Low Hypoperfusion Intensity Ratio Is Associated with a Favorable Outcome Even in Large Ischemic Core and Delayed Recanalization Time

Baek, Jang Hyun; Lee, Ki Jeong; Choi, Jin Kyo; Baik, Minyoul; Kim, Byung Moon; Kim, Dong Joon; Heo, Ji Hoe; Nam, Hyo Suk

doi:10.3390/jcm10091869

Cited by 9 publications

(7 citation statements)

References 22 publications

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“…Analogously, we found that ASPECTS at baseline and on follow-up imaging and the risk of developing malignant edema were significantly associated with the HIR. The median HIR in our study lies within the range of the cutoff values applied in previous studies (0.4–0.7) [ 17 , 18 , 21 , 22 , 23 , 24 , 25 , 26 , 27 ]. However, further research is necessary to define a generally valid cutoff value for HIR.…”

Section: Discussionsupporting

confidence: 83%

“…Both over- and underestimation of the FIV may have important consequences in the management of acute stroke, especially in cases where the decision whether to perform MT or not is not obvious. Such delicate cases particularly apply to patients with very advanced age or in whom secondary referral to a thrombectomy center involves delays for transportation [ 21 , 24 , 25 , 26 ]. HIR might be helpful in assessing the situation and making rational decisions in this time-sensitive phase.…”

Section: Discussionmentioning

confidence: 99%

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Prognostic Accuracy of CTP Summary Maps in Patients with Large Vessel Occlusive Stroke and Poor Revascularization after Mechanical Thrombectomy—Comparison of Three Automated Perfusion Software Applications

et al. 2022

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Background: Innovative automated perfusion software solutions offer support in the management of acute stroke by providing information about the infarct core and penumbra. While the performance of different software solutions has mainly been investigated in patients with successful recanalization, the prognostic accuracy of the hypoperfusion maps in cases of futile recanalization has hardly been validated. Methods: In 39 patients with acute ischemic stroke (AIS) due to large vessel occlusion (LVO) in the anterior circulation and poor revascularization (thrombolysis in cerebral infarction (TICI) 0-2a) after mechanical thrombectomy (MT), hypoperfusion analysis was performed using three different automated perfusion software solutions (A: RAPID, B: Brainomix e-CTP, C: Syngo.via). The hypoperfusion volumes (HV) as Tmax > 6 s were compared with the final infarct volumes (FIV) on follow-up CT 36–48 h after futile recanalization. Bland–Altman analysis was applied to display the levels of agreement and to evaluate systematic differences. Based on the median hypoperfusion intensity ratio (HIR, volumetric ratio of tissue with a Tmax > 10 s and Tmax > 6 s) patients were dichotomized into high- and low-HIR groups. Subgroup analysis with favorable (<0.6) and unfavorable (≥0.6) HIR was performed with respect to the FIV. HIR was correlated to clinical baseline and outcome parameters using Pearson’s correlation. Results: Overall, there was good correlation without significant differences between the HVs and the FIVs with package A (r = 0.78, p < 0.001) being slightly superior to B and C. However, levels of agreement were very wide for all software applications in Bland-Altman analysis. In cases of large infarcts exceeding 150 mL the performance of the automated software solutions generally decreased. Subgroup analysis revealed the FIV to be generally underestimated in patients with HIR ≥ 0.6 (p < 0.05). In the subgroup with favorable HIR, however, there was a trend towards an overestimation of the FIV. Nevertheless, packages A and B showed good correlation between the HVs and FIVs without significant differences (p > 0.2), while only package C significantly overestimated the FIV (−54.6 ± 56.0 mL, p = 0.001). The rate of modified Rankin Scale (mRS) 0–3 after 3 months was significantly higher in favorable vs. unfavorable HIR (42.1% vs. 13.3%, p = 0.02). Lower HIR was associated with higher Alberta Stroke Program Early CT Score (ASPECTS) at presentation and on follow-up imaging, lower risk of malignant edema, and better outcome (p < 0.05). Conclusion: Overall, the performance of the automated perfusion software solutions to predict the FIV after futile recanalization is good, with decreasing accuracy in large infarcts exceeding 150 mL. However, depending on the HIR, FIV can be significantly over- and underestimated, with Syngo showing the widest range. Our results indicate that the HIR can serve as valuable parameter for outcome predictions and facilitate the decision whether or not to perform MT in delicate cases.

