• James E Siegler, Steven R Messé, Heidi Sucharew, Scott E Kasner, Tapan Mehta, Niraj Arora, Amy K Starosciak, Felipe De Los Rios La Rosa, Natasha R Barnhill, Akshitkumar M Mistry, Kishan Patel, Salman Assad, Amjad Tarboosh, Katarina Dakay, Jeff Wagner, Alicia Bennett, Bharathi Jagadeesan, Christopher Streib, Stewart A Weber, Rohan Chitale, John J Volpi, Stephan A Mayer, Shadi Yaghi, Mahesh V Jayaraman, Pooja Khatri, and Eva A Mistry.
• Department of Neurology, Hospital of the University of Pennsylvania, Philadelphia, PA.
• J Neuroimaging. 2020 Mar 1; 30 (2): 219-226.

Background And PurposeThe 2018 AHA guidelines recommend perfusion imaging to select patients with acute large vessel occlusion (LVO) for thrombectomy in the extended window. However, the relationship between noncontrast CT and CT perfusion imaging has not been sufficiently characterized >6 hours after last known normal (LKN).MethodsFrom a multicenter prospective cohort of consecutive adults who underwent thrombectomy for anterior LVO 0-24 hours after LKN, we correlated baseline core volume (rCBF < 30%) and the Alberta Stroke Program Early CT Scale (ASPECTS) score. We compared perfusion findings between patients with an unfavorable ASPECTS (<6) against those with a favorable ASPECTS (≥6), and assessed findings over time.ResultsOf 485 enrolled patients, 177 met inclusion criteria (median age: 69 years, interquartile range [IQR: 57-81], 49% female, median ASPECTS 8 [IQR: 6-9], median core 10 cc [IQR: 0-30]). ASPECTS and core volume moderately correlated (r = -.37). A 0 cc core was observed in 54 (31%) patients, 70% of whom had ASPECTS <10. Of the 28 patients with ASPECTS <6, 3 (11%) had a 0 cc core. After adjustment for age and stroke severity, there was a lower ASPECTS for every 1 hour delay from LKN (cOR: 0.95, 95% confidence of interval [CI]: 0.91-1.00, P = .04). There was no difference in core (P = .51) or penumbra volumes (P = .87) across patients over time.ConclusionsIn this multicenter prospective cohort of patients who underwent thrombectomy, one-third of patients had normal CTP core volumes despite nearly three quarters of patients showing ischemic changes on CT. This finding emphasizes the need to carefully assess both noncontrast and perfusion imaging when considering thrombectomy eligibility.© 2019 by the American Society of Neuroimaging.

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