Association of CT Perfusion Parameters with Hemorrhagic Transformation in Acute Ischemic Stroke

Jain, Anunaya; Jain, Minal; Kanthala, A.R.; Damania, Dushyant; Ganti, Latha; Wang, H.Z.; Jahromi, Babak S.

doi:10.3174/ajnr.a3502

Cited by 62 publications

(60 citation statements)

References 41 publications

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“…The maximum AUC for predicting HT found in our study was relatively low at 0.77, but was within the range of the results of other multivariate analyses in studies investigating predictors of HT with CTP (range 0.69–0.92) [13, 16, 17, 19, 31]. We did find a significant relation between CBV deficit and BBBP, and the occurrence of HT in univariate analysis, but this could not be confirmed in our multivariate analysis.…”

Section: Discussionsupporting

confidence: 54%

Computed Tomography Perfusion Derived Blood-Brain Barrier Permeability Does Not Yet Improve Prediction of Hemorrhagic Transformation

et al. 2018

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Introduction: Hemorrhagic transformation (HT) in acute ischemic stroke can occur as a result of reperfusion treatment. While withholding treatment may be warranted in patients with increased risk of HT, prediction of HT remains difficult. Nonlinear regression analysis can be used to estimate blood-brain barrier permeability (BBBP). The aim of this study was to identify a combination of clinical and imaging variables, including BBBP estimations, that can predict HT. Materials and Methods: From the Dutch acute stroke study, 545 patients treated with intravenous recombinant tissue plasminogen activator and/or intra-arterial treatment were selected, with available admission extended computed tomography (CT) perfusion and follow-up imaging. Patient admission treatment characteristics and CT imaging parameters regarding occlusion site, stroke severity, and BBBP were recorded. HT was assessed on day 3 follow-up imaging. The association between potential predictors and HT was analyzed using univariate and multivariate logistic regression. To compare the added value of BBBP, areas under the curve (AUCs) were created from 2 models, with and without BBBP. Results: HT occurred in 57 patients (10%). In univariate analysis, older age (OR 1.03, 95% CI 1.006–1.05), higher admission National Institutes of Health Stroke Scale (NIHSS; OR 1.13, 95% CI 1.08–1.18), higher clot burden (OR 1.28, 95% CI 1.16–1.41), poor collateral score (OR 3.49, 95% CI 1.85–6.58), larger Alberta Stroke Program Early CT Score cerebral blood volume deficit size (OR 1.26, 95% CI 1.14–1.38), and increased BBBP (OR 2.22, 95% CI 1.46–3.37) were associated with HT. In multivariate analysis with age and admission NIHSS, the addition of BBBP did not improve the AUC compared to both independent predictors alone (AUC 0.77, 95% CI 0.71–0.83). Conclusion: BBBP predicts HT but does not improve prediction with age and admission NIHSS.

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Section: Discussionsupporting

confidence: 54%

Computed Tomography Perfusion Derived Blood-Brain Barrier Permeability Does Not Yet Improve Prediction of Hemorrhagic Transformation

et al. 2018

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“…In series ranging from 68 to 96 patients, various perfusion parameters, including relative cerebral blood flow (rCBF), relative mean transit time, relative cerebral blood volume (rCBV), and time to peak, have been found to be associated with hemorrhagic transformation. [24][25][26] Given that minor hemorrhagic transformation is common and generally not clinically relevant, 27 we sought to identify the optimal whole-brain CTP parameter for prediction of cerebral parenchymal hematoma (PH) after stroke.…”

Section: Strokementioning

confidence: 99%

Prediction of Poststroke Hemorrhagic Transformation Using Computed Tomography Perfusion

