Top

Published in:

Open Access 01-09-2021 | Stroke | Diagnostic Neuroradiology

CT perfusion in hyper-acute ischemic stroke: the acid test for COVID-19 fear

Authors: Giovanni Furlanis, Miloš Ajčević, Ilario Scali, Alex Buoite Stella, Sasha Olivo, Carlo Lugnan, Paola Caruso, Roberta Antea Pozzi Mucelli, Agostino Accardo, Maria Assunta Cova, Marcello Naccarato, Paolo Manganotti

Published in: Neuroradiology | Issue 9/2021

Abstract

Purpose

The fear of COVID-19 infection may discourage patients from going to the hospital even in case of sudden onset of disabling symptoms. There is growing evidence of the reduction of stroke admissions and higher prevalence of severe clinical presentation. Yet, no studies have investigated the perfusion pattern of acute strokes admitted during the lockdown. We aimed to evaluate the effects of the COVID-19 pandemic on hyper-acute stroke CT perfusion (CTP) pattern during the first months of the pandemic in Italy.

Methods

In this retrospective observational study, we analyzed CTP images and clinical data of ischemic stroke patients admitted between 9 March and 2 June 2020 that underwent CTP (n = 30), to compare ischemic volumes and clinical features with stroke patients admitted during the same period in 2019 (n = 51). In particular, CTP images were processed to calculate total hypoperfused volumes, core volumes, and mismatch. The final infarct volumes were calculated on follow-up CT.

Results

Significantly higher total CTP hypoperfused volume (83.3 vs 18.5 ml, p = 0.003), core volume (27.8 vs 1.0 ml, p < 0.001), and unfavorable mismatch (0.51 vs 0.91, p < 0.001) were found during the COVID-19 period compared to no-COVID-19 one. The more unfavorable perfusion pattern at admission resulted in higher infarct volume on follow-up CT during COVID-19 (35.5 vs 3.0 ml, p < 0.001). During lockdown, a reduction of stroke admissions (− 37%) and a higher prevalence of severe clinical presentation (NIHSS ≥ 10; 53% vs 36%, p = 0.029) were observed.

Conclusion

The results of CTP analysis provided a better insight in the higher prevalence of major severity stroke patients during the COVID-19 period.

Grasselli G, Pesenti A, Cecconi M (2020) Critical care utilization for the COVID-19 outbreak in Lombardy, Italy: early experience and forecast during an emergency response. JAMA 323(16):1545–1546. https://doi.org/10.1001/jama.2020.4031CrossRefPubMed

Naccarato M, Scali I, Olivo S, Ajčević M, Buoite Stella A, Furlanis G, Lugnan C, Caruso P, Peratoner A, Cominotto F, Manganotti P (2020) Has COVID-19 played an unexpected ‘stroke’ on the chain of survival? J Neurol Sci 414:116889. https://doi.org/10.1016/j.jns.2020.116889CrossRefPubMedPubMedCentral

Vilela P, Rowley HA (2017) Brain ischemia: CT and MRI techniques in acute ischemic stroke. Eur J Radiol 96:162–172CrossRef

Stragapede L, Furlanis G, Ajcevic M et al (2019) Brain oscillatory activity and CT perfusion in hyper-acute ischemic stroke. J Clin Neurosci 69:184–189. https://doi.org/10.1016/j.jocn.2019.07.068CrossRefPubMed

Furlanis G, Ajcevic M, Stragapede L et al (2018) Ischemic volume and neurological deficit: correlation of computed tomography perfusion with the National Institutes of Health Stroke Scale Score in acute ischemic stroke. J Stroke Cerebrovasc Dis 27:2200–2207CrossRef

Manganotti P, Furlanis G, Ajčević M, Polverino P, Caruso P, Ridolfi M, Pozzi-Mucelli RA, Cova MA, Naccarato M (2019) CT perfusion and EEG patterns in patients with acute isolated aphasia in seizure-related stroke mimics. Seizure - Eur J Epilepsy 71:110–115CrossRef

Gonzalez RG (2006) Imaging-guided acute ischemic stroke therapy: from ‘time is brain’ to ‘physiology is brain’. AJNR Am J Neuroradiol 27:728–735PubMedPubMedCentral

Etherton MR, Barreto AD, Schwamm LH, Wu O (2018) Neuroimaging paradigms to identify patients for reperfusion therapy in stroke of unknown onset. Front Neurol 9:327. https://doi.org/10.3389/fneur.2018.00327CrossRefPubMedPubMedCentral

