to identify predictors of good outcome (mRS ≤ 2). Results Of 1917 patients who underwent thrombectomy, 208 (11%) were treated within a time window ≥ 6–24 h and met the baseline trial criteria. Of these, 27 patients (13%) were eligible for DAWN and 39 (19%) for DEFUSE3 and 156 patients were not eligible for DAWN or DEFUSE3 (75%), mainly because there was no perfusion imaging (62%; n = 129). Good outcome was not significantly higher in trial-ineligible (27%) than in trial-eligible (20%) patients (p = 0.343). Patients with large trial-ineligible CT perfusion imaging (CTP) lesions had significantly more hemorrhagic complications (33%) as well as unfavorable outcomes. Conclusion In clinical practice, the high number of patients with a good clinical outcome after endovascular therapy ≥ 6–24 h as in DAWN/DEFUSE3 could not be achieved. Similar outcomes are seen in patients selected for EVT ≥ 6 h based on factors other than CTP. Patients triaged without CTP showed trends for shorter arrival to reperfusion times and higher rates of independence.

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