Diagnostic accuracy of computed tomography perfusion in patients with acute stroke: A meta-analysis

Ye, Xin; Han, Fei

doi:10.1016/j.jns.2015.11.046

Cited by 17 publications

(18 citation statements)

References 20 publications

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“…False negative CTP scans in the present study were associated with smaller infarct volumes with lacunar, small embolic, or posterior fossa patterns. Consistent with previous work, 3,22,23,28 more than half of false negatives in our study were lacunar. Garcia-Esperon, Visser, Churilov, Miteff, Bivard, Lillicrap, Levi, Spratt and Parsons 29 retrospectively analysed lacunar presentations with confirmed stroke diagnosis and reported qualitative CTP maps had higher sensitivity (34%) than NCCT (<4%) for detection of infarct in lacunar presentations.…”

Section: Discussionsupporting

confidence: 93%

Diagnostic Utility of Computed Tomography Perfusion in the Telestroke Setting

Arora

Gaekwad

Evans

et al. 2022

Stroke

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Background: Definitive diagnosis of acute ischemic stroke is challenging, particularly in telestroke settings. Although the prognostic utility of CT perfusion (CTP) has been questioned, its diagnostic value remains under-appreciated, especially in cases without an easily visible intracranial occlusion. We assessed the diagnostic accuracy of routine CTP in the acute telestroke setting. Methods: Acute and follow-up data collected prospectively from consecutive suspected patients with stroke assessed by a state-wide telestroke service between March 2020 and August 2021 at 12 sites in Australia were analyzed. All patients in the final analysis had been assessed with multimodal CT, including CTP, which was post-processed with automated volumetric software. Diagnostic sensitivity and specificity were calculated for multimodal CT and each individual component (noncontrast CT [NCCT], CT angiogram [CTA], and CTP). Final diagnosis determined by consensus review of follow-up imaging and clinical data was used as the reference standard. Results: During the study period, complete multimodal CT examination was obtained in 831 patients, 457 of whom were diagnosed with stroke. Diagnostic sensitivity for ischemic stroke increased by 19.5 percentage points when CTP was included with NCCT and CTA compared with NCCT and CTA alone (73.1% positive with NCCT+CTA+CTP [95% CI, 68.8–77.1] versus 53.6% positive with NCCT+CTA alone [95% CI, 48.9–58.3], P <0.001). No difference was observed between specificities of NCCT+CTA and NCCT+CTA+CTP (98.7% [95% CI, 98.5–100] versus 98.7% [95% CI, 96.9–99.6], P =0.13). Multimodal CT, including CTP, demonstrated the highest negative predictive value (75.0% [95% CI, 72.1–77.7]). Patients with stroke not evident on CTP had small volume infarcts on follow-up (1.2 mL, interquartile range 0.5–2.7mL). Conclusions: Acquisition of CTP as part of a telestroke imaging protocol permits definitive diagnosis of cerebral ischemia in 1 in 5 patients with normal NCCT and CTA.

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Section: Discussionsupporting

confidence: 93%

Diagnostic Utility of Computed Tomography Perfusion in the Telestroke Setting

Arora

Gaekwad

Evans

et al. 2022

Stroke

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“…Although quantitative CTP has been used successfully for treatment selection of patients with AIS in a controlled environment of randomized clinical trials, its day-to-day use may still be challenging due to inconsistencies of the results that are reflected in the literature. 13,16,17,19,25,28,29 There are several barriers to effective implementation of CTP in acute stroke care, including differences in CT scanners and hardware, postprocessing methodology such as different software packages, and different deconvolution techniques for quantitative analysis. [30][31][32][33] One of the potential limitations of quantitative CTP is related to the inherently noisy nature of CTP data, which can affect postprocessing and result in erroneous calculation of the ischemic core.…”

Section: Discussionmentioning

confidence: 99%

Defining Ischemic Core in Acute Ischemic Stroke Using CT Perfusion: A Multiparametric Bayesian-Based Model

