Computed Tomographic Perfusion Predicts Poor Outcomes in a Randomized Trial of Endovascular Therapy

Wannamaker, Robert; Guinand, Taurian; Menon, Bijoy K; Demchuk, Andrew M.; Goyal, Mayank; Frei, Donald; Bharatha, Aditya; Jovin, Tudor G; Shankar, Jai; Krings, Timo; Baxter, Blaise; Holmstedt, Christine; Swartz, Richard H.; Dowlatshahi, Dar; Chan, Richard; Tampieri, Donatella; Choe, Hana; Burns, Paul; Gentile, Nina; Rempel, Jeremy; Shuaib, Ashfaq; Buck, Brian; Bivard, Andrew; Hill, Michael D.; Butcher, Ken

doi:10.1161/strokeaha.117.019806

Cited by 29 publications

(22 citation statements)

References 34 publications

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“…Our results are in line with the previous finding that most patients who had a proximal large vessel occlusion with a moderate-to-good collateral circulation on the ASPECTS collateral score are more likely to have a large penumbral volume (17). For example, the ESCAPE trial (Endovascular Treatment for Small Core and Anterior Circulation Proximal Occlusion with Emphasis on Minimizing CT to Recanalization Times) used collateral assessments on mCTA for endovascular thrombectomy patient selection (5), and most patients included in the ESCAPE trial who underwent CTP imaging had a penumbral pattern (17). This is because patient with a good collateral circulation are more likely to have a large penumbra lesion with a corresponding small ischemic core and so were very likely to have target mismatch.…”

Section: Discussionsupporting

confidence: 93%

Dynamic CT but Not Optimized Multiphase CT Angiography Accurately Identifies CT Perfusion Target Mismatch Ischemic Stroke Patients

et al. 2019

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Imaging protocols for acute ischemic stroke varies significantly from center to center leading to challenges in research translation. We aimed to assess the inter-rater reliability of collateral grading systems derived from dynamic computed tomography angiography (CTA) and an optimized multiphase CTA and, to analyze the association of the two CTA modalities with CT perfusion (CTP) compartments by comparing the accuracy of dynamic CTA (dCTA) and optimized multiphase CTA (omCTA) in identifying CT perfusion (CTP) target mismatch patients. Acute ischemic stroke patients with a proximal large vessel occlusion who underwent whole brain CTP were included in the study. Collateral status were assessed using ASPECTS collaterals (Alberta Stroke Program Early CT Score on Collaterals) and ASITN/SIR collateral system (the American Society of Interventional and Therapeutic Neuroradiology/Society of Interventional Radiology) on dCTA and omCTA. Eighty-one patients were assessed, with a median ischemic core volume of 29 mL. The collateral assessment with ASPECTS collaterals using dCTA have a similar inter-rater agreement (K-alpha: 0.71) compared to omCTA (K-alpha: 0.69). However, the agreement between dCTA and CTP in classifying patients with target mismatch was higher compared to omCTA (Kappa, dCTA: 0.81; omCTA: 0.64). We found dCTA was more accurate than omCTA in identifying target mismatch patients with proximal large vessel occlusion.

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Section: Discussionsupporting

confidence: 93%

Dynamic CT but Not Optimized Multiphase CT Angiography Accurately Identifies CT Perfusion Target Mismatch Ischemic Stroke Patients

et al. 2019

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“…It is likely that insufficient collateral flow that leads to rapid tissue infarction accounts for the lack of benefit due to recanalization in many of these patients. Supporting this, multiphase CT angiography data from the ESCAPE (Endovascular treatment for Small Core and Anterior circulation Proximal occlusion with Emphasis on minimizing CT to recanalization times) trial identified a strong association between pre-treatment cerebral pial collaterals and favorable outcome after recanalization [30][31][32] . Similarly, patients with "slow-growing infarcts" due to good collateral circulation in the (DWI or CTP Assessment with Clinical Mismatch in the Triage of Wake-Up and Late Presenting Strokes Undergoing Neurointervention with Trevo) and DEFUSE3 (Endovascular Therapy Following Imaging Evaluation for Ischemic Stroke 3) trials benefitted from late thrombectomy (6 to 24 h after stroke onset), likely due to sufficient collateral circulation to maintain tissue viability prior to recanalization up to 24 h post stroke [33][34][35][36][37][38][39][40][41][42] .…”

