Skip to main content

Graphical Abstract

Multidetector computed tomography (CT) perfusion (MDCTP) volume estimation using RAPID software (iSchemaView, Menlo Park, CA) has been validated in clinical trials for endovascular thrombectomy (EVT) selection.1,2 The availability of cone-beam CT perfusion (CBCTP) in the angiosuite might shorten workflow times in late-window patients transferred from primary centers without CTP capabilities. We evaluate whether quantitative analysis of MDCTP and CBCTP using RAPID software would lead to comparable ischemic core and hypoperfused tissue volumes in patients undergoing EVT.

Methods

Anonymized data are available upon reasonable request. This single-center study was approved by our Institutional Review Board and all participants/proxies signed a written informed consent form. We conducted a prospective, single-arm interventional study including patients with anterior circulation large-vessel occlusion stroke eligible for EVT. MDCTP and CBCTP datasets were processed using RAPID software (Data Supplement).
Ischemic core was defined as relative cerebral blood flow of <30% on MDCTP and <45% on CBCTP of the corresponding contralateral territory. The hypoperfused tissue was evaluated using time-to-maximum >6.0 s and time-to-maximum >10.0 s thresholds. We compared MDCTP and CBCTP volumes using intraclass correlation coefficient, Bland-Altman agreement plots, and Pearson and Spearman correlations. Finally, we compared CBCTP ischemic core and the final infarct volume in reperfused patients.

Results

Thirteen patients were included in the final analysis (Figure I and Table I in the Data Supplement). We found a strong correlation between MDCTP and CBCTP for the ischemic core (Pearson=0.91, Spearman=0.87) and time-to-maximum >6.0 s (Pearson=0.90, Spearman=0.85). Bland-Altman analysis showed 92% agreement for both perfusion parameters (Figure). We observed an intraclass correlation coefficient of 0.89 (95% CI, 0.67–0.96) for the ischemic core and 0.86 (95% CI, 0.55–0.96) for time-to-maximum >6.0 s (Table II in the Data Supplement).
Figure. Ischemic core and hypoperfused tissue analysis. Scatterplot with regression line of relative cerebral blood flow (CBF) (A) and time-to-maximum (Tmax) >6.0 s (C) from multidetector computed tomography (CT) perfusion (MDCTP) and cone-beam CT perfusion (CBCTP). Bland-Altman plots comparing CBF (B) and Tmax>6.0 s (D) between MDCTP and CBCTP. Scatterplot with regression line and Bland-Altman plot comparing CBCTP ischemic core and final infarct volume in successful reperfusion patients. FIV indicates final infarct volume; and TICI, Thrombolysis in Cerebral Infarction.
Comparing CBCTP ischemic core and the final infarct volume, we found a strong correlation (Pearson=0.87, Spearman=0.87) and 90% of agreement. We also observed an intraclass correlation coefficient of 0.81 (95% CI, 0.48–0.94).

Discussion

This study demonstrates that automated analysis of ischemic core and hypoperfused tissue volumes derived from MDCTP and CBCTP in patients with stroke eligible for EVT provides comparable results.
In our study, the contrast dose received in CBCTP after MDCTP was relatively low, and the median time between studies was short, which could reduce perfusion variations between modalities. Potential infarct growth between modalities was considered and 91% (10/11) of cases had concordant results using the DEFUSE 3 trial (Endovascular Therapy Following Imaging Evaluation for Ischemic Stroke) eligibility criteria for EVT.2
An automated real-time perfusion volumetric processing in the angiosuite would allow bypassing the emergency department for transferred large-vessel occlusion late-window patients. Thus, this technology might reduce reperfusion times and improve patients’ functional outcomes. In addition, CBCTP images could provide a more accurate assessment of perfusion parameters during and immediately after EVT. Downsides of transferring patients from primary centers to angiosuite might include EVT ineligibility due to large core infarct, low stroke severity, distal occlusion, among others.3
The study is limited by the small sample size. Additional limitations are included in the Data Supplement.

