The Role of CT Perfusion in Defining the Clinically Relevant Core Infarction to Guide Thrombectomy Selection in Patients with Acute Stroke

Abstract

BACKGROUND AND PURPOSE Infarct core assessment on presentation is important to evaluate salvageable tissue to select patients for thrombectomy. Our study aims to evaluate the correlation between infarct core volume measured by computed tomography (CT) perfusion (CTP) and magnetic resonance diffusion‐weighted imaging (MR‐DWI) in patients with acute large‐vessel occlusion. METHODS We studied patients who underwent CTP on presentation to the emergency department for stroke symptoms. National Institute of Health Stroke Scale (NIHSS), collateral status, symptomatic vessels, and modified Rankin scale (mRS) at 90 days were collected. Admission infarct core volume was measured on initial relative cerebral blood volume and final infarct core volume on follow‐up DWI. The correlation between two measures was assessed using Pearson's correlation coefficient. RESULTS Seventy‐four patients were studied of which 41.9% were female. Median NIHSS was 13 (2‐30). Middle cerebral artery occlusion was present in 53 (71.6%) patients and 54 (72.9%) had good collaterals. Good functional outcome of mRS 0‐2 was achieved by 60.8% at 90 days. There was a strong correlation between CTP and MR‐DWI (r = .94). There was no significant difference between volume (in milliliters) on CTP (54.1 ± 69.8) and volume on DWI (50.3 ± 59.7; P = .18) using the paired t‐test. CONCLUSION CTP provides a good estimation of the core infarct volume. It performs well within the clinically relevant thresholds for patient selection for thrombectomy.

Mechanical Thrombectomy for Acute Stroke: Early versus Late Time Window Outcomes

“…26 False overestimation of infarct core is rare. 27 Recent studies have shown that penumbral profile on CTP is a better predictor of outcome as compared to ischemic changes on NCCT and collaterals on CTA even within the early (0-6 hours) treatment window and is a better modality for patient selection. [25][26][27][28] Recent studies have suggested superiority of MRI in assessing ischemic core as compared to CTP.…”

“…27 Recent studies have shown that penumbral profile on CTP is a better predictor of outcome as compared to ischemic changes on NCCT and collaterals on CTA even within the early (0-6 hours) treatment window and is a better modality for patient selection. [25][26][27][28] Recent studies have suggested superiority of MRI in assessing ischemic core as compared to CTP. [29][30][31] However, subgroup analyses from SWIFT-PRIME (early window) and DEFUSE III (late window) studies did not show a difference in outcome for CTP versus MRI selected patients.…”

“…CTP has been shown to provide accurate infarct core assessment using MRI‐DWI as reference standard 26 . False overestimation of infarct core is rare 27 . Recent studies have shown that penumbral profile on CTP is a better predictor of outcome as compared to ischemic changes on NCCT and collaterals on CTA even within the early (0‐6 hours) treatment window and is a better modality for patient selection 25‐28 .…”

Automated CT Perfusion Detection of the Acute Infarct Core in Ischemic Stroke: A Systematic Review and Meta-Analysis

“…A search of the references of included studies and previous systematic reviews [17, 18, 20, 21] identified 4 additional studies. A total of 167 full-text papers were reviewed and 48 studies [8, 12‒14, 29‒72] met the inclusion criteria (Fig. 1).…”