Advertisement

Cerebral perfusion imaging predicts final infarct volume after basilar artery thrombectomy

      Abstract

      Objectives

      Cerebral perfusion imaging may be used to identify the ischemic core in acute ischemic stroke (AIS) patients with a large vessel occlusion of the anterior circulation; however, perfusion parameters that predict the ischemic core in AIS patients with a basilar artery occlusion (BAO) are poorly described. We determined which cerebral perfusion parameters best predict the ischemic core after successful endovascular thrombectomy (EVT) in BAO patients.

      Materials and methods

      We performed multicenter retrospective study of BAO patients with perfusion imaging before EVT and a DWI after successful EVT. The ischemic core was defined as regions on CTP, which were co-registered to the final DWI infarct. Various time-to-maximum (Tmax) and cerebral blood flow (CBF) thresholds were compared to final infarct volume to determine the best predictor of the final infarct.

      Results

      28 patients were included in the analysis for this study. Tmax >8s (r2: 0.56; median absolute error, 16.0 mL) and Tmax >10s (r2: 0.73; median absolute error, 11.3 mL) showed the strongest agreement between the pre-EVT CTP study and the final DWI. CBF <38% (r2: 0.76; median absolute error, 8.2 mL) and CBF <34% (r2: 0.76; median absolute error, 9.1 mL) also correlated well with final infarct volume on DWI.

      Conclusions

      Pre-EVT CT perfusion imaging is useful to predict the final ischemic infarct volume in BAO patients. Tmax >8s and Tmax >10s were the strongest predictors of the post-EVT final infarct volume.

      Key Words

      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Subscribe:

