Brain hemorrhage after endovascular reperfusion therapy of ischemic stroke: a threshold-finding whole-brain perfusion CT study

Abstract

Endovascular reperfusion therapy is increasingly used for acute ischemic stroke treatment. The occurrence of parenchymal hemorrhage is clinically relevant and increases with reperfusion therapies. Herein we aimed to examine the optimal perfusion CT-derived parameters and the impact of the duration of brain ischemia for the prediction of parenchymal hemorrhage after endovascular therapy. A cohort of 146 consecutive patients with anterior circulation occlusions and treated with endovascular reperfusion therapy was analyzed. Recanalization was assessed at the end of reperfusion treatment, and the rate of parenchymal hemorrhage at follow-up neuroimaging. In regression analyses, cerebral blood volume and cerebral blood flow performed better than Delay Time maps for the prediction of parenchymal hemorrhage. The most informative thresholds (receiver operating curves) for relative cerebral blood volume and relative cerebral blood flow were values lower than 2.5% of normal brain. In binary regression analyses, the volume of regions with reduced relative cerebral blood volume and/or relative cerebral blood flow was significantly associated with an increased risk of parenchymal hemorrhage, as well as delayed vessel recanalization. These results highlight the relevance of the severity and duration of ischemia as drivers of blood-brain barrier disruption in acute ischemic stroke and support the role of perfusion CT for the prediction of parenchymal hemorrhage.

Vessel Wall Enhancement and Blood–Cerebrospinal Fluid Barrier Disruption After Mechanical Thrombectomy in Acute Ischemic Stroke

“…Intravenous r-tPA was given within 4.5 hours from stroke onset after current recommendations, and MT was performed within 8 hours in eligible patients with proximal occlusions on CT angiography. 13 The presence of a malignant profile in CT perfusion and the absence of mismatch in patients with symptoms lasting >4.5 hours from stroke onset were exclusion criteria for receiving MT. In patients treated with rescue MT after systemic thrombolysis, r-tPA infusion was interrupted prematurely according to endovascular suite availability.…”

Elevated glucose is associated with hemorrhagic transformation after mechanical thrombectomy in acute ischemic stroke patients with severe pretreatment hypoperfusion

“…S1 online). MT was performed according to contemporary guidelines in patients with a proximal artery occlusion on CT angiography and a pretreatment ASPECTS equal or higher than 6, as previously reported 11 . Final vessel patency was graded on digital subtraction angiography (DSA) at the end of MT according to the modified Thrombolysis in Cerebral Infarction (TICI) score and successful recanalization was defined as a grade 2b-3.…”

“…ctp imaging analysis. Patients were scanned using a SIEMENS Somatom Definition Flash 128-section dual-source multidetector scanner (Siemens Healthineers, Erlangen, Germany), with a 98 mm z-coverage and a total acquisition time of 60 s (31 time points), as previously described 11 . The imaging protocol included a baseline multimodal whole-brain CT scan, which included a Non-Contrast CT (NCCT), a CT angiography and a CTP.…”

Complete reperfusion is required for maximal benefits of mechanical thrombectomy in stroke patients

“…The imaging protocol integrated a multimodal whole-brain CT scan, including a non-contrast CT (NCCT), CT angiography (CTA) and CT perfusion (CTP), which were performed at hospital admission using a SIEMENS Somatom Definition Flash unit, as reported 22 . Pre-treatment perfusion evaluation was performed using a commercially available semi-automated perfusion analysis software (Siemens) based on the maximum slope model of perfusion.…”