CT-Perfusion in ischemic stroke: prediction of the ASPECTS's outcomes through the scores of core and penumbra
DOI:
https://doi.org/10.25758/set.2275Keywords:
Computed tomography perfusion, Stroke, ASPECTS, Cerebral blood volume, Penumbra, Core, ThrombectomyAbstract
Introduction – According to the 2017 Portuguese Program for Cardio-Cerebrovascular Diseases, the OECD reports that cardiovascular diseases are the leading cause of death in member states of the European Union, representing about 36% of deaths in the region in 2010. This figure includes brain vascular diseases. It was intended to evaluate the value of cerebral blood flow (CBF) that best predicts the outcomes from the Via Verde procedure in stroke, with patients undergoing thrombectomy. It was also purpose of this study to increase the reliability of prognosis, optimizing the technique and radiological procedures for determining volumes of ‘core’ and ‘penumbra’. Methods – This was a retrospective study whose clinical cases were collected
from the database of Hospital de Beatriz Ângelo (Loures, PT) based on predefined inclusion criteria. After the acquisition of perfusion computed tomography (PCT), a sample of 17 patients, admitted through the Via Verde stroke program, was post-processed using the syngo.via software (NEURO Perfusion application). The data resulting from the perfusion maps were analyzed statistically using the SPSS® [IBM v. 23.0], allowing an analysis that reflected the CBF values related to the
volumes of ‘core’ and ‘penumbra’. Results – It was found that there is no statistically significant correlation between age, stroke time extends, and pre-therapeutic ASPECTS with the other variables under study. Relating the post-therapeutic ASPECTS to the core levels 10, 20, and 30 of CBF, it was found that the higher value of ASPECTS corresponds lower volume of the core. A statistically significant reduction (p=0.003) of the ASPECTS values was detected from pre- to post-therapy. The ‘core’ 10CBF value presents a lower volume of brain tissue infarcted in relation to the ‘core’ 30CBF, pointing to an inverse trend with the value of ‘penumbra’ volume. Conclusion – This study proves that it is possible, with a CBF of 10mL / 100g / min, to restore the flow needed to repair the neurological function of affected tissue, and with this CBF the largest volume of brain tissue is
obtained for the ‘penumbra’ and a lower volume of ‘core’. The processing and interpretation of the perfusion maps induce variation in the volume of the score of ‘core’ and ‘penumbra’.
Downloads
References
Coupland AP, Thapar A, Qureshi MI, Jenkins H, Davies AH. The definition of stroke. J R Soc Med. 2017;110(1):9-12.
Mikulik R, Caso V, Wahlgren N. Past & future of stroke care in Europe. CNS. 2017;2:(2):19-26.
Stevens E, Emmett E, Wang Y, McKevitt C, Wolfe C. The burden of stroke in Europe [Internet]. London: King’s College; 2017. Available from: https://kclpure.kcl.ac.uk/portal/en/publications/the-burden-of-stroke-in-europe(7fa92842-d35e-4bc2-80e9-bf87562920cf).html
Wilkins E, Wilson L, Wickramasinghe K, Bhatnagar P, Leal J, Luengo-Fernandez R, et al. European cardiovascular disease statistics 2017 [Internet]. Brussels: European Heart Network; 2017. Available from: https://ehnheart.org/images/CVD-statistics-report-August-2017.pdf
Direção-Geral da Saúde. Programa nacional para as doenças cérebro-cardiovasculares. Lisboa: DGS; 2017.
Heiss WD, Zaro-Weber O. Extension of therapeutic window in ischemic stroke by selective mismatch imaging. Int J Stroke. 2019;14(4):351-8
Pinto AM. Fisiopatologia: fundamentos e aplicações. 2ª ed. Lisboa: LIDEL; 2009. 9789897520082
Direção-Geral da Saúde. Via Verde do acidente vascular cerebral no adulto: norma nº. 015/2017, de 13/07/2017. Lisboa: DGS; 2017.
Sauser K, Levine DA, Nickles AV, Reeves MJ. Hospital variation in thrombolysis times among patients with acute ischemic stroke: the contributions of door-to-imaging time and imaging-to-needle time. JAMA Neurol. 2014;71(9):1155-61.
Kawano H, Bivard A, Lin L, Ma H, Cheng X, Aviv R, et al. Perfusion computed tomography in patients with stroke thrombolysis. Brain. 2017;140(3):684-91.
Lui YW, Tang ER, Allmendinger AM, Spektor V. Evaluation of CT perfusion in the setting of cerebral ischemia: patterns and pitfalls. AJNR Am J Neuroradiol. 2010;31(9):1552-63.
El-Tawil S, Wardlaw J, Ford I, Mair G, Robinson T, Kalra L, et al. Penumbra and re-canalization acute computed tomography in ischemic stroke evaluation: PRACTISE study protocol. Int J Stroke. 2017;12(6):671-8.
Sociedade Portuguesa do AVC. 13º Congresso Português do AVC. Lisboa: SPAVC; 2019.
Ducroux C, Khoury N, Lecler A, Blanc R, Chetrit A, Redjem H, et al. Application of the DAWN clinical imaging mismatch and DEFUSE 3 selection criteria: benefit seems similar but restrictive volume cut-offs might omit potential responders. Eur J Neurol. 2018;25(8):1093-9.
Albers GW, Marks MP, Kemp S, Christensen S, Tsai JP, Ortega- Gutierrez S, et al. Thrombectomy for stroke at 6 to 16 hours with selection by perfusion imaging. N Engl J Med. 2018;378(8):708-18.
