Infarct Core Reliability by CT Perfusion is a Time‐Dependent Phenomenon

Hoffmann, Rotem Sivan; Saban, Mor; Buxbaum, Chen; Firas, Srour; Sprecher, Elliot; Eran, Ayelet; Abergel, Eitan; Telman, Gregory

doi:10.1111/jon.12692

Cited by 26 publications

(35 citation statements)

References 25 publications

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“…Conventional CT-perfusion protocols come at the cost of higher radiation dose and the need for more contrast agent. Moreover, CT perfusion may not allow to withhold patients from MT either, due to the risk of infarct overestimation in the hyperacute setting [20][21][22][23].…”

Section: Discussionmentioning

confidence: 99%

Accuracy and Prognostic Role of NCCT-ASPECTS Depend on Time from Acute Stroke Symptom-onset for both Human and Machine-learning Based Evaluation

et al. 2021

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Purpose We hypothesize that the detectability of early ischemic changes on non-contrast computed tomography (NCCT) is limited in hyperacute stroke for both human and machine-learning based evaluation. In short onset-time-to-imaging (OTI), the CT angiography collateral status may identify fast stroke progressors better than early ischemic changes quantified by ASPECTS. Methods In this retrospective, monocenter study, CT angiography collaterals (Tan score) and ASPECTS on acute and follow-up NCCT were evaluated by two raters. Additionally, a machine-learning algorithm evaluated the ASPECTS scale on the NCCT (e-ASPECTS). In this study 136 patients from 03/2015 to 12/2019 with occlusion of the main segment of the middle cerebral artery, with a defined symptom-onset-time and successful mechanical thrombectomy (MT) (modified treatment in cerebral infarction score mTICI = 2c or 3) were evaluated. Results Agreement between acute and follow-up ASPECTS were found to depend on OTI for both human (Intraclass correlation coefficient, ICC = 0.43 for OTI < 100 min, ICC = 0.57 for OTI 100–200 min, ICC = 0.81 for OTI ≥ 200 min) and machine-learning based ASPECTS evaluation (ICC = 0.24 for OTI < 100 min, ICC = 0.61 for OTI 100–200 min, ICC = 0.63 for OTI ≥ 200 min). The same applied to the interrater reliability. Collaterals were predictors of a favorable clinical outcome especially in hyperacute stroke with OTI < 100 min (collaterals: OR = 5.67 CI = 2.38–17.8, p < 0.001; ASPECTS: OR = 1.44, CI = 0.91–2.65, p = 0.15) while ASPECTS was in prolonged OTI ≥ 200 min (collaterals OR = 4.21,CI = 1.36–21.9, p = 0.03; ASPECTS: OR = 2.85, CI = 1.46–7.46, p = 0.01). Conclusion The accuracy and reliability of NCCT-ASPECTS are time dependent for both human and machine-learning based evaluation, indicating reduced detectability of fast stroke progressors by NCCT. In hyperacute stroke, collateral status from CT-angiography may help for a better prognosis on clinical outcome and explain the occurrence of futile recanalization.

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Section: Discussionmentioning

confidence: 99%

Accuracy and Prognostic Role of NCCT-ASPECTS Depend on Time from Acute Stroke Symptom-onset for both Human and Machine-learning Based Evaluation

et al. 2021

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“…In fact, up to 20% of such patients might present with a final infarct volume lower than that of the admission volume, due to an overestimation of the latter by CTP in the early hours after stroke onset. 33,34 In the opposite situation of low ASPECTS associated with acceptable core volumes on CTP, a revision of early ischemic NCCT changes should be considered (eg, to exclude old infarctions or NCCT artifacts), especially for patients imaged in the extended time window and with good collateral circulation.…”

Section: Discussionmentioning

confidence: 99%

Correlation between ASPECTS and Core Volume on CT Perfusion: Impact of Time since Stroke Onset and Presence of Large-Vessel Occlusion

