Top

Published in:

01-12-2015 | Original Article

Multimodal Computed Tomography Based Definition of Cerebral Imaging Profiles for Acute Stroke Reperfusion Therapy (CT-DEFINE): Results of a Prospective Observational Study

Authors: K. Barlinn, MD, J. Seibt, MD, K. Engellandt, MD, J. Gerber, MD, V. Puetz, MD, J. Kepplinger, MD, O. Wunderlich, MD, L.-P. Pallesen, MD, U. Bodechtel, MD, R. Koch, PhD, R. von Kummer, MD, PhD, I. Dzialowski, MD

Published in: Clinical Neuroradiology | Issue 4/2015

Abstract

Purpose

To prospectively evaluate the prognostic impact of multimodal computed tomography-based imaging in ischemic stroke patients potentially eligible for reperfusion therapy.

Methods

Anterior circulation stroke patients underwent non-contrast CT (NCCT), CT-angiography, and CT-perfusion within 12 h from symptom-onset. Patients could be treated with intravenous-tissue plasminogen activator (IV-tPA), endovascular or combined reperfusion therapies. Cerebral imaging profiles (IP) were NCCT-Alberta Stroke Program Early CT Score (ASPECTS) > 7 (IP1); NCCT-ASPECTS > 5 and proximal occlusion on CT-angiography (IP2); CT-perfusion mismatch between cerebral blood volume (CBV)-ASPECTS, and cerebral blood flow (CBF)-ASPECTS ≥ 2 (IP3). Favorable outcome was defined as modified Rankin Scale ≤ 2 at 3 months.

Results

Of 102 included patients, 62 (61 %) received any reperfusion therapy. In IP2 and IP3, favorable outcome was more frequent in patients with reperfusion therapy than in those without; however, this did not reach statistical significance (IP2: 39 % vs 15 %, p = 0.26; IP3: 50 % vs 17 %; p = 0.31). No difference was seen in IP1 (58 % vs 58 %, p = 1.0). In IP2, patients with IV-tPA alone achieved better functional outcome (50 % vs 11 %, p = 0.03) and lower mortality (0 % vs 28 %, p = 0.045) than those without.

Conclusions

Our results suggest a benefit with imaging profile selection based upon the combination of a small-to-moderate-sized infarction and a visible intracranial occlusion in patients receiving IV-tPA. Reperfusion therapy may be futile in patients without proven vessel occlusion.

Hacke W, Kaste M, Bluhmki E, Brozman M, Dávalos A, Guidetti D, Larrue V, Lees KR, Medeghri Z, Machnig T, Schneider D, von Kummer R, Wahlgren N, Toni D, ECASS Investigators. Thrombolysis with alteplase 3–4.5 hours after acute ischemic stroke. N Engl J Med. 2008;359:1317–29.CrossRefPubMed

Saver JL, Fonarow GC, Smith EE, Reeves MJ, Grau-Sepulveda MV, Pan W, Olson DM, Hernandez AF, Peterson ED, Schwamm LH. Time to treatment with intravenous tissue plasminogen activator and outcome from acute ischemic stroke. JAMA. 2013;309:2480–8.CrossRefPubMed

Khatri P, Abruzzo T, Yeatts SD, Nichols C, Broderick JP, Tomsick TA. Good clinical outcome after ischemic stroke with successful revascularization is time-dependent. Neurology. 2009;73:1066–72.PubMedCentralCrossRefPubMed

Kleindorfer D, Lindsell CJ, Brass L, Koroshetz W, Broderick JP. National US estimates of recombinant tissue plasminogen activator use: ICD-9 codes substantially underestimate. Stroke. 2008;39:924–8.CrossRefPubMed

Barreto AD, Alexandrov AV. Adjunctive and alternative approaches to current reperfusion therapy. Stroke. 2012;43:591–8.PubMedCentralCrossRefPubMed

Liebeskind DS, Alexandrov AV. Advanced multimodal CT/MRI approaches to hyperacute stroke diagnosis, treatment, and monitoring. Ann N Y Acad Sci. 2012;1268:1–7.PubMedCentralCrossRefPubMed

Schlaug G, Benfield A, Baird AE, Siewert B, Lövblad KO, Parker RA, Edelman RR, Warach S. The ischemic penumbra: operationally defined by diffusion and perfusion MRI. Neurology. 1999;53:1528–37.CrossRefPubMed

Mishra NK, Albers GW, Davis SM, Donnan GA, Furlan AJ, Hacke W, Lees KR. Mismatch-based delayed thrombolysis: a meta-analysis. Stroke. 2010;41:e25–33.CrossRefPubMed

Parsons M. W. Perfusion CT: is it clinically useful? Int J Stroke. 2008;3:41–50.CrossRefPubMed

10.

