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Perfusion vs non-perfusion computed tomography imaging in the late window of emergent large vessel ischemic stroke: A
Jose Danilo B Diestro1,2, Abdelsimar T Omar3, Yu-Qing Zhang1,4,5
1Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada.
Insights
For emergent large vessel ischemic stroke (ELVIS) patients treated beyond 6 hours, CT neuroimaging type showed minimal impact on clinical outcomes and symptomatic intracranial hemorrhage. Perfusion CT may reduce mortality risk, but evidence quality is low.
Area of Science:
- Neurology
- Radiology
- Interventional Cardiology
Background:
- Guidelines recommend endovascular thrombectomy (EVT) for emergent large vessel ischemic stroke (ELVIS) patients presenting beyond 6 hours, often based on perfusion CT.
- This study compares outcomes for ELVIS patients based on whether they received perfusion CT or non-perfusion CT.
Approach:
- A systematic review and meta-analysis of 7 observational cohorts was conducted.
- Studies included late-presenting ELVIS patients undergoing EVT with data on both non-perfusion and perfusion CT.
- Data were pooled using a random effects model following PRISMA guidelines.
Key Points:
- No significant difference in long-term clinical outcomes (RR: 0.96) or symptomatic intracranial hemorrhage (sICH) (RR: 1.08) between non-perfusion and perfusion CT.
- Perfusion CT was associated with significantly lower mortality (RR: 1.22).
- The certainty of evidence was rated as very low due to risk of bias, indirectness, and imprecision.
Conclusions:
- Non-perfusion and perfusion CT appear to have similar effects on long-term clinical outcomes and sICH in late-presenting EVT patients.
- Perfusion CT may be associated with reduced mortality risk.
- Further randomized trial data are needed due to the uncertainty of the current evidence.
Background:
Guidelines recommend the treatment of emergent large vessel ischemic stroke (ELVIS) patients presenting beyond 6 hours of last known well time with endovascular thrombectomy (EVT) based on perfusion computed tomography (CT) neuroimaging. We compared the outcomes (long-term good clinical outcomes, symptomatic intracranial hemorrhage (sICH), and mortality) of ELVIS patients according to the type of CT neuroimaging they underwent.
Methods:
We searched the following databases: Medline, Embase, CENTRAL, and Scopus from January 1, 2015, to June 14, 2023. We included studies of late-presenting ELVIS patients undergoing EVT that had with data for non-perfusion and perfusion CT neuroimaging. We followed the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. Data were pooled using a random effects model.
Results:
We found 7 observational cohorts. Non-perfusion versus perfusion CT was not statistically significantly different for both long-term clinical (n = 3,224; RR: 0.96; 95% CI 0.86 to 1.06; I2 = 18%) and sICH (n = 3,724; RR: 1.08 95% CI 0.60 to 1.94; I2 = 76%). Perfusion CT had less mortality (n = 3874; RR: 1.22; 95% CI 1.07 to 1.40; I2 = 0%). The certainty of these findings is very low because of limitations in the risk of bias, indirectness, and imprecision domains of the Grading of Recommendations, Assessment, Development and Evaluations.
Conclusion:
The use of either non-perfusion or perfusion CT neuroimaging may have little to no effect on long-term clinical outcomes and sICH for late-presenting EVT patients. Perfusion CT neuroimaging may be associated with a reduced the risk of mortality. Evidence uncertainty warrants randomized trial data.
