Defining Core and Penumbra in Ischemic Stroke: A Voxel- and Volume-Based Analysis of Whole Brain CT Perfusion

Yu, Yannan; Han, Qingpeng; Ding, Xi; Chen, Q.; Ye, Keqi; Zhang, Sheng; Yan, Shiyu; Campbell, Bruce; Parsons, Mark; Wang, Yilong; Lou, Min

doi:10.1038/srep20932

Cited by 59 publications

(66 citation statements)

References 29 publications

(40 reference statements)

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“…7 The effective dose (calculated by multiplying dose-length products with published conversion factors) amounted to 3.68 mSV for VPCT and 2.19 mSV for NCCT acquisition. All images were reconstructed using commercial software (MIStar; Apollo Medical Imaging Technology, Melbourne, Australia).…”

Section: Methodsmentioning

confidence: 99%

Absent Filling of Ipsilateral Superficial Middle Cerebral Vein Is Associated With Poor Outcome After Reperfusion Therapy

Zhang

Lai

Ding

et al. 2017

Stroke

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Background and purpose Our aim was to study the effect of drainage of cortical veins, including the superficial middle cerebral vein (SMCV), vein of Trolard (VOT), and vein of Labbé (VOL) on neurological outcomes after reperfusion therapy. Methods Consecutive ischemic stroke patients who underwent pretreatment CT perfusion (CTP) and 24-hour CTP or MR perfusion after intravenous thrombolysis were included. We defined “absent filling of ipsilateral cortical vein” (e.g. SMCV-) as no contrast filling of the vein across the whole venous phase on four-dimensional CT angiography in the ischemic hemisphere. Results Of 228 patients, SMCV-, VOT- and VOL- were observed in 50 (21.9%), 27 (11.8%), and 32 (14.0%) patients, respectively. Only SMCV- independently predicted poor outcome (3-month modified Rankin Scale score>2) (OR=2.710, p=0.040). No difference was found in reperfusion rate after treatment between patients with and without SMCV- (p>0.05). In patients achieving major reperfusion (≥80%), there was no difference in 24-hour infarct volume, or rate of poor outcome between patients with and without SMCV- (p>0.05). However, in those without major reperfusion, patients with SMCV- had larger 24-hour infarct volume (p=0.011), higher rate of poor outcome (p=0.012), and death (p=0.032), compared to those with SMCV filling. SMCV- was significantly associated with brain edema at 24 hours (p=0.037) which, in turn, was associated with poor 3-month outcome (p=0.002). Conclusions Lack of SMCV filling contributed to poor outcome after thrombolysis, especially when reperfusion was not achieved. The main deleterious effect of poor venous filling appears related to the development of brain edema.

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Section: Methodsmentioning

confidence: 99%

Absent Filling of Ipsilateral Superficial Middle Cerebral Vein Is Associated With Poor Outcome After Reperfusion Therapy

Zhang

Lai

Ding

et al. 2017

Stroke

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“…Volumes of the acute perfusion lesion (relative delay time (DT) ≥ 3 seconds) and acute infarct core (relative CBF ≤ 30%) were calculated using previously validated thresholds848. Penumbra volume was defined as the volume of the perfusion lesion (DT threshold ≥ 3 seconds) minus the volume of the infarct core (relative CBF threshold < 30% within the DT ≥ 3 sec lesion).…”

Section: Methodsmentioning

confidence: 99%

“…Penumbra volume was defined as the volume of the perfusion lesion (DT threshold ≥ 3 seconds) minus the volume of the infarct core (relative CBF threshold < 30% within the DT ≥ 3 sec lesion). The threshold of DT ≥ 3 seconds was based on previous studies4849.…”

Section: Methodsmentioning

confidence: 99%

Association of Cortical Vein Filling with Clot Location and Clinical Outcomes in Acute Ischaemic Stroke Patients

