Abstract Details

Title Underestimation of Ischemic Core on Perfusion CT in Patients with Acute Large Vessel Occlusion: Results from the BEST Prospective Cohort Study

Topic Cerebrovascular Disease and Interventional Neurology

Presentation(s) P5 - Poster Session 5 (5:30 PM-6:30 PM)

Poster/Presentation
Number 3-050

Objective To determine the degree of correlation between unenhanced CT and CT perfusion core infarct volumes in patients with large vessel occlusion.

Background The 2018 AHA guidelines recommend patients with acute large vessel occlusion (LVO) be considered for thrombectomy in the 6 to 24-hour window based on perfusion imaging. Within 6 hours, CT perfusion (CTP) core estimates may underestimate volume of irreversible infarction visualized on the unenhanced CT; however this has not been well characterized in later time windows.

Design/Methods

Using a multi-center prospective cohort of patients who underwent thrombectomy for LVO 0-24 hours after last known normal, we correlated baseline CTP core infarct volume (rCBF<30%) and unenhanced CT ASPECTS score. We compared CTP findings between patients with an unfavorable ASPECTS (<6) against those with a favorable ASPECTS (≥6), and assessed findings over time.

Results

Of 443 patients, 165 who underwent CTP were included (median age 69y, 50% female, with a median ASPECTS of 8 [IQR 6-9] and core of 9cc [IQR 0-28]). ASPECTS and core volume moderately correlated (r=-0.35, p<0.01). An absent core (0cc) was observed in 32% of patients, among whom the median ASPECTS score was 8 (IQR 8-10). After adjustment for age and baseline NIHSS, the ASPECTS score declined significantly over time (cOR 1.05, 95%CI 1.01-1.10, p=0.01), while the core (p=0.69) and penumbra volumes (p=0.74) remained unchanged.

Conclusions In this multi-center prospective cohort of patients who underwent thrombectomy, one-third of patients had normal core infarct volumes despite half of these patients showing irreversible infarction on the unenhanced CT (ASPECTS ≤8). As time progresses, the unenhanced CT demonstrates evolution of irreversible infarction, whereas the perfusion core appears static. This finding emphasizes the need to carefully assess both unenhanced CT and CTP when considering thrombectomy eligibility in the late time window.

