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Clinical and therapeutic variables may influence the association between infarct core predicted by CT perfusion and clinical outcome in acute stroke

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Abstract

Objectives

After an acute ischemic stroke, patients with a large CT perfusion (CTP) predicted infarct core (pIC) have poor clinical outcome. However, previous research suggests that this relationship may be relevant for subgroups of patients determined by pretreatment and treatment-related variables while negligible for others. We aimed to identify these variables.

Methods

We included a cohort of 828 patients with acute proximal carotid arterial occlusions imaged with a whole-brain CTP within 8 h from stroke onset. pIC was computed on CTP Maps (cerebral blood flow < 30%), and poor clinical outcome was defined as a 90-day modified Rankin Scale score > 2. Potential mediators of the association between pIC and clinical outcome were evaluated through first-order and advanced interaction analyses in the derivation cohort (n = 654) for obtaining a prediction model. The derived model was further validated in an independent cohort (n = 174).

Results

The volume of pIC was significantly associated with poor clinical outcome (OR = 2.19, 95% CI = 1.73 – 2.78, p < 0.001). The strength of this association depended on baseline National Institute of Health Stroke Scale, glucose levels, the use of thrombectomy, and the interaction of age with thrombectomy. The model combining these variables showed good discrimination for predicting clinical outcome in both the derivation cohort and validation cohorts (area under the receiver operating characteristic curve 0.780 (95% CI = 0.746–0.815) and 0.782 (95% CI = 0.715–0.850), respectively).

Conclusions

In patients imaged within 8 h from stroke onset, the association between pIC and clinical outcome is significantly modified by baseline and therapeutic variables. These variables deserve consideration when evaluating the prognostic relevance of pIC.

Key Points

•The volume of CT perfusion (CTP) predicted infarct core (pIC) is associated with poor clinical outcome in acute ischemic stroke imaged within 8 h of onset.

•The relationship between pIC and clinical outcome may be modified by baseline clinical severity, glucose levels, thrombectomy use, and the interaction of age with thrombectomy.

•CTP pIC should be evaluated in an individual basis for predicting clinical outcome in patients imaged within 8 h from stroke onset.

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Abbreviations

AAI:

Advanced analysis of interaction

ASPECTS:

Alberta Stroke Program Early CT Score

AUC-ROC:

Area under the receiver operating characteristic curve

CV:

Cross-validation

CTP:

CT perfusion

ICA-T:

Internal carotid artery terminal segment

IVT:

Intravenous treatment

MT:

Mechanical thrombectomy

mRS:

Modified Rankin Scale score

mTICI:

Modified thrombolysis in cerebral infarction

NIHSS:

National Institute of Health Stroke Scale

PO:

Poor outcome

pIC:

Predicted infarct core

rCBF:

Relative cerebral blood flow threshold

SE:

Standard error

TOAST:

Trial of Org 10 172 in acute stroke treatment

VAR:

Variance

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Acknowledgements

This work was partially developed at the building Centro Esther Koplowitz, Barcelona, CERCA Programme / Generalitat de Catalunya.

Funding

This study has received funding from Instituto de Salud Carlos III (ISCIII) and was co-funded by the European Regional Development Fund. CL and SR receive funding from ISCIII (PFIS-FI16/00231, CM18/00116) and JCP from MCIU (PTA2017-13580-I).

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Author notes

  1. Carlos Laredo and Aleix Solanes contributed equally to this work.

Authors and Affiliations

  1. Comprehensive Stroke Center, Hospital Clinic of Barcelona, Villarroel-170, 08036, Barcelona, Spain

    Carlos Laredo, Arturo Renú, Salvatore Rudilosso, Laura Llull, Alejandro Rodriguez, Xabier Urra, Victor Obach, Ángel Chamorro & Sergio Amaro

  2. August Pi i Sunyer Biomedical Research Institute (IDIBAPS), Barcelona, Spain

    Carlos Laredo, Aleix Solanes, Arturo Renú, Salvatore Rudilosso, Laura Llull, Alejandro Rodriguez, Xabier Urra, Victor Obach, Jose Carlos Pariente, Ángel Chamorro, Joaquim Radua & Sergio Amaro

  3. Imaging of Mood- and Anxiety-Related Disorders (IMARD) Group, Center for Networking Biomedical Research in Mental Health (CIBERSAM), Madrid, Spain

    Aleix Solanes & Joaquim Radua

  4. Department of Radiