The accuracy of ischemic core perfusion thresholds varies according to time to recanalization in stroke patients treated with mechanical thrombectomy: A comprehensive whole-brain computed tomography perfusion study.
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SUBMITTER: Laredo C
PROVIDER: S-EPMC7181085 | biostudies-literature |
REPOSITORIES: biostudies-literature
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Project description:PurposeFlat-panel computed tomography (FP-CT) is increasingly available in angiographic rooms and hybrid OR's. Considering its easy access, cerebral imaging using FP-CT is an appealing modality for intra-procedural applications. The purpose of this systematic review is to assess the diagnostic accuracy of FP-CT compared with perfusion computed tomography (CTP) and perfusion magnetic resonance (MRP) in cerebral perfusion imaging.MethodsWe performed a systematic literature search in the Cochrane Library, MEDLINE, Embase, and Web of Science up to June 2019 for studies directly comparing FP-CT with either CTP or MRP in vivo. Methodological quality was assessed using the QUADAS-2 tool. Data on diagnostic accuracy was extracted and pooled if possible.ResultsWe found 11 studies comparing FP-CT with CTP and 5 studies comparing FP-CT with MRP. Most articles were pilot or feasibility studies, focusing on scanning and contrast protocols. All patients studied showed signs of cerebrovascular disease. Half of the studies were animal trials. Quality assessment showed unclear to high risks of bias and low concerns regarding applicability. Five studies reported on diagnostic accuracy; FP-CT shows good sensitivity (range 0.84-1.00) and moderate specificity (range 0.63-0.88) in detecting cerebral blood volume (CBV) lesions.ConclusionsEven though FP-CT provides similar CBV values and reconstructed blood volume maps as CTP in cerebrovascular disease, additional studies are required in order to reliably compare its diagnostic accuracy with cerebral perfusion imaging.
| S-EPMC6848034 | biostudies-literature
Project description:BackgroundGuidelines by the Endocrine Society Guideline on bypassing adrenal vein sampling (AVS) in patients <35 years old with marked primary aldosteronism (PA) (hypokalemia and elevated plasma aldosterone concentration [PAC]) and a unilateral lesion on computed tomography (CT) are based on limited number of studies. We aimed to determine the accuracy of CT in PA patients according to age.MethodsIn this retrospective study, we investigated the concordance between CT and AVS in 466 PA patients from two tertiary centers who successfully underwent AVS.ResultsCT had an overall accuracy of 64.4% (300/466). In the group with unilateral lesion, patients with hypokalemia had higher concordance than those without hypokalemia (85.0% vs. 43.6%, P<0.001). In the group with marked PA (hypokalemia and PAC >15.9 ng/dL) and unilateral lesion, accuracy of CT was 84.6% (11/13) in patients aged <35 years; 100.0% (20/20), aged 35 to 39 years; 89.4% (59/66), aged 40 to 49 years; and 79.8% (79/99), aged ≥50 years. Cut-off age and PAC for concordance was <50 years and >29.6 ng/dL, respectively. The significant difference in accuracy of CT in 198 patients with marked PA and a unilateral lesion between the <50-year age group and ≥50-year age group (90.9% vs. 79.8%, P=0.044) disappeared in 139 of 198 patients with PAC > 30.0 ng/dL (91.9% vs. 87.7%, P=0.590).ConclusionPatients with hypokalemia, PAC >30.0 ng/dL, and unilateral lesion were at high risk of unilateral PA regardless of age.
