Hypoperfusion Index Ratio as a Surrogate of Collateral Scoring on CT Angiogram in Large Vessel Stroke

Wang, Chunmin; Chang, Yu‐Ming; Sung, Pi Shan; Chen, Chih‐Hung

doi:10.3390/jcm10061296

Cited by 20 publications

(10 citation statements)

References 27 publications

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“…Thus, HIR has an impact on the evolution of the ischemic lesion. Our results correspond to previous studies, which could show that lower HIR is associated with a smaller infarct growth and better collateral circulation [ 17 , 18 , 21 , 22 , 23 ]. In the group of favorable HIR, FIV was rather overestimated by the perfusion software solutions with the exception of Brainomix, while it was generally underestimated in the group of unfavorable HIR.…”

Section: Discussionsupporting

confidence: 92%

“…Analogously, we found that ASPECTS at baseline and on follow-up imaging and the risk of developing malignant edema were significantly associated with the HIR. The median HIR in our study lies within the range of the cutoff values applied in previous studies (0.4–0.7) [ 17 , 18 , 21 , 22 , 23 , 24 , 25 , 26 , 27 ]. However, further research is necessary to define a generally valid cutoff value for HIR.…”

Section: Discussionsupporting

confidence: 83%

“…Tissue with a higher percentage of less prolonged blood flow, however, may be at lower risk of infarction. The hypoperfusion intensity ratio (HIR), which represents the proportion of Tmax > 6 s lesion with a Tmax > 10 s delay, has been found to be an indicator of the collateral circulation [ 17 ]. It helps to identify tissue with more severely reduced cerebral blood flow, which has a potential impact on the evolution of the acute ischemic lesion [ 18 ].…”

Section: Introductionmentioning

confidence: 99%

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Prognostic Accuracy of CTP Summary Maps in Patients with Large Vessel Occlusive Stroke and Poor Revascularization after Mechanical Thrombectomy—Comparison of Three Automated Perfusion Software Applications

et al. 2022

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Background: Innovative automated perfusion software solutions offer support in the management of acute stroke by providing information about the infarct core and penumbra. While the performance of different software solutions has mainly been investigated in patients with successful recanalization, the prognostic accuracy of the hypoperfusion maps in cases of futile recanalization has hardly been validated. Methods: In 39 patients with acute ischemic stroke (AIS) due to large vessel occlusion (LVO) in the anterior circulation and poor revascularization (thrombolysis in cerebral infarction (TICI) 0-2a) after mechanical thrombectomy (MT), hypoperfusion analysis was performed using three different automated perfusion software solutions (A: RAPID, B: Brainomix e-CTP, C: Syngo.via). The hypoperfusion volumes (HV) as Tmax > 6 s were compared with the final infarct volumes (FIV) on follow-up CT 36–48 h after futile recanalization. Bland–Altman analysis was applied to display the levels of agreement and to evaluate systematic differences. Based on the median hypoperfusion intensity ratio (HIR, volumetric ratio of tissue with a Tmax > 10 s and Tmax > 6 s) patients were dichotomized into high- and low-HIR groups. Subgroup analysis with favorable (<0.6) and unfavorable (≥0.6) HIR was performed with respect to the FIV. HIR was correlated to clinical baseline and outcome parameters using Pearson’s correlation. Results: Overall, there was good correlation without significant differences between the HVs and the FIVs with package A (r = 0.78, p < 0.001) being slightly superior to B and C. However, levels of agreement were very wide for all software applications in Bland-Altman analysis. In cases of large infarcts exceeding 150 mL the performance of the automated software solutions generally decreased. Subgroup analysis revealed the FIV to be generally underestimated in patients with HIR ≥ 0.6 (p < 0.05). In the subgroup with favorable HIR, however, there was a trend towards an overestimation of the FIV. Nevertheless, packages A and B showed good correlation between the HVs and FIVs without significant differences (p > 0.2), while only package C significantly overestimated the FIV (−54.6 ± 56.0 mL, p = 0.001). The rate of modified Rankin Scale (mRS) 0–3 after 3 months was significantly higher in favorable vs. unfavorable HIR (42.1% vs. 13.3%, p = 0.02). Lower HIR was associated with higher Alberta Stroke Program Early CT Score (ASPECTS) at presentation and on follow-up imaging, lower risk of malignant edema, and better outcome (p < 0.05). Conclusion: Overall, the performance of the automated perfusion software solutions to predict the FIV after futile recanalization is good, with decreasing accuracy in large infarcts exceeding 150 mL. However, depending on the HIR, FIV can be significantly over- and underestimated, with Syngo showing the widest range. Our results indicate that the HIR can serve as valuable parameter for outcome predictions and facilitate the decision whether or not to perform MT in delicate cases.

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Section: Discussionsupporting

confidence: 92%

Section: Discussionsupporting

confidence: 83%

Section: Introductionmentioning

confidence: 99%

See 1 more Smart Citation

Prognostic Accuracy of CTP Summary Maps in Patients with Large Vessel Occlusive Stroke and Poor Revascularization after Mechanical Thrombectomy—Comparison of Three Automated Perfusion Software Applications

et al. 2022

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“…21 Our analysis supports the hypothesis and explores perfusion imaging parameters to potentially guide anesthesia choice. Although HIR may have shown good correlation with collaterals flow on CT angiogram, 15,22,23 variations within good and poor grades of HIR may have contributed to some of our findings.…”

