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Updated: Jan 3, 2026
Optimized Management of Endovascular Treatment for Acute Ischemic Stroke
Published on: January 18, 2018
Noncontrast CT versus Perfusion-Based Core Estimation in Large Vessel Occlusion: The Blood Pressure after
James E Siegler1, Steven R Messé1, Heidi Sucharew2
1Department of Neurology, Hospital of the University of Pennsylvania, Philadelphia, PA.
Insights
One-third of patients undergoing thrombectomy for large vessel occlusion (LVO) had normal CT perfusion (CTP) core volumes, even with ischemic changes on CT. Careful assessment of both noncontrast CT and CTP is crucial for selecting eligible patients.
Area of Science:
- Neurology
- Radiology
- Cardiovascular Medicine
Background:
- The 2018 AHA guidelines suggest perfusion imaging for selecting acute large vessel occlusion (LVO) patients for thrombectomy in extended windows.
- Characterizing the relationship between noncontrast CT and CT perfusion (CTP) imaging beyond 6 hours after last known normal (LKN) is crucial.
Purpose of the Study:
- To correlate baseline core infarct volume with the Alberta Stroke Program Early CT Score (ASPECTS) in patients with anterior LVO.
- To compare perfusion findings between patients with favorable (ASPECTS ≥6) and unfavorable (ASPECTS <6) scores.
- To assess changes in perfusion findings over time.
Main Methods:
- A multicenter prospective cohort study included adults undergoing thrombectomy for anterior LVO within 24 hours of LKN.
- Correlations between baseline core infarct volume (rCBF <30%) and ASPECTS were analyzed.
- Perfusion findings were compared based on ASPECTS and assessed over time.
Main Results:
- Of 177 patients, ASPECTS and core volume showed a moderate negative correlation (r = -0.37).
- 31% of patients had a 0 cc core infarct volume, with 70% having ASPECTS <10.
- Lower ASPECTS were associated with each 1-hour delay from LKN (adjusted odds ratio: 0.95; 95% CI: 0.91-1.00; P = .04).
- No significant differences in core or penumbra volumes were observed over time.
Conclusions:
- One-third of patients had normal CTP core volumes despite evidence of ischemic changes on CT.
- This highlights the importance of evaluating both noncontrast CT and perfusion imaging for thrombectomy eligibility.
- Further research is needed to fully characterize CT and CTP imaging relationships in extended time windows.
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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