| S-EPMC8090455 | biostudies-literature
Project description:Background and Purpose- If anterior circulation large vessel occlusion acute ischemic stroke patients presenting with ASPECTS 0-5 (Alberta Stroke Program Early CT Score) should be treated with mechanical thrombectomy remains unclear. Purpose of this study was to report on the outcome of patients with ASPECTS 0-5 treated with mechanical thrombectomy and to provide data regarding the effect of successful reperfusion on clinical outcomes and safety measures in these patients. Methods- Multicenter, pooled analysis of 7 institutional prospective registries: Bernese-European Registry for Ischemic Stroke Patients Treated Outside Current Guidelines With Neurothrombectomy Devices Using the SOLITAIRE FR With the Intention for Thrombectomy (Clinical Trial Registration-URL: https://www.clinicaltrials.gov . Unique identifier: NCT03496064). Primary outcome was defined as modified Rankin Scale 0-3 at day 90 (favorable outcome). Secondary outcomes included rates of day 90 modified Rankin Scale 0-2 (functional independence), day 90 mortality and occurrence of symptomatic intracerebral hemorrhage. Multivariable logistic regression analyses were performed to assess the association of successful reperfusion with clinical outcomes. Outputs are displayed as adjusted Odds Ratios (aOR) and 95% CI. Results- Two hundred thirty-seven of 2046 patients included in this registry presented with anterior circulation large vessel occlusion and ASPECTS 0-5. In this subgroup, the overall rates of favorable outcome and mortality at day 90 were 40.1% and 40.9%. Achieving successful reperfusion was independently associated with favorable outcome (aOR, 5.534; 95% CI, 2.363-12.961), functional independence (aOR, 5.583; 95% CI, 1.964-15.873), reduced mortality (aOR, 0.180; 95% CI, 0.083-0.390), and lower rates of symptomatic intracerebral hemorrhage (aOR, 0.235; 95% CI, 0.062-0.887). The mortality-reducing effect remained in patients with ASPECTS 0-4 (aOR, 0.167; 95% CI, 0.056-0.499). Sensitivity analyses did not change the primary results. Conclusions- In patients presenting with ASPECTS 0-5, who were treated with mechanical thrombectomy, successful reperfusion was beneficial without increasing the risk of symptomatic intracerebral hemorrhage. Although the results do not allow for general treatment recommendations, formal testing of mechanical thrombectomy versus best medical treatment in these patients in a randomized controlled trial is warranted.
| S-EPMC6430594 | biostudies-literature
Project description:To assess the utility of computed tomographic (CT) perfusion for selection of patients for endovascular therapy up to 18 hours after symptom onset.We conducted a multicenter cohort study of consecutive acute stroke patients scheduled to undergo endovascular therapy within 90 minutes after a baseline CT perfusion. Patients were classified as "target mismatch" if they had a small ischemic core and a large penumbra on their baseline CT perfusion. Reperfusion was defined as >50% reduction in critical hypoperfusion between the baseline CT perfusion and the 36-hour follow-up magnetic resonance imaging.Of the 201 patients enrolled, 190 patients with an adequate baseline CT perfusion study who underwent angiography were included (mean age?=?66 years, median NIH Stroke Scale [NIHSS]?=?16, median time from symptom onset to endovascular therapy?=?5.2 hours). Rate of reperfusion was 89%. In patients with target mismatch (n?=?131), reperfusion was associated with higher odds of favorable clinical response, defined as an improvement of ?8 points on the NIHSS (83% vs 44%; p?=?0.002, adjusted odds ratio [OR]?=?6.6, 95% confidence interval [CI]?=?2.1-20.9). This association did not differ between patients treated within 6 hours (OR?=?6.4, 95% CI?=?1.5-27.8) and those treated?>?6 hours after symptom onset (OR?=?13.7, 95% CI?=?1.4-140).The robust association between endovascular reperfusion and good outcome among patients with the CT perfusion target mismatch profile treated up to 18 hours after symptom onset supports a randomized trial of endovascular therapy in this patient population. Ann Neurol 2017;81:849-856.
