J Korean Neurosurg Soc.  2020 Mar;63(2):188-201. 10.3340/jkns.2019.0131.

Single Centre Experience on Decision Making for Mechanical Thrombectomy Based on Single-Phase CT Angiography by Including NCCT and Maximum Intensity Projection Images – A Comparison with Magnetic Resonance Imaging after Non-Contrast CT

• Kim MS
• Kim GS

• KMID: 2501705
• DOI: http://doi.org/10.3340/jkns.2019.0131

Abstract

Objective
: The purpose of this study was to suggest that computed tomography angiography (CTA) is valuable as the only preliminary examination for mechanical thrombectomy (MT). MT after single examination of CTA including non-contrast computed tomography (NCCT) and maximum intensity projection (MIP) improves door-to-puncture time as well as results in favorable outcomes.
Methods
: A total of 157 patients who underwent MT at Dong Kang Medical Center from April 2015 to March 2019 were divided into two groups based on the examination performed prior to MT : CTA group who underwent CTA with NCCT and MIP, and NCCT+magnetic resonance image (MRi) group who underwent MRI including perfusion images after NCCT. In the two groups, time to CTA imaging or NCCT+MRi imaging after symptom onset, and time to arterial puncture and reperfusion were characterized as time-related outcomes. The evaluation of vascular recanalization after MT was defined as a modified thrombolysis in cerebral infarction (mTICI) scale. National Institutes of Health Stroke Scale (NIHSS) was assessed at the time of the visit to the emergency room and modified Rankin Scale (mRS) was assessed after 90 days.
Results
: Typically, there were 34 patients in the CTA group and 33 patients in the NCCT+MRi group. A significantly shorter delay for door-to-puncture time was observed (mean, 86±22.1 vs. 176±47.5 minutes; p<0.01). Also, a significantly shorter door-to-imege time in the CTA group was observed (mean, 13±6.8 vs. 93±30.8 minutes; p<0.01). Moreover, a significantly shorter onset-to-puncture time was observed (mean, 195±128.0 vs. 314±157.6 minutes; p<0.01). Reperfusion result of mTICI ≥2b was 100% (34/34) in the CTA group and 94% (31/33) in the NCCT+MRi group, and mTICI 3 in 74% (25/34) in the CTA group and 73% (24/33) in the NCCT+MRi group. Favorable functional outcomes (mRS score ≤2 at 90 days) were 68% (23/34) in the CTA group and 60% (20/33) in the NCCT+MRi group.
Conclusion
: A single-phase CTA including NCCT and MIP images was performed as a single preliminary examination, which led to a reduction in the time of the procedure and resulted in good results of prognosis. Consequently, it is concluded that this method is of sufficient value as the only preliminary examination for decision making.

Keyword

Stroke; Thrombectomy; Computed tomography angiography

Figure

• 

  Fig. 1. Single-phase CT angiography images including NCCT and MIP images. A 62-year-old woman with a left M1 MCA occlusion. A : Thin-section NCCT (no hypodense lesion, no hemorrage). B : MIP intracranial axial image (arrow, left M1 MCA occlusion). C : MIP intracranial coronal image (arrow, left M1 MCA occlusion). D : MIP intracranial sagittal image (arrow, left M1 MCA occlusion). E : Contrast-enhanced CT image. F : Axial image showing the aortic arch (arrow, left CCA; origin of Brachiocephalic trunk, left CCA, and left subclavian artery). G : MIP extracranial coronal image (arrow, no stenosis of left CCA-ICA and tortuosity of left cervical ICA). H : MIP extracranial sagittal image (arrow, tortuosity of left mid CCA). CT : computed tomography, NCCT : non-contrast computed tomography, MIP : maximum intensity projection, MCA : middle cerebral artery, CCA : common carotid artery, ICA : internal carotid artery.