Authors/Disclosures
James E. Siegler III, MD (University of Chicago) PRESENTER	Dr. Siegler has received personal compensation in the range of $500-$4,999 for serving as a Consultant for Novartis. Dr. Siegler has received personal compensation in the range of $5,000-$9,999 for serving as a Consultant for Bayer. Dr. Siegler has received personal compensation in the range of $500-$4,999 for serving as a Consultant for Serb. Dr. Siegler has received personal compensation in the range of $500-$4,999 for serving as a Consultant for Ceribell. Dr. Siegler has received personal compensation in the range of $500-$4,999 for serving on a Scientific Advisory or Data Safety Monitoring board for Wallaby Phenox. Dr. Siegler has received personal compensation in the range of $500-$4,999 for serving as an Editor, Associate Editor, or Editorial Advisory Board Member for Stroke: Vascular and Interventional Neurology. Dr. Siegler has received personal compensation in the range of $50,000-$99,999 for serving as an Expert Witness for Precision Medicine, LLC. The institution of Dr. Siegler has received research support from Philips. The institution of Dr. Siegler has received research support from Medtronic.
Steven R. Messe, MD, FAHA, FAAN (Hospital of the University of Pennsylvania)	Dr. Messe has received personal compensation in the range of $500-$4,999 for serving on a Scientific Advisory or Data Safety Monitoring board for Novo Nordisk. Dr. Messe has received personal compensation in the range of $500-$4,999 for serving on a Scientific Advisory or Data Safety Monitoring board for Terumo. Dr. Messe has received personal compensation in the range of $500-$4,999 for serving on a Scientific Advisory or Data Safety Monitoring board for WL Gore. The institution of Dr. Messe has received research support from WL Gore. The institution of Dr. Messe has received research support from Mallinkrodt. The institution of Dr. Messe has received research support from Biogen. Dr. Messe has received intellectual property interests from a discovery or technology relating to health care. Dr. Messe has received publishing royalties from a publication relating to health care. Dr. Messe has received personal compensation in the range of $500-$4,999 for serving as a Clinical Event Committee for the CONFORMAL left atrial appendage occlusion trial with Yale Cardiovascular Research Group.
	No disclosure on file
Tapan Mehta, MD (University of Connecticut, Hartford Hospital)	Dr. Mehta has received personal compensation in the range of $10,000-$49,999 for serving as a Consultant for Balt, Medtronic, J&J, Terumo.
Niraj A. Arora, MD (University of Missouri, Columbia)	Dr. Arora has nothing to disclose.
	No disclosure on file
Felipe De Los Rios La Rosa, MD (Miami Neuroscience Institute)	Dr. De Los Rios La Rosa has nothing to disclose.
	No disclosure on file
	No disclosure on file
Kishan Patel, MD (Providence Brain and Spine Institute)	No disclosure on file
	No disclosure on file
Amjad Tarboosh, MD	No disclosure on file
Katarina B. Dakay, DO	No disclosure on file
Jeff Wagner	No disclosure on file
Alicia E. Bennett, DO (CarePoint HC)	Dr. Bennett has nothing to disclose.
	No disclosure on file
Christopher Streib, MD (Department of Neurology)	Dr. Streib has nothing to disclose.
Stewart A. Weber, MD (OHSU)	No disclosure on file
	No disclosure on file
John J. Volpi, MD	Dr. Volpi has received personal compensation in the range of $500-$4,999 for serving as a Consultant for NovaSignal. Dr. Volpi has received personal compensation in the range of $5,000-$9,999 for serving as a Consultant for W.L. Gore. Dr. Volpi has received personal compensation in the range of $0-$499 for serving on a Scientific Advisory or Data Safety Monitoring board for Diamedica. Dr. Volpi has received personal compensation in the range of $10,000-$49,999 for serving on a Speakers Bureau for Janssen. Dr. Volpi has received personal compensation in the range of $5,000-$9,999 for serving on a Speakers Bureau for Amgen. Dr. Volpi has received intellectual property interests from a discovery or technology relating to health care.
Stephan A. Mayer, MD (Henry Ford Hospital)	Dr. Mayer has received personal compensation in the range of $500-$4,999 for serving as a Consultant for Ceribell. Dr. Mayer has received personal compensation in the range of $500-$4,999 for serving as a Consultant for Phagenesis. Dr. Mayer has received personal compensation in the range of $500-$4,999 for serving as a Consultant for ISchemaView. Dr. Mayer has stock in Neuroptics. Dr. Mayer has received publishing royalties from a publication relating to health care.
Shadi Yaghi, MD (Hackensack Meridian Health)	Dr. Yaghi has nothing to disclose.
Mahesh Jayaraman	No disclosure on file
Pooja Khatri, MD, FAAN (Univ of Cincinnati/Dept of Neuro)	The institution of Dr. Khatri has received personal compensation in the range of $10,000-$49,999 for serving as a Consultant for Lumosa. Dr. Khatri has received personal compensation in the range of $10,000-$49,999 for serving as a Consultant for Bayer. The institution of Dr. Khatri has received personal compensation in the range of $500-$4,999 for serving on a Scientific Advisory or Data Safety Monitoring board for Diamedica. Dr. Khatri has received personal compensation in the range of $5,000-$9,999 for serving on a Scientific Advisory or Data Safety Monitoring board for Basking Biosciences. Dr. Khatri has received personal compensation in the range of $10,000-$49,999 for serving as an Editor, Associate Editor, or Editorial Advisory Board Member for American Heart Association. The institution of Dr. Khatri has received research support from Cerenovus. Dr. Khatri has received publishing royalties from a publication relating to health care.
Eva A. Mistry, MD (UCCOM Neurology Stroke - 0525)	Dr. Mistry has received personal compensation in the range of $500-$4,999 for serving as a Consultant for RAPID AI. Dr. Mistry has received personal compensation in the range of $500-$4,999 for serving as a Consultant for AbbVIe. The institution of Dr. Mistry has received personal compensation in the range of $10,000-$49,999 for serving as a Consultant for Silvercreek Pharma. Dr. Mistry has received personal compensation in the range of $500-$4,999 for serving as a Consultant for Takeda Pharmaceuticals. Dr. Mistry has received personal compensation in the range of $500-$4,999 for serving on a Scientific Advisory or Data Safety Monitoring board for InspireMD. Dr. Mistry has received personal compensation in the range of $500-$4,999 for serving on a Scientific Advisory or Data Safety Monitoring board for Shionogi. Dr. Mistry has received personal compensation in the range of $10,000-$49,999 for serving as an Editor, Associate Editor, or Editorial Advisory Board Member for American Heart Association. The institution of Dr. Mistry has received research support from National Institutes of Health. The institution of Dr. Mistry has received research support from Patient Centered Outcomes Research Institure.

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