Section: Discussionmentioning

confidence: 67%

Thrombectomy Outcomes With General vs Nongeneral Anesthesia

et al. 2023

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Background and Objectives:The effect of anesthesia choice on endovascular thrombectomy(EVT) outcomes is unclear. Collateral status on perfusion imaging may help identify the optimal anesthesia choice.Methods:In a pooled patient level analysis of EXTEND-IA, EXTEND-IA TNK, EXTEND-IA TNK part II and SELECT, EVT functional outcomes(mRS distribution) were compared between general anesthesia(GA) vs non-general anesthesia(non-GA) in a propensity matched sample. Further, we evaluated the association of collateral flow on perfusion imaging, assessed by hypoperfusion intensity ratio(HIR) – Tmax>10s/Tmax>6s(good collaterals – HIR<0.4, poor collaterals – HIR≥0.4) on the association between anesthesia type and EVT outcomes.Results:Of 725 treated with EVT, 299(41%) received GA and 426(59%) non-GA. The baseline characteristics differed in presentation NIHSS(median[IQR]-GA:18[13-22], non-GA:16[11-20],p<0.001) and ischemic core volume(GA:15.0mL[3.2-38.0] vs non-GA:9.0mL[0.0-31.0],p<0.001). Additionally, GA was associated with longer last-known-well(LKW) to arterial access (203min[157-267] vs 186min[138-252],p=0.002), but similar procedural time (35.5min[23-59] vs 34min[22-54],p=0.51). Of 182 matched pairs using propensity scores, baseline characteristics were similar. In the PS-matched pairs, GA was independently associated with worse functional outcomes(adj cOR:0.64,95%CI:0.44-0.93,p=0.021) and higher neurological worsening(GA:14.9% vs non-GA:8.9%, aOR:2.10,95%CI: 1.02-4.33,p=0.045). Patients with poor collaterals had worse functional outcomes with GA(adj cOR:0.47,95%CI:0.29-0.76,p=0.002), while no difference was observed in those with good collaterals(adj. cOR:0.93,95%CI:0.50-1.74,p=0.82), Pinteraction:0.07. No difference was observed in infarct growth overall and in patients with good collaterals, whereas patients with poor collaterals demonstrated larger infarct growth with GA with a significant interaction between collaterals and anesthesia type on infarct growth rate(Pinteraction:0.020).Conclusion:GA was associated with worse functional outcomes after EVT, particularly in patients with poor collaterals in a PS matched analysis from a pooled, patient-level cohort from 3 randomized trials and one prospective cohort study. The confounding by indication may persist despite the doubly robust nature of the analysis. These findings have implications for randomized trials of GA vs non-GA and may be of utility for clinicians when making anesthesia type choice.Classification of Evidence:This study provides Class III evidence that that use of general anesthesia is associated with worse functional outcome in patients undergoing endovascular thrombectomy.Trial registrations:EXTEND-IA:ClinicalTrials.gov (NCT01492725); EXTEND-IA TNK:ClinicalTrials.gov (NCT02388061); EXTEND-IA TNK part II:ClinicalTrials.gov (NCT03340493); SELECT:ClinicalTrials.gov (NCT02446587).

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“…In patients suffering from AIS, collateral circulation plays an important role in maintaining the blood flow to the tissue at risk of becoming ischemic, and in reducing the risk of hemorrhagic transformation in patients undergoing MT [ 14 ]. HI has been shown to be a good surrogate for predicting the CS in patients with acute LVO [ 15 ]. Various previous studies have explored the association between patient baseline characteristics and the CS, however variable results have been reported, most likely due to the heterogenous nature of the patient population [ 16 , 17 , 18 , 19 , 20 , 21 , 22 ].…”

Section: Discussionmentioning

confidence: 99%

Baseline Characteristics Associated with Good Collateral Status Using Hypoperfusion Index as an Outcome

et al. 2022

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Up to 30% of ischemic stroke cases are due to large vessel occlusion (LVO), causing significant morbidity. Studies have shown that the collateral circulation of patients with acute ischemic stroke (AIS) secondary to LVO can predict their clinical and radiological outcomes. The aim of this study is to identify baseline patient characteristics that can help predict the collateral status of these patients for improved triage. In this IRB approved retrospective study, consecutive patients presenting with AIS secondary to anterior circulation LVO were identified between September 2019 and August 2021. The baseline patient characteristics, laboratory values, imaging features and outcomes were collected using a manual chart review. From the 181 consecutive patients initially reviewed, 54 were confirmed with a clinical diagnosis of AIS and anterior circulation LVO. In patients with poor collateral status, the body mass index (BMI) was found to be significantly lower compared to those with good collateral status (26.4 ± 5.6 vs. 31.7 ± 12.3; p = 0.045). BMI of >35 kg/m2 was found to predict the presence of good collateral status. Age was found to be significantly higher (70.5 ± 9.6 vs. 58.9 ± 15.6; p = 0.034) in patients with poor collateral status and M1 strokes associated with older age and BMI.

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Hypoperfusion Index Ratio as a Surrogate of Collateral Scoring on CT Angiogram in Large Vessel Stroke

Cited by 20 publications

References 27 publications

Prognostic Accuracy of CTP Summary Maps in Patients with Large Vessel Occlusive Stroke and Poor Revascularization after Mechanical Thrombectomy—Comparison of Three Automated Perfusion Software Applications

Prognostic Accuracy of CTP Summary Maps in Patients with Large Vessel Occlusive Stroke and Poor Revascularization after Mechanical Thrombectomy—Comparison of Three Automated Perfusion Software Applications

Thrombectomy Outcomes With General vs Nongeneral Anesthesia

Baseline Characteristics Associated with Good Collateral Status Using Hypoperfusion Index as an Outcome

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