Matthias P Fabritius1, Kolja M Thierfelder2, Felix G Meinel1, Ahmed E Othman1, Franziska Dorn1, Bastian O Sabel1, Pierre Scheffler1, Birgit Ertl-Wagner1, Wieland H Sommer1, Wolfgang G Kunz1. 1. From the Institute for Clinical Radiology (M.P.F., K.M.T., F.G.M., B.O.S., B.E.-W., W.H.S., W.G.K.), Department of Neuroradiology (F.D.), and Department of Neurology (P.S.), Ludwig-Maximilians-University Hospital Munich, Germany; and Department for Diagnostic and Interventional Radiology, Eberhard Karls University Tuebingen, University Hospital Tuebingen, Germany (A.E.O.). 2. From the Institute for Clinical Radiology (M.P.F., K.M.T., F.G.M., B.O.S., B.E.-W., W.H.S., W.G.K.), Department of Neuroradiology (F.D.), and Department of Neurology (P.S.), Ludwig-Maximilians-University Hospital Munich, Germany; and Department for Diagnostic and Interventional Radiology, Eberhard Karls University Tuebingen, University Hospital Tuebingen, Germany (A.E.O.). kolja.thierfelder@med.lmu.de.
Abstract
BACKGROUND AND PURPOSE: Malignant cerebellar edema (MCE) is a life-threatening complication of acute ischemic stroke that requires timely diagnosis and management. Aim of this study was to identify imaging predictors in initial multiparametric computed tomography (CT), including whole-brain CT perfusion (WB-CTP). METHODS: We consecutively selected all subjects with cerebellar ischemic WB-CTP deficits and follow-up-confirmed cerebellar infarction from an initial cohort of 2635 patients who had undergone multiparametric CT because of suspected stroke. Follow-up imaging was assessed for the presence of MCE, measured using an established 10-point scale, of which scores ≥4 are considered malignant. Posterior circulation-Acute Stroke Prognosis Early CT Score (pc-ASPECTS) was determined to assess ischemic changes on noncontrast CT, CT angiography (CTA), and parametric WB-CTP maps (cerebellar blood flow [CBF]; cerebellar blood volume; mean transit time; time to drain). Fisher's exact tests, Mann-Whitney U tests, and receiver operating characteristics analyses were performed for statistical analyses. RESULTS: Out of a total of 51 patients who matched the inclusion criteria, 42 patients (82.4%) were categorized as MCE- and 9 (17.6%) as MCE+. MCE+ patients had larger CBF, cerebellar blood volume, mean transit time, and time to drain deficit volumes (all with P<0.001) and showed significantly lower median pc-ASPECTS assessed using WB-CTP (CBF, cerebellar blood volume, mean transit time, time to drain; all with P<0.001) compared with MCE- patients, while median pc-ASPECTS on noncontrast CT and CTA was not significantly different (both P>0.05). Receiver operating characteristics analyses yielded the largest area under the curve values for the prediction of MCE development for CBF (0.979) and cerebellar blood volume deficit volumes (0.956) and pc-ASPECTS on CBF (0.935), whereas pc-ASPECTS on noncontrast CT (0.648) and CTA (0.684) had less diagnostic value. The optimal cutoff value for CBF deficit volume was 22 mL, yielding 100% sensitivity and 90% specificity for MCE classification. CONCLUSIONS: WB-CTP provides added diagnostic value for the early identification of patients at risk for MCE development in acute cerebellar stroke.
BACKGROUND AND PURPOSE:Malignant cerebellar edema (MCE) is a life-threatening complication of acute ischemic stroke that requires timely diagnosis and management. Aim of this study was to identify imaging predictors in initial multiparametric computed tomography (CT), including whole-brain CT perfusion (WB-CTP). METHODS: We consecutively selected all subjects with cerebellar ischemic WB-CTP deficits and follow-up-confirmed cerebellar infarction from an initial cohort of 2635 patients who had undergone multiparametric CT because of suspected stroke. Follow-up imaging was assessed for the presence of MCE, measured using an established 10-point scale, of which scores ≥4 are considered malignant. Posterior circulation-Acute Stroke Prognosis Early CT Score (pc-ASPECTS) was determined to assess ischemic changes on noncontrast CT, CT angiography (CTA), and parametric WB-CTP maps (cerebellar blood flow [CBF]; cerebellar blood volume; mean transit time; time to drain). Fisher's exact tests, Mann-Whitney U tests, and receiver operating characteristics analyses were performed for statistical analyses. RESULTS: Out of a total of 51 patients who matched the inclusion criteria, 42 patients (82.4%) were categorized as MCE- and 9 (17.6%) as MCE+. MCE+ patients had larger CBF, cerebellar blood volume, mean transit time, and time to drain deficit volumes (all with P<0.001) and showed significantly lower median pc-ASPECTS assessed using WB-CTP (CBF, cerebellar blood volume, mean transit time, time to drain; all with P<0.001) compared with MCE- patients, while median pc-ASPECTS on noncontrast CT and CTA was not significantly different (both P>0.05). Receiver operating characteristics analyses yielded the largest area under the curve values for the prediction of MCE development for CBF (0.979) and cerebellar blood volume deficit volumes (0.956) and pc-ASPECTS on CBF (0.935), whereas pc-ASPECTS on noncontrast CT (0.648) and CTA (0.684) had less diagnostic value. The optimal cutoff value for CBF deficit volume was 22 mL, yielding 100% sensitivity and 90% specificity for MCE classification. CONCLUSIONS:WB-CTP provides added diagnostic value for the early identification of patients at risk for MCE development in acute cerebellar stroke.
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