Ischemic core and hypoperfusion volumes predict infarct size in SWIFT PRIME
Corresponding Author
Gregory W. Albers MD
Stanford Stroke Center, Stanford University School of Medicine, Stanford, CA
Address correspondence to Dr Albers, 780 Welch Road, Suite 350, Palo Alto, CA 94304. E-mail: [email protected]Search for more papers by this authorMayank Goyal MD
Departments of Radiology and Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada
Search for more papers by this authorReza Jahan MD
Division of Interventional Neuroradiology, University of California, Los Angeles, Los Angeles, CA
Search for more papers by this authorAlain Bonafe MD
Department of Neuroradiology, Gui de Chauliac Hospital, Montpellier, France
Search for more papers by this authorHans-Christoph Diener MD
Department of Neurology, Duisburg-Essen University Hospital, Essen, Germany
Search for more papers by this authorElad I. Levy MD, MBA
Department of Neurosurgery, State University of New York at Buffalo, Buffalo, NY
Search for more papers by this authorVitor M. Pereira MD
Division of Neuroradiology and Division of Neurosurgery, Department of Medical Imaging and Department of Surgery, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada
Search for more papers by this authorChristophe Cognard MD
Department of Diagnostic and Therapeutic Neuroradiology, University Hospital of Toulouse, Toulouse, France
Search for more papers by this authorDavid J. Cohen MD
Saint Luke's Mid America Heart Institute and University of Missouri-Kansas City School of Medicine, Kansas City, MO
Search for more papers by this authorWerner Hacke MD
Department of Neurology, University of Heidelberg, Heidelberg, Germany
Search for more papers by this authorOlav Jansen MD
Department of Radiology and Neuroradiology, Christian Albrechts University of Kiel, Kiel, Germany
Search for more papers by this authorTudor G. Jovin MD
Department of Neurology, University of Pittsburgh Medical Center, Pittsburgh, PA
Search for more papers by this authorHeinrich P. Mattle MD
Department of Neurology, Inselspital, University of Bern, Bern, Switzerland
Search for more papers by this authorRaul G. Nogueira MD
Marcus Stroke and Neuroscience Center, Grady Memorial Hospital, Department of Neurology, Emory University School of Medicine, Atlanta, GA
Search for more papers by this authorAdnan H. Siddiqui MD
Department of Neurosurgery, Toshiba Stroke and Vascular Research Center, State University of New York at Buffalo, Buffalo, NY
Search for more papers by this authorDileep R. Yavagal MD
Department of Neurology and Neurosurgery, University of Miami Miller School of Medicine/Jackson Memorial Hospital, Miami, FL
Search for more papers by this authorBlaise W. Baxter MD
Department of Radiology, Erlanger Hospital at University of Tennessee, Chattanooga, TN
Search for more papers by this authorThomas G. Devlin MD
Division of Neurology, Erlanger Hospital at University of Tennessee, Chattanooga, TN
Search for more papers by this authorDemetrius K. Lopes MD
Department of Neurosurgery, Rush University Medical Center, Chicago, IL
Search for more papers by this authorVivek K. Reddy MD
Department of Neurology, University of Pittsburgh Medical Center, Pittsburgh, PA
Search for more papers by this authorRichard du Mesnil de Rochemont MD
Institute of Neuroradiology, Goethe University Hospital, Frankfurt, Germany
Search for more papers by this authorOliver C. Singer MD
Department of Neurology, Goethe University Hospital, Frankfurt, Germany
Search for more papers by this authorRoland Bammer PhD
Stanford Stroke Center, Stanford University School of Medicine, Stanford, CA
Search for more papers by this authorJeffrey L. Saver MD
Department of Neurology and Comprehensive Stroke Center, David Geffen School of Medicine at the University of California, Los Angeles, Los Angeles, CA
Search for more papers by this authorCorresponding Author
Gregory W. Albers MD
Stanford Stroke Center, Stanford University School of Medicine, Stanford, CA
