Automated CT Perfusion Detection of the Acute Infarct Core in Ischemic Stroke: A Systematic Review and Meta-Analysis

With no measurement of 100% recovery, what the fuck are you doing in stroke?

Automated CT Perfusion Detection of the Acute Infarct Core in Ischemic Stroke: A Systematic Review and Meta-Analysis

Nicholas E. Lim;

Benjamin Chia;

Max K. Bulsara

;

Mark Parsons

;

Graeme J. Hankey

;

Andrew Bivard

Cerebrovasc Dis (2023) 52 (1): 97–109.

https://doi.org/10.1159/000524916

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Abstract

Introduction: In patients with acute ischemic stroke, the location and volume of an irreversible infarct core determine prognosis and treatment. We aimed to determine if automated CT perfusion (CTP) is non-inferior to diffusion-weighted imaging (DWI) or fluid-attenuated inversion recovery (FLAIR) in predicting the acute infarct core.  

Methods: In this systematic review and meta-analysis, we searched MEDLINE and EMBASE from 1960 to December 2020. Five outcome measures were examined: volumetric difference, volumetric correlation, sensitivity and specificity at the patient level, Dice coefficient, and sensitivity and specificity at the voxel level. A random-effects meta-analysis was performed for volumetric difference and correlation. Results: From 3,986 studies retrieved, 48 studies met our inclusion criteria with 46 studies on anterior circulation, one study on posterior circulation, and one study on lacunar infarct strokes. In anterior circulation stroke, there were no significant mean volumetric differences between CTP and acute DWI (cerebral blood flow [CBF] 0.52 mL, 95% CI [−0.07, 1.11], I² 0.0%; relative CBF [rCBF] 3.01 mL, 95% CI [−0.46, 6.48], I² 82.6%; relative cerebral blood volume [rCBV] −12.84 mL, 95% CI [−38.56, 12.88], I² 96.2%) and between CTP and delayed DWI or FLAIR (rCBF −1.29 mL, 95% CI [−6.49, 3.92], I² 91.8%; rCBV −5.80 mL, 95% CI [−16.20, 4.60], I² 84.2%). Mean correlation between CTP and acute DWI was 0.90 (95% CI [0.80, 0.95], I² 60.0%) for rCBF and 0.84 (95% CI [0.58, 0.94], I² 93.5%) for rCBV. Mean correlation between CTP and delayed DWI or FLAIR was 0.74 (95% CI [0.57, 0.85], I² 94.6%) for rCBF and 0.90 (95% CI [0.69, 0.97], I² 93.1%) for rCBV. Sensitivity and specificity at the patient level were reported by three studies and Dice coefficient by four studies. Statistical analysis could not be performed for sensitivity and specificity at the voxel level. Limited evidence was available for posterior circulation or lacunar infarct strokes.  

Conclusion: Due to significant heterogeneity and insufficient high-quality studies reporting each outcome, there is insufficient evidence to reliably determine the accuracy of CTP prediction of the infarct core compared to DWI or FLAIR.

Diagnosis of DWI-negative acute ischemic stroke

Absolutely no clue what this means or how it could be used to get stroke survivors to 100% recovery. More wasted research.
http://www.neurology.org/content/early/2017/06/14/WNL.0000000000004120.short?rss=1

A meta-analysis

1. Brian L. Edlow, MD,
2. Shelley Hurwitz, PhD and
3. Jonathan A. Edlow, MD

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1. Correspondence to Dr. Edlow: bedlow@mgh.harvard.edu

1. Published online before print June 14, 2017, doi: http:/​/​dx.​doi.​org/​10.​1212/​WNL.​0000000000004120 Neurology 10.1212/WNL.0000000000004120

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Abstract

Objective: To determine the prevalence of diffusion-weighted imaging (DWI)–negative acute ischemic stroke (AIS) and to identify clinical characteristics of patients with DWI-negative AIS.

Methods: We systematically searched PubMed and Ovid/MEDLINE for relevant studies between 1992, the year that the DWI sequence entered clinical practice, and 2016. Studies were included based upon enrollment of consecutive patients presenting with a clinical diagnosis of AIS prior to imaging. Meta-analysis was performed to synthesize study-level data, estimate DWI-negative stroke prevalence, and estimate the odds ratios (ORs) for clinical characteristics associated with DWI-negative stroke.

Results: Twelve articles including 3,236 AIS patients were included. The meta-analytic synthesis yielded a pooled prevalence of DWI-negative AIS of 6.8%, 95% confidence interval (CI) 4.9–9.3. In the 5 studies that reported proportion data for DWI-negative and DWI-positive AIS based on the ischemic vascular territory (n = 1,023 AIS patients), DWI-negative stroke was strongly associated with posterior circulation ischemia, as determined by clinical diagnosis at hospital discharge or repeat imaging (OR 5.1, 95% CI 2.3–11.6, p <0.001).

Conclusions: A small but significant percentage of patients with AIS have a negative DWI scan. Patients with neurologic deficits consistent with posterior circulation ischemia have 5 times the odds of having a negative DWI scan compared to patients with anterior circulation ischemia. AIS remains a clinical diagnosis and urgent reperfusion therapy should be considered even when an initial DWI scan is negative.

• Received January 21, 2017.
• Accepted in final form April 20, 2017.

• © 2017 American Academy of Neurology