Footnote

Nonstandard Abbreviations and Acronyms

CBCTP
cone-beam CT perfusion
CT
computed tomography
EVT
endovascular thrombectomy
MDCTP
multidetector CT perfusion

Supplemental Material

File (str_stroke-2021-035992d_supp1.pdf)

References

1.
Albers GW, Goyal M, Jahan R, Bonafe A, Diener HC, Levy EI, Pereira VM, Cognard C, Cohen DJ, Hacke W, et al. Ischemic core and hypoperfusion volumes predict infarct size in SWIFT PRIME. Ann Neurol. 2016;79:76–89. doi: 10.1002/ana.24543
2.
Albers GW, Marks MP, Kemp S, Christensen S, Tsai JP, Ortega-Gutierrez S, McTaggart RA, Torbey MT, Kim-Tenser M, Leslie-Mazwi T, et al; DEFUSE 3 Investigators. Thrombectomy for stroke at 6 to 16 hours with selection by perfusion imaging. N Engl J Med. 2018;378:708–718. doi: 10.1056/NEJMoa1713973
3.
Reddy ST, Savitz SI, Friedman E, Arevalo O, Zhang J, Ankrom C, Trevino A, Tzu-Ching W. Patients transferred within a telestroke network for large-vessel occlusion [published online September 20, 2020]. J Telemed Telecare. 2020. doi: 1357633X20957894

eLetters(0)

eLetters should relate to an article recently published in the journal and are not a forum for providing unpublished data. Comments are reviewed for appropriate use of tone and language. Comments are not peer-reviewed. Acceptable comments are posted to the journal website only. Comments are not published in an issue and are not indexed in PubMed. Comments should be no longer than 500 words and will only be posted online. References are limited to 10. Authors of the article cited in the comment will be invited to reply, as appropriate.

Comments and feedback on AHA/ASA Scientific Statements and Guidelines should be directed to the AHA/ASA Manuscript Oversight Committee via its Correspondence page.

Information & Authors

Information

Published In

Go to Stroke

Versions

You are viewing the most recent version of this article.

History

Published online: 28 July 2021
Published in print: September 2021

Permissions

Request permissions for this article.

Keywords

  1. angiography
  2. reperfusion
  3. software
  4. thrombectomy
  5. tomography

Subjects

Authors

Affiliations

Darko Quispe-Orozco, MD
Department of Neurology, University of Iowa Carver College of Medicine, Iowa City (D.Q.-O., C.Z., M.F., A.M.-R., S.O.-G.).
Mudassir Farooqui, MD, MPH
Department of Neurology, University of Iowa Carver College of Medicine, Iowa City (D.Q.-O., C.Z., M.F., A.M.-R., S.O.-G.).
Cynthia Zevallos, MD
Department of Neurology, University of Iowa Carver College of Medicine, Iowa City (D.Q.-O., C.Z., M.F., A.M.-R., S.O.-G.).
Sebastian Schafer, PhD
Siemens Healthcare, Imaging and Therapy Systems, Forchheim, Germany (S.S.).
Alan Mendez-Ruiz, MD
Department of Neurology, University of Iowa Carver College of Medicine, Iowa City (D.Q.-O., C.Z., M.F., A.M.-R., S.O.-G.).
Gregory Albers, MD
Department of Neurology and Neurological Sciences, Stanford University, Stanford, CA (G.A.).
Nils Petersen, MD, PhD
Department of Neurology, Yale University School of Medicine, New Haven, CT (N.P.).
Department of Neurology, University of Iowa Carver College of Medicine, Iowa City (D.Q.-O., C.Z., M.F., A.M.-R., S.O.-G.).

Notes

The Data Supplement is available with this article at Supplemental Material.
For Sources of Funding and Disclosures, see page e543.
Presented in part at the Society of Vascular and Interventional Neurology Annual Meeting, virtual, November 18–21, 2020, and the American Academy of Neurology Annual Meeting, virtual, April 17–22, 2021.
Correspondence to: Santiago Ortega-Gutierrez, MD, MSc, University of Iowa Hospitals and Clinics, 200 Hawkins Dr, Iowa City, IA 52242. Email [email protected]

Disclosures

Disclosures Dr Ortega-Gutierrez is consultant for Medtronic and Stryker. Dr Albers is consultant for Genentech, and ownership interest and consultant on the advisory board for iSchema View. Dr Schafer is employee of Siemens Healthineers. The other authors report no conflicts.