Address correspondence to Dr Albers, 780 Welch Road, Suite 350, Palo Alto, CA 94304. E-mail: [email protected]Search for more papers by this authorMayank Goyal MD
Departments of Radiology and Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada
Search for more papers by this authorReza Jahan MD
Division of Interventional Neuroradiology, University of California, Los Angeles, Los Angeles, CA
Search for more papers by this authorAlain Bonafe MD
Department of Neuroradiology, Gui de Chauliac Hospital, Montpellier, France
Search for more papers by this authorHans-Christoph Diener MD
Department of Neurology, Duisburg-Essen University Hospital, Essen, Germany
Search for more papers by this authorElad I. Levy MD, MBA
Department of Neurosurgery, State University of New York at Buffalo, Buffalo, NY
Search for more papers by this authorVitor M. Pereira MD
Division of Neuroradiology and Division of Neurosurgery, Department of Medical Imaging and Department of Surgery, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada
Search for more papers by this authorChristophe Cognard MD
Department of Diagnostic and Therapeutic Neuroradiology, University Hospital of Toulouse, Toulouse, France
Search for more papers by this authorDavid J. Cohen MD
Saint Luke's Mid America Heart Institute and University of Missouri-Kansas City School of Medicine, Kansas City, MO
Search for more papers by this authorWerner Hacke MD
Department of Neurology, University of Heidelberg, Heidelberg, Germany
Search for more papers by this authorOlav Jansen MD
Department of Radiology and Neuroradiology, Christian Albrechts University of Kiel, Kiel, Germany
Search for more papers by this authorTudor G. Jovin MD
Department of Neurology, University of Pittsburgh Medical Center, Pittsburgh, PA
Search for more papers by this authorHeinrich P. Mattle MD
Department of Neurology, Inselspital, University of Bern, Bern, Switzerland
Search for more papers by this authorRaul G. Nogueira MD
Marcus Stroke and Neuroscience Center, Grady Memorial Hospital, Department of Neurology, Emory University School of Medicine, Atlanta, GA
Search for more papers by this authorAdnan H. Siddiqui MD
Department of Neurosurgery, Toshiba Stroke and Vascular Research Center, State University of New York at Buffalo, Buffalo, NY
Search for more papers by this authorDileep R. Yavagal MD
Department of Neurology and Neurosurgery, University of Miami Miller School of Medicine/Jackson Memorial Hospital, Miami, FL
Search for more papers by this authorBlaise W. Baxter MD
Department of Radiology, Erlanger Hospital at University of Tennessee, Chattanooga, TN
Search for more papers by this authorThomas G. Devlin MD
Division of Neurology, Erlanger Hospital at University of Tennessee, Chattanooga, TN
Search for more papers by this authorDemetrius K. Lopes MD
Department of Neurosurgery, Rush University Medical Center, Chicago, IL
Search for more papers by this authorVivek K. Reddy MD
Department of Neurology, University of Pittsburgh Medical Center, Pittsburgh, PA
Search for more papers by this authorRichard du Mesnil de Rochemont MD
Institute of Neuroradiology, Goethe University Hospital, Frankfurt, Germany
Search for more papers by this authorOliver C. Singer MD
Department of Neurology, Goethe University Hospital, Frankfurt, Germany
Search for more papers by this authorRoland Bammer PhD
Stanford Stroke Center, Stanford University School of Medicine, Stanford, CA
Search for more papers by this authorJeffrey L. Saver MD
Department of Neurology and Comprehensive Stroke Center, David Geffen School of Medicine at the University of California, Los Angeles, Los Angeles, CA
Search for more papers by this authorAbstract
Objective
Within the context of a prospective randomized trial (SWIFT PRIME), we assessed whether early imaging of stroke patients, primarily with computed tomography (CT) perfusion, can estimate the size of the irreversibly injured ischemic core and the volume of critically hypoperfused tissue. We also evaluated the accuracy of ischemic core and hypoperfusion volumes for predicting infarct volume in patients with the target mismatch profile.
