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AJNR - American Journal of Neuroradiology

Published ahead of print on January 22, 2009
doi: 10.3174/ajnr.A1439

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Perfusion CT in Patients with Acute Ischemic Stroke Treated with Intra-Arterial Thrombolysis: Predictive Value of Infarct Core Size on Clinical Outcome

R. Gasparotti^a, M. Grassi^b, D. Mardighian^a, M. Frigerio^a, M. Pavia^a, R. Liserre^a, M. Magoni^c, L. Mascaro^d, A. Padovani^e and A. Pezzini^e

^a Dipartimento di Diagnostica per Immagini, Neuroradiologia, Università di Brescia, Brescia, Italy
^b Dipartimento di Scienze Sanitarie Applicate, Sezione di Statistica Medica e Epidemiologia, Università di Pavia, Pavia, Italy
^c Stroke Unit, Neurologia Vascolare, Spedali Civili di Brescia, Brescia, Italy
^d Dipartimento di Diagnostica per Immagini, Fisica Medica, Spedali Civili di Brescia, Brescia, Italy
^e Dipartimento di Scienze Mediche e Chirurgiche, Clinica Neurologica, Università degli Studi di Brescia, Brescia, Italy

View larger version (10K): [in this window] [in a new window]   Fig 1. Box and whisker graphs of infarct core size according to clinical outcome (A) and infarct growth according to recanalization after IAT (B).

View larger version (96K): [in this window] [in a new window]   Fig 2. A 35-year-old man with left hemiplegia, imaged 3 hours after symptom onset. NCCT, CBV, CBF, and TTP maps, delayed NCCT (A–E, first level; F–L, second level); and IAT (M–O). NCCT shows mild hypoattenuation of the right lenticular nucleus. PCT color maps show small multiple areas with severely reduced CBV (CBV ratio <33%) and CBF (<11.5 mL/100 g/min) in the anterior third of the right lenticular nucleus; external capsule; and fronto-opercular, insular, posterior temporal and parietal cortices, corresponding to the infarct core (solid line). The infarct core is surrounded by a large perfusion deficit in the right MCA cortical territory, characterized by reduced CBF (color-coded blue) and increased TTP (color-coded red), indicating a TTP-CBV mismatch, which corresponds to the ischemic penumbra. IADSA, performed after PCT, shows proximal right M1 occlusion (M), with poor collateral leptomeningeals. The patient underwent intra-arterial thrombolysis with injection of rtPA and mechanical clot manipulation, followed by percutaneous transluminal angioplasty, with complete right MCA recanalization (N). A mild residual M1 stenosis is identifiable at the end of the procedure (O). Follow-up CT scans (E and L), obtained 2 days after stroke, show small multiple infarcts in the right caudate and anterior third of the lenticular nucleus; insular cortex; and temporal, frontal, and parietal cortices, which correspond to the infarct core, with consequent recovery of a large portion of the mismatch area. At 3 months, the patient was independent (mRS score, 1).