Nael

Tadayon

Wheelwright

et al. 2019

AJNR Am J Neuroradiol

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BACKGROUND AND PURPOSE: The Bayesian probabilistic method has shown promising results to offset noise-related variability in perfusion analysis. Using CTP, we aimed to find optimal Bayesian-estimated thresholds based on multiparametric voxel-level models to estimate the ischemic core in patients with acute ischemic stroke. MATERIALS AND METHODS: Patients with anterior circulation acute ischemic stroke who had baseline CTP and achieved successful recanalization were included. In a subset of patients, multiparametric voxel-based models were constructed between Bayesian-processed CTP maps and follow-up MRIs to identify pretreatment CTP parameters that were predictive of infarction using robust logistic regression. Subsequently CTP-estimated ischemic core volumes from our Bayesian model were compared against routine clinical practice oscillation singular value decomposition-relative cerebral blood flow Ͻ30%, and the volumetric accuracy was assessed against final infarct volume. RESULTS: In the constructed multivariate voxel-based model, 4 variables were identified as independent predictors of infarction: TTP, relative CBF, differential arterial tissue delay, and differential mean transit time. At an optimal cutoff point of 0.109, this model identified infarcted voxels with nearly 80% accuracy. The limits of agreement between CTP-estimated ischemic core and final infarct volume ranged from Ϫ25 to 27 mL for the Bayesian model, compared with Ϫ61 to 52 mL for oscillation singular value decomposition-relative CBF. CONCLUSIONS: We established thresholds for the Bayesian model to estimate the ischemic core. The described multiparametric Bayesian-based model improved consistency in CTP estimation of the ischemic core compared with the methodology used in current clinical routine. ABBREVIATIONS: AIS ϭ acute ischemic stroke; ATD ϭ arterial tissue delay; AUC ϭ area under the curve; diff ϭ differential; oSVD ϭ oscillation singular value decomposition; rCBF ϭ relative CBF

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“…Furthermore, methodology and workflow of the studies should be easily reproducible and accessible. In this regard, as previously suggested (54,55), CT seems to represent a fair trade-off between diagnostic detail and feasibility in acute stroke setting due to availability and few contraindications; however, MR is likely more accurate in detection of both BBB disruption and HT. Use of machine learning algorithms for MR (56) may help standardization of acquisition protocols and assessment of BBB in acute stroke; however, there is still no available evidence in this regard.…”

Section: Discussionmentioning

confidence: 84%

Blood–Brain Barrier Disruption and Hemorrhagic Transformation in Acute Ischemic Stroke: Systematic Review and Meta-Analysis

et al. 2021

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Introduction: Hemorrhagic transformation (HT) is a complication of reperfusion therapy for acute ischemic stroke. Blood–brain barrier (BBB) disruption is a crucial step toward HT; however, in clinical studies, there is still uncertainty about this relation. Hence, we conducted a systematic review and meta-analysis to summarize the current evidence.Methods: We performed systematic review and meta-analysis of observational studies from January 1990 to March 2020 about the relation between BBB disruption and HT in patients with acute ischemic stroke with both computed tomography (CT) and magnetic resonance (MR) assessment of BBB. The outcome of interest was HT at follow-up imaging evaluation (within 48 h from symptom onset). We pooled data from available univariate odds ratios (ORs) in random-effects models with DerSimonian–Laird weights and extracted cumulative ORs.Results: We included 30 eligible studies (14 with CT and 16 with MR), N = 2,609 patients, with 88% and 70% of patients included in CT and MR studies treated with acute stroke therapy, respectively. The majority of studies were retrospective and had high or unclear risk of bias. BBB disruption was measured with consistent methodology in CT studies, whereas in MR studies, there was more variability. All CT studies provided a BBB disruption cutoff predictive of HT. Four CT and 10 MR studies were included in the quantitative analysis. We found that BBB disruption was associated with HT with both CT (OR = 3.42; 95%CI = 1.62–7.23) and MR (OR = 9.34; 95%CI = 3.16–27.59). There was a likely publication bias particularly for MR studies.Conclusion: Our results confirm that BBB disruption is associated with HT in both CT and MR studies. Compared with MR, CT has been more uniformly applied in the literature and has resulted in more consistent results. However, more efforts are needed for harmonization of protocols and methodology for implementation of BBB disruption as a neuroradiological marker in clinical practice.

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Diagnostic accuracy of computed tomography perfusion in patients with acute stroke: A meta-analysis

Abstract: All three CTP modes had adequate sensitivity but very high specificity, and among the three CTP modes, CBF had the best diagnostic characteristics.

Cited by 17 publications

References 20 publications

Diagnostic Utility of Computed Tomography Perfusion in the Telestroke Setting

Diagnostic Utility of Computed Tomography Perfusion in the Telestroke Setting

Defining Ischemic Core in Acute Ischemic Stroke Using CT Perfusion: A Multiparametric Bayesian-Based Model

Blood–Brain Barrier Disruption and Hemorrhagic Transformation in Acute Ischemic Stroke: Systematic Review and Meta-Analysis

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