Ma H, Campbell BCV, Parsons MW, Churilov L, Levi CR, Hsu C, Kleinig TJ, Wijeratne T, Curtze S, Dewey HM, Miteff F, Tsai CH, Lee JT, Phan TG, Mahant N, Sun MC, Krause M, Sturm J, Grimley R, Chen CH, Hu CJ, Wong AA, Field D, Sun Y, Barber PA, Sabet A, Jannes J, Jeng JS, Clissold B, Markus R, Lin CH, Lien LM, Bladin CF, Christensen S, Yassi N, Sharma G, Bivard A, Desmond PM, Yan B, Mitchell PJ, Thijs V, Carey L, Meretoja A, Davis SM, Donnan GA (2019) Thrombolysis guided by perfusion imaging up to 9 hours after onset of stroke. N Engl J Med 380:1795–1803CrossRef

10.

Thomalla G, Simonsen CZ, Boutitie F, Andersen G, Berthezene Y, Cheng B, Cheripelli B, Cho TH, Fazekas F, Fiehler J, Ford I, Galinovic I, Gellissen S, Golsari A, Gregori J, Günther M, Guibernau J, Häusler KG, Hennerici M, Kemmling A, Marstrand J, Modrau B, Neeb L, Perez de la Ossa N, Puig J, Ringleb P, Roy P, Scheel E, Schonewille W, Serena J, Sunaert S, Villringer K, Wouters A, Thijs V, Ebinger M, Endres M, Fiebach JB, Lemmens R, Muir KW, Nighoghossian N, Pedraza S, Gerloff C (2018) MRI-guided thrombolysis for stroke with unknown time of onset. N Engl J Med 379:611–622CrossRef

11.

Furlanis G, Ajcevic M, Buoite Stella A et al (2020) Wake-up stroke: thrombolysis reduces ischemic lesion volume and neurological deficit. J Neurol 267:666–673CrossRef

12.

Ajčević M, Furlanis G, Buoite Stella A et al (2020) A CT perfusion based model predicts outcome in wake-up stroke patients treated with recombinant tissue plasminogen activator. Physiol Meas 41(7):075011. https://doi.org/10.1088/1361-6579/ab9c70CrossRefPubMed

13.

Choi V, Kate M, Kosior JC, Buck B, Steve T, McCourt R, Jeerakathil T, Shuaib A, Emery D, Butcher K (2015) National Institutes of Health Stroke Scale score is an unreliable predictor of perfusion deficits in acute stroke. Int J stroke Off J Int Stroke Soc 10:582–588CrossRef

14.

Tong DC, Yenari MA, Albers GW, O'Brien M, Marks MP, Moseley ME (1998) Correlation of perfusion- and diffusion-weighted MRI with NIHSS score in acute (<6.5 hour) ischemic stroke. Neurology 50:864–870CrossRef

15.

Jacobs MA, Mitsias P, Soltanian-Zadeh H, Santhakumar S, Ghanei A, Hammond R, Peck DJ, Chopp M, Patel S (2001) Multiparametric MRI tissue characterization in clinical stroke with correlation to clinical outcome: part 2. Stroke 32:950–957CrossRef

16.

Bagher-Ebadian H, Jafari-Khouzani K, Mitsias PD, Lu M, Soltanian-Zadeh H, Chopp M, Ewing JR (2011) Predicting final extent of ischemic infarction using artificial neural network analysis of multi-parametric MRI in patients with stroke. PLoS One 6:e22626CrossRef

17.

Baracchini C, Pieroni A, Viaro F, Cianci V, Cattelan AM, Tiberio I, Munari M, Causin F (2020) Acute stroke management pathway during coronavirus-19 pandemic. Neurol Sci 41:1003–1005CrossRef

18.

Caso V, Federico A (2020) No lockdown for neurological diseases during COVID19 pandemic infection. Neurol Sci 41(5):999–1001CrossRef

19.

Powers WJ, Rabinstein AA, Ackerson T et al (2019) Guidelines for the early management of patients with acute ischemic stroke: 2019 update to the 2018 guidelines for the early management of acute ischemic stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke. Stroke 50:e344–e418CrossRef

20.

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 (2008) Thrombolysis with alteplase 3 to 4.5 hours after acute ischemic stroke. N Engl J Med 359:1317–1329CrossRef

21.

