Evaluation of hyperacute infarct volume using ASPECTS and brain CT perfusion core volume

Demeestere, Jelle; García-Esperón, Carlos; García-Bermejo, Pablo; Ombelet, Fouke; McElduff, Patrick; Bivard, Andrew; Parsons, Mark; Levi, Christopher

doi:10.1212/wnl.0000000000004028

Cited by 92 publications

(69 citation statements)

References 21 publications

(30 reference statements)

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“…However, contrary to this hypothesis, our results indicate that CTP CV does not alter the overall performance of the prognostic model. Consistent with our findings, a recent study also found no significant difference between predictive accuracies of CTP and CT ASPECTS in predicting hyperacute MRI lesion volumes in acute ischemic stroke 19. Therefore, our results suggest that additional incorporation of perfusion imaging data in preintervention prognostic models such as the THRIVE, PRE, or MR PREDICTS scores will not yield higher prognostic accuracy 6 9…”

Section: Discussionsupporting

confidence: 90%

Prognostic importance of CT ASPECTS and CT perfusion measures of infarction in anterior emergent large vessel occlusions

Raza

Barreira

Rodrigues

et al. 2018

J NeuroIntervent Surg

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BackgroundAge, neurologic deficits, core volume (CV), and clinical core or radiographic mismatch are considered in selection for endovascular therapy (ET) in anterior circulation emergent large vessel occlusion (aELVO). Semiquantitative CV estimation by Alberta Stroke Programme Early CT Score (CT ASPECTS) and quantitative CV estimation by CT perfusion (CTP) are both used in selection paradigms.ObjectiveTo compare the prognostic value of CTP CV with CT ASPECTS in aELVO.MethodsPatients in an institutional endovascular registry who had aELVO, pre-ET National Institutes of Health Stroke Scale (NIHSS) score, non-contrast CT head and CTP imaging, and prospectively collected 3-month modified Rankin Scale (mRS) score were included. Age- and NIHSS-adjusted models, including either CT ASPECTS or CTP volumes (relative cerebral blood flow <30% of normal tissue, total hypoperfusion, and radiographic mismatch), were compared using receiver operator characteristic analyses.ResultsWe included 508 patients with aELVO (60.8% M1 middle cerebral artery, 34% internal carotid artery, mean age 64.1±15.3 years, median baseline NIHSS score 16 (12–20), median baseline CT ASPECTS 8 (7–9), mean CV 16.7±24.8 mL). Age, pre-ET NIHSS, CT ASPECTS, CV, hypoperfusion, and perfusion imaging mismatch volumes were predictors of good outcome (mRS score 0–2). There were no differences in prognostic accuracies between reference (age, baseline NIHSS, CT ASPECTS; area under the curve (AUC)=0.76) and additional models incorporating combinations of age, NIHSS, and CTP metrics including CV, total hypoperfusion or mismatch volume (AUCs 0.72–0.75). Predicted outcomes from CT ASPECTS or CTP CV-based models had excellent agreement (R2=0.84, p<0.001).ConclusionsIncorporating CTP measures of core or penumbral volume, instead of CT ASPECTS, did not improve prognostication of 3-month outcomes, suggesting prognostic equivalence of CT ASPECTS and CTP CV.

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Section: Discussionsupporting

confidence: 90%

Prognostic importance of CT ASPECTS and CT perfusion measures of infarction in anterior emergent large vessel occlusions

Raza

Barreira

Rodrigues

et al. 2018

J NeuroIntervent Surg

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“…Our results showed that most patients who finally presented GIC had the high ASPECTS on admission despite presumed large infarct cores on CTP, suggesting that in this early time window, patient selection according to noncontrast CT might avoid wrong exclusions from EVT [24].…”

Section: Discussionmentioning

confidence: 75%

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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“…ASPECTS = Alberta Stroke Program Early CT Scale; n = number of patients; OR = odds ratio; CI = confidence interval; ICH = intracerebral hemorrhage; mRS = modified Rankin Scale; NIHSS = National Institutes of Health Stroke Scale; and TICI = thrombolysis in cerebral infarction, with a score of 2b/3 indicating >50% recanalization of the previously occluded vessel. on noncontrast CT in the hyperacute (<3 hours) 10 and acute (<6 hours) 11 settings. However, the relationship between early noncontrast CT changes and perfusion core volumes has not been well characterized in the extended window (6 to 24 hours after LKN).…”

Section: Discussionmentioning

confidence: 99%

Noncontrast CT versus Perfusion‐Based Core Estimation in Large Vessel Occlusion: The Blood Pressure after Endovascular Stroke Therapy Study

Siegler

Messé

Sucharew

et al. 2019

Journal of Neuroimaging

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BACKGROUND AND PURPOSE The 2018 AHA guidelines recommend perfusion imaging to select patients with acute large vessel occlusion (LVO) for thrombectomy in the extended window. However, the relationship between noncontrast CT and CT perfusion imaging has not been sufficiently characterized >6 hours after last known normal (LKN). METHODS From a multicenter prospective cohort of consecutive adults who underwent thrombectomy for anterior LVO 0–24 hours after LKN, we correlated baseline core volume (rCBF < 30%) and the Alberta Stroke Program Early CT Scale (ASPECTS) score. We compared perfusion findings between patients with an unfavorable ASPECTS (<6) against those with a favorable ASPECTS (≥6), and assessed findings over time. RESULTS Of 485 enrolled patients, 177 met inclusion criteria (median age: 69 years, interquartile range [IQR: 57‐81], 49% female, median ASPECTS 8 [IQR: 6‐9], median core 10 cc [IQR: 0‐30]). ASPECTS and core volume moderately correlated (r = −.37). A 0 cc core was observed in 54 (31%) patients, 70% of whom had ASPECTS <10. Of the 28 patients with ASPECTS <6, 3 (11%) had a 0 cc core. After adjustment for age and stroke severity, there was a lower ASPECTS for every 1 hour delay from LKN (cOR: 0.95, 95% confidence of interval [CI]: 0.91‐1.00, P = .04). There was no difference in core (P = .51) or penumbra volumes (P = .87) across patients over time. CONCLUSIONS In this multicenter prospective cohort of patients who underwent thrombectomy, one‐third of patients had normal CTP core volumes despite nearly three quarters of patients showing ischemic changes on CT. This finding emphasizes the need to carefully assess both noncontrast and perfusion imaging when considering thrombectomy eligibility.

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Evaluation of hyperacute infarct volume using ASPECTS and brain CT perfusion core volume

Cited by 92 publications

References 21 publications

Prognostic importance of CT ASPECTS and CT perfusion measures of infarction in anterior emergent large vessel occlusions

Prognostic importance of CT ASPECTS and CT perfusion measures of infarction in anterior emergent large vessel occlusions

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

Noncontrast CT versus Perfusion‐Based Core Estimation in Large Vessel Occlusion: The Blood Pressure after Endovascular Stroke Therapy Study

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