Document Type : Original Article


Department of Neurology, University of Louisville, Kentucky, USA


Background: Computed Tomography Perfusion (CTP) maps ischemic core volume (CV) and penumbra following a stroke; however, its accuracy in early symptom onset is not well studied. We compared the accuracy of CTP RAPID estimated CV with diffusion weighted imaging (DWI) infarct volume (IV) in patients following thrombectomy.
Methods: Charts of anterior circulation large vessel occlusion post-thrombectomy cases with thrombolysis in cerebral infarction (TICI) 2b/3 reperfusion from 2017 to 2019 were reviewed. CTP time was dichotomized as 0-3 hours and ≥ 3 hours from the last known normal (LKN) cognition. The volumetric difference (VD), defined as DWI IV minus CTP CV, core volume overestimation (CVO), defined as CTP CV minus DWI IV and Alberta stroke programme early CT score (ASPECTS) were calculated. Large CV was defined as ≥ 50 ml CV. Modified Rankin Score (mRS) at 90 days were reviewed. We performed independent sample t-test and Spearman correlation coefficient test.
Results: Total cases (n) were 61. In < 3 hours window from LKN (n = 27), the mean VD was 58.3 ± 0.1 ml (P = 0.990) and CVO (n = 11; 40.7%) was39.6 ± 35.7 ml (P = 0.008). Mean large CV (n = 8) was 78.3 ± 25.4 ml with median ASPECTS of 8 [interquartile range (IQR) = 6.5-9.0]and median mRS at 90 days of 2 (IQR = 0.8-3.3). In ≥ 3 hours window from LKN (n = 34), CVO (n = 5) was uncommon and large CV had median mRS at 90 days of 5 (IQR = 4.0-6.0).
Conclusion: CTP more frequently overestimates CV in patients who are < 3 hours from LKN. The treated patients with large CV in < 3 hours and > 3 hours had good and poor functional outcomes, respectively.


  1. Murphy BD, Fox AJ, Lee DH, Sahlas DJ, Black SE, Hogan MJ, et al. Identification of penumbra and infarct in acute ischemic stroke using computed tomography perfusion-derived blood flow and blood volume Stroke 2006; 37(7): 1771-7.
  2. 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 N Engl J Med 2018; 378(8): 708-18.
  3. Goyal M, Menon BK, van Zwam WH, Dippel DW, Mitchell PJ, Demchuk AM, et Endovascular thrombectomy after large-vessel ischaemic stroke: A meta- analysis of individual patient data from five randomised trials. Lancet 2016; 387(10029): 1723-31.
  4. Nogueira RG, Jadhav AP, Haussen DC, Bonafe A, Budzik RF, Bhuva P, et Thrombectomy 6 to 24 hours after stroke with a mismatch between deficit and infarct. N Engl J Med 2018; 378(1): 11-21.
  5. Campbell BCV, Ma H, Ringleb PA, Parsons MW, Churilov L, Bendszus M, et Extending thrombolysis to 4.5-9 h and wake-up stroke using perfusion imaging: A systematic review and meta-analysis of individual patient data. Lancet 2019; 394(10193): 139-47.
  6. Yushkevich PA, Piven J, Hazlett HC, Smith RG, Ho S, Gee JC, et User- guided 3D active contour segmentation of anatomical structures: Significantly improved efficiency and reliability. Neuroimage 2006; 31(3): 1116-28.
  7. Yoo AJ, Verduzco LA, Schaefer PW, Hirsch JA, Rabinov JD, Gonzalez MRI-based selection for intra-arterial stroke therapy: Value of pretreatment diffusion-weighted imaging lesion volume in selecting patients with acute stroke who will benefit from early recanalization. Stroke 2009; 40(6): 2046-54.
  8. Wilson AT, Dey S, Evans JW, Najm M, Qiu W, Menon BK. Minds treating brains: understanding the interpretation of non- contrast CT ASPECTS in acute ischemic Expert Rev Cardiovasc Ther 2018; 16(2): 143-53.
  9. d'Esterre CD, Boesen ME, Ahn SH, Pordeli P, Najm M, Minhas P, et al. Time- dependent computed tomographic perfusion thresholds for patients with acute ischemic Stroke 2015; 46(12): 3390-7.
  10. Schroder J, Thomalla G. A critical review of alberta stroke program early CT score for evaluation of acute stroke Front Neurol 2016; 7: 245.
  11. Berkhemer OA, Fransen PS, Beumer D, van den Berg LA, Lingsma HF, Yoo AJ, et A randomized trial of intraarterial treatment for acute ischemic stroke. N Engl J Med 2015; 372(1): 11-20.
  12. Jovin TG, Chamorro A, Cobo E, de Miquel MA, Molina CA, Rovira A, et al. Thrombectomy within 8 hours after symptom onset in ischemic stroke. N Engl J Med 2015; 372(24): 2296-306.
  13. Saver JL, Goyal M, Bonafe A, Diener HC, Levy EI, Pereira VM, et al. Stent-retriever thrombectomy after intravenous t-PA t- PA alone in stroke. N Engl J Med 2015; 372(24): 2285-95.
  14. Campbell BC, Mitchell PJ, Kleinig TJ, Dewey HM, Churilov L, Yassi N, et al. Endovascular therapy for ischemic stroke with perfusion-imaging N Engl J Med 2015; 372(11): 1009-18.
  15. Goyal M, Demchuk AM, Menon BK, Eesa M, Rempel JL, Thornton J, et Randomized assessment of rapid endovascular treatment of ischemic stroke. N Engl J Med 2015; 372(11): 1019-30.
  16. Ma H, Campbell BCV, Parsons MW, Churilov L, Levi CR, Hsu C, et Thrombolysis guided by perfusion imaging up to 9 hours after onset of stroke. N Engl J Med 2019; 380(19): 1795-1803.
  17. Lui YW, Tang ER, Allmendinger AM, Spektor V. Evaluation of CT perfusion in the setting of cerebral ischemia: Patterns and AJNR Am J Neuroradiol 2010; 31(9): 1552-63.
  18. Copen WA, Deipolyi AR, Schaefer PW, Schwamm LH, Gonzalez RG, Wu Exposing hidden truncation-related errors in acute stroke perfusion imaging. AJNR Am J Neuroradiol 2015; 36(4): 638-45.
  19. Lima FO, Furie KL, Silva GS, Lev MH, Camargo EC, Singhal AB, et The pattern of leptomeningeal collaterals on CT angiography is a strong predictor of long-term functional outcome in stroke patients with large vessel intracranial occlusion. Stroke 2010; 41(10): 2316-22.
  20. Menon BK, d'Esterre CD, Qazi EM, Almekhlafi M, Hahn L, Demchuk AM, et Multiphase CT angiography: A new tool for the imaging triage of patients with acute ischemic stroke. Radiology 2015; 275(2): 510-20.