Goyal M, Menon BK, Derdeyn CP. Perfusion imaging in acute ischemic stroke: let us improve the science before changing practice. Radiology. 2013;266:16–21.CrossRefPubMed

11.

González RG1, Lev MH, Goldmacher GV, Smith WS, Payabvash S, Harris GJ, Halpern EF, Koroshetz WJ, Camargo EC, Dillon WP, Furie KL. Improved outcome prediction using CT angiography in addition to standard ischemic stroke assessment: results from the STOPStroke study. PLoS ONE. 2012;7:e30352.PubMedCentralCrossRefPubMed

12.

Souza LC1, Yoo AJ, Chaudhry ZA, Payabvash S, Kemmling A, Schaefer PW, Hirsch JA, Furie KL, González RG, Nogueira RG, Lev MH. Malignant CTA collateral profile is highly specific for large admission DWI infarct core and poor outcome in acute stroke. AJNR Am J Neuroradiol. 2012;33:1331–6.PubMedCentralCrossRefPubMed

13.

Puetz V, Dzialowski I, Hill MD, Demchuk AM. The alberta stroke program early CT score in clinical practice: what have we learned? Int J Stroke. 2009;4:354–64.CrossRefPubMed

14.

Berger C, Fiorelli M, Steiner T, Schäbitz WR, Bozzao L, Bluhmki E, Hacke W, von Kummer R. Hemorrhagic transformation of ischemic brain tissue: asymptomatic or symptomatic? Stroke. 2001;32:1330–5.CrossRefPubMed

15.

Hill MD, Rowley HA, Adler F, Eliasziw M, Furlan A, Higashida RT, Wechsler LR, Roberts HC, Dillon WP, Fischbein NJ, Firszt CM, Schulz GA, Buchan AM, PROACT-II Investigators. Selection of acute ischemic stroke patients for intra-arterial thrombolysis with pro-urokinase by using ASPECTS. Stroke. 2003;34:1925–31.CrossRefPubMed

16.

Parsons MW, Pepper EM, Chan V, Siddique S, Rajaratnam S, Bateman GA, Levi CR. Perfusion computed tomography: prediction of final infarct extent and stroke outcome. Ann Neurol. 2005;58:672–9.CrossRefPubMed

17.

Byrt T. How good is that agreement? Epidemiology. 1996;7:561.PubMed

18.

Sylaja PN, Dzialowski I, Puetz V, Eliasziw M, Hill MD, Krol A, O’Reilly C, Demchuk AM. Does intravenous rtPA benefit patients in the absence of CT angiographically visible intracranial occlusion? Neurol India. 2009;57:739–43.CrossRefPubMed

19.

von Kummer R, Gerber J. IMS-3, synthesis, and MR rescue: no disaster, but down to earth. Clin Neuroradiol. 2013;23:1–3.CrossRef

20.

von Kummer R, Albers GW, Mori E. The Desmoteplase in Acute Ischemic Stroke (DIAS) clinical trial program. Int J Stroke. 2012;7:589–96.CrossRef

21.

Hill MD. Desmoteplase and imaging science. Lancet Neurol. 2009;8:126–8.CrossRefPubMed

22.

Alexander LD, Pettersen JA, Hopyan JJ, Sahlas DJ, Black SE. Long-term prediction of functional outcome after stroke using the alberta stroke program early computed tomography score in the subacute stage. J Stroke Cerebrovasc Dis. 2012;21:737–44.CrossRefPubMed

23.

Hill MD, Kenney C, Dzialowski I, Boulanger JM, Demchuk AM, Barber PA, Watson TW, Weir NU, Buchan AM. Tissue Window in Stroke Thrombolysis study (TWIST): a safety study. Can J Neurol Sci. 2013;40:17–20.CrossRefPubMed

24.

Sztriha LK, Manawadu D, Jarosz J, Keep J, Kalra L. Safety and clinical outcome of thrombolysis in ischaemic stroke using a perfusion CT mismatch between 3 and 6 hours. PLoS ONE. 2011;6:e25796.PubMedCentralCrossRefPubMed

25.

Lee JY, Kim SH, Lee MS, Park SH, Lee SS. Prediction of clinical outcome with baseline and 24-hour perfusion CT in acute middle cerebral artery territory ischemic stroke treated with intravenous recanalization therapy. Neuroradiology. 2008;50:391–6.CrossRefPubMed

26.

