Amrou Sarraj1, Bruce C V Campbell1, Soren Christensen1, Clark W Sitton1, Shekhar Khanpara1, Roy F Riascos1, Deep Pujara1, Faris Shaker1, Gagan Sharma1, Maarten G Lansberg1, Gregory W Albers1. 1. From the Department of Neurology (A.S.), Case Western Reserve University-University Hospitals Cleveland Medical Center, OH; Department of Neurology (B.C.V.C., G.S.), The Royal Melbourne Hospital, University of Melbourne, Parkville, Australia; Department of Neurology (S.C., M.G.L., G.W.A.), Stanford University Medical Center, CA; Departments of Diagnostic and Interventional Imaging (C.W.S., S.K., R.F.R.) and Neurology (F.S.), UTHealth McGovern Medical School, Houston, TX; and Department of Neurology (D.P.), University Hospitals Cleveland Medical Center, OH.
Abstract
BACKGROUND AND OBJECTIVES: To assess the accuracy of baseline CT perfusion (CTP) ischemic core estimates. METHODS: From SELECT (Optimizing Patient Selection for Endovascular Treatment in Acute Ischemic Stroke), a prospective multicenter cohort study of imaging selection, patients undergoing endovascular thrombectomy who achieved complete reperfusion (modified Thrombolysis In Cerebral Ischemia score 3) and had follow-up diffusion-weighted imaging (DWI) available were evaluated. Follow-up DWI lesions were coregistered to baseline CTP. The difference between baseline CTP core (relative cerebral blood flow [rCBF] <30%) volume and follow-up infarct volume was classified as overestimation (core ≥10 mL larger than infarct), adequate, or underestimation (core ≥25 mL smaller than infarct) and spatial overlap was evaluated. RESULTS: Of 101 included patients, median time from last known well (LKW) to imaging acquisition was 138 (82-244) minutes. The median baseline ischemic core estimate was 9 (0-31.9) mL and median follow-up infarct volume was 18.4 (5.3-68.7) mL. All 6/101 (6%) patients with overestimation of the subsequent infarct volume were imaged within 90 minutes of LKW and achieved rapid reperfusion (within 120 minutes of CTP). Using rCBF <20% threshold to estimate ischemic core in patients presenting within 90 minutes eliminated overestimation. Volumetric correlation between the ischemic core estimate and follow-up imaging improved as LKW time to imaging acquisition increased: Spearman ρ <90 minutes 0.33 (p = 0.049), 90-270 minutes 0.63 (p < 0.0001), >270 minutes 0.86 (p < 0.0001). Assessment of the spatial overlap between baseline CTP ischemic core lesion and follow-up infarct demonstrated that a median of 3.2 (0.0-9.0) mL of estimated core fell outside the subsequent infarct. These regions were predominantly in white matter. DISCUSSION: Significant overestimation of irreversibly injured ischemic core volume was rare, was only observed in patients who presented within 90 minutes of LKW and achieved reperfusion within 120 minutes of CTP acquisition, and occurred primarily in white matter. Use of a more conservative (rCBF <20%) threshold for estimating ischemic core in patients presenting within 90 minutes eliminated all significant overestimation cases. TRIAL REGISTRATION INFORMATION: ClinicalTrials.gov: NCT03876457.
BACKGROUND AND OBJECTIVES: To assess the accuracy of baseline CT perfusion (CTP) ischemic core estimates. METHODS: From SELECT (Optimizing Patient Selection for Endovascular Treatment in Acute Ischemic Stroke), a prospective multicenter cohort study of imaging selection, patients undergoing endovascular thrombectomy who achieved complete reperfusion (modified Thrombolysis In Cerebral Ischemia score 3) and had follow-up diffusion-weighted imaging (DWI) available were evaluated. Follow-up DWI lesions were coregistered to baseline CTP. The difference between baseline CTP core (relative cerebral blood flow [rCBF] <30%) volume and follow-up infarct volume was classified as overestimation (core ≥10 mL larger than infarct), adequate, or underestimation (core ≥25 mL smaller than infarct) and spatial overlap was evaluated. RESULTS: Of 101 included patients, median time from last known well (LKW) to imaging acquisition was 138 (82-244) minutes. The median baseline ischemic core estimate was 9 (0-31.9) mL and median follow-up infarct volume was 18.4 (5.3-68.7) mL. All 6/101 (6%) patients with overestimation of the subsequent infarct volume were imaged within 90 minutes of LKW and achieved rapid reperfusion (within 120 minutes of CTP). Using rCBF <20% threshold to estimate ischemic core in patients presenting within 90 minutes eliminated overestimation. Volumetric correlation between the ischemic core estimate and follow-up imaging improved as LKW time to imaging acquisition increased: Spearman ρ <90 minutes 0.33 (p = 0.049), 90-270 minutes 0.63 (p < 0.0001), >270 minutes 0.86 (p < 0.0001). Assessment of the spatial overlap between baseline CTP ischemic core lesion and follow-up infarct demonstrated that a median of 3.2 (0.0-9.0) mL of estimated core fell outside the subsequent infarct. These regions were predominantly in white matter. DISCUSSION: Significant overestimation of irreversibly injured ischemic core volume was rare, was only observed in patients who presented within 90 minutes of LKW and achieved reperfusion within 120 minutes of CTP acquisition, and occurred primarily in white matter. Use of a more conservative (rCBF <20%) threshold for estimating ischemic core in patients presenting within 90 minutes eliminated all significant overestimation cases. TRIAL REGISTRATION INFORMATION: ClinicalTrials.gov: NCT03876457.