Sources of Funding

This study has been funded by an investigator-initiated grant from iSchemaView.

Metrics & Citations

Metrics

Citations

Download Citations

If you have the appropriate software installed, you can download article citation data to the citation manager of your choice. Select your manager software from the list below and click Download.

  1. Recanalization Does Not Always Equate to Reperfusion: No-Reflow Phenomenon After Successful Thrombectomy, Stroke, 56, 1, (183-189), (2024)./doi/10.1161/STROKEAHA.124.048994
    Abstract
  2. Flat-panel Detector Perfusion Imaging and Conventional Multidetector Perfusion Imaging in Patients with Acute Ischemic Stroke, Clinical Neuroradiology, 34, 3, (625-635), (2024).https://doi.org/10.1007/s00062-024-01401-7
    Crossref
  3. Intravenous Thrombolysis before Complete Angiographic Reperfusion: Beyond Angiographic Assessment to Target Microvascular Obstruction?, Annals of Neurology, 95, 4, (762-773), (2024).https://doi.org/10.1002/ana.26867
    Crossref
  4. Effect of incomplete reperfusion patterns on clinical outcome: insights from the ESCAPE-NA1 trial, Journal of NeuroInterventional Surgery, 16, 8, (809-814), (2023).https://doi.org/10.1136/jnis-2023-020553
    Crossref
  5. The Benefit of a Complete over a Successful Reperfusion Decreases with Time, Annals of Neurology, 93, 5, (934-941), (2023).https://doi.org/10.1002/ana.26599
    Crossref
  6. Effective Dose Measurements of the Latest-Generation Angiographic System in Patients with Acute Stroke: A Comparison with the Newest Multidetector CT Generation, American Journal of Neuroradiology, 43, 11, (1621-1626), (2022).https://doi.org/10.3174/ajnr.A7658
    Crossref
  7. Correlation of Collateral Scores Derived from Whole-Brain Time-Resolved Flat Panel Detector Imaging in Acute Ischemic Stroke, American Journal of Neuroradiology, 43, 11, (1627-1632), (2022).https://doi.org/10.3174/ajnr.A7657
    Crossref
  8. Direct to angiosuite strategy versus standard workflow triage for endovascular therapy: systematic review and meta-analysis, Journal of NeuroInterventional Surgery, 15, e1, (e17-e25), (2022).https://doi.org/10.1136/neurintsurg-2022-018895
    Crossref
  9. Evaluation of time-resolved whole brain flat panel detector perfusion imaging using RAPID ANGIO in patients with acute stroke: comparison with CT perfusion imaging, Journal of NeuroInterventional Surgery, 15, 4, (387-392), (2022).https://doi.org/10.1136/neurintsurg-2021-018464
    Crossref
  10. Angiography suite cone‐beam CT perfusion for selection of thrombectomy patients: A pilot study, Journal of Neuroimaging, 32, 3, (493-501), (2022).https://doi.org/10.1111/jon.12988
    Crossref
Loading...

View Options

View options

PDF and All Supplements

Download PDF and All Supplements

PDF/EPUB

View PDF/EPUB
Login options

Check if you have access through your login credentials or your institution to get full access on this article.

Personal login Institutional Login
Purchase Options

Purchase this article to access the full text.

Purchase access to this article for 24 hours

Angiography Suite Cone-Beam Computed Tomography Perfusion Imaging in Large-Vessel Occlusion Patients Using RAPID Software: A Pilot Study
Stroke
  • Vol. 52
  • No. 9

Purchase access to this journal for 24 hours

Stroke
  • Vol. 52
  • No. 9
Restore your content access

Enter your email address to restore your content access:

Note: This functionality works only for purchases done as a guest. If you already have an account, log in to access the content to which you are entitled.

Figures

Tables

Media

Share

Share

Share article link

Share

Comment Response