Nannoni

Ricciardi

Strambo

et al. 2021

AJNR Am J Neuroradiol

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BACKGROUND AND PURPOSE: Both ASPECTS and core volume on CTP are used to estimate infarct volume in acute ischemic stroke. To evaluate the potential role of ASPECTS for acute endovascular treatment decisions, we studied the correlation between ASPECTS and CTP core, depending on the timing and the presence of large-vessel occlusion. MATERIALS AND METHODS:We retrospectively reviewed all MCA acute ischemic strokes with standardized reconstructions of CTP maps entered in the Acute STroke Registry and Analysis of Lausanne (ASTRAL) registry. Correlation between ASPECTS and CTP core was determined for early (,6 hours) versus late (6-24 hours) times from stroke onset and in the presence versus absence of large-vessel occlusion. We used correlation coefficients and adjusted multiple linear regression models. RESULTS:We included 1046 patients with a median age of 71.4 years (interquartile range, IQR ¼ 59.8-79.4 years), an NIHSS score of 12 (IQR,(6)(7)(8)(9)(10)(11)(12)(13)(14)(15)(16)(17)(18), an ASPECTS of 9 (IQR, 7-10), and a CTP core of 13.6 mL (IQR, 0.6-52.8 mL). The overall correlation between ASPECTS and CTP core was moderate (r ¼ -0.49, P , .01) but significantly stronger in the late-versus-early window (r ¼ -0.56 and r ¼ -0.48, respectively; P ¼ .05) and in the presence versus absence of large-vessel occlusion (r ¼ -0.40 and r ¼ -0.20, respectively; P , .01). In the regression model, the independent association between ASPECTS and CTP core was confirmed and was twice as strong in late-arriving patients with large-vessel occlusion (b ¼ -0.21 per 10 mL; 95% CI, À0.27 to -0.15; P , .01) than in the overall population (b ¼ -0.10; 95% CI, À0.14 to -0.07; P , .01). CONCLUSIONS:In a large cohort of patients with acute ischemic stroke, we found a moderate correlation between ASPECTS and CTP core. However, this was stronger in patients with large-vessel occlusion and longer delay from stroke onset. Our results could support the use of ASPECTS as a surrogate marker of CTP core in late-arriving patients with acute ischemic stroke with large-vessel occlusion. ABBREVIATIONS: AIS¼ acute ischemic stroke; ASTRAL ¼ Acute STroke Registry and Analysis of Lausanne; CBS ¼ clot burden score; CTP ¼ Computed tomographic perfusion; EVT ¼ endovascular treatment; LPGH ¼ last proof of good health; LVO ¼ large-vessel occlusion; MCA ¼ middle cerebral artery; NCCT ¼ non-contrast CT scan

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“…Similarly, the HERMES collaboration that pooled patient-level data from all randomized controlled trials that compared endovascular thrombectomy with standard medical therapy in patients with an anterior circulation ischaemic stroke demonstrated that TTR mattered mostly for low stroke ischemic core volumes ( 9 ). Yet, actual recommendations argue against computed tomography perfusion (CTP) imaging in early onset LVO on the basis of: (1) the delay incurred in further imaging acquisitions, (2) the risk of potential overestimation of the core volume in early LVO (Ghost effect) ( 10 ) reported in as many as 50% of cases ( 10 , 11 ), (3) the technical issues that make CTP unreliable in as many as 13% of cases ( 12 ). Still, the increasing number of patients treated by mechanical thrombectomy for LVO and the associated costs of the procedure plead an accurate selection of patients who will most benefit from the procedure within 6 h of symptom onset.…”

Section: Introductionmentioning

confidence: 99%

Stroke Core Volume Weighs More Than Recanalization Time for Predicting Outcome in Large Vessel Occlusion Recanalized Within 6 h of Symptoms Onset

et al. 2022

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IntroductionCurrent guidelines suggest that perfusion imaging should only be performed > 6 h after symptom onset. Pathophysiologically, brain perfusion should matter whatever the elapsed time. We aimed to compare relative contribution of recanalization time and stroke core volume in predicting functional outcome in patients treated by endovascular thrombectomy within 6-h of stroke-onset.MethodsConsecutive patients presenting between January 2015 and June 2021 with (i) an acute ischaemic stroke due to an anterior proximal occlusion, (ii) a successful thrombectomy (TICI >2a) within 6-h of symptom-onset and (iii) CT perfusion imaging were included. Core stroke volume was automatically computed using RAPID software. Two linear regression models were built that included in the null hypothesis the pre-treatment NIHSS score and the hypoperfusion volume (Tmax > 6 s) as confounding variables and 24 h post-recanalization NIHSS and 90 days mRS as outcome variables. Time to recanalization was used as covariate in one model and stroke core volume as covariate in the other.ResultsFrom a total of 377 thrombectomies, 94 matched selection criteria. The Model null hypothesis explained 37% of the variability for 24 h post-recanalization NIHSS and 42% of the variability for 90 days MRS. The core volume as covariate increased outcome variability prediction to 57 and 56%, respectively. Time to recanalization as covariate marginally increased outcome variability prediction from 37 and 34% to 40 and 42.6%, respectively.ConclusionCore stroke volume better explains outcome variability in comparison to the time to recanalization in anterior large vessel occlusion stroke with successful thrombectomy done within 6 h of symptoms onset. Still, a large part of outcome variability prediction fails to be explained by the usual predictors.

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Infarct Core Reliability by CT Perfusion is a Time‐Dependent Phenomenon

Cited by 26 publications

References 25 publications

Accuracy and Prognostic Role of NCCT-ASPECTS Depend on Time from Acute Stroke Symptom-onset for both Human and Machine-learning Based Evaluation

Accuracy and Prognostic Role of NCCT-ASPECTS Depend on Time from Acute Stroke Symptom-onset for both Human and Machine-learning Based Evaluation

Correlation between ASPECTS and Core Volume on CT Perfusion: Impact of Time since Stroke Onset and Presence of Large-Vessel Occlusion

Stroke Core Volume Weighs More Than Recanalization Time for Predicting Outcome in Large Vessel Occlusion Recanalized Within 6 h of Symptoms Onset

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