Advertisement

European Radiology

, Volume 26, Issue 7, pp 2215–2222 | Cite as

Thrombus length discrepancy on dual-phase CT can predict clinical outcome in acute ischemic stroke

  • Mina Park
  • Kyung-eun Kim
  • Na-Young ShinEmail author
  • Seung-Koo Lee
  • Soo Mee Lim
  • Dongbeom Song
  • Ji Hoe Heo
  • Jin Woo Kim
  • Se Won Oh
Neuro

Abstract

Objectives

The thrombus length may be overestimated on early arterial computed tomography angiography (CTA) depending on the collateral status. We evaluated the value of a grading system based on the thrombus length discrepancy on dual-phase CT in outcome prediction.

Methods

Forty-eight acute ischemic stroke patients with M1 occlusion were included. Dual-phase CT protocol encompassed non-contrast enhanced CT, CTA with a bolus tracking technique, and delayed contrast enhanced CT (CECT) performed 40s after contrast injection. The thrombus length discrepancy between CTA and CECT was graded by using a three-point scale: G0 = no difference; G1 = no difference in thrombus length, but in attenuation distal to thrombus; G2 = difference in thrombus length. Univariate and multivariate analyses were performed to define independent predictors of poor clinical outcome at 3 months.

Results

The thrombus discrepancy grade showed significant linear relationships with both the collateral status (P = 0.008) and the presence of antegrade flow on DSA (P = 0.010) with good interobserver agreement (κ = 0.868). In a multivariate model, the presence of thrombus length discrepancy (G2) was an independent predictor of poor clinical outcome [odds ratio = 11.474 (1.350–97.547); P =0.025].

Conclusions

The presence of thrombus length discrepancy on dual-phase CT may be a useful predictor of unfavourable clinical outcome in acute M1 occlusion patients.

Key points

Early arterial phase CTA may underestimate thrombus length.

Thrombus length discrepancy grade reflects collateral status or presence of antegrade flow.

Outcome prediction may be better with thrombus length grade than collateral score.

Keywords

Brain Infarction Stroke Neuroimaging Tomography, X-Ray computed Middle cerebral artery 

Abbreviations

CECT

Contrast enhanced CT

NECT

Non-contrast enhanced CT

DSA

Digital subtraction angiography

TOAST

Trial of Org 10172 in Acute Stroke Treatment

mRS

Modified Rankin scale score

ASPECTS

Alberta Stroke Program Early CT Score

MIP

Maximum intensity projection

TICI

Thrombolysis in cerebral infarction

NIHSS

National Institutes of Health stroke scale

tPA

Tissue plasminogen activator

Notes

Acknowledgments

The scientific guarantor of this publication is Seung-Koo Lee. The authors of this manuscript declare no relationships with any companies whose products or services may be related to the subject matter of the article. The authors state that this work has not received any funding. No complex statistical methods were necessary for this paper. Institutional review board approval was obtained. The institutional review board of Yonsei University Health System approved this study and granted a waiver of consent. Some study subjects (n = 34/48) have been previously reported in ‘Dual-phase CT collateral score: a predictor of clinical outcome in patients with acute ischemic stroke. PLoS One 9:e107379’. However, an additional 14 patients were included for this study and the primary aim of the two studies are different. Methodology: retrospective, diagnostic or prognostic study, performed at one institution.

Supplementary material

330_2015_4018_MOESM1_ESM.docx (17 kb)
ESM 1 (DOCX 17 kb)