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confidence: 86%

Improved collateral flow and reduced damage after remote ischemic perconditioning during distal middle cerebral artery occlusion in aged rats

Shuaib

et al. 2020

Sci Rep

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circulation through cerebral collaterals can maintain tissue viability until reperfusion is achieved. However, collateral circulation is time limited, and failure of collaterals is accelerated in the aged. Remote ischemic perconditioning (RIPerC), which involves inducing a series of repetitive, transient peripheral cycles of ischemia and reperfusion at a site remote to the brain during cerebral ischemia, may be neuroprotective and can prevent collateral failure in young adult rats. Here, we demonstrate the efficacy of RIPerC to improve blood flow through collaterals in aged (16-18 months of age) Sprague Dawley rats during a distal middle cerebral artery occlusion. Laser speckle contrast imaging and two-photon laser scanning microscopy were used to directly measure flow through collateral connections to ischemic tissue. Consistent with studies in young adult rats, RIPerC enhanced collateral flow by preventing the stroke-induced narrowing of pial arterioles during ischemia. This improved flow was associated with reduced early ischemic damage in RIPerC treated aged rats relative to controls. Thus, RIPerC is an easily administered, non-invasive neuroprotective strategy that can improve penumbral blood flow via collaterals. Enhanced collateral flow supports further investigation as an adjuvant therapy to recanalization therapy and a protective treatment to maintain tissue viability prior to reperfusion.

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“…A large area of irreversible infarct and a small area of "ischemic penumbra" or peripheral zone of reversible ischemia is considered a contraindication for endovascular reperfusion due to the risk of hemorrhage and low likelihood of a good outcome. CTP, however, has been shown to be useful in clinical practice because it can elucidate the presence of a large penumbral zone, which is a predictor of good neurologic outcome after reperfusion [10].…”

Section: Discussionmentioning

confidence: 99%

CT Perfusion Protocol for Acute Stroke Expedites Mechanical Thrombectomy

Jenson

Libby

Soule

et al. 2019

Cureus

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The evaluation of a patient suspected of having an acute cerebrovascular accident is initiated with computed tomography (CT) and computed tomography angiogram (CTA) cross-sectional imaging of the head. Eligible patients may subsequently receive magnetic resonance imaging (MRI) utilizing a hyperacute stroke protocol. Clinical and imaging selection criteria are used to assess candidates for possible thrombectomy or thrombolysis. Prompt restoration of flow to ischemic regions of the cerebrum may result in improved neurological outcomes. Reducing delays in diagnosis and treatment remains paramount to effective treatment of ischemic cerebrovascular events. In an effort to expedite intra-arterial intervention, we replaced our institutional MRI protocol with a CT perfusion protocol. The amount of time the patient spent undergoing imaging was measured with each protocol and is referred to as "stroke imaging time." The purpose of this study was to compare the difference in the amount of time patients spent undergoing imaging when the acute stroke workup was performed with MRI vs. CT perfusion. Stroke imaging time decreased from an average of 158 minutes to 81 minutes (49%) by substituting CT perfusion for MRI. Utilizing CT perfusion in lieu of MRI in the hyperacute stroke protocol may expedite intra-arterial intervention.

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Computed Tomographic Perfusion Predicts Poor Outcomes in a Randomized Trial of Endovascular Therapy

Cited by 29 publications

References 34 publications

Dynamic CT but Not Optimized Multiphase CT Angiography Accurately Identifies CT Perfusion Target Mismatch Ischemic Stroke Patients

Dynamic CT but Not Optimized Multiphase CT Angiography Accurately Identifies CT Perfusion Target Mismatch Ischemic Stroke Patients

Improved collateral flow and reduced damage after remote ischemic perconditioning during distal middle cerebral artery occlusion in aged rats

CT Perfusion Protocol for Acute Stroke Expedites Mechanical Thrombectomy

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