Methods
Baseline ischemic core and hypoperfusion volumes were assessed prior to randomized treatment with intravenous (IV) tissue plasminogen activator (tPA) alone versus IV tPA + endovascular therapy (Solitaire stent-retriever) using RAPID automated postprocessing software. Reperfusion was assessed with angiographic Thrombolysis in Cerebral Infarction scores at the end of the procedure (endovascular group) and Tmax > 6-second volumes at 27 hours (both groups). Infarct volume was assessed at 27 hours on noncontrast CT or magnetic resonance imaging (MRI).
Results
A total of 151 patients with baseline imaging with CT perfusion (79%) or multimodal MRI (21%) were included. The median baseline ischemic core volume was 6ml (interquartile range = 0–16). Ischemic core volumes correlated with 27-hour infarct volumes in patients who achieved reperfusion (r = 0.58, p < 0.0001). In patients who did not reperfuse (<10% reperfusion), baseline Tmax > 6-second lesion volumes correlated with 27-hour infarct volume (r = 0.78, p = 0.005). In target mismatch patients, the union of baseline core and early follow-up Tmax > 6-second volume (ie, predicted infarct volume) correlated with the 27-hour infarct volume (r = 0.73, p < 0.0001); the median absolute difference between the observed and predicted volume was 13ml.
Interpretation
Ischemic core and hypoperfusion volumes, obtained primarily from CT perfusion scans, predict 27-hour infarct volume in acute stroke patients who were treated with reperfusion therapies. ANN NEUROL 2016;79:76–89
References
- 1 Jung S, Gilgen M, Slotboom J, et al. Factors that determine penumbral tissue loss in acute ischaemic stroke. Brain 2013; 136: 3554–3560.
- 2 Inoue M, Mlynash M, Straka M, et al. Clinical outcomes strongly associated with the degree of reperfusion achieved in target mismatch patients: pooled data from the Diffusion and Perfusion Imaging Evaluation for Understanding Stroke Evolution studies. Stroke 2013; 44: 1885–1890.
- 3 Khatri P, Yeatts SD, Mazighi M, et al. Time to angiographic reperfusion and clinical outcome after acute ischaemic stroke: an analysis of data from the Interventional Management of Stroke (IMS III) phase 3 trial. Lancet Neurol 2014; 13: 567–574.
- 4 Mlynash M, Lansberg MG, De Silva DA, et al. Refining the definition of the malignant profile: insights from the DEFUSE-EPITHET pooled data set. Stroke 2011; 42: 1270–1275.
- 5 Inoue M, Mlynash M, Straka M, et al. Patients with the malignant profile within 3 hours of symptom onset have very poor outcomes after intravenous tissue-type plasminogen activator therapy. Stroke 2012; 43: 2494–2496.
- 6 Albers GW, Thijs VN, Wechsler L, et al. Magnetic resonance imaging profiles predict clinical response to early reperfusion: the diffusion and perfusion imaging evaluation for understanding stroke evolution (DEFUSE) study. Ann Neurol 2006; 60: 508–517.
- 7 Lansberg MG, Straka M, Kemp S, et al. MRI profile and response to endovascular reperfusion after stroke (DEFUSE 2): a prospective cohort study. Lancet Neurol 2012; 11: 860–867.
- 8 Wheeler HM, Mlynash M, Inoue M, et al. Early diffusion-weighted imaging and perfusion-weighted imaging lesion volumes forecast final infarct size in DEFUSE 2. Stroke 2013; 44: 681–685.
- 9 Kamalian S, Kamalian S, Maas MB, et al. CT cerebral blood flow maps optimally correlate with admission diffusion-weighted imaging in acute stroke but thresholds vary by postprocessing platform. Stroke 2011; 42: 1923–1928.