      Subscribe to Journal of Stroke and Cerebrovascular Diseases
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • Powers WJ
        • Rabinstein AA
        • Ackerson T
        • et al.
        2018 guidelines for the early management of patients with acute ischemic stroke: a guideline for healthcare professionals from the American heart association/American stroke association.
        Stroke. 2018; 49https://doi.org/10.1161/STR.0000000000000158
        • Berkhemer OA
        • Fransen PSS
        • Beumer D
        • et al.
        A randomized trial of intraarterial treatment for acute ischemic stroke.
        N Engl J Med. 2015; 372: 11-20https://doi.org/10.1056/NEJMoa1411587
        • Jovin TG
        • Chamorro A
        • Cobo E
        • et al.
        Thrombectomy within 8 hours after symptom onset in ischemic stroke.
        N Engl J Med. 2015; 372: 2296-2306https://doi.org/10.1056/NEJMoa1503780
        • Goyal M
        • Demchuk AM
        • Menon BK
        • et al.
        Randomized assessment of rapid endovascular treatment of ischemic stroke.
        N Engl J Med. 2015; 372: 1019-1030https://doi.org/10.1056/NEJMoa1414905
        • Campbell BCV
        • Mitchell PJ
        • Kleinig TJ
        • et al.
        Endovascular Therapy for Ischemic Stroke with Perfusion-Imaging Selection.
        N Engl J Med. 2015; 372: 1009-1018https://doi.org/10.1056/NEJMoa1414792
        • Saver JL
        • Goyal M
        • Bonafe A
        • et al.
        Stent-Retriever Thrombectomy after Intravenous t-PA vs. t-PA Alone in Stroke.
        N Engl J Med. 2015; 372: 2285-2295https://doi.org/10.1056/NEJMoa1415061
        • Nogueira RG
        • Jadhav AP
        • Haussen DC
        • et al.
        Thrombectomy 6 to 24 Hours after Stroke with a Mismatch between Deficit and Infarct.
        N Engl J Med. 2018; 378: 11-21https://doi.org/10.1056/NEJMoa1706442
        • Albers GW
        • Marks MP
        • Kemp S
        • et al.
        Thrombectomy for Stroke at 6 to 16 Hours with Selection by Perfusion Imaging.
        N Engl J Med. 2018; 378: 708-718https://doi.org/10.1056/NEJMoa1713973
        • Merwick A
        • Werring D.
        Posterior circulation ischaemic stroke.
        BMJ. 2014; 348 (may19 33g3175-g3175)https://doi.org/10.1136/bmj.g3175
        • Schonewille WJ
        • Wijman CA
        • Michel P
        • et al.
        Treatment and outcomes of acute basilar artery occlusion in the Basilar Artery International Cooperation Study (BASICS): a prospective registry study.
        Lancet Neurol. 2009; 8: 724-730https://doi.org/10.1016/S1474-4422(09)70173-5
        • Liu X
        • Dai Q
        • Ye R
        • et al.
        Endovascular treatment versus standard medical treatment for vertebrobasilar artery occlusion (BEST): an open-label, randomised controlled trial.
        Lancet Neurol. 2020; 19: 115-122https://doi.org/10.1016/S1474-4422(19)30395-3
        • Langezaal LCM
        • van der Hoeven EJRJ
        • Mont'Alverne FJA
        • et al.
        Endovascular Therapy for Stroke Due to Basilar-Artery Occlusion.
        N Engl J Med. 2021; 384: 1910-1920https://doi.org/10.1056/NEJMoa2030297
        • Zi W
        • Qiu Z
        • et al.
        Assessment of Endovascular Treatment for Acute Basilar Artery Occlusion via a Nationwide Prospective Registry.
        JAMA Neurol. 2020; 77 (Writing Group for the BASILAR Group): 561-573https://doi.org/10.1001/jamaneurol.2020.0156
        • Jovin TG
        • Li C
        • Wu L
        • et al.
        Trial of Thrombectomy 6 to 24 Hours after Stroke Due to Basilar-Artery Occlusion.
        N Engl J Med. 2022; 387: 1373-1384https://doi.org/10.1056/NEJMoa2207576
        • Tao C
        • Nogueira RG
        • Zhu Y
        • et al.
        Trial of Endovascular Treatment of Acute Basilar-Artery Occlusion.
        N Engl J Med. 2022; 387: 1361-1372https://doi.org/10.1056/NEJMoa2206317
        • Bill O
        • Inácio NM
        • Lambrou D
        • et al.
        Focal hypoperfusion in acute ischemic stroke perfusion ct: clinical and radiologic predictors and accuracy for infarct prediction.
        AJNR Am J Neuroradiol. 2019; 40: 483-489https://doi.org/10.3174/ajnr.A5984
        • Wannamaker R
        • Buck B
        • Butcher K.
        Multimodal CT in Acute Stroke.
        Curr Neurol Neurosci Rep. 2019; 19: 63https://doi.org/10.1007/s11910-019-0978-z
        • Sporns P
        • Schmidt R
        • Minnerup J
        • et al.
        Computed tomography perfusion improves diagnostic accuracy in acute posterior circulation stroke.
        Cerebrovasc Dis. 2016; 41: 242-247https://doi.org/10.1159/000443618
        • Prabhakaran S
        • Soltanolkotabi M
        • Honarmand AR
        • et al.
        Perfusion-based selection for endovascular reperfusion therapy in anterior circulation acute ischemic stroke.
        Am J Neuroradiol. 2014; 35: 1303-1308https://doi.org/10.3174/ajnr.A3889
        • Mlynash M
        • Lansberg MG
        • De Silva DA
        • et al.
        Refining the definition of the malignant profile: insights from the DEFUSE-EPITHET Pooled Data Set.
        Stroke. 2011; 42: 1270-1275https://doi.org/10.1161/STROKEAHA.110.601609
        • Campbell BCV
        • Christensen S
        • Levi CR
        • et al.
        Cerebral blood flow is the optimal CT perfusion parameter for assessing infarct core.
        Stroke. 2011; 42: 3435-3440https://doi.org/10.1161/STROKEAHA.111.618355