Wintermark M, Meuli R, Browaeys P, Reichhart M, Bogousslavsky J, Schnyder P, Michel P. Comparison of CT perfusion and angiography and MRI in selecting stroke patients for acute treatment. Neurology. 2007;68:694–7.CrossRefPubMed

27.

Obach V, Oleaga L, Urra X, Macho J, Amaro S, Capurro S, Gomez-Choco M, San Román L, Cervera A, Blasco J, Vargas M, Torres F, Chamorro Á. Multimodal CT-assisted thrombolysis in patients with acute stroke: a cohort study. Stroke. 2011;42:1129–31.CrossRefPubMed

28.

Hassan AE, Zacharatos H, Rodriguez GJ, Vazquez G, Miley JT, Tummala RP, Suri MF, Taylor RA, Qureshi AI. A comparison of computed tomography perfusion-guided and time-guided endovascular treatments for patients with acute ischemic stroke. Stroke. 2010;41:1673–8.CrossRefPubMed

29.

Chalouhi N, Ghobrial G, Tjoumakaris S, Dumont AS, Gonzalez LF, Witte S, Davanzo J, Starke RM, Randazzo C, Flanders AE, Hasan D, Chitale R, Rosenwasser R, Jabbour P. CT perfusion-guided versus time-guided mechanical recanalization in acute ischemic stroke patients. Clin Neurol Neurosurg. 2013;115:2471–5.CrossRefPubMed

30.

Sheth KN, Terry JB, Nogueira RG, Horev A, Nguyen TN, Fong AK, Gandhi D, Prabhakaran S, Wisco D, Glenn BA, Tayal AH, Ludwig B, Hussain MS, Jovin TG, Clemmons PF, Cronin C, Liebeskind DS, Tian M, Gupta R. Advanced modality imaging evaluation in acute ischemic stroke may lead to delayed endovascular reperfusion therapy without improvement in clinical outcomes. J Neurointerv Surg. 2013;5(Suppl 1):i62–5.PubMedCentralCrossRefPubMed

31.

Wintermark M, Flanders AE, Velthuis B, Meuli R, van Leeuwen M, Goldsher D, Pineda C, Serena J, van der Schaaf I, Waaijer A, Anderson J, Nesbit G, Gabriely I, Medina V, Quiles A, Pohlman S, Quist M, Schnyder P, Bogousslavsky J, Dillon WP, Pedraza S. Perfusion-CT assessment of infarct core and penumbra: receiver operating characteristic curve analysis in 130 patients suspected of acute hemispheric stroke. Stroke. 2006;37:979–85.CrossRefPubMed

32.

Murphy BD, Fox AJ, Lee DH, Sahlas DJ, Black SE, Hogan MJ, Coutts SB, Demchuk AM, Goyal M, Aviv RI, Symons S, Gulka IB, Beletsky V, Pelz D, Hachinski V, Chan R, Lee TY. Identification of penumbra and infarct in acute ischemic stroke using computed tomography perfusion-derived blood flow and blood volume measurements. Stroke. 2006;37:1771–7.CrossRefPubMed

33.

Campbell BC, Christensen S, Levi CR, Desmond PM, Donnan GA, Davis SM, Parsons MW. Cerebral blood flow is the optimal CT perfusion parameter for assessing infarct core. Stroke. 2011;42:3435–40.CrossRefPubMed

34.

Kamalian S, Kamalian S, Konstas AA, Maas MB, Payabvash S, Pomerantz SR, Schaefer PW, Furie KL, González RG, Lev MH. CT perfusion mean transit time maps optimally distinguish benign oligemia from true “at-risk” ischemic penumbra, but thresholds vary by postprocessing technique. AJNR Am J Neuroradiol. 2012;33:545–9.PubMedCentralCrossRefPubMed

35.

Kidwell CS, Jahan R, Gornbein J, Alger JR, Nenov V, Ajani Z, Feng L, Meyer BC, Olson S, Schwamm LH, Yoo AJ, Marshall RS, Meyers PM, Yavagal DR, Wintermark M, Guzy J, Starkman S, Saver JL, MR RESCUE Investigators. A trial of imaging selection and endovascular treatment for ischemic stroke. N Engl J Med. 2013;368:914–23.PubMedCentralCrossRefPubMed

36.

Lemmens R, Mlynash M, Straka M, Kemp S, Bammer R, Marks MP, Albers GW, Lansberg MG. Comparison of the response to endovascular reperfusion in relation to site of arterial occlusion. Neurology. 2013;81:614–8.PubMedCentralCrossRefPubMed

37.