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Section: Discussionsupporting

confidence: 83%

Section: Discussionmentioning

confidence: 99%

Prognostic Accuracy of CTP Summary Maps in Patients with Large Vessel Occlusive Stroke and Poor Revascularization after Mechanical Thrombectomy—Comparison of Three Automated Perfusion Software Applications

et al. 2022

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“…In addition to the ischemic core volume itself, the mismatch between the core and the tissue at risk (commonly called penumbra) plays a pivotal role in patient selection for MT [ 4 , 7 ]. Hypoperfusion intensity ratio (HIR) is used to assess collateral status with low HIR being associated with robust collaterals and described as a potential selection factor for thrombectomy eligibility and a predictor of favorable outcome [ 8 , 9 ]. Despite residual uncertainties regarding the benefit of MT beyond 6 h from symptom onset in large ischemic cores, the short-term benefit of MT in this population after selection by advanced imaging criteria are well known [ 9 – 13 ].…”

Section: Introductionmentioning

confidence: 99%

“…Hypoperfusion intensity ratio (HIR) is used to assess collateral status with low HIR being associated with robust collaterals and described as a potential selection factor for thrombectomy eligibility and a predictor of favorable outcome [ 8 , 9 ]. Despite residual uncertainties regarding the benefit of MT beyond 6 h from symptom onset in large ischemic cores, the short-term benefit of MT in this population after selection by advanced imaging criteria are well known [ 9 – 13 ]. In contrast, the long-term effects of MT, especially based on advanced imaging criteria, remain poorly described [ 14 ].…”

Section: Introductionmentioning

confidence: 99%

Long-Term Effect of Mechanical Thrombectomy in Stroke Patients According to Advanced Imaging Characteristics.

Beyeler,

Pohle,

Weber

et al. 2023

Clin Neuroradiol

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Purpose Data on long-term effect of mechanical thrombectomy (MT) in patients with large ischemic cores (≥ 70 ml) are scarce. Our study aimed to assess the long-term outcomes in MT-patients according to baseline advanced imaging parameters. Methods We performed a single-centre retrospective cohort study of stroke patients receiving MT between January 1, 2010 and December 31, 2018. We assessed baseline imaging to determine core and mismatch volumes and hypoperfusion intensity ratio (with low ratio reflecting good collateral status) using RAPID automated post-processing software. Main outcomes were cross-sectional long-term mortality, functional outcome and quality of life by May 2020. Analysis were stratified by the final reperfusion status. Results In total 519 patients were included of whom 288 (55.5%) have deceased at follow-up (median follow-up time 28 months, interquartile range 1–55). Successful reperfusion was associated with lower long-term mortality in patients with ischemic core volumes ≥ 70 ml (adjusted hazard ratio (aHR) 0.20; 95% confidence interval (95% CI) 0.10–0.44) and ≥ 100 ml (aHR 0.26; 95% CI 0.08–0.87). The effect of successful reperfusion on long-term mortality was significant only in the presence of relevant mismatch (aHR 0.17; 95% CI 0.01–0.44). Increasing reperfusion grade was associated with a higher rate of favorable outcomes (mRS 0–3) also in patients with ischemic core volume ≥ 70 ml (aOR 3.58, 95% CI 1.64–7.83). Conclusion Our study demonstrated a sustainable benefit of better reperfusion status in patients with large ischemic core volumes. Our results suggest that patient deselection based on large ischemic cores alone is not advisable.

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“…Among various tools, hypoperfusion severity can be estimated using the hypoperfusion intensity ratio (HIR). Baek et al, studied the association between HIR and clinical outcomes [ 8 ]. They found that the low-HIR group had a more favorable outcome, even with an unfavorable Alberta Stroke Program Early CT score and onset-to-recanalization time.…”

mentioning

confidence: 99%

Advance of Thrombolysis and Thrombectomy in Acute Ischemic Stroke

Nam

Kim

2023

JCM

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Low Hypoperfusion Intensity Ratio Is Associated with a Favorable Outcome Even in Large Ischemic Core and Delayed Recanalization Time

Cited by 9 publications

References 22 publications

Prognostic Accuracy of CTP Summary Maps in Patients with Large Vessel Occlusive Stroke and Poor Revascularization after Mechanical Thrombectomy—Comparison of Three Automated Perfusion Software Applications

Prognostic Accuracy of CTP Summary Maps in Patients with Large Vessel Occlusive Stroke and Poor Revascularization after Mechanical Thrombectomy—Comparison of Three Automated Perfusion Software Applications

Long-Term Effect of Mechanical Thrombectomy in Stroke Patients According to Advanced Imaging Characteristics.

Advance of Thrombolysis and Thrombectomy in Acute Ischemic Stroke

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