The Prognostic Value of CT Angiography and CT Perfusion in Acute Ischemic Stroke.

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Abstract

CT angiography (CTA) and CT perfusion (CTP) are important diagnostic tools in acute ischemic stroke. We investigated the prognostic value of CTA and CTP for clinical outcome and determined whether they have additional prognostic value over patient characteristics and non-contrast CT (NCCT).

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Most cited references 34

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Analysis of pooled data from the randomised controlled trials of endarterectomy for symptomatic carotid stenosis

PM Rothwell, M Eliasziw, SA Gutnikov … (2003)

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Perfusion-CT assessment of infarct core and penumbra: receiver operating characteristic curve analysis in 130 patients suspected of acute hemispheric stroke.

Max Wintermark, Adam Flanders, Birgitta K. Velthuis … (2006)

Different definitions have been proposed to define the ischemic penumbra from perfusion-CT (PCT) data, based on parameters and thresholds tested only in small pilot studies. The purpose of this study was to perform a systematic evaluation of all PCT parameters (cerebral blood flow, volume [CBV], mean transit time [MTT], time-to-peak) in a large series of acute stroke patients, to determine which (combination of) parameters most accurately predicts infarct and penumbra. One hundred and thirty patients with symptoms suggesting hemispheric stroke < or =12 hours from onset were enrolled in a prospective multicenter trial. They all underwent admission PCT and follow-up diffusion-weighted imaging/fluid-attenuated inversion recovery (DWI/FLAIR); 25 patients also underwent admission DWI/FLAIR. PCT maps were assessed for absolute and relative reduced CBV, reduced cerebral blood flow, increased MTT, and increased time-to-peak. Receiver-operating characteristic curve analysis was performed to determine the most accurate PCT parameter, and the optimal threshold for each parameter, using DWI/FLAIR as the gold standard. The PCT parameter that most accurately describes the tissue at risk of infarction in case of persistent arterial occlusion is the relative MTT (area under the curve=0.962), with an optimal threshold of 145%. The PCT parameter that most accurately describes the infarct core on admission is the absolute CBV (area under the curve=0.927), with an optimal threshold at 2.0 ml x 100 g(-1). In a large series of 130 patients, the optimal approach to define the infarct and the penumbra is a combined approach using 2 PCT parameters: relative MTT and absolute CBV, with dedicated thresholds.

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The independent predictive utility of computed tomography angiographic collateral status in acute ischaemic stroke.

Patrick McElduff, Neil Spratt, F Miteff … (2009)

It is unknown whether collateral vessel status, as seen on computed tomography angiography, can predict the fate of penumbral tissue identified on perfusion computed tomography and thereby influence clinical outcome. We tested this hypothesis in consecutive patients who underwent perfusion computed tomography/computed tomography angiography within 6 h of anterior circulation stroke, who also had repeat perfusion/infarct volume imaging at 24 h, and modified Rankin Scale at 3 months. Collateral status was graded as good or reduced depending on the extent of contrast visualized distal to the occlusion on computed tomography angiography. 'Perfusion computed tomography mismatch' ratio was calculated from the ratio of the mean transit time lesion/cerebral blood volume lesion. Of 92 patients with proximal intracranial vessel occlusion, good collateral status (51/92) was significantly associated with reduced infarct expansion and more favourable functional outcomes (modified Rankin Scale 0-2). Significant univariate predictors of favourable outcome were good collateral status, major reperfusion at 24 h, presence of perfusion computed tomography mismatch (for a range of ratios: > or = 1.2, > or = 2, > or = 3, > or = 3.5) and baseline National Institutes of Health Stroke Scale score. Notably, none of the 37 patients with a perfusion computed tomography mismatch ratio < 3.0 had a favourable outcome. In patients with perfusion computed tomography mismatch, significant independent predictors of favourable outcome were good collateral status, major reperfusion and baseline National Institutes of Health Stroke Scale score. There was also a strong interaction between major reperfusion and good collateral status in the regression models. In patients with proximal vessel occlusion, perfusion computed tomography mismatch is a prerequisite for a favourable clinical response, but good collateral status appears a critical determinant of ultimate outcome, particularly if major reperfusion occurs.