Davis SM, Donnan GA, Parsons MW, Levi C, Butcher KS, Peeters A, Barber PA, Bladin C, De Silva DA, Byrnes G, Chalk JB, Fink JN, Kimber TE, Schultz D, Hand PJ, Frayne J, Hankey G, Muir K, Gerraty R, Tress BM, Desmond PM, EPITHET investigators. Effects of alteplase beyond 3 h after stroke in the Echoplanar Imaging Thrombolytic Evaluation Trial (EPITHET): a placebo-controlled randomised trial. Lancet Neurol. 2008;7:299–309.CrossRefPubMed

38.

Campbell BC, Christensen S, Levi CR, Desmond PM, Donnan GA, Davis SM, Parsons MW. Comparison of computed tomography perfusion and magnetic resonance imaging perfusion-diffusion mismatch in ischemic stroke. Stroke. 2012;43:2648–53.CrossRefPubMed

39.

Zaro-Weber O, Moeller-Hartmann W, Heiss WD, Sobesky J. Maps of time to maximum and time to peak for mismatch definition in clinical stroke studies validated with positron emission tomography. Stroke. 2010;41:2817–21.CrossRefPubMed

40.

Parsons M, Spratt N, Bivard A, Campbell B, Chung K, Miteff F, O’Brien B, Bladin C, McElduff P, Allen C, Bateman G, Donnan G, Davis S, Levi C. A randomized trial of tenecteplase versus alteplase for acute ischemic stroke. N Engl J Med. 2012;366:1099–107.CrossRefPubMed

41.

Campbell BC, Weir L, Desmond PM, Tu HT, Hand PJ, Yan B, Donnan GA, Parsons MW, Davis SM. CT perfusion improves diagnostic accuracy and confidence in acute ischaemic stroke. J Neurol Neurosurg Psychiatry. 2013;84:613–8.CrossRefPubMed

42.

Salomon EJ, Barfett J, Willems PW, Geibprasert S, Bacigaluppi S, Krings T. Dynamic CT angiography and CT perfusion employing a 320-detector row CT: protocol and current clinical applications. Klin Neuroradiol. 2009;19:187–96.CrossRefPubMed

43.

Zhu G, Michel P, Aghaebrahim A, Patrie JT, Xin W, Eskandari A, Zhang W, Wintermark M. Prediction of recanalization trumps prediction of tissue fate: the penumbra: a dual-edged sword. Stroke. 2013;44:1014–9.CrossRefPubMed

Title: Multimodal Computed Tomography Based Definition of Cerebral Imaging Profiles for Acute Stroke Reperfusion Therapy (CT-DEFINE): Results of a Prospective Observational Study
Authors: K. Barlinn, MD
J. Seibt, MD
K. Engellandt, MD
J. Gerber, MD
V. Puetz, MD
J. Kepplinger, MD
O. Wunderlich, MD
L.-P. Pallesen, MD
U. Bodechtel, MD
R. Koch, PhD
R. von Kummer, MD, PhD
I. Dzialowski, MD
Publication date: 01-12-2015
Publisher: Springer Berlin Heidelberg
Published in: Clinical Neuroradiology / Issue 4/2015
Print ISSN: 1869-1439
Electronic ISSN: 1869-1447
DOI: https://doi.org/10.1007/s00062-014-0320-8

Keynote webinar | Spotlight on medication adherence

Springer Medicine

Multimodal Computed Tomography Based Definition of Cerebral Imaging Profiles for Acute Stroke Reperfusion Therapy (CT-DEFINE): Results of a Prospective Observational Study

Abstract

Purpose

Methods

Results

Conclusions

Keynote webinar | Spotlight on medication adherence

Springer Medicine

Abstract

Purpose

Methods

Results

Conclusions

Please log in to get access to this content

Other articles of this Issue 4/2015

Unusual Magnetic Resonance Imaging and Catheter Angiographic Signs of Intravascular Lymphoma

Ultrasonography of Multifocal Acquired Demyelinating Sensory and Motor Neuropathy (MADSAM)

Freiburg Neuropathology Case Conference. A Mass Lesion of the Fourth Ventricle

Clinical Applications of Cine Balanced Steady-State Free Precession MRI for the Evaluation of the Subarachnoid Spaces

Kernohan–Woltman Notch Phenomenon Secondary to a Subdural Hematoma in a Young Man

The Transdural Course of Radicular Spinal Cord Veins—A Microangiographical and Microscopical Study