Yassi

Parsons

Christensen

et al. 2013

Stroke

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Early treatment of ischemic stroke with recombinant tissue-type plasminogen activator (rtPA) has been shown to improve functional outcome and to reduce disability. 1 However, this benefit is coupled with the potential risk of intracerebral hemorrhage, a potentially life-threatening complication. In prospective trials and meta-analyses, the rate of significant intracerebral hemorrhage has been reported to be between 2.4% and 11% with rtPA and between 0% and 3.4% with placebo.1-8 Large stroke thrombolysis registries have reported symptomatic intracerebral hemorrhage rates of between 1.6% and 4.8% with rtPA.9-13 Moreover, mortality rates of up to 45% have been attributed directly to rtPA-related intracerebral hemorrhage, 14 and it remains the most feared potential complication of an otherwise highly effective therapy.Several clinical risk factors for thrombolysis-related cerebral hemorrhage have been identified, including advancing age, stroke severity, pretreatment hypertension, and concurrent use of antithrombotic agents, in addition to imaging and laboratory factors, such as hyperglycemia, thrombocytopenia, and extensive early ischemic changes on computed tomography (CT), or the hyperdense middle cerebral artery sign. [15][16][17][18] The use of MRI, including perfusion imaging, provides more detailed assessment of acute stroke pathophysiology Background and Purpose-Intracerebral hemorrhage is a serious potential complication of stroke thrombolysis. We investigated the optimal computed tomography perfusion (CTP) parameter to predict cerebral parenchymal hematoma (PH) in acute ischemic stroke. Methods-Patients with hyperacute ischemic stroke had whole-brain CTP and follow-up computed tomography/MRI to identify hemorrhagic transformation. The association of the 3 parameters relative cerebral blood flow, relative cerebral blood volume, and time to maximum (T max ) with PH was examined using receiver operating characteristic analysis and multivariate logistic regression. Results-Of 132 patients, 70 were treated with thrombolysis, and 14 (10.6%) developed PH on follow-up imaging. Baseline National Institutes of Health Stroke Scale score (P=0.033) and thrombolysis (P=0.003) were both predictive of PH.Receiver operating characteristic analysis revealed that T max >14 s (area under the curve=0.748; P=0.002) and relative cerebral blood flow <30% of contralateral mean (area under the curve=0.689, P=0.021) were the optimal thresholds, and the Bayesian information criterion (+2.6) indicated that T max was more strongly associated with PH than relative cerebral blood flow. T max >14 s volumes of >5 mL allowed prediction of PH with sensitivity of 79%, specificity of 68%, and negative likelihood ratio of 3.16. T max >14 s volume and thrombolysis were both independently predictive of PH in a multivariate logistic regression model (P<0.05). Conclusions-T max >14 s was the CTP parameter most strongly associated with PH. This outperformed relative cerebral blood flow <30%, which closely equates to CTP estimates of ischemic core vo...

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“…MRI-based clinical studies of patients with acute stroke treated or not with thrombolysis have shown that very severe reductions of CBV (termed as Very Low CBV) are strongly associated with the risk of PH, [7][8][9] particularly when delayed reperfusion occurs after thrombolysis. 8 Using perfusion CT, the risk of hemorrhagic transformation has been related to a myriad of perfusion measures such as low relative CBV values, 10 low relative CBF values, 11 longer relative MTT or Tmax values, 11,12 and severe hypoperfusion detected in TTP maps. 13 Specifically in patients receiving endovascular reperfusion therapies, reduced pretreatment CBV or CBF values measured with perfusion CT have been associated with poor clinical outcomes, 14 including the risk of development of intracranial hemorrhage.…”

Section: Introductionmentioning

confidence: 99%

Brain hemorrhage after endovascular reperfusion therapy of ischemic stroke: a threshold-finding whole-brain perfusion CT study

Renú

Laredo

Tudela

et al. 2016

J Cereb Blood Flow Metab

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Endovascular reperfusion therapy is increasingly used for acute ischemic stroke treatment. The occurrence of parenchymal hemorrhage is clinically relevant and increases with reperfusion therapies. Herein we aimed to examine the optimal perfusion CT-derived parameters and the impact of the duration of brain ischemia for the prediction of parenchymal hemorrhage after endovascular therapy. A cohort of 146 consecutive patients with anterior circulation occlusions and treated with endovascular reperfusion therapy was analyzed. Recanalization was assessed at the end of reperfusion treatment, and the rate of parenchymal hemorrhage at follow-up neuroimaging. In regression analyses, cerebral blood volume and cerebral blood flow performed better than Delay Time maps for the prediction of parenchymal hemorrhage. The most informative thresholds (receiver operating curves) for relative cerebral blood volume and relative cerebral blood flow were values lower than 2.5% of normal brain. In binary regression analyses, the volume of regions with reduced relative cerebral blood volume and/or relative cerebral blood flow was significantly associated with an increased risk of parenchymal hemorrhage, as well as delayed vessel recanalization. These results highlight the relevance of the severity and duration of ischemia as drivers of blood-brain barrier disruption in acute ischemic stroke and support the role of perfusion CT for the prediction of parenchymal hemorrhage.

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Association of CT Perfusion Parameters with Hemorrhagic Transformation in Acute Ischemic Stroke

Cited by 62 publications

References 41 publications

Computed Tomography Perfusion Derived Blood-Brain Barrier Permeability Does Not Yet Improve Prediction of Hemorrhagic Transformation

Computed Tomography Perfusion Derived Blood-Brain Barrier Permeability Does Not Yet Improve Prediction of Hemorrhagic Transformation

Prediction of Poststroke Hemorrhagic Transformation Using Computed Tomography Perfusion

Brain hemorrhage after endovascular reperfusion therapy of ischemic stroke: a threshold-finding whole-brain perfusion CT study

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