Bhaskar

Bivard

Stanwell

et al. 2016

Sci Rep

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Delay in cortical vein filling during the late-venous phase (delayed-LCVFIdentification of patients who are most likely to benefit from reperfusion therapy using clinical and imaging markers is important in the quest for a more tailored approach to treatment in acute ischemic stroke (AIS). We recently reported a novel CT angiographic (CTA) finding on the presence of delayed cortical vein filling in late-venous phase in AIS patients 1 . Delayed late-phase cortical vein filling (delayed-LCVF) is characterised by late-venous phase opacification of cortical veins despite contrast clearance from contralateral cortical veins on four-dimensional (4D) dynamic time-resolved CTA (dCTA). We found that delayed-LCVF is independently associated with poor baseline collateral status. Currently, assessment of arterial leptomeningeal collateral status is indirect and performed qualitatively through visual examination of the extent and rate of backfilling of pial arteries that are fed by collateral vessels. Therefore, delayed-LCVF, a more 'direct' and reproducible measure, may prove to be very helpful to assess collateral status. There is growing interest in the role of leptomeningeal collaterals in AIS [1][2][3][4][5][6][7][8] . The presence of baseline arterial collaterals is emerging as an important parameter in the evaluation and treatment of cerebral ischemia 9 , and is linked to infarct core volume 10 , and functional outcomes 6,11,12 . Good collaterals are associated with good clinical outcomes; conversely, poor collaterals are linked to infarct growth 3 . Studies on the role of cortical veins in stroke pathophysiology and prognosis are limited 1,2,[12][13][14][15][16][17] . Location and the volume of the thrombus are also important factors in prognostication of AIS [18][19][20][21][22][23][24][25][26][27] . Proximal, high volume clots have poor clinical outcomes, while, low-volume, distal thrombus is associated with good clinical outcomes. Moreover, the size of thrombus and the anatomical differentiation between a proximal and a distal

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“…The volume of the acute perfusion lesion was defined as tissue with relative delay time > 3 seconds, and the threshold of acute ischemic core was relative cerebral blood flow < 30% of contralateral as we previously described. 25 Mismatch ratio was defined as perfusion lesion/ischemic core. First segment of middle cerebral artery 9 (40) 8 (35) Second segment of middle cerebral artery 12 (51) 11 (48) ASPECT score 7 (5-7) 6 (5-7) 0.162…”

Section: Imaging Evaluationmentioning

confidence: 99%

Fingolimod enhances the efficacy of delayed alteplase administration in acute ischemic stroke by promoting anterograde reperfusion and retrograde collateral flow

Tian

Shi

Zhu

et al. 2018

Annals of Neurology

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ObjectiveThe present study was undertaken to determine the efficacy of coadministration of fingolimod with alteplase in acute ischemic stroke patients in a delayed time window.MethodsThis was a prospective, randomized, open‐label, blinded endpoint clinical trial, enrolling patients with internal carotid artery or middle cerebral artery proximal occlusion within 4.5 to 6 hours from symptom onset. Patients were randomly assigned to receive alteplase alone or alteplase with fingolimod. All patients underwent pretreatment and 24‐hour noncontrast computed tomography (CT)/perfusion CT/CT angiography. The coprimary endpoints were the decrease of National Institutes of Health Stroke Scale scores over 24 hours and the favorable shift of modified Rankin Scale score (mRS) distribution at day 90. Exploratory outcomes included vessel recanalization, anterograde reperfusion, and retrograde reperfusion of collateral flow.ResultsEach treatment group included 23 patients. Compared with alteplase alone, patients receiving fingolimod plus alteplase exhibited better early clinical improvement at 24 hours and a favorable shift of mRS distribution at day 90. In addition, patients who received fingolimod and alteplase exhibited a greater reduction in the perfusion lesion accompanied by suppressed infarct growth by 24 hours. Fingolimod in conjunction with alteplase significantly improved anterograde reperfusion of downstream territory and prevented the failure of retrograde reperfusion from collateral circulation.InterpretationFingolimod may enhance the efficacy of alteplase administration in the 4.5‐ to 6‐hour time window in patients with a proximal cerebral arterial occlusion and salvageable penumbral tissue by promoting both anterograde reperfusion and retrograde collateral flow. These findings are instructive for the design of future trials of recanalization therapies in extended time windows. Ann Neurol 2018;84:725–736

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Defining Core and Penumbra in Ischemic Stroke: A Voxel- and Volume-Based Analysis of Whole Brain CT Perfusion

Cited by 59 publications

References 29 publications

Absent Filling of Ipsilateral Superficial Middle Cerebral Vein Is Associated With Poor Outcome After Reperfusion Therapy

Absent Filling of Ipsilateral Superficial Middle Cerebral Vein Is Associated With Poor Outcome After Reperfusion Therapy

Association of Cortical Vein Filling with Clot Location and Clinical Outcomes in Acute Ischaemic Stroke Patients

Fingolimod enhances the efficacy of delayed alteplase administration in acute ischemic stroke by promoting anterograde reperfusion and retrograde collateral flow

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