Ghost Infarct Core and Admission Computed Tomography Perfusion: Redefining the Role of Neuroimaging in Acute Ischemic Stroke

Nuno Martins; Ana Aires; Beatriz Mendez; Sandra Boned; Marta Rubiera; Alejandro Tomasello; Pilar Coscojuela; David Hernandez; Marián Muchada; David Rodríguez-Luna; Noelia Rodríguez; Jesús M Juega; Jorge Pagola; Carlos A Molina; Marc Ribó

doi:10.1159/000490117

Ghost Infarct Core and Admission Computed Tomography Perfusion: Redefining the Role of Neuroimaging in Acute Ischemic Stroke

Interv Neurol. 2018 Oct;7(6):513-521. doi: 10.1159/000490117. Epub 2018 Aug 31.

Authors

Nuno Martins¹, Ana Aires^{2

3}, Beatriz Mendez⁴, Sandra Boned^{5

6}, Marta Rubiera^{5

6}, Alejandro Tomasello⁷, Pilar Coscojuela⁷, David Hernandez⁷, Marián Muchada^{5

6}, David Rodríguez-Luna^{5

6}, Noelia Rodríguez^{5

6}, Jesús M Juega^{5

6}, Jorge Pagola^{5

6}, Carlos A Molina^{5

6}, Marc Ribó^{5

6}

Affiliations

¹ Department of Internal Medicine, Hospital Fernando Fonseca, Amadora, Portugal.
² Department of Neurology, São João Hospital Center, Porto, Portugal.
³ Department of Clinical Neurosciences and Mental Health, Faculty of Medicine, University of Porto, Porto, Portugal.
⁴ Instituto Nacional de Neurología y Neurocirugía, Mexico City, Mexico.
⁵ Stroke Unit, Department of Neurology, Vall d'Hebron University Hospital, Vall d'Hebron Research Institute, Barcelona, Spain.
⁶ Departament de Medicina, Universitat Autónoma de Barcelona, Barcelona, Spain.
⁷ Department of Neuroradiology, Vall d'Hebron University Hospital, Barcelona, Spain.

Abstract

Background: Determining the size of infarct extent is crucial to elect patients for reperfusion therapies. Computed tomography perfusion (CTP) based on cerebral blood volume may overestimate infarct core on admission and consequently include ghost infarct core (GIC) in a definitive lesional area.

Purpose: Our goal was to confirm and better characterize the GIC phenomenon using CTP cerebral blood flow (CBF) as the reference parameter to determine infarct core.

Methods: We performed a retrospective, single-center analysis of consecutive thrombectomies of middle cerebral or intracranial internal carotid artery occlusions considering noncontrast CT Alberta Stroke Program Early CT Score ≥6 in patients with pretreatment CTP. We used the RAPID® software to measure admission infarct core based on initial CBF. The final infarct was extracted from follow-up CT. GIC was defined as initial core minus final infarct > 10 mL.

Results: A total of 123 patients were included. The median National Institutes of Health Stroke Scale score was 18 (13-20), the median time from symptoms to CTP was 188 (67-288) min, and the recanalization rate (Thrombolysis in Cerebral Infarction score 2b, 2c, or 3) was 83%. Twenty patients (16%) presented with GIC. GIC was associated with shorter time to recanalization (150 [105-291] vs. 255 [163-367] min, p = 0.05) and larger initial CBF core volume (38 [26-59] vs. 6 [0-27] mL, p < 0.001). An adjusted logistic regression model identified time to recanalization < 302 min (OR 4.598, 95% CI 1.143-18.495, p = 0.032) and initial infarct volume (OR 1.01, 95% CI 1.001-1.019, p = 0.032) as independent predictors of GIC. At 24 h, clinical improvement was more frequent in patients with GIC (80 vs. 49%, p = 0.01).

Conclusions: CTP CBF < 30% may overestimate infarct core volume, especially in patients imaged in the very early time window and with fast complete reperfusion. Therefore, the CTP CBF technique may exclude patients who would benefit from endovascular treatment.

Keywords: Acute ischemic stroke; Cerebral blood flow; Computed tomography perfusion; Endovascular treatment; Ghost core infarct.