| S-EPMC5521988 | biostudies-literature
Project description:IntroductionMechanical thrombectomy (MT) for acute ischemic stroke has become a standard therapy, and the recanalization rate has significantly improved. However, some cases of unsuccessful recanalization still occur. We aimed to clarify patient factors associated with unsuccessful recanalization after MT for acute ischemic stroke.MethodsThis was a single-center, retrospective study of 119 consecutive patients with anterior circulation acute ischemic stroke who underwent MT at our hospital between April 2015 and March 2019. Successful recanalization after MT was defined as modified Treatment in Cerebral Ischemia (mTICI) grade 2b or 3, and unsuccessful recanalization was defined as mTICI grades 0-2a. Several factors were analyzed to assess their effect on recanalization rates.ResultsSuccessful recanalization was achieved in 88 patients (73.9%). The univariate analysis showed that female sex (38.6 vs. 67.7%, p = 0.007), a history of hypertension (53.4 vs. 83.9%, p = 0.003), and a longer time from groin puncture to recanalization (median 75 vs. 124 min, p < 0.001) were significantly associated with unsuccessful recanalization. The multivariate analysis confirmed that female sex (OR 3.18; 95% CI 1.12-9.02, p = 0.030), a history of hypertension (OR 4.84; 95% CI 1.32-17.8, p = 0.018), M2-3 occlusion (OR 4.26; 95% CI 1.36-13.3, p = 0.013), and the time from groin puncture to recanalization (per 10-min increase, OR 1.22; 95% CI 1.09-1.37, p < 0.001) were independently associated with unsuccessful recanalization.ConclusionFemale sex and a history of hypertension might be predictors of unsuccessful recanalization after MT for anterior circulation acute ischemic stroke. Further studies are needed to fully evaluate predictors of recanalization.
| S-EPMC6792430 | biostudies-literature
Project description:PurposeEvaluate concordance of provider practices with clinical guidelines for thrombectomy screening in an emergency department (ED) via computed tomography perfusion and angiogram (CT-P/A).MethodsA retrospective observational study was conducted for patients 18 years or older who received a CT-P/A of the head and neck in a US Midwestern ED between September 2019 through June 2021. Healthcare system records reviewed for patient information, CT-P/A findings, and treatment decisions.ResultsDuring study period, 68,403 patients presented to the ED with 718 (1.1%) receiving a CT-P/A. Of these patients, 105 (14.6%) were transferred to a regional facility for potential thrombectomy, with 74 (70.5%) receiving procedure, 28 (26.7%) not receiving procedure, and 3 (2.9%) with insufficient follow-up information. Of patients receiving CT-P/A, 23 met DAWN criteria for thrombectomy, with 21 (91.3%) transferred for potential thrombectomy and 20 (95.2%) receiving the procedure; in comparison, 81 patients (11.7%) did not meet all DAWN criteria and were transferred for potential thrombectomy, with 52 (64.2%) receiving procedure. Lastly, 55 patients met DEFUSE-3 criteria for thrombectomy with 49 (89.1%) being transferred for potential thrombectomy and 45 (91.8%) receiving procedure. In comparison, 53 patients who did not meet all DEFUSE-3 criteria were transferred for potential thrombectomy, with 27 (50.9%) receiving procedure.ConclusionsThis study helps to understand CT-P/A usage, especially in patients that fall outside of treatment criteria in the current thrombectomy literature. Results may have value to institutions interested in using CT-P/A as a diagnostic tool as well as institutions already incorporating it in stroke assessments.