- 10 Campbell BC, Christensen S, Levi CR, et al. Comparison of computed tomography perfusion and magnetic resonance imaging perfusion-diffusion mismatch in ischemic stroke. Stroke 2012; 43: 2648–2653.
- 11 Campbell BC, Christensen S, Levi CR, et al. Cerebral blood flow is the optimal CT perfusion parameter for assessing infarct core. Stroke 2011; 42: 3435–3440.
- 12 Olivot JM, Mlynash M, Thijs VN, et al. Optimal Tmax threshold for predicting penumbral tissue in acute stroke. Stroke 2009; 40: 469–475.
- 13 Lansberg MG, Lee J, Christensen S, et al. RAPID automated patient selection for reperfusion therapy: a pooled analysis of the Echoplanar Imaging Thrombolytic Evaluation Trial (EPITHET) and the Diffusion and Perfusion Imaging Evaluation for Understanding Stroke Evolution (DEFUSE) study. Stroke 2011; 42: 1608–1614.
- 14 Olivot JM, Mlynash M, Zaharchuk G, et al. Perfusion MRI (Tmax and MTT) correlation with xenon CT cerebral blood flow in stroke patients. Neurology 2009; 72: 1140–1145.
- 15 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: 2817–2821.
- 16 Lin L, Bivard A, Levi CR, Parsons MW. Comparison of computed tomographic and magnetic resonance perfusion measurements in acute ischemic stroke: back-to-back quantitative analysis. Stroke 2014; 45: 1727–1732.
- 17 Saver JL, Goyal M, Bonafe A, et al. Solitaire with the Intention for Thrombectomy as Primary Endovascular Treatment for Acute Ischemic Stroke (SWIFT PRIME) trial: protocol for a randomized, controlled, multicenter study comparing the Solitaire revascularization device with IV tPA with IV tPA alone in acute ischemic stroke. Int J Stroke 2015; 10: 439–448.
- 18 Straka M, Albers GW, Bammer R. Real-time diffusion-perfusion mismatch analysis in acute stroke. J Magn Reson Imaging 2010; 32: 1024–1037.
- 19 Cereda CW, Christensen S, Campbell, BC, et al. A benchmarking tool that evaluates computer tomography perfusion infarct core predictions against a DWI standard. J Cereb Blood Flow Metab. Published online October 19, 2015.
- 20 Purushotham A, Campbell BC, Straka M, et al. Apparent diffusion coefficient threshold for delineation of ischemic core. Int J Stroke 2015; 10: 348–353.
- 21 Chemmanam T, Campbell BC, Christensen S, et al. Ischemic diffusion lesion reversal is uncommon and rarely alters perfusion-diffusion mismatch. Neurology 2010; 75: 1040–1047.
- 22 Campbell BC, Purushotham A, Christensen S, et al. The infarct core is well represented by the acute diffusion lesion: sustained reversal is infrequent. J Cereb Blood Flow Metab 2012; 32: 50–56.
- 23 Kudo K, Sasaki M, Yamada K, et al. Differences in CT perfusion maps generated by different commercial software: quantitative analysis by using identical source data of acute stroke patients. Radiology 2010; 254: 200–209.
- 24 Kudo K, Christensen S, Sasaki M, et al. Accuracy and reliability assessment of CT and MR perfusion analysis software using a digital phantom. Radiology 2013; 267: 201–211.
- 25 Lansberg MG, O'Brien MW, Tong DC, et al. Evolution of cerebral infarct volume assessed by diffusion-weighted magnetic resonance imaging. Arch Neurol 2001; 58: 613–617.
- 26 Wheeler HM, Mlynash M, Inoue M, et al. The growth rate of early DWI lesions is highly variable and associated with penumbral salvage and clinical outcomes following endovascular reperfusion. Int J Stroke 2015; 10: 723–729.