J Stroke.  2021 Sep;23(3):377-387. 10.5853/jos.2021.00619.

Impact of Multiphase Computed Tomography Angiography for Endovascular Treatment Decision-Making on Outcomes in Patients with Acute Ischemic Stroke

• Ospel JM
• Volny O
• Qiu W
• Najm M
• Hafeez M
• Abdalrahman S
• Fainardi E
• Rubiera M
• Khaw A
• Shankar JJ
• Hill MD
• Almekhlafi MA
• Demchuk AM
• Goyal M
• Menon BK

• KMID: 2520915
• DOI: http://doi.org/10.5853/jos.2021.00619

Abstract

Background and Purpose
Various imaging paradigms are used for endovascular treatment (EVT) decision-making and outcome estimation in acute ischemic stroke (AIS). We aim to compare how these imaging paradigms perform for EVT patient selection and outcome estimation.
Methods
Prospective multi-center cohort study of patients with AIS symptoms with multi-phase computed tomography angiography (mCTA) and computed tomography perfusion (CTP) baseline imaging. mCTA-based EVT-eligibility was defined as presence of large vessel occlusion (LVO) and moderate-to-good collaterals on mCTA. CTP-based eligibility was defined as presence of LVO, ischemic core (defined on relative cerebral blood flow, absolute cerebral blood flow, and cerebral blood volume maps) <70 mL, mismatch-ratio >1.8, absolute mismatch >15 mL. EVT-eligibility and adjusted rates of good outcome (modified Rankin Scale 0–2) based on these imaging paradigms were compared.
Results
Of 289/464 patients with LVO, 263 (91%) were EVT-eligible by mCTA-criteria versus 63 (22%), 19 (7%) and 103 (36%) by rCBF, aCBF, and CBV-CTP-criteria. CTP and mCTA-criteria were discordant in 40% to 53%. Estimated outcomes were best in patients who met both mCTA and CTP eligibility-criteria and were treated with EVT (62% to 87% good outcome). Patients eligible for EVT by mCTA-criteria and not by CTP-criteria receiving EVT achieved good outcome rates of 53% to 57%. Few patients met CTP-criteria and not mCTA-criteria for EVT.
Conclusions
Simpler imaging selection criteria that rely on little else than detection of the occluded blood vessel may be more sensitive and less specific, thus resulting in more patients being offered EVT and arguably benefiting from it.

Keyword

Ischemic stroke; Ischemia; Cerebrovascular circulation

Figure

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  Figure 1. Proportional Venn diagrams illustrating the number of patients with anterior circulation large vessel occlusion (LVO), i.e., target for endovascular treatment (EVT; grey circles), and EVT eligible patients based on computed tomography perfusion (CTP) criteria (blue circles) and multi-phase computed tomography angiography (mCTA) criteria (green circles). (A) Illustrates CTP based EVT-eligibility for relative cerebral blood flow (rCBF) <30% as core threshold, (B) illustrates CTP based EVT-eligibility for absolute cerebral blood flow (aCBF) <7 mL/100 g/min as core threshold, and (C) illustrates CTP based EVT-eligibility for absolute cerebral blood volume (aCBV) <2 mL/100 g as core threshold.

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  Figure 2. Median adjusted probability (model estimated) of major clinical improvement (A) and good outcome (B) conditional on computed tomography perfusion (CTP) vs. multi-phase computed tomography angiography (mCTA) based imaging selection criteria vs. both vs. neither and by treatment offered (endovascular treatment [EVT] vs. no EVT). Bars labelled with indicate probabilities for relative cerebral blood flow <30% as core threshold; bars labelled with indicate probabilities for absolute cerebral blood flow <7 mL/100 g/min as core threshold; and bars labelled with indicate probabilities for cerebral blood volume <2 mL/100 g as core threshold. Note that groups with less than 20 patients are not represented in this figure.

Reference

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