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Accuracy and Reliability of Multiphase CTA Perfusion for Identifying Ischemic Core

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A Correction to this article was published on 03 June 2019

This article has been updated

Abstract

Purpose

Acute stroke treatment requires simple, quick and accurate detection of early ischemic changes to facilitate treatment decisions guided by published selection criteria. The aim of this study was to determine the accuracy and reliability of multiphase computed tomography angiography (mCTA) perfusion hypoattenuation for detecting early severe ischemia.

Methods

Non-contrast CT (NCCT), mCTA for regional leptomeningeal score (mCTA-rLMC), and mCTA perfusion lesion visibility (mCTA-arterial and mCTA-venous) were assessed blinded to clinical information in patients treated with endovascular therapy (EVT). The extent of early ischemia defined by regions of hypoattenuation was evaluated by the Alberta Stroke Program Early CT Score (ASPECTS). The ASPECTS scores were dichotomized based on the American Heart Association (AHA) guidelines for EVT selection, ASPECTS ≥6 vs. <6. The diagnostic accuracy was calculated by comparison to 24-h magnetic resonance imaging (MRI) or CT ASPECTS. Inter-observer reliability of NCCT and mCTA ASPECTS was evaluated. Machine learning models were used to predict the clinical follow-up outcome, e.g. National Institutes of Health Stroke scale (NIHSS) and modified Rankin scale (mRS) from baseline imaging data and patient information.

Results

A total of 89 acute stroke patients (68 ± 15 years of age) were analyzed (33 TICI-0, 56 TICI-2b or 3). Median baseline NIHSS was 17. The mCTA-venous had a large effect on accurately identifying early ischemia when dichotomized for ASPECTS ≥6 vs <6 (likelihood ratio [LR+] > 10 vs. [LR−] < 0.29) compared to the moderate effect of NCCT ([LR+] = 6.7; [LR−] = 0.56) and mCTA-rLMC [(LR+ = 8.0; (LR–) = 0.83)]. The inter-observer reliability in mCTA-venous was almost perfect for all ASPECTS regions except the internal capsule. The machine learning support factor regression model identified mCTA-venous as the most important imaging covariate for predicting 24-h NIHSS and 90-day mRS.

Conclusion

The assessment of mCTA-venous permits a more accurate detection of early ischemia than NCCT and mCTA-rLMC score and is predictive of clinical outcome. We would recommend the inclusion of mCTA perfusion lesion in future endovascular trials aiming at extending current AHA guidelines for EVT in stroke patients with low ASPECTS.

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Change history

  • 03 June 2019

    <Emphasis Type="Bold">Correction to:</Emphasis>

    <Emphasis Type="Bold">Clin Neuroradiol 2018</Emphasis>

    <ExternalRef><RefSource>https://doi.org/10.1007/s00062-018-0717-x</RefSource><RefTarget Address="10.1007/s00062-018-0717-x" TargetType="DOI"/></ExternalRef>

    Unfortunately, the author list of the original version of this article contains a mistake. The middle name of the author “Rani Gupta Sah” was erroneously tagged as part of the surname in the article’s metadata.

    This mistake

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Acknowledgements

We acknowledge the Calgary Stroke Program and the Seaman MR Center for their support. Supported by a Canadian Institute of Health Research Operating Grant and bridge funding from the Faculty of Medicine, University of Calgary.

Funding

Supported by a Canadian Institute of Health Research Operating Grant and bridge funding from the Faculty of Medicine, University of Calgary.

Author information

Authors and Affiliations

  1. Department of Medical Sciences, University of Calgary, Calgary, Canada

    Meaghan Reid & Moiz Hafeez

  2. Calgary Stroke Program, Department of Clinical Neurosciences, University of Calgary, 3330 Hospital Drive NW, AB T2N 4N1, Calgary, Canada

    Meaghan Reid, Nils D. Forkert, Amith Sitaram, Moiz Hafeez, Mohamed Najm, Bijoy K. Menon, Andrew Demchuk, Mayank Goyal, Rani Gupta Sah, Christopher D. d’Esterre & Philip Barber

  3. Seaman Family Center, University of Calgary, Calgary, Canada

    Akinrinola O. Famuyide, Nils D. Forkert, Amith Sitaram, Bijoy K. Menon, Andrew Demchuk, Mayank Goyal, Rani Gupta Sah, Christopher D. d’Esterre & Philip Barber

  4. Department of Radiology, University of Calgary, Calgary, Canada

    Akinrinola O. Famuyide, Nils D. Forkert, Aron Sahand Talai, Mayank Goyal, Rani Gupta Sah, Christopher D. d’Esterre & Philip Barber

  5. Department of Neurosciences, Gosford Hospital, Gosford, Australia

    James W. Evans

  6. Department of Community Health Sciences, University of Calgary, Calgary, Canada

    Bijoy K. Menon

Authors
  1. Meaghan Reid
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  2. Akinrinola O. Famuyide
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  4. Aron Sahand Talai
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  5. James W. Evans
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  6. Amith Sitaram
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  7. Moiz Hafeez
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  8. Mohamed Najm
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  9. Bijoy K. Menon
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  10. Andrew Demchuk
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  11. Mayank Goyal
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  12. Rani Gupta Sah
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  13. Christopher D. d’Esterre
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  14. Philip Barber
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Corresponding author

Correspondence to Philip Barber.

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Conflict of interest

M. Goyal has a patent and licensing agreement with GE Healthcare re: systems of stroke diagnosis. In addition, he has a consulting agreement with Medtronic, Stryker, Microvention, Cenernovus. Medtronic has provided an unrestricted research grant to the University of Calgary for the HERMES collaboration. M. Goyal is the Chair of this collaboration. M. Reid, A.O. Famuyide, N.D. Forkert, A. Sahand Talai, J.W. Evans, A. Sitaram, M. Hafeez, M. Najm, B.K. Menon, A. Demchuk, R. Gupta Sah, C.D. d’Esterre and P. Barber declare that they have no competing interests.

Ethical standards

The local ethics boards approved the study. All participants gave informed consent prior to their inclusion in this study. All procedures performed were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

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62_2018_717_MOESM1_ESM.docx

The positive predictive values, negative predictive values, positive likelihood ratios (LR+) and negative likelihood ratios (LR-) of ASPECTS scoring on NCCT, mCTA-arterial, mCTA-venous and mCTA-rLMC compared to CT/MRI infarction at 24-hours dichotimized by TICI score and by onset to CT time (0–3 or >3 hours).

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Reid, M., Famuyide, A.O., Forkert, N.D. et al. Accuracy and Reliability of Multiphase CTA Perfusion for Identifying Ischemic Core. Clin Neuroradiol 29, 543–552 (2019). https://doi.org/10.1007/s00062-018-0717-x

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  • DOI: https://doi.org/10.1007/s00062-018-0717-x

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