| S-EPMC9925360 | biostudies-literature
Project description:PurposeComputed tomography (CT)-derived ventilation methods compute respiratory induced volume changes as a surrogate for pulmonary ventilation. Currently, there are no known methods to derive perfusion information from noncontrast CT. We introduce a novel CT-Perfusion (CT-P) method for computing the magnitude mass changes apparent on dynamic noncontrast CT as a surrogate for pulmonary perfusion.MethodsCT-Perfusion is based on a mass conservation model which describes the unknown mass change as a linear combination of spatially corresponding inhale and exhale HU estimated voxel densities. CT-P requires a deformable image registration (DIR) between the inhale/exhale lung CT pair, a preprocessing lung volume segmentation, and an estimate for the Jacobian of the DIR transformation. Given this information, the CT-P image, which provides the magnitude mass change for each voxel within the lung volume, is formulated as the solution to a constrained linear least squares problem defined by a series of subregional mean magnitude mass change measurements. Similar to previous robust CT-ventilation methods, the amount of uncertainty in a subregional sample mean measurement is related to measurement resolution and can be characterized with respect to a tolerance parameter τ . Spatial Spearman correlation between single photon emission CT perfusion (SPECT-P) and the proposed CT-P method was assessed in two patient cohorts via a parameter sweep of τ . The first cohort was comprised of 15 patients diagnosed with pulmonary embolism (PE) who had SPECT-P and 4DCT imaging acquired within 24 h of PE diagnosis. The second cohort was comprised of 15 nonsmall cell lung cancer patients who had SPECT-P and 4DCT images acquired prior to radiotherapy. For each test case, CT-P images were computed for 30 different uncertainty parameter values, uniformly sampled from the range [0.01, 0.125], and the Spearman correlation between the SPECT-P and the resulting CT-P images were computed.ResultsThe median correlations between CT-P and SPECT-P taken over all 30 test cases ranged between 0.49 and 0.57 across the parameter sweep. For the optimal tolerance τ = 0.0385, the CT-P and SPECT-P correlations across all 30 test cases ranged between 0.02 and 0.82. A one-sample sign test was applied separately to the PE and lung cancer cohorts. A low Spearmen correlation of 15% was set as the null median value and two-sided alternative was tested. The PE patients showed a median correlation of 0.57 (IQR = 0.305). One-sample sign test was statistically significant with 96.5 % confidence interval: 0.20-0.63, P < 0.00001. Lung cancer patients had a median correlation of 0.57(IQR = 0.230). Again, a one-sample sign test for median was statistically significant with 96.5 percent confidence interval: 0.45-0.71, P < 0.00001.ConclusionCT-Perfusion is the first mechanistic model designed to quantify magnitude blood mass changes on noncontrast dynamic CT as a surrogate for pulmonary perfusion. While the reported correlations with SPECT-P are promising, further investigation is required to determine the optimal CT acquisition protocol and numerical method implementation for CT-P imaging.
| S-EPMC8252085 | biostudies-literature
Project description:BackgroundEstablishing the diagnosis of coronary artery disease (CAD) in symptomatic patients allows appropriately allocating preventative measures. Single-photon emission computed tomography (CT)-acquired myocardial perfusion imaging (SPECT-MPI) is frequently used for the evaluation of CAD, but coronary CT angiography (CTA) has emerged as a valid alternative.Methods and resultsWe compared the accuracy of SPECT-MPI and CTA for the diagnosis of CAD in 391 symptomatic patients who were prospectively enrolled in a multicenter study after clinical referral for cardiac catheterization. The area under the receiver operating characteristic curve was used to evaluate the diagnostic accuracy of CTA and SPECT-MPI for identifying patients with CAD defined as the presence of ≥1 coronary artery with ≥50% lumen stenosis by quantitative coronary angiography. Sensitivity to identify patients with CAD was greater for CTA than SPECT-MPI (0.92 versus 0.62, respectively; P<0.001), resulting in greater overall accuracy (area under the receiver operating characteristic curve, 0.91 [95% confidence interval, 0.88-0.94] versus 0.69 [0.64-0.74]; P<0.001). Results were similar in patients without previous history of CAD (area under the receiver operating characteristic curve, 0.92 [0.89-0.96] versus 0.67 [0.61-0.73]; P<0.001) and also for the secondary end points of ≥70% stenosis and multivessel disease, as well as subgroups, except for patients with a calcium score of ≥400 and those with high-risk anatomy in whom the overall accuracy was similar because CTA's superior sensitivity was offset by lower specificity in these settings. Radiation doses were 3.9 mSv for CTA and 9.8 for SPECT-MPI (P<0.001).ConclusionsCTA is more accurate than SPECT-MPI for the diagnosis of CAD as defined by conventional angiography and may be underused for this purpose in symptomatic patients.Clinical trial registrationURL: http://www.clinicaltrials.gov. Unique identifier: NCT00934037.
