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Computed tomographic perfusion to Predict Response to Recanalization in ischemic stroke
Maarten G Lansberg1, Soren Christensen1, Stephanie Kemp1
1Department of Neurology, Stanford University, Stanford, CA.
Insights
Computed tomographic (CT) perfusion helps identify acute stroke patients who benefit from endovascular therapy up to 18 hours after symptom onset. The "target mismatch" profile on CT perfusion indicates a higher likelihood of successful reperfusion and improved clinical outcomes.
Area of Science:
- Neurology
- Radiology
- Medical Imaging
Background:
- Acute ischemic stroke requires timely reperfusion therapy.
- Endovascular therapy is a key treatment for select stroke patients.
- Accurate patient selection is crucial for optimizing endovascular therapy outcomes.
Purpose of the Study:
- To evaluate the effectiveness of computed tomographic (CT) perfusion imaging in selecting patients for endovascular therapy.
- To determine if CT perfusion can identify patients who benefit from treatment up to 18 hours after stroke symptom onset.
Main Methods:
- A multicenter cohort study included acute stroke patients undergoing endovascular therapy.
- Patients were assessed using baseline CT perfusion to identify a "target mismatch" profile (small core, large penumbra).
- Reperfusion was confirmed by follow-up imaging, and clinical outcomes were evaluated based on NIH Stroke Scale (NIHSS) improvement.
Main Results:
- Out of 190 included patients, 89% achieved reperfusion.
- Patients with the CT perfusion "target mismatch" profile showed significantly higher rates of favorable clinical response (83% vs. 44%).
- This association between reperfusion and favorable outcome was consistent in patients treated within 6 hours and those treated after 6 hours.
Conclusions:
- CT perfusion's "target mismatch" profile is robustly associated with good outcomes after endovascular reperfusion in stroke patients treated up to 18 hours.
- These findings support conducting a randomized trial for endovascular therapy in this extended time window.
- CT perfusion is a valuable tool for patient selection in late-window stroke treatment.
Objective:
To assess the utility of computed tomographic (CT) perfusion for selection of patients for endovascular therapy up to 18 hours after symptom onset.
Methods:
We conducted a multicenter cohort study of consecutive acute stroke patients scheduled to undergo endovascular therapy within 90 minutes after a baseline CT perfusion. Patients were classified as "target mismatch" if they had a small ischemic core and a large penumbra on their baseline CT perfusion. Reperfusion was defined as >50% reduction in critical hypoperfusion between the baseline CT perfusion and the 36-hour follow-up magnetic resonance imaging.
Results:
Of the 201 patients enrolled, 190 patients with an adequate baseline CT perfusion study who underwent angiography were included (mean age = 66 years, median NIH Stroke Scale [NIHSS] = 16, median time from symptom onset to endovascular therapy = 5.2 hours). Rate of reperfusion was 89%. In patients with target mismatch (n = 131), reperfusion was associated with higher odds of favorable clinical response, defined as an improvement of ≥8 points on the NIHSS (83% vs 44%; p = 0.002, adjusted odds ratio [OR] = 6.6, 95% confidence interval [CI] = 2.1-20.9). This association did not differ between patients treated within 6 hours (OR = 6.4, 95% CI = 1.5-27.8) and those treated > 6 hours after symptom onset (OR = 13.7, 95% CI = 1.4-140).
Interpretation:
The robust association between endovascular reperfusion and good outcome among patients with the CT perfusion target mismatch profile treated up to 18 hours after symptom onset supports a randomized trial of endovascular therapy in this patient population. Ann Neurol 2017;81:849-856.
