Overestimation of core infarct by computed tomography perfusion in the golden hour

This is what is so bad, NO mention of how close to recovery the intervention did. And nothing about what the next steps were to get her 100% recovered.

 Overestimation of core infarct by computed tomography perfusion in the golden hour

Aldo A Mendez¹, Darko Quispe-Orozco¹, Sudeepta Dandapat¹, Edgar A Samaniego², Emily Tamadonfar¹, Cynthia B Zevallos¹, Mudassir Farooqui¹, Colin P Derdeyn³, Santiago Ortega-Gutierrez^2
1 Department of Neurology and University of Iowa Hospitals and Clinics, Iowa City, IA, USA
² Department of Neurology; Department of Neurosurgery; Department of Radiology, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
³ Department of Radiology, University of Iowa Hospitals and Clinics, Iowa City, IA, USA

Date of Submission	02-Mar-2020
Date of Decision	04-Jun-2020
Date of Acceptance	16-Jul-2020
Date of Web Publication	30-Sep-2020

Correspondence Address:
Santiago Ortega-Gutierrez
Department of Neurology, University of Iowa Hospitals and Clinics, 200 Hawkins Drive, 2155 Roy Carver Pavilion, Iowa City, IA 52242
USA

DOI: 10.4103/bc.bc_7_20

Abstract

A nonagenarian patient developed a right middle cerebral artery syndrome during recovery after a right internal carotid artery (ICA) balloon angioplasty. Emergent head computed tomography (CT) revealed no acute ischemic changes; CT angiography (CTA) and CT perfusion (CTP) demonstrated a right ICA occlusion with a large right hemispheric predicted core infarct by cerebral blood flow thresholds and minimal mismatch volume. She underwent complete reperfusion in <45 min from symptom onset. Magnetic resonance imaging brain obtained within 48 h showed a decreased infarct volume as that estimated by CTP. This case emphasizes the limitations of estimating the ischemic core with CTP in the golden hour with ultra-early reperfusion and suggests that CTP thresholds should not be used to exclude patients from treatment in the very early time window.

Keywords: Acute ischemic stroke, cerebral blood flow, computed tomography perfusion, endovascular treatment, ghost core infarct

How to cite this article: Mendez AA, Quispe-Orozco D, Dandapat S, Samaniego EA, Tamadonfar E, Zevallos CB, Farooqui M, Derdeyn CP, Ortega-Gutierrez S. Overestimation of core infarct by computed tomography perfusion in the golden hour. Brain Circ 2020;6:211-4

How to cite this URL: Mendez AA, Quispe-Orozco D, Dandapat S, Samaniego EA, Tamadonfar E, Zevallos CB, Farooqui M, Derdeyn CP, Ortega-Gutierrez S. Overestimation of core infarct by computed tomography perfusion in the golden hour. Brain Circ [serial online] 2020 [cited 2020 Nov 20];6:211-4. Available from: http://www.braincirculation.org/text.asp?2020/6/3/211/296749

Introduction

Determining the irreversibly injured tissue has major implications for acute stroke management, including the decision to pursue reperfusion therapies, hemorrhagic transformation prognosis, and long-term clinical outcome.^[1] Currently, most dedicated stroke centers have incorporated multimodal imaging techniques for acute stroke detection.^[2] Although magnetic resonance imaging (MRI) is an imaging modality accepted to evaluate for acute stroke, due to its impracticality, computed tomography (CT) perfusion (CTP)-derived hemodynamic thresholds are being widely incorporated to delineate acute tissue states.^[1],[2] In addition to being increasingly available, CT angiography (CTA) with CTP is fast, safe, affordable, and obtained simultaneously with a single contrast bolus.^[3],[4],[5] While its effectiveness in selecting patients for mechanical thrombectomy was demonstrated in two of the early window trial (0–6 h),^[6],[7] its use in routine clinical practice became widely spread after the 2018 American Heart Association Stroke Guidelines recommended the use of perfusion imaging as the preferred selection method for patients with large vessel occlusion presenting between 6 and 24 h after last seen well.^[8],[9]

CTP provides maps for predicting core and tissue at risk, but the accuracy of prediction is not well established, particularly during the early window.^[5] Infarct core areas are predicted using different thresholds of cerebral blood flow (CBF) and cerebral blood volume (CBV). Recent publications suggest that the use of CTP-CBF technique may overestimate infarct core volume in the very early window and with fast complete reperfusion, also known as the ghost infarct core concept.^[10],[11] While acute stroke management workflow and early recanalization improve, inaccurate calculation of core infarct might deprive eligible patients from reperfusion therapy.^[5],[12] Herein, we present a case of ultra-early reperfusion in a patient with a right internal carotid artery (ICA) occlusion, in which a preprocedural CTP failed to accurately estimate the core infarct volume.