De Havenon A, Mlynash M, Kim-Tenser MA, Landsberg MG, Leslie-Mazwi T, Christensen S, et al. Results from DEFUSE 3: good collaterals are associated with reduced ischemic core growth but not neurologic outcome. Stroke. 2019;50(3):632-8.
Nogueira RG, Jadhav AP, Haussen DC, Bonafe A, Budzik RF, Bhuva P, et al. Thrombectomy 6 to 24 hours after
stroke with a mismatch between deficit and infarct. N Engl J Med. 2018;378(1):11-21.
Prakkamakul S, Yoo AJ. ASPECTS CT in acute ischemia: review of current data. Top Magn Reson Imaging. 2017;26(3):103-12.
Pexman JH, Barber PA, Hill MD, Sevick RJ, Demchuk AM, Hudon ME, et al. Use of the Alberta Stroke Program Early CT Score (ASPECTS) for assessing CT scans in patients with acute stroke. AJNR Am J Neuroradiol. 2001;22(8):1534-42.
Schröder J, Thomalla G. A critical review of Alberta Stroke Program Early CT Score for evaluation of acute stroke imaging. Front Neurol. 2017;7:245.
Barber P. Alberta Stroke program Early CT Score (ASPECTS): determines MCA stroke severity using available CT data [homepage]. MDCalc© 2005-2020 [cited 2019 Oct 22]. Available from: https://www.mdcalc.com/alberta-stroke-program-early-ct-score-aspects#next-steps
Norrving B, Barrick J, Davalos A, Dichgans M, Cordonnier C, Guekht A, et al. Action plan for stroke in Europe 2018- 2030. Eur Stroke J. 2018;3(4):309-36.
Sabarudin A, Subramaniam C, Sun Z. Cerebral CT angiography and CT perfusion in acute stroke detection: a systematic review of diagnostic value. Quant Imaging Med Surg. 2014;4(4):282-90.
Sallustío F, Motta C, Pizzuto S, Diomedi M, Rizzato B, Panella M, et al. CT angiography ASPECTS predicts outcome much better than noncontrast CT in patients with stroke treated endovascularly. AJNR Am J Neuroradiol. 2017;38(8):1569-73.
Pan JW, Yu XR, Zhou SY, Wang JH, Zhang J, Geng DY, et al. Computed tomography perfusion and computed tomography angiography for prediction of clinical outcomes in ischemic stroke patients after thrombolysis. Neural Regen Res. 2017;12(1):103-8.
Borst J, Marquering HA, Beenen LF, Berkhemer OA, Dankbaar JW, Riordan AJ, et al. Effect of extended CT perfusion acquisition time on ischemic core and penumbra volume estimation in patients with acute ischemic stroke due to a large vessel occlusion. PLoS One.
;10(3):e0119409.
Ukmar M, Degrassi F, Mucelli RA, Neri F, Mucelli FP, Cova MA. Perfusion CT in acute stroke: effectiveness of automatically-generated colour maps. Br J Radiol. 2017;90(1072):20150472.
Wouters A, Christensen S, Straka M, Mlynash M, Liggins J, Bammer R, et al. A comparison of relative time to peak and Tmax for mismatch-based patient selection. Front Neurol. 2017;8:539.
Powers WJ, Rabinstein AA, Ackerson T, Adeoye OM, Bambakidia NC, Becker K, et al. 2018 Guidelines for the early management of patients with acute ischemic stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association.
Stroke. 2018;49(3):e46-e110.
Ambrosioni J, Urra X, Hernández-Meneses M, Almela M, Falces C, Tellez A, et al. Mechanical thrombectomy for acute ischemic stroke secondary to infective endocarditis. Clin Infect Dis. 2018;66(8):1286-9.
Campbell BC, Donnan GA, Lees KR, Hacke W, Khatri P, Hill MD, et al. Endovascular stent thrombectomy: the new standard of care for large vessel ischaemic stroke. Lancet Neurol. 2015;14(8):846-54.
Fugate JE, Klunder AM, Kallmes DF. What is meant by ‘TICI’? AJNR Am J Neuroradiol. 2013;34(9):1792-7.
Jenson M, Libby J, Soule E, Sandhu SJ, Fiester PJ, Rao D. CT perfusion protocol for acute stroke expedites mechanical thrombectomy. Cureus. 2019;11(4):e4546.
Austein F, Riedel C, Kerby T, Meyne J, Binder A, Lindner T, et al. Comparison of perfusion CT software to predict the final infarct volume after thrombectomy. Stroke. 2016;47(9):2311-7.
Teixeira S. Gestão das organizações. 3ª ed. Lisboa: Escolar Editora; 2000. ISBN 9789725924075
Downloads
Published
Issue
Section
License
Copyright (c) 2022 Saúde e Tecnologia
This work is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License.
The journal Saúde & Tecnologia offers immediate free access to its content, following the principle that making scientific knowledge available to the public free of charge provides greater worldwide democratization of knowledge.
The journal Saúde & Tecnologia does not charge authors any submission or article processing charges (APC).
All content is licensed under a Creative Commons CC-BY-NC-ND license. Authors have the right to: reproduce their work in physical or digital form for personal, professional, or teaching use, but not for commercial use (including the sale of the right to access the article); deposit on their website, that of their institution or in a repository an exact copy in electronic format of the article published by Saúde & Tecnologia, provided that reference is made to its publication in Saúde & Tecnologia and its content (including symbols identifying the journal) is not altered; publish in a book of which they are authors or editors the total or partial content of the manuscript, provided that reference is made to its publication in Saúde & Tecnologia.