References

  1. 1.
    Lima FO, Furie KL, Silva GS et al (2010) The pattern of leptomeningeal collaterals on CT angiography is a strong predictor of long-term functional outcome in stroke patients with large vessel intracranial occlusion. Stroke 41:2316–2322CrossRefPubMedGoogle Scholar
  2. 2.
    Maas MB, Lev MH, Ay H et al (2009) Collateral vessels on CT angiography predict outcome in acute ischemic stroke. Stroke 40:3001–3005CrossRefPubMedPubMedCentralGoogle Scholar
  3. 3.
    Mokin M, Morr S, Natarajan SK et al (2014) Thrombus density predicts successful recanalization with Solitaire stent retriever thrombectomy in acute ischemic stroke. J Neurointerv Surg. doi: 10.1136/neurintsurg-2013-011017 PubMedCentralGoogle Scholar
  4. 4.
    Saarinen JT, Rusanen H, Sillanpaa N (2014) Collateral score complements clot location in predicting the outcome of intravenous thrombolysis. AJNR Am J Neuroradiol 35:1892–1896CrossRefPubMedGoogle Scholar
  5. 5.
    Frolich AM, Schrader D, Klotz E et al (2013) 4D CT angiography more closely defines intracranial thrombus burden than single-phase CT angiography. AJNR Am J Neuroradiol 34:1908–1913CrossRefPubMedGoogle Scholar
  6. 6.
    Mishra SM, Dykeman J, Sajobi TT et al (2014) Early Reperfusion Rates with IV tPA Are Determined by CTA Clot Characteristics. AJNR Am J Neuroradiol 35:2265–2272CrossRefPubMedGoogle Scholar
  7. 7.
    Tan IY, Demchuk AM, Hopyan J et al (2009) CT angiography clot burden score and collateral score: correlation with clinical and radiologic outcomes in acute middle cerebral artery infarct. AJNR Am J Neuroradiol 30:525–531CrossRefPubMedGoogle Scholar
  8. 8.
    Yeo LL, Paliwal P, Teoh HL et al (2014) Assessment of intracranial collaterals on CT angiography in anterior circulation acute ischemic stroke. AJNR Am J Neuroradiol. doi: 10.3174/ajnr.A4117 PubMedGoogle Scholar
  9. 9.
    Yoo AJ, Hu R, Hakimelahi R et al (2012) CT angiography source images acquired with a fast-acquisition protocol overestimate infarct core on diffusion weighted images in acute ischemic stroke. J Neuroimaging 22:329–335CrossRefPubMedGoogle Scholar
  10. 10.
    Choi JY, Kim EJ, Hong JM et al (2011) Conventional enhancement CT: a valuable tool for evaluating pial collateral flow in acute ischemic stroke. Cerebrovasc Dis 31:346–352CrossRefPubMedGoogle Scholar
  11. 11.
    Frolich AM, Wolff SL, Psychogios MN et al (2014) Time-resolved assessment of collateral flow using 4D CT angiography in large-vessel occlusion stroke. Eur Radiol 24:390–396CrossRefPubMedGoogle Scholar
  12. 12.
    Mortimer AM, Little DH, Minhas KS, Walton ER, Renowden SA, Bradley MD (2014) Thrombus length estimation in acute ischemic stroke: a potential role for delayed contrast enhanced CT. J Neurointerv Surg 6:244–248CrossRefPubMedGoogle Scholar
  13. 13.
    Pulli B, Schaefer PW, Hakimelahi R et al (2012) Acute ischemic stroke: infarct core estimation on CT angiography source images depends on CT angiography protocol. Radiology 262:593–604CrossRefPubMedPubMedCentralGoogle Scholar
  14. 14.
    Calleja AI, Cortijo E, Garcia-Bermejo P et al (2013) Collateral circulation on perfusion-computed tomography-source images predicts the response to stroke intravenous thrombolysis. Eur J Neurol 20:795–802CrossRefPubMedGoogle Scholar
  15. 15.
    Jung SL, Lee YJ, Ahn KJ et al (2011) Assessment of collateral flow with multi-phasic CT: correlation with diffusion weighted MRI in MCA occlusion. J Neuroimaging 21:225–228CrossRefPubMedGoogle Scholar
  16. 16.
    Lee KH, Cho SJ, Byun HS et al (2000) Triphasic perfusion computed tomography in acute middle cerebral artery stroke: a correlation with angiographic findings. Arch Neurol 57:990–999CrossRefPubMedGoogle Scholar
  17. 17.
    Shin NY, Kim KE, Park M et al (2014) Dual-phase CT collateral score: a predictor of clinical outcome in patients with acute ischemic stroke. PLoS One 9, e107379CrossRefPubMedPubMedCentralGoogle Scholar
  18. 18.
    Menon BK, d'Esterre CD, Qazi EM et al (2015) Multiphase CT angiography: a New tool for the imaging triage of patients with acute ischemic stroke. Radiology 275:510–520CrossRefPubMedGoogle Scholar
  19. 19.
