Current Evidence on Periprocedural Flat-Panel CT in Endovascular Stroke Treatment: A Systematic Review and...

Periprocedural flat-panel computed tomography (FPCT) may complement real-time decision-making during endovascular treatment for stroke. This study aims to summarize current evidence on diagnostic findings, prognostic associations, and clinical applications of periprocedural FPCT in the angiography suite.

A systematic review and meta-analysis was preregistered (URL: https://www.crd.york.ac.uk/PROSPERO/; Unique identifier: CRD420251142156), conducted and reported according to MOOSE guidelines. Medline, Embase, and Scopus were searched for studies published between January 2019 and September 2025 reporting on periprocedural FPCT in endovascular treatment patients (noncontrast FPCT, 3-dimensional-digital subtraction angiography/contrast-enhanced FPCT, or FPCT perfusion). Random-effects models were used to calculate pooled prevalences and odds ratios for associations with outcomes, primarily functional status assessed via the 90-day modified Rankin Scale score.

Forty studies comprising 4139 patients were included. For noncontrast FPCT, 3 distinct imaging biomarkers were identified. Intraparenchymal hyperattenuations were frequent (pooled prevalence 49% [95% CI, 42%-56%]) and associated with any intracranial hemorrhage (odds ratio, 10.4 [95% CI, 4.5-24.1]), parenchymal hematoma (odds ratio, 4.3 [95% CI, 2.2-8.7]) and lower rates of good outcomes (eg, 90-day modified Rankin Scale score 0-2; odds ratio, 0.35 [95% CI, 0.24-0.50]). Subarachnoid hyperattenuations occurred in 23% (95% CI, 14%-35%) of patients and were associated with distal occlusions, markers of procedural aggressiveness, and poor outcome (eg, 90-day modified Rankin Scale score >2; odds ratio, 0.69 [95% CI, 0.53-0.91]). Intravascular hyperattenuations (distal occlusion tracker sign; pooled prevalence 35%, 95% CI, 24%-49%) showed high specificity (93%, 95% CI, 87%-96%) for residual distal occlusions after endovascular treatment. Advanced vessel imaging improved thrombus conspicuity and technical efficacy, while postoperative flat-panel computed tomography perfusion shows added value for the detection of residual hypoperfusion, diagnosis of hemodynamic alterations, and prediction of final infarct. There was evidence for selection bias, suggesting slight overreporting of the above imaging signs.

Periprocedural FPCT may offer real-time neurovascular and parenchymal assessment when conventional 3-dimensional imaging is unavailable. In our cohort, FPCT findings were associated with clinical outcomes and improved recognition of complications. FPCT may hence assist intraprocedural decision-making regarding adjunctive manoeuvres or drug administrations if further prospective validation can be demonstrated.