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Updated: Oct 11, 2025
Optimized Management of Endovascular Treatment for Acute Ischemic Stroke
Published on: January 18, 2018
Systematic CT perfusion acquisition in acute stroke increases vascular occlusion detection and thrombectomy rates
Marta Olive-Gadea1,2, Manuel Requena1,3, Facundo Diaz4
1Stroke Unit, Neurology, Hospital Vall d'Hebron, Barcelona, Barcelona, Spain.
Insights
Adding CT perfusion (CTP) to stroke imaging protocols can improve the detection of intracranial vessel occlusions (VO) missed by CT angiography (CTA), potentially increasing endovascular treatment (EVT) rates.
Area of Science:
- Neurology
- Radiology
- Medical Imaging
Background:
- Current stroke guidelines recommend non-invasive vascular imaging for identifying intracranial vessel occlusions (VO) eligible for endovascular treatment (EVT).
- CT angiography (CTA) can miss VOs, potentially delaying or preventing timely EVT.
- The impact of consistently incorporating CT perfusion (CTP) into acute stroke imaging protocols needs evaluation.
Purpose of the Study:
- To evaluate the impact of systematically including CTP in acute ischemic stroke imaging.
- To compare the diagnostic accuracy of CTP versus CTA in detecting intracranial VOs.
- To assess the effect on endovascular treatment (EVT) rates.
Main Methods:
- Patients with suspected acute ischemic stroke underwent non-contrast CT, CTA, and CTP.
- VOs were identified by CTP-defined hypoperfusion (Tmax >6s).
- Two neuroradiologists retrospectively reviewed CTA (blinded to CTP) to identify VOs.
Main Results:
- CTP identified VOs in 46.5% of patients, while CTA detected VOs in only 24.5%.
- CTA sensitivity for CTP-VO detection was 50.3%, with high specificity (97.8%).
- Including CTP increased the EVT rate to 65.6% of CTP-identified VOs, with CTA missing 30.1% of EVT-treated cases.
Conclusions:
- Systematic inclusion of CTP in acute stroke imaging protocols can enhance VO diagnosis.
- CTP may lead to an increased rate of EVT in eligible stroke patients.
- CTP complements CTA by identifying VOs that might otherwise be missed.
Background:
In patients with stroke, current guidelines recommend non-invasive vascular imaging to identify intracranial vessel occlusions (VO) that may benefit from endovascular treatment (EVT). However, VO can be missed in CT angiography (CTA) readings. We aim to evaluate the impact of consistently including CT perfusion (CTP) in admission stroke imaging protocols.
Methods:
From April to October 2020 all patients admitted with a suspected acute ischemic stroke underwent urgent non-contrast CT, CTA and CTP and were treated accordingly. Hypoperfusion areas defined by time-to-maximum of the tissue residue function (Tmax) >6 s, congruent with the clinical symptoms and a vascular territory, were considered VO (CTP-VO). In addition, two experienced neuroradiologists blinded to CTP but not to clinical symptoms retrospectively evaluated non-contrast CT and CTA to identify intracranial VO (CTA-VO).
Results:
Of the 338 patients included in the analysis, 157 (46.5%) presented with CTP-VO (median Tmax >6s: 73 (29-127) mL). CTA-VO was identified in 83 (24.5%) of the cases. Overall CTA-VO sensitivity for the detection of CTP-VO was 50.3% and specificity was 97.8%. Higher hypoperfusion volume was associated with increased CTA-VO detection (OR 1.03; 95% CI 1.02 to 1.04). EVT was performed in 103 patients (30.5%; Tmax >6s: 102 (63-160) mL), representing 65.6% of all CTP-VO. Overall CTA-VO sensitivity for the detection of EVT-VO was 69.9% and specificity was 95.3%. Among patients who received EVT, the rate of false negative CTA-VO was 30.1% (Tmax >6s: 69 (46-99.5) mL).
Conclusion:
Systematically including CTP in acute stroke admission imaging protocols may increase the diagnosis of VO and rate of EVT.
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