Admission CT perfusion may overestimate initial infarct core: the ghost infarct core concept

Boned, Sandra; Padroni, Marina; Rubiera, Marta; Tomasello, Alejandro; Coscojuela, Pilar; Romero, Nicolás; Muchada, Marián; Rodríguez‐Luna, David; Flores, Alan; Rodriguez, Noelia; Juega, Jesús; Pagola, Jorge; Alvarez-Sabin, José; Molina, Carlos A.; Ribó, Marc

doi:10.1136/neurintsurg-2016-012494

Cited by 137 publications

(153 citation statements)

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“…In this study, we found a cutoff of approximately 4.5 h to imaging and of 5 h to recanalization as independent predictors of GIC in CBF < 30%. These results are in line with our previous findings [15] and others [9].…”

Section: Discussionsupporting

confidence: 83%

“…GIC is defined as the infarct core initially predicted by CTP that appears as intact brain tissue on follow-up imaging. The existence of GIC implies that the initial core estimated by CTP may include, to some extent, salvageable brain tissue [15]. Characterization of this phenomenon is crucial to avoid exclusion of patients from a treatment that can still be of benefit.…”

Section: Discussionmentioning

confidence: 99%

“…The phenomenon was named "ghost infarct core" (GIC) and was associated with early imaging after onset followed by early complete recanalization [15]. In the present study, we aimed to confirm and better characterize this phenomenon using CTP CBF as the reference parameter to determine infarct core.…”

Section: Introductionmentioning

confidence: 97%

“…Final infarct volume was measured on follow-up imaging at 24 h on noncontrast cerebral tomography by a vascular neurologist using the A × B × C / 2 formula [16]. GIC was defined and considered when initial core volume minus final infarct volume was > 10 mL [15] (Fig. 1).…”

Section: Methodsmentioning

confidence: 99%

“…Whereas some authors found a good correlation between the initial lesion characterized by decreased cerebral blood volume (CBV) and final infarct [9][10][11][12], others such as Bivard et al [13], considered cerebral blood flow (CBF) a more specific parameter to define infarct core. The best CTP predictor of infarct core is not validated yet, and models using several perfusion measures have been proposed [14,15].…”

Section: Introductionmentioning

confidence: 99%

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Ghost Infarct Core and Admission Computed Tomography Perfusion: Redefining the Role of Neuroimaging in Acute Ischemic Stroke

et al. 2018

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Background: Determining the size of infarct extent is crucial to elect patients for reperfusion therapies. Computed tomography perfusion (CTP) based on cerebral blood volume may overestimate infarct core on admission and consequently include ghost infarct core (GIC) in a definitive lesional area. Purpose: Our goal was to confirm and better characterize the GIC phenomenon using CTP cerebral blood flow (CBF) as the reference parameter to determine infarct core. Methods: We performed a retrospective, single-center analysis of consecutive thrombectomies of middle cerebral or intracranial internal carotid artery occlusions considering noncontrast CT Alberta Stroke Program Early CT Score ≥6 in patients with pretreatment CTP. We used the RAPID® software to measure admission infarct core based on initial CBF. The final infarct was extracted from follow-up CT. GIC was defined as initial core minus final infarct > 10 mL. Results: A total of 123 patients were included. The median National Institutes of Health Stroke Scale score was 18 (13–20), the median time from symptoms to CTP was 188 (67–288) min, and the recanalization rate (Thrombolysis in Cerebral Infarction score 2b, 2c, or 3) was 83%. Twenty patients (16%) presented with GIC. GIC was associated with shorter time to recanalization (150 [105–291] vs. 255 [163–367] min, p = 0.05) and larger initial CBF core volume (38 [26–59] vs. 6 [0–27] mL, p < 0.001). An adjusted logistic regression model identified time to recanalization < 302 min (OR 4.598, 95% CI 1.143–18.495, p = 0.032) and initial infarct volume (OR 1.01, 95% CI 1.001–1.019, p = 0.032) as independent predictors of GIC. At 24 h, clinical improvement was more frequent in patients with GIC (80 vs. 49%, p = 0.01). Conclusions: CTP CBF < 30% may overestimate infarct core volume, especially in patients imaged in the very early time window and with fast complete reperfusion. Therefore, the CTP CBF technique may exclude patients who would benefit from endovascular treatment.

