Skip to main content
SpringerLink
Log in

Comparison of CT angiography collaterals for predicting target perfusion profile and clinical outcome in patients with acute ischemic stroke

  • Neuro
  • Published:
European Radiology Aims and scope Submit manuscript

Abstract

Objectives

To compare collateral status on single-phase CT angiography (sCTA) and multiphase CT angiography (mCTA) and their ability to predict a target mismatch on CT perfusion (CTP) and clinical outcome in patients with acute ischemic stroke (AIS).

Methods

Seventy-three AIS patients with stroke onset between 5 and 15 h or with unclear onset time and occlusions in the M1/M2 segment of the middle cerebral artery and/or intracranial internal carotid artery underwent head non-contrast CT and CTP. Simulated sCTA and mCTA were reconstructed from CTP data and were compared for collaterals assessment. The ability to predict target mismatch on CTP (an ischemic core < 70 ml, a mismatch ratio ≥ 1.8, and an absolute difference ≥ 15 ml) and 90-day modified Rankin Scale (mRS) score of 0–2 was compared between sCTA and mCTA by using receiver operating curve analysis.

Results

sCTA underestimated the collateral status when compared with mCTA (p < 0.01). The ability of mCTA to predict target mismatch (AUC = 0.902, 95% confidence interval [CI] 0.809, 0.959) and clinical outcome (AUC = 0.771; 95% CI, 0.655, 0.864) was better than that of sCTA (p < 0.05 overall). A mCTA collateral score of > 3 best identified the target mismatch (sensitivity, 78.4%; specificity, 90.9%) and predicted 90-day mRS score of 0–2 (sensitivity, 84.8%; specificity, 69.4%).

Conclusions

The collaterals were better estimated by mCTA compared with sCTA. A mCTA collateral score of > 3 optimized the prediction of a target mismatch on CTP and a good clinical outcome in patients with AIS.

Key Points

• Collateral circulation is a key determinant of ischemic core and penumbra. Better collaterals are associated with smaller ischemic core volumes and larger mismatch ratios on CT perfusion.

• The collaterals can be better estimated by multiphase CTA compared with single-phase CTA.

• A collateral score of > 3 on multiphase CTA best identifies patients with target mismatch on CT perfusion and predicts 90-day mRS score of 0–2.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2
Fig. 3

Similar content being viewed by others

Abbreviations

AIF:

Arterial input function

AIS:

Acute ischemic stroke

AUC:

Area under the ROC curve

CBF:

Cerebral blood flow

CTA:

CT angiography

CTP:

CT perfusion

ICA:

Internal carotid artery

IMS:

Interventional Management of Stroke

MCA:

Middle cerebral artery (MCA)

mCTA:

Multiphase CT angiography

NCCT:

Non-contrast CT

NIHSS:

National Institute of Health Stroke Scale

RCTs:

Randomized controlled trials

ROC:

Receiver operating characteristic

sCTA:

Single-phase CT angiography

Tmax :

Time to maximum

VIF:

Venous input function

VPCT:

Volume perfusion CT

References

  1. Berkhemer OA, Fransen PS, Beumer D et al (2015) A randomized trial of intraarterial treatment for acute ischemic stroke. N Engl J Med 372:11–20

    Article  CAS  PubMed  Google Scholar 

  2. Campbell BC, Mitchell PJ, Kleinig TJ et al (2015) Endovascular therapy for ischemic stroke with perfusion-imaging selection. N Engl J Med 372:1009–1018

    Article  CAS  PubMed  Google Scholar 

  3. Goyal M, Demchuk AM, Menon BK et al (2015) Randomized assessment of rapid endovascular treatment of ischemic stroke. N Engl J Med 372:1019–1030

    Article  CAS  PubMed  Google Scholar 

  4. Jovin TG, Chamorro A, Cobo E et al (2015) Thrombectomy within 8 hours after symptom onset in ischemic stroke. N Engl J Med 372:2296–2306

    Article  CAS  PubMed  Google Scholar 

  5. Saver JL, Goyal M, Bonafe A et al (2015) Stent-retriever thrombectomy after intravenous t-PA vs. t-PA alone in stroke. N Engl J Med 372:2285–2295

    Article  CAS  PubMed  Google Scholar 

  6. Goyal M, Menon BK, Derdeyn CP (2013) Perfusion imaging in acute ischemic stroke: let us improve the science before changing clinical practice. Radiology 266:16–21

    Article  PubMed  Google Scholar 

  7. Kudo K, Sasaki M, Yamada K et al (2010) Differences in CT perfusion maps generated by different commercial software: quantitative analysis by using identical source data of acute stroke patients. Radiology 254:200–209

    Article  PubMed  Google Scholar 

  8. Bivard A, Levi C, Spratt N, Parsons M (2013) Perfusion CT in acute stroke: a comprehensive analysis of infarct and penumbra. Radiology 267:543–550

    Article  PubMed  Google Scholar 

  9. Liebeskind DS (2003) Collateral circulation. Stroke 34:2279–2284

    Article  PubMed  Google Scholar 

  10. Menon BK, Qazi E, Nambiar V et al (2015) Differential effect of baseline computed tomographic angiography collaterals on clinical outcome in patients enrolled in the Interventional Management of Stroke III trial. Stroke 46:1239–1244

    Article  PubMed  PubMed Central  Google Scholar 

  11. Berkhemer OA, Jansen IG, Beumer D et al (2016) Collateral status on baseline computed tomographic angiography and intra-arterial treatment effect in patients with proximal anterior circulation stroke. Stroke 47:768–776