    Kloska SP, Dittrich R, Fischer T et al (2007) Perfusion CT in acute stroke: prediction of vessel recanalization and clinical outcome in intravenous thrombolytic therapy. Eur Radiol 17:2491–2498CrossRefPubMedGoogle Scholar
  20. 20.
    Lee BI, Nam HS, Heo JH, Kim DI, Yonsei Stroke T (2001) Yonsei Stroke Registry. Analysis of 1,000 patients with acute cerebral infarctions. Cerebrovasc Dis 12:145–151CrossRefPubMedGoogle Scholar
  21. 21.
    Adams HP Jr, Bendixen BH, Kappelle LJ et al (1993) Classification of subtype of acute ischemic stroke. Definitions for use in a multicenter clinical trial. TOAST. Trial of Org 10172 in acute stroke treatment. Stroke 24:35–41CrossRefPubMedGoogle Scholar
  22. 22.
    Barber PA, Demchuk AM, Zhang J, Buchan AM (2000) Validity and reliability of a quantitative computed tomography score in predicting outcome of hyperacute stroke before thrombolytic therapy. ASPECTS study group. Alberta stroke programme early CT score. Lancet 355:1670–1674CrossRefPubMedGoogle Scholar
  23. 23.
    Higashida RT, Furlan AJ, Roberts H et al (2003) Trial design and reporting standards for intra-arterial cerebral thrombolysis for acute ischemic stroke. Stroke 34:e109–e137CrossRefPubMedGoogle Scholar
  24. 24.
    Landis JR, Koch GG (1977) The measurement of observer agreement for categorical data. Biometrics 33:159–174CrossRefPubMedGoogle Scholar
  25. 25.
    Kim SJ, Noh HJ, Yoon CW et al (2012) Multiphasic perfusion computed tomography as a predictor of collateral flow in acute ischemic stroke: comparison with digital subtraction angiography. Eur Neurol 67:252–255CrossRefPubMedGoogle Scholar
  26. 26.
    Berkhemer OA, Fransen PS, Beumer D et al (2015) A randomized trial of intraarterial treatment for acute ischemic stroke. N Engl J Med 372:11–20CrossRefPubMedGoogle Scholar
  27. 27.
    Abels B, Villablanca JP, Tomandl BF, Uder M, Lell MM (2012) Acute stroke: a comparison of different CT perfusion algorithms and validation of ischaemic lesions by follow-up imaging. Eur Radiol 22:2559–2567CrossRefPubMedGoogle Scholar
  28. 28.
    Frolich AM, Psychogios MN, Klotz E, Schramm R, Knauth M, Schramm P (2012) Antegrade flow across incomplete vessel occlusions can be distinguished from retrograde collateral flow using 4-dimensional computed tomographic angiography. Stroke 43:2974–2979CrossRefPubMedGoogle Scholar
  29. 29.
    Nambiar V, Sohn SI, Almekhlafi MA et al (2014) CTA collateral status and response to recanalization in patients with acute ischemic stroke. AJNR Am J Neuroradiol 35:884–890CrossRefPubMedGoogle Scholar
  30. 30.
    Sacks D, Black CM, Cognard C et al (2013) Multisociety consensus quality improvement guidelines for intraarterial catheter-directed treatment of acute ischemic stroke, from the American Society of Neuroradiology, Canadian Interventional Radiology Association, Cardiovascular and Interventional Radiological Society of Europe, Society for Cardiovascular Angiography and Interventions, Society of Interventional Radiology, Society of NeuroInterventional Surgery, European Society of Minimally Invasive Neurological Therapy, and Society of Vascular and Interventional Neurology. Catheter Cardiovasc Interv 82:E52–E68CrossRefPubMedGoogle Scholar
  31. 31.
    Souza LC, Yoo AJ, Chaudhry ZA et al (2012) Malignant CTA collateral profile is highly specific for large admission DWI infarct core and poor outcome in acute stroke. AJNR Am J Neuroradiol 33:1331–1336CrossRefPubMedPubMedCentralGoogle Scholar

Copyright information

© European Society of Radiology 2015

Authors and Affiliations

  • Mina Park
    • 1
  • Kyung-eun Kim
    • 1
  • Na-Young Shin
    • 2
    Email author
  • Seung-Koo Lee
    • 1
  • Soo Mee Lim
    • 2
  • Dongbeom Song
    • 3
  • Ji Hoe Heo
    • 3
  • Jin Woo Kim
    • 4
  • Se Won Oh
    • 5
  1. 1.Department of RadiologyResearch Institute of Radiological Science, Yonsei University College of MedicineSeoulRepublic of Korea
  2. 2.Department of RadiologyEwha Womans University School of MedicineSeoulKorea
  3. 3.Department of NeurologyYonsei University College of MedicineSeoulKorea
  4. 4.Department of Radiology, Ilsan Paik HospitalInje University College of MedicineGyeonggi-DoKorea
  5. 5.Department of RadiologySoonchunhyang University Cheonan HospitalCheonanKorea

Personalised recommendations