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Section: Discussionsupporting

confidence: 83%

Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 97%

Section: Methodsmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

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Ghost Infarct Core and Admission Computed Tomography Perfusion: Redefining the Role of Neuroimaging in Acute Ischemic Stroke

et al. 2018

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Association of Noncontrast Computed Tomography and Perfusion Modalities With Outcomes in Patients Undergoing Late-Window Stroke Thrombectomy

et al. 2022

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ImportanceThere is substantial controversy with regards to the adequacy and use of noncontrast head computed tomography (NCCT) for late-window acute ischemic stroke in selecting candidates for mechanical thrombectomy.ObjectiveTo assess clinical outcomes of patients with acute ischemic stroke presenting in the late window who underwent mechanical thrombectomy stratified by NCCT admission in comparison with selection by CT perfusion (CTP) and diffusion-weighted imaging (DWI).Design, Setting, and ParticipantsIn this multicenter retrospective cohort study, prospectively maintained Stroke Thrombectomy and Aneurysm (STAR) database was used by selecting patients within the late window of acute ischemic stroke and emergent large vessel occlusion from 2013 to 2021. Patients were selected by NCCT, CTP, and DWI. Admission Alberta Stroke Program Early CT Score (ASPECTS) as well as confounding variables were adjusted. Follow-up duration was 90 days. Data were analyzed from November 2021 to March 2022.ExposuresSelection by NCCT, CTP, or DWI.Main Outcomes and MeasuresPrimary outcome was functional independence (modified Rankin scale 0-2) at 90 days.ResultsAmong 3356 patients, 733 underwent late-window mechanical thrombectomy. The median (IQR) age was 69 (58-80) years, 392 (53.5%) were female, and 449 (65.1%) were White. A total of 419 were selected with NCCT, 280 with CTP, and 34 with DWI. Mean (IQR) admission ASPECTS were comparable among groups (NCCT, 8 [7-9]; CTP, 8 [7-9]; DWI 8, [7-9]; P = .37). There was no difference in the 90-day rate of functional independence (aOR, 1.00; 95% CI, 0.59-1.71; P = .99) after adjusting for confounders. Symptomatic intracerebral hemorrhage (NCCT, 34 [8.6%]; CTP, 37 [13.5%]; DWI, 3 [9.1%]; P = .12) and mortality (NCCT, 78 [27.4%]; CTP, 38 [21.1%]; DWI, 7 [29.2%]; P = .29) were similar among groups.Conclusions and RelevanceIn this cohort study, comparable outcomes were observed in patients in the late window irrespective of neuroimaging selection criteria. Admission NCCT scan may triage emergent large vessel occlusion in the late window.

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Disentangling Workflow Paradigms and Treatment Decision-Making in Acute Ischemic Stroke—Reply

Ribó

Requena

2022

JAMA Neurol

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Dr Ospel reported receiving consultant fees from NICOLab. Dr Goyal reported receiving consulting fees from Medtronic, Stryker, Microvention, and Mentice and has a patent for systems of stroke diagnosis licensed to GE Healthcare. No other disclosures were reported.1. Requena M, Olivé-Gadea M, Muchada M, et al. Direct-to-angiography suite without stopping for computed tomography imaging for patients with acute stroke: a randomized clinical trial.

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Admission CT perfusion may overestimate initial infarct core: the ghost infarct core concept

Abstract: CT perfusion may overestimate final infarct core, especially in the early time window. Selecting patients for reperfusion therapies based on the CTP mismatch concept may deny treatment to patients who might still benefit from reperfusion.

Cited by 137 publications

References 23 publications

Ghost Infarct Core and Admission Computed Tomography Perfusion: Redefining the Role of Neuroimaging in Acute Ischemic Stroke

Ghost Infarct Core and Admission Computed Tomography Perfusion: Redefining the Role of Neuroimaging in Acute Ischemic Stroke

Association of Noncontrast Computed Tomography and Perfusion Modalities With Outcomes in Patients Undergoing Late-Window Stroke Thrombectomy

Disentangling Workflow Paradigms and Treatment Decision-Making in Acute Ischemic Stroke—Reply

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