    Article  CAS  PubMed  Google Scholar 

  12. Dehkharghani S, Bammer R, Straka M et al (2016) Performance of CT ASPECTS and collateral score in risk stratification: can target perfusion profiles be predicted without perfusion imaging? AJNR Am J Neuroradiol 37:1399–1404

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  13. Vagal A, Menon BK, Foster LD et al (2016) Association between CT angiogram collaterals and CT perfusion in the Interventional Management of Stroke III trial. Stroke 47:535–538

    Article  PubMed  Google Scholar 

  14. Menon BK, d'Esterre CD, Qazi EM et al (2015) Multiphase CT angiography: a new tool for the imaging triage of patients with acute ischemic stroke. Radiology 275:510–520

    Article  PubMed  Google Scholar 

  15. Frolich AM, Psychogios MN, Klotz E, Schramm R, Knauth M, Schramm P (2012) Angiographic reconstructions from whole-brain perfusion CT for the detection of large vessel occlusion in acute stroke. Stroke 43:97–102

    Article  PubMed  Google Scholar 

  16. Campbell BC, Christensen S, Levi CR et al (2011) Cerebral blood flow is the optimal CT perfusion parameter for assessing infarct core. Stroke 42:3435–3440

    Article  PubMed  Google Scholar 

  17. Calamante F, Christensen S, Desmond PM, Ostergaard L, Davis SM, Connelly A (2010) The physiological significance of the time-to-maximum (Tmax) parameter in perfusion MRI. Stroke 41:1169–1174

    Article  PubMed  Google Scholar 

  18. Olivot JM, Mlynash M, Thijs VN et al (2009) Optimal Tmax threshold for predicting penumbral tissue in acute stroke. Stroke 40:469–475

    Article  PubMed  Google Scholar 

  19. Albers GW, Marks MP, Kemp S et al (2018) Thrombectomy for stroke at 6 to 16 hours with selection by perfusion imaging. N Engl J Med 378:708–718

    Article  PubMed  PubMed Central  Google Scholar 

  20. Saver JL, Jahan R, Levy EI et al (2012) Solitaire flow restoration device versus the merci retriever in patients with acute ischaemic stroke (SWIFT): a randomised, parallel-group, non-inferiority trial. Lancet 380:1241–1249

    Article  PubMed  Google Scholar 

  21. Boers AM, Jansen IG, Berkhemer OA et al (2017) Collateral status and tissue outcome after intra-arterial therapy for patients with acute ischemic stroke. J Cereb Blood Flow Metab 37:3589–3598

    Article  PubMed  Google Scholar 

  22. Kim EY, Shin DH, Noh Y, Goh BH, Lee YB (2016) Comparison of imaging selection criteria for intra-arterial thrombectomy in acute ischemic stroke with advanced CT. Eur Radiol 26:2974–2981

    Article  PubMed  Google Scholar 

  23. Powers WJ, Rabinstein AA, Ackerson T et al (2018) 2018 guidelines for the early management of patients with acute ischemic stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke 49:e46–e110

    Article  PubMed  Google Scholar 

  24. Yang CY, Chen YF, Lee CW et al (2008) Multiphase CT angiography versus single-phase CT angiography: comparison of image quality and radiation dose. AJNR Am J Neuroradiol 29:1288–1295

    Article  PubMed  PubMed Central  Google Scholar 

Download references

Acknowledgements

We sincerely thank Mrs. Min-lin Zhou from the National Clinical Research Center of Kidney Diseases, Jinling Hospital, for her reviewing of all the statistics. We also thank Dr. Kai Qiu and Dr. Wei Wang for their kind help in collecting the clinical information.

Funding

The authors state that this work has not received any funding.

Author information

Authors and Affiliations

  1. Department of Radiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu Province, China

    Shan-shan Lu, Xuan Zhang, Xiao-quan Xu & Fei-yun Wu

  2. Department of Interventional Radiology, The First Affiliated Hospital of Nanjing Medical University, No.300 Guangzhou Road, Gulou district, Nanjing, Jiangsu Province, China

    Yue-zhou Cao, Lin bo Zhao, Sheng Liu & Hai-bin Shi

  3. Department of Emergency, The First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu Province, China

    Qiang-hui Liu

Authors
  1. Shan-shan Lu
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Xuan Zhang
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Xiao-quan Xu
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Yue-zhou Cao
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Lin bo Zhao
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Qiang-hui Liu
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. Fei-yun Wu
    View author publications

    You can also search for this author in PubMed Google Scholar

  8. Sheng Liu
    View author publications

    You can also search for this author in PubMed Google Scholar

  9. Hai-bin Shi
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Hai-bin Shi.

Ethics declarations

Guarantor

The scientific guarantor of this publication is Dr. Hai-bin Shi.

Email address: shihb@njmu.edu.cn.

Conflict of interest

The authors of this manuscript declare no relationships with any companies whose products or services may be related to the subject matter of the article.

Statistics and biometry

Mrs. Min-lin Zhou from national clinical research center of kidney diseases, Jinling Hospital, kindly provided statistical advice for this manuscript.

Informed consent

Written informed consent was waived by the Institutional Review Board.

Ethical approval

Institutional Review Board approval was obtained.

Methodology

• Retrospective

• Case-control study

• Performed at one institution

Additional information

Publisher’s note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Lu, Ss., Zhang, X., Xu, Xq. et al. Comparison of CT angiography collaterals for predicting target perfusion profile and clinical outcome in patients with acute ischemic stroke. Eur Radiol 29, 4922–4929 (2019). https://doi.org/10.1007/s00330-019-06027-9

Download citation

  • Received:

  • Revised:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00330-019-06027-9

Keywords

Search

Navigation