James E Siegler1, Steven R Messé1, Heidi Sucharew2, Scott E Kasner1, Tapan Mehta3,4,5, Niraj Arora6, Amy K Starosciak7, Felipe De Los Rios La Rosa7, Natasha R Barnhill8, Akshitkumar M Mistry9, Kishan Patel10, Salman Assad11, Amjad Tarboosh11, Katarina Dakay12, Jeff Wagner13, Alicia Bennett13, Bharathi Jagadeesan14, Christopher Streib3,4, Stewart A Weber8, Rohan Chitale9, John J Volpi10, Stephan A Mayer11, Shadi Yaghi12, Mahesh V Jayaraman12,15,16, Pooja Khatri17, Eva A Mistry9. 1. Department of Neurology, Hospital of the University of Pennsylvania, Philadelphia, PA. 2. Cincinnati Children's Hospital Medical Center, University of Cincinnati, Cincinnati, OH. 3. Department of Neurology, University of Minnesota Medical Center, Minneapolis, MN. 4. Department of Neurology, Fairview Southdale Hospital, Minneapolis, MN. 5. Department of Neurology, Hennepin County Medical Center, Minneapolis, MN. 6. Department of Neurology, Jackson Memorial Hospital, Miami, FL. 7. Baptist Health Neuroscience Center, Miami, FL. 8. Department of Neurology, Oregon Health and Science University, Portland, OR. 9. Department of Neurosurgery, Vanderbilt University Medical Center, Nashville, TN. 10. Department of Neurology, Houston Methodist Medical Center, Houston, TX. 11. Department of Neurology, Henry Ford Health System, Detroit, MI. 12. Department of Neurology, Brown University, Providence, RI. 13. Department of Neurology, Blue Sky Neurology, Englewood, CO. 14. Department of Radiology, University of Minnesota Medical Center, Minneapolis, MN. 15. Department of Diagnostic Imaging, Brown University, Providence, RI. 16. Department of Neurosurgery, Brown University, Providence, RI. 17. Department of Neurology, University of Cincinnati, Cincinnati, OH.
Abstract
BACKGROUND AND PURPOSE: The 2018 AHA guidelines recommend perfusion imaging to select patients with acute large vessel occlusion (LVO) for thrombectomy in the extended window. However, the relationship between noncontrast CT and CT perfusion imaging has not been sufficiently characterized >6 hours after last known normal (LKN). METHODS: From a multicenter prospective cohort of consecutive adults who underwent thrombectomy for anterior LVO 0-24 hours after LKN, we correlated baseline core volume (rCBF < 30%) and the Alberta Stroke Program Early CT Scale (ASPECTS) score. We compared perfusion findings between patients with an unfavorable ASPECTS (<6) against those with a favorable ASPECTS (≥6), and assessed findings over time. RESULTS: Of 485 enrolled patients, 177 met inclusion criteria (median age: 69 years, interquartile range [IQR: 57-81], 49% female, median ASPECTS 8 [IQR: 6-9], median core 10 cc [IQR: 0-30]). ASPECTS and core volume moderately correlated (r = -.37). A 0 cc core was observed in 54 (31%) patients, 70% of whom had ASPECTS <10. Of the 28 patients with ASPECTS <6, 3 (11%) had a 0 cc core. After adjustment for age and stroke severity, there was a lower ASPECTS for every 1 hour delay from LKN (cOR: 0.95, 95% confidence of interval [CI]: 0.91-1.00, P = .04). There was no difference in core (P = .51) or penumbra volumes (P = .87) across patients over time. CONCLUSIONS: In this multicenter prospective cohort of patients who underwent thrombectomy, one-third of patients had normal CTP core volumes despite nearly three quarters of patients showing ischemic changes on CT. This finding emphasizes the need to carefully assess both noncontrast and perfusion imaging when considering thrombectomy eligibility.
BACKGROUND AND PURPOSE: The 2018 AHA guidelines recommend perfusion imaging to select patients with acute large vessel occlusion (LVO) for thrombectomy in the extended window. However, the relationship between noncontrast CT and CT perfusion imaging has not been sufficiently characterized >6 hours after last known normal (LKN). METHODS: From a multicenter prospective cohort of consecutive adults who underwent thrombectomy for anterior LVO 0-24 hours after LKN, we correlated baseline core volume (rCBF < 30%) and the Alberta Stroke Program Early CT Scale (ASPECTS) score. We compared perfusion findings between patients with an unfavorable ASPECTS (<6) against those with a favorable ASPECTS (≥6), and assessed findings over time. RESULTS: Of 485 enrolled patients, 177 met inclusion criteria (median age: 69 years, interquartile range [IQR: 57-81], 49% female, median ASPECTS 8 [IQR: 6-9], median core 10 cc [IQR: 0-30]). ASPECTS and core volume moderately correlated (r = -.37). A 0 cc core was observed in 54 (31%) patients, 70% of whom had ASPECTS <10. Of the 28 patients with ASPECTS <6, 3 (11%) had a 0 cc core. After adjustment for age and stroke severity, there was a lower ASPECTS for every 1 hour delay from LKN (cOR: 0.95, 95% confidence of interval [CI]: 0.91-1.00, P = .04). There was no difference in core (P = .51) or penumbra volumes (P = .87) across patients over time. CONCLUSIONS: In this multicenter prospective cohort of patients who underwent thrombectomy, one-third of patients had normal CTP core volumes despite nearly three quarters of patients showing ischemic changes on CT. This finding emphasizes the need to carefully assess both noncontrast and perfusion imaging when considering thrombectomy eligibility.
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