Authors: Chushuang Chen; Andrew Bivard; Longting Lin; Christopher R Levi; Neil J Spratt; Mark W Parsons Journal: J Cereb Blood Flow Metab Date: 2017-11-27 Impact factor: 6.200
Authors: Gregory W Albers; Michael P Marks; Stephanie Kemp; Soren Christensen; Jenny P Tsai; Santiago Ortega-Gutierrez; Ryan A McTaggart; Michel T Torbey; May Kim-Tenser; Thabele Leslie-Mazwi; Amrou Sarraj; Scott E Kasner; Sameer A Ansari; Sharon D Yeatts; Scott Hamilton; Michael Mlynash; Jeremy J Heit; Greg Zaharchuk; Sun Kim; Janice Carrozzella; Yuko Y Palesch; Andrew M Demchuk; Roland Bammer; Philip W Lavori; Joseph P Broderick; Maarten G Lansberg Journal: N Engl J Med Date: 2018-01-24 Impact factor: 91.245
Authors: Tudor G Jovin; Angel Chamorro; Erik Cobo; María A de Miquel; Carlos A Molina; Alex Rovira; Luis San Román; Joaquín Serena; Sonia Abilleira; Marc Ribó; Mònica Millán; Xabier Urra; Pere Cardona; Elena López-Cancio; Alejandro Tomasello; Carlos Castaño; Jordi Blasco; Lucía Aja; Laura Dorado; Helena Quesada; Marta Rubiera; María Hernandez-Pérez; Mayank Goyal; Andrew M Demchuk; Rüdiger von Kummer; Miquel Gallofré; Antoni Dávalos Journal: N Engl J Med Date: 2015-04-17 Impact factor: 91.245
Authors: Friederike Austein; Christian Riedel; Tina Kerby; Johannes Meyne; Andreas Binder; Thomas Lindner; Monika Huhndorf; Fritz Wodarg; Olav Jansen Journal: Stroke Date: 2016-08-09 Impact factor: 7.914
Authors: Mohamed Najm; Fahad S Al-Ajlan; Mari E Boesen; Lisa Hur; Chi Kyung Kim; Enrico Fainardi; Michael D Hill; Andrew M Demchuk; Mayank Goyal; Ting Y Lee; Bijoy K Menon Journal: Can J Neurol Sci Date: 2018-02-19 Impact factor: 2.104
Authors: S Nannoni; F Ricciardi; D Strambo; G Sirimarco; M Wintermark; V Dunet; P Michel Journal: AJNR Am J Neuroradiol Date: 2021-01-28 Impact factor: 3.825
Authors: Andrew Bivard; Tim Kleinig; Ferdinand Miteff; Kenneth Butcher; Longting Lin; Christopher Levi; Mark Parsons Journal: Ann Neurol Date: 2017-12 Impact factor: 10.422
Authors: Álvaro García-Tornel; Daniel Campos; Marta Rubiera; Sandra Boned; Marta Olivé-Gadea; Manuel Requena; Ludovico Ciolli; Marian Muchada; Jorge Pagola; David Rodriguez-Luna; Matias Deck; Jesus Juega; Noelia Rodríguez-Villatoro; Estela Sanjuan; Alejandro Tomasello; Carlos Piñana; David Hernández; José Álvarez-Sabin; Carlos A Molina; Marc Ribó Journal: Stroke Date: 2021-03-08 Impact factor: 7.914
Authors: Jan W Hoving; Henk A Marquering; Charles B L M Majoie; Nawaf Yassi; Gagan Sharma; David S Liebeskind; Aad van der Lugt; Yvo B Roos; Wim van Zwam; Robert J van Oostenbrugge; Mayank Goyal; Jeffrey L Saver; Tudor G Jovin; Gregory W Albers; Antoni Davalos; Michael D Hill; Andrew M Demchuk; Serge Bracard; Francis Guillemin; Keith W Muir; Philip White; Peter J Mitchell; Geoffrey A Donnan; Stephen M Davis; Bruce C V Campbell Journal: Stroke Date: 2018-10 Impact factor: 7.914