• 

  Fig. 2. A 78-year-old woman with a right distal M1 MCA occlusion. OTD 240 minutes, NIHSS 16, DTI 16 minutes, DTP 82 minutes, mTICI 3, 90 days mRS 1. A : MIP intracranial axial image (arrow, right distal M1 MCA occlusion). B and C : Good pial collaterals (score 5). D : Axial image showing the aortic arch (arrow, Brachiocephalic trunk; origin of Brachiocephalic trunk, left CCA, and left subclavian artery). E : MIP extracranial coronal image (arrow, no significant stenosis of right CCA to cervical ICA). F : MIP extracranial sagittal image (arrow, tortuosity of proximal right cervical CCA). MCA : middle cerebral artery, OTD : onset-to-door time, NIHSS : National Institutes of Health Stroke Scale, DTI : door-to-image time, DTP : door-to-puncture time, mTICI : modified thrombolysis in cerebral infarction, mRS : modified Rankin Scale, MIP : maximum intensity projection, CCA : common carotid artery, ICA : internal carotid artery.

• 

  Fig. 3. A 70-year-old man with a left mid M1 MCA occlusion. OTD 22 minutes, NIHSS 12, DTI 6 minutes, DTP 70 minutes, mTICI 2b, 90 days mRS 2. A : MIP intracranial axial image (arrow, left mid M1 MCA occlusion). B and C : Moderate pial collaterals (score 3). D : Axial image showing the aortic arch (arrow, left CCA; origin of Brachiocephalic trunk, left CCA, aberrant left VA, and left subclavian artery). E : MIP extracranial coronal image (arrow, bovine origin of left CCA). F : MIP extracranial sagittal image (no significant stenosis of left CCA to cervical ICA). MCA : middle cerebral artery, OTD : onset-to-door time, NIHSS : National Institutes of Health Stroke Scale, DTI : door-to-image time, DTP : door-to-puncture time, mTICI : modified thrombolysis in cerebral infarction, mRS : modified Rankin Scale, MIP : maximum intensity projection, CCA : common carotid artery, VA : vertebral artery, ICA : internal carotid artery.

• 

  Fig. 4. A 63-year-old man with a right proximal M1 MCA occlusion. OTD 48 minutes, NIHSS 18, DTI 14 mintues, DTP 67 minutes, mTICI 3, 90 days mRS 5. A : MIP intracranial axial image (arrow, right proximal M1 MCA occlusion). B and C : Poor pial collaterals (score 0). D : Axial image showing the aortic arch (arrow, Brachiocephalic trunk; origin of Brachiocephalic trunk, left CCA, and left subclavian artery). E and F : MIP extracranial coronal and sagittal images (no significant stenosis of right CCA to cervical ICA). MCA : middle cerebral artery, OTD : onset-to-door time, NIHSS : National Institutes of Health Stroke Scale, DTI : door-to-image time, DTP : door-to-puncture time, mTICI : modified thrombolysis in cerebral infarction, mRS : modified Rankin Scale, MIP : maximum intensity projection, CCA : common carotid artery, ICA : internal carotid artery.

• 

  Fig. 5. A 80-year-old man with a right proximal cervical ICA occlusion. OTD 304 minutes, NIHSS 21, DTI 78 minutes, DTP 164 minutes, mTICI 3, 90 days mRS 0. A and B : MIP intracranial axial image (no occlusion, good pial collaterals). C : MRA image (occlusion of ICA and weak flow of MCA). D-F : MRI images (perfusion-diffusion mismatch). G : Left ICA angiography (pre-MT, irrigation of contralateral ACA and MCA). H : Right ICA angiography (post-MT, successful recanalization, mTICI 3). ICA : internal carotid artery, OTD : onset-to-door time, NIHSS : National Institutes of Health Stroke Scale, DTI : door-toimage time, DTP : door-to-puncture time, mTICI : modified thrombolysis in cerebral infarction, mRS : modified Rankin Scale, MIP : maximum intensity projection, MRA : magnetic resonance angiography, MCA : middle cerebral artery, MRI : magnetic resonance image, MT : mechanical thrombectomy, ACA : anterior cerebral artery.

Reference

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