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Time-resolved assessment of collateral flow using 4D CT angiography in large-vessel occlusion stroke

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Abstract

Objectives

In acute stroke patients with large vessel occlusion, collateral blood flow affects tissue fate and patient outcome. The visibility of collaterals on computed tomography angiography (CTA) strongly depends on the acquisition phase, but the optimal time point for collateral imaging is unknown.

Methods

We analysed collaterals in a time-resolved fashion using four-dimensional (4D) CTA in 82 endovascularly treated stroke patients, aiming to determine which acquisition phase best depicts collaterals and predicts outcome. Early, peak and late phases as well as temporally fused maximum intensity projections (tMIP) were graded using a semiquantitative regional leptomeningeal collateral score, compared with conventional single-phase CTA and correlated with functional outcome.

Results

The total extent of collateral flow was best visualised on tMIP. Collateral scores were significantly lower on early and peak phase as well as on single-phase CTA. Collateral grade was associated with favourable functional outcome and the strength of this relationship increased from earlier to later phases, with collaterals on tMIP showing the strongest correlation with outcome.

Conclusions

Temporally fused tMIP images provide the best depiction of collateral flow. Our findings suggest that the total extent of collateral flow, rather than the velocity of collateral filling, best predicts clinical outcome.

Key Points

• Collateral flow visibility on CTA strongly depends on the acquisition phase

• tMIP offers the best visualisation of the extent of collaterals

• Outcome prediction may be better with tMIP than with earlier phases

• Total extent of collaterals seems more important than their filling speed

• If triggered too early, CTA may underestimate collateral flow

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Abbreviations

4D CTA:

Four-dimensional computed tomographic angiography

ASPECTS:

Alberta Stroke Program Early CT Score

CBF:

Cerebral blood flow

CBV:

Cerebral blood volume

ICC:

Intraclass correlation coefficient

MIP:

Maximum intensity projection

MMCT:

Multi-modal Computed Tomography

mRS:

Modified Rankin Scale score

NIHSS:

National Institutes of Health stroke scale

rLMC:

Regional leptomeningeal score

spCTA:

Single-phase computed tomography angiography

TICI:

Thrombolysis in cerebral infarction

tMIP:

Temporal maximum intensity projection

TTD:

Time to drain

VPCT:

Volume perfusion computed tomography

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Acknowledgments

The department has a research agreement with Siemens AG, Forchheim, Germany. Andreas Frölich, Michael Knauth and Peter Schramm have received speaker’s honoraria from Siemens AG, Forchheim, Germany. Ernst Klotz is a full-time employee of Siemens AG, Forchheim, Germany.

We would like to inform you that part of the current patient collective (about two-thirds of the population) has been subject to previous analyses. However, the current study reports fundamentally new data on collateral strength assessed in a time-resolved fashion, while previous analyses were focused on the delineation of thrombi [12], the depiction of incomplete vascular occlusions [13] and the predictive value of perfusion parameter maps [18].

Author information

Authors and Affiliations

  1. Department of Neuroradiology, University Medical Centre Göttingen, Robert-Koch-Str. 40, 37075, Göttingen, Germany

    Andreas M. J. Frölich, Sarah Lena Wolff, Marios N. Psychogios, Ramona Schramm, Michael Knauth & Peter Schramm

  2. Department of Neurology, University Medical Centre Göttingen, Robert-Koch-Str. 40, 37075, Göttingen, Germany

    Katrin Wasser

  3. Siemens AG, Computed Tomography H IM CR R&D PA, Siemensstr. 1, 91301, Forchheim, Germany

    Ernst Klotz

Authors
  1. Andreas M. J. Frölich
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  2. Sarah Lena Wolff
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  3. Marios N. Psychogios
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  4. Ernst Klotz
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  5. Ramona Schramm
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  6. Katrin Wasser
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  7. Michael Knauth
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  8. Peter Schramm
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Corresponding author

Correspondence to Andreas M. J. Frölich.

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Frölich, A.M.J., Wolff, S.L., Psychogios, M.N. et al. Time-resolved assessment of collateral flow using 4D CT angiography in large-vessel occlusion stroke. Eur Radiol 24, 390–396 (2014). https://doi.org/10.1007/s00330-013-3024-6

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  • DOI: https://doi.org/10.1007/s00330-013-3024-6

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