Angiography suite cone‐beam CT perfusion for selection of thrombectomy patients: A pilot study

Abstract

Background and Purpose:The availability of cone-beam CT perfusion (CBCTP) in angiography suites may improve large-vessel occlusion (LVO) triage and reduce reperfusion times for patients presenting during extended time window. We aim to evaluate the perfusion maps correlation and agreement between multidetector CT perfusion (MDCTP) and CBCTP when obtained sequentially in patients undergoing endovascular therapy. Methods: This is a prospective, pilot, single-arm interventional cohort study of consecutive patients with anterior circulation LVO. All patients underwent MDCTP and CBCTP prior to endovascular therapy, generating cerebral blood flow (CBF), cerebral blood volume (CBV), mean transit time (MTT), and time-to-maximum/time to peak contrast concentration maps. We compared the two imaging modalities using three different methods: (1) six regions of interest (ROIs) placed in the anterior circulation territory; (2) ROIs placed in all 10 Alberta Stroke Program Early CT Score regions; and (3) ROI drawn around the entire ischemic area. ROI ratios (unaffected/affected area) were compared for all sequences in each method. We used the intraclass correlation coefficient to calculate the correlation between the studies. Bland-Altman plots were also created to measure the degree of agreement. Finally, a sensitivity analysis was done comparing both modalities in patients with low infarct growth rate. Results: Fourteen patients were included (median age 81 years [74-87], 50% males, median National Institutes of Health Stroke Scale 19 [14][15][16][17][18][19][20][21][22]). Median time between studies was 42 minutes (interquartile range 29-61). Independently of the method used, we found moderate to excellent correlation in CBF, CBV, and MTT between modalities. CBF correlation further improved in patients with low infarct growth. Conclusion: These results demonstrate promising accuracy of CBCTP in evaluating ischemic tissue in patients presenting with LVO ischemic stroke.

Intravenous Thrombolysis before Complete Angiographic Reperfusion: Beyond Angiographic Assessment to Target Microvascular Obstruction?

“…The assessment of brain perfusion, using cone-beam CT perfusion immediately after angiographic reperfusion in the catheterization laboratory, could be a promising approach to tailor the patient's management after successful EVT. 29,30 Because arterial recanalization by EVT has now been mastered by most teams worldwide, efforts should be directed toward the evaluation and therapeutic targeting of microvascular with baseline NIHSS >20 and in patients who underwent >2 passes during EVT. Several preclinical as well as clinical studies performed by our team and others demonstrated that the size of the core, neutrophil extracellular trap covering the clot and making it more difficult to retrieve, and the endothelial damage caused by repetitive devices passes all contribute to the thromboinflammatory cascade initiated in the microcirculation downstream of LVO.…”

“…In this context, new tools are needed to assess cerebral perfusion in the acute setting after EVT. The assessment of brain perfusion, using cone‐beam CT perfusion immediately after angiographic reperfusion in the catheterization laboratory, could be a promising approach to tailor the patient's management after successful EVT 29,30 . Because arterial recanalization by EVT has now been mastered by most teams worldwide, efforts should be directed toward the evaluation and therapeutic targeting of microvascular thrombosis after and despite successful angiographic reperfusion.…”

The Benefit of a Complete over a Successful Reperfusion Decreases with Time

“…Nevertheless, our results highlight the dynamic of AIS evolution from the baseline imaging to reperfusion, and suggest that additional parameters could be considered before going further into the procedure after obtaining a successful reperfusion. New tools are required to provide a multimodal assessment of the brain parenchyma in the angio suite, such as cone‐beam computed tomography perfusion imaging 27–29 . This could be important for the design of future trials in the field, aiming at proving the prognostic value of targeting a complete reperfusion over a successful reperfusion in different settings.…”

“…New tools are required to provide a multimodal assessment of the brain parenchyma in the angio suite, such as cone-beam computed tomography perfusion imaging. [27][28][29] This could be important for the design of future trials in the field, aiming at proving the prognostic value of targeting a complete reperfusion over a successful reperfusion in different settings.…”

Current State of Evidence for Neuroimaging Paradigms in Management of Acute Ischemic Stroke

“…With continuous advances in the field of acquisition and post-processing protocols, recent results from cone-beam CTs have been more than promising for both excluding hemorrhages 124,125 and assessing perfusion parameters. 126 These advances may become more widely implemented and potentially bypass standard multidetector CT acquisition protocols to expedite thrombectomy delivery.…”