Adams HPJ, Bendixen BH, Kappelle LJ et al (1993) Classification of subtype of acute ischemic stroke. Definitions for use in a multicenter clinical trial. TOAST. Trial of Org 10172 in Acute Stroke Treatment. Stroke 24:35–41CrossRef

22.

Wintermark M, Flanders AE, Velthuis B, Meuli R, van Leeuwen M, Goldsher D, Pineda C, Serena J, 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 (2006) Perfusion-CT assessment of infarct core and penumbra: receiver operating characteristic curve analysis in 130 patients suspected of acute hemispheric stroke. Stroke 37:979–985CrossRef

23.

Solomon MD, McNulty EJ, Rana JS et al (2020) The Covid-19 Pandemic and the incidence of acute myocardial infarction. The New England journal of medicine. 383:691–693. https://doi.org/10.1056/NEJMc2015630CrossRefPubMed

24.

Guglielmi V, LeCouffe NE, Zinkstok SM et al (2019) Collateral circulation and outcome in atherosclerotic versus cardioembolic cerebral large vessel occlusion. Stroke 50:3360–3368CrossRef

25.

Marcon G, Manganotti P, Tettamanti M (2020) Is Parkinson’s disease a very rare pathology in centenarians? A clinical study in a cohort of subjects. J Alzheimers Dis 73:73–76CrossRef

26.

Shankar JJS, Langlands G, Doucette S, Phillips S (2016) CT perfusion in acute stroke predicts final infarct volume- inter-observer study. Can J Neurol Sci 43:93–97CrossRef

27.

Padroni M, Bernardoni A, Tamborino C et al Cerebral blood volume ASPECTS is the best predictor of clinical outcome in acute ischemic stroke: a retrospective, combined semi-quantitative and quantitative assessment. PLoS One 11:e0147910

28.

Granato A, D’Acunto L, Ajčević M, Furlanis G, Ukmar M, Mucelli RAP, Manganotti P (2020) A novel computed tomography perfusion-based quantitative tool for evaluation of perfusional abnormalities in migrainous aura stroke mimic. Neurol Sci 41:3321–3328. https://doi.org/10.1007/s10072-020-04476-5CrossRefPubMed

29.

Naccarato M, Ajčević M, Furlanis G, Lugnan C, Buoite Stella A, Scali I, Caruso P, Stragapede L, Ukmar M, Manganotti P (2020) Novel quantitative approach for crossed cerebellar diaschisis detection in acute ischemic stroke using CT perfusion. Journal of the Neurological Sciences 416:117008. https://doi.org/10.1016/j.jns.2020.117008CrossRefPubMed

30.

Parsons MW (2008) Perfusion CT: is it clinically useful? Int J Stroke 3:41–50CrossRef

Title: CT perfusion in hyper-acute ischemic stroke: the acid test for COVID-19 fear
Authors: Giovanni Furlanis
Miloš Ajčević
Ilario Scali
Alex Buoite Stella
Sasha Olivo
Carlo Lugnan
Paola Caruso
Roberta Antea Pozzi Mucelli
Agostino Accardo
Maria Assunta Cova
Marcello Naccarato
Paolo Manganotti
Publication date: 01-09-2021
Publisher: Springer Berlin Heidelberg
Keywords: Stroke
COVID-19
Anxiety
Published in: Neuroradiology / Issue 9/2021
Print ISSN: 0028-3940
Electronic ISSN: 1432-1920
DOI: https://doi.org/10.1007/s00234-021-02639-5

Keynote webinar | Spotlight on medication adherence

Springer Medicine

CT perfusion in hyper-acute ischemic stroke: the acid test for COVID-19 fear

Abstract

Purpose

Methods

Results

Conclusion

Keynote webinar | Spotlight on medication adherence

Springer Medicine

Abstract

Purpose

Methods

Results

Conclusion

Please log in to get access to this content

Other articles of this Issue 9/2021

Collateral and permeability imaging derived from dynamic contrast material-enhanced MR angiography in prediction of PH 2 hemorrhagic transformation after acute ischemic stroke: a pilot study

Use of quantitative angiographic methods with a data-driven model to evaluate reperfusion status (mTICI) during thrombectomy

Identification of hippocampal cortical microinfarcts on postmortem 3-T magnetic resonance imaging

Association between perihematomal perfusion and intracerebral hemorrhage shape

European Society of Neuroradiology (ESNR)

Effective connectivity alteration according to recurrence in transient global amnesia