| S-EPMC6604852 | biostudies-literature
Project description:See Saver (doi:10.1093/awx020) for a scientific commentary on this article.Stroke shortens an individual's disability-free life. We aimed to assess the relative prognostic influence of pre- and post-treatment perfusion computed tomography imaging variables (e.g. ischaemic core and penumbral volumes) compared to standard clinical predictors (such as onset-to-treatment time) on long-term stroke disability in patients undergoing thrombolysis. We used data from a prospectively collected international, multicentre, observational registry of acute ischaemic stroke patients who had perfusion computed tomography and computed tomography angiography before treatment with intravenous alteplase. Baseline perfusion computed tomography and follow-up magnetic resonance imaging were analysed to derive the baseline penumbra volume, baseline ischaemic core volume, and penumbra salvaged from infarction. The primary outcome measure was the effect of imaging and clinical variables on Disability-Adjusted Life Year. Clinical variables were age, sex, National Institutes of Health Stroke Scale score, and onset-to-treatment time. Age, sex, country, and 3-month modified Rankin Scale were extracted from the registry to calculate disability-adjusted life-year due to stroke, such that 1 year of disability-adjusted life-year equates to 1 year of healthy life lost due to stroke. There were 772 patients receiving alteplase therapy. The number of disability-adjusted life-year days lost per 1 ml of baseline ischaemic core volume was 17.5 (95% confidence interval, 13.2-21.9 days, P < 0.001). For every millilitre of penumbra salvaged, 7.2 days of disability-adjusted life-year days were saved (β = -7.2, 95% confidence interval, -10.4 to -4.1 days, P < 0.001). Each minute of earlier onset-to-treatment time resulted in a saving of 4.4 disability-free days after stroke (1.3-7.5 days, P = 0.006). However, after adjustment for imaging variables, onset-to-treatment time was not significantly associated with savings in disability-adjusted life-year days. Pretreatment perfusion computed tomography can (independently of clinical variables) predict significant gains, or loss, of disability-free life in patients undergoing reperfusion therapy for stroke. The effect of earlier treatment on disability-free life appears explained by salvage of penumbra, particularly when the ischaemic core is not too large.
| S-EPMC5382947 | biostudies-literature
Project description:AIMS:To evaluate the diagnostic power of integrating the results of computed tomography angiography (CTA) and CT myocardial perfusion (CTP) to identify coronary artery disease (CAD) defined as a flow limiting coronary artery stenosis causing a perfusion defect by single photon emission computed tomography (SPECT). METHODS AND RESULTS:We conducted a multicentre study to evaluate the accuracy of integrated CTA-CTP for the identification of patients with flow-limiting CAD defined by ?50% stenosis by invasive coronary angiography (ICA) with a corresponding perfusion deficit on stress single photon emission computed tomography (SPECT/MPI). Sixteen centres enroled 381 patients who underwent combined CTA-CTP and SPECT/MPI prior to conventional coronary angiography. All four image modalities were analysed in blinded independent core laboratories. The prevalence of obstructive CAD defined by combined ICA-SPECT/MPI and ICA alone was 38 and 59%, respectively. The patient-based diagnostic accuracy defined by the area under the receiver operating characteristic curve (AUC) of integrated CTA-CTP for detecting or excluding flow-limiting CAD was 0.87 [95% confidence interval (CI): 0.84-0.91]. In patients without prior myocardial infarction, the AUC was 0.90 (95% CI: 0.87-0.94) and in patients without prior CAD the AUC for combined CTA-CTP was 0.93 (95% CI: 0.89-0.97). For the combination of a CTA stenosis ?50% stenosis and a CTP perfusion deficit, the sensitivity, specificity, positive predictive, and negative predicative values (95% CI) were 80% (72-86), 74% (68-80), 65% (58-72), and 86% (80-90), respectively. For flow-limiting disease defined by ICA-SPECT/MPI, the accuracy of CTA was significantly increased by the addition of CTP at both the patient and vessel levels. CONCLUSIONS:The combination of CTA and perfusion correctly identifies patients with flow limiting CAD defined as ?50 stenosis by ICA causing a perfusion defect by SPECT/MPI.
| S-EPMC6693293 | biostudies-literature