        • Albers GW
        • Goyal M
        • Jahan R
        • et al.
        Ischemic core and hypoperfusion volumes predict infarct size in SWIFT PRIME: CT Perfusion Volumes.
        Ann Neurol. 2016; 79: 76-89https://doi.org/10.1002/ana.24543
        • Cereda CW
        • Bianco G
        • Mlynash M
        • et al.
        Perfusion Imaging predicts favorable outcomes after basilar artery thrombectomy.
        Ann Neurol. 2022; 91: 23-32https://doi.org/10.1002/ana.26272
        • Fabritius MP
        • Tiedt S
        • Puhr-Westerheide D
        • et al.
        Computed tomography perfusion deficit volumes predict functional outcome in patients with basilar artery occlusion.
        Stroke. 2021; 52: 2016-2023https://doi.org/10.1161/STROKEAHA.120.032924
        • Pallesen LP
        • Winzer S
        • Barlinn K
        • et al.
        Safety of inter-hospital transfer of patients with acute ischemic stroke for evaluation of endovascular thrombectomy.
        Sci Rep. 2020; 10: 5655https://doi.org/10.1038/s41598-020-62528-4
        • Goldman-Yassen AE
        • Straka M
        • Uhouse M
        • Dehkharghani S.
        Normative distribution of posterior circulation tissue time-to-maximum: Effects of anatomic variation, tracer kinetics, and implications for patient selection in posterior circulation ischemic stroke.
        J Cereb Blood Flow Metab. 2021; 41: 1912-1923https://doi.org/10.1177/0271678×20982395
        • Hoyer C
        • Szabo K.
        Pitfalls in the Diagnosis of Posterior Circulation Stroke in the Emergency Setting.
        Front Neurol. 2021; 12682827https://doi.org/10.3389/fneur.2021.682827
        • Puetz V
        • Sylaja PN
        • Coutts SB
        • et al.
        Extent of Hypoattenuation on CT Angiography Source Images Predicts Functional Outcome in Patients With Basilar Artery Occlusion.
        Stroke. 2008; 39: 2485-2490https://doi.org/10.1161/STROKEAHA.107.511162
        • Faizy TD
        • Kabiri R
        • Christensen S
        • et al.
        Venous Outflow Profiles Are Linked to Cerebral Edema Formation at Noncontrast Head CT after Treatment in Acute Ischemic Stroke Regardless of Collateral Vessel Status at CT Angiography.
        Radiology. 2021; 299: 682-690https://doi.org/10.1148/radiol.2021203651
        • Alemseged F
        • Shah DG
        • Diomedi M
        • et al.
        The Basilar Artery on Computed Tomography Angiography Prognostic Score for Basilar Artery Occlusion.
        Stroke. 2017; 48: 631-637https://doi.org/10.1161/STROKEAHA.116.015492
        • van der Hoeven EJ
        • McVerry F
        • Vos JA
        • et al.
        Collateral flow predicts outcome after basilar artery occlusion: The posterior circulation collateral score.
        Int J Stroke. 2016; 11: 768-775https://doi.org/10.1177/1747493016641951
        • Khatibi K
        • Nour M
        • Tateshima S
        • et al.
        Posterior Circulation Thrombectomy—pc-ASPECT Score Applied to Preintervention Magnetic Resonance Imaging Can Accurately Predict Functional Outcome.
        World Neurosurg. 2019; 129: e566-e571https://doi.org/10.1016/j.wneu.2019.05.217
        • Caruso P
        • Ridolfi M
        • Lugnan C
        • et al.
        Multimodal CT pc-ASPECTS in infratentorial stroke: diagnostic and prognostic value.
        Neurol Sci. 2021; 42: 4231-4240https://doi.org/10.1007/s10072-021-05072-x
        • Dehkharghani S
        • Bammer R
        • Straka M
        • et al.
        Performance and Predictive Value of a User-Independent Platform for CT Perfusion Analysis: Threshold-Derived Automated Systems Outperform Examiner-Driven Approaches in Outcome Prediction of Acute Ischemic Stroke.
        AJNR Am J Neuroradiol. 2015; 36: 1419-1425https://doi.org/10.3174/ajnr.A4363
        • Amukotuwa SA
        • Wu A
        • Zhou K
        • Page I
        • Brotchie P
        • Bammer R.
        Distal Medium Vessel Occlusions Can Be Accurately and Rapidly Detected Using Tmax Maps.
        Stroke. 2021; 52: 3308-3317https://doi.org/10.1161/STROKEAHA.120.032941
        • Capasso R
        • Vallone S
        • Serra N
        • et al.
        Qualitative versus automatic evaluation of CT perfusion parameters in acute posterior circulation ischaemic stroke.
        Neuroradiology. 2021; 63: 317-330https://doi.org/10.1007/s00234-020-02517-6
        • Straka M
        • Albers GW
        • Bammer R.
        Real-time diffusion-perfusion mismatch analysis in acute stroke.
        J Magn Reson Imaging JMRI. 2010; 32: 1024-1037https://doi.org/10.1002/jmri.22338
        • Chung CY
        • Hu R
        • Peterson RB
        • Allen JW.
        Automated Processing of Head CT Perfusion Imaging for Ischemic Stroke Triage: A Practical Guide to Quality Assurance and Interpretation.
        Am J Roentgenol. 2021; 217: 1401-1416https://doi.org/10.2214/AJR.21.26139
        • Kauw F
        • Heit JJ
        • Martin BW
        • et al.
        Computed Tomography Perfusion Data for Acute Ischemic Stroke Evaluation Using Rapid Software: Pitfalls of Automated Postprocessing.
        J Comput Assist Tomogr. 2020; 44: 75-77https://doi.org/10.1097/RCT.0000000000000946
        • Huynh DC
        • Parsons MW
        • Wintermark M
        • et al.
        Can CT perfusion accurately assess infarct core?.
        Neurovascular Imaging. 2016; 2: 7https://doi.org/10.1186/s40809-016-0018-1