Computed tomography perfusion–based selection of patients for endovascular recanalization

Abstract

<jats:p>Intravenous and intraarterial recombinant tissue plasminogen activator remains underutilized in the treatment of acute ischemic stroke, largely due to strict adherence to the concept of the therapeutic time window for administration. Recent efforts to expand the number of patients eligible for thrombolysis have been mirrored by an evolution in endovascular recanalization technology and techniques. As a result, there is a growing need to establish efficient and reliable means by which to select candidates for endovascular intervention beyond the traditional criteria of time from symptom onset. Perfusion imaging techniques, particularly CT perfusion used in combination with CT angiography, represent an increasingly recognized means by which to identify those patients who stand to benefit most from endovascular recanalization. Additionally, CT perfusion and CT angiography appear to provide sufficient data by which to exclude patients in whom there is little chance of neurological recovery or a substantial risk of postprocedure symptomatic intracranial hemorrhage. The authors review the current literature as it pertains to the limitations of time-based selection of patients for intervention, the increasing utilization of endovascular therapy, and the development of a CT perfusion-based selection of acute stroke patients for endovascular recanalization. Future endeavors must prospectively evaluate the utility and safety of CT perfusion-based selection of candidates for endovascular intervention.</jats:p>

Interventional Stroke Therapies in the Elderly: Are We Helping?

“…Recent studies have indicated that the extent of perfusion deficits may indicate risk of hemorrhagic transformation. 41 The high mortality rate in the older age group makes analysis of long-term functional outcomes susceptible to selection bias. We did not distinguish between anterior and posterior circulation strokes or the different types of recanalization methods (due to the small numbers).…”

Pretreatment Advanced Imaging in Patients with Stroke Treated with IV Thrombolysis: Evaluation of a Multihospital Data Base

“…[4][5][6] CT perfusion may potentially allow discrimination between salvageable brain ("penumbra") and brain already doomed to infarction ("ischemic core") 2,[7][8][9][10] and thus may be useful in helping to refine selection of patients for IV thrombolysis 11,12 or intra-arterial thrombectomy. [13][14][15] MR perfusion and diffusion imaging have also been reported to be useful in screening patients for intravenous therapy. [16][17][18][19][20][21][22] While advanced imaging techniques hold promise for the evaluation of patients with acute ischemic stroke, there is variation in techniques and definitions of parameters that limit wide application and acceptance of these techniques.…”

Diagnostic and Prognostic Impact of pc‐ASPECTS Applied to Perfusion CT in the Basilar Artery International Cooperation Study

“…In patients with anterior circulation stroke, CTP seems to allow an estimation of the final infarct size similarly to stroke MRI . Areas with increased MTT include potentially reversible ischemic lesions, whereas almost all areas with relatively reduced CBV or hypoattenuation on CTA‐SI may lead to irreversible ischemia . For patients with posterior circulation stroke, the data on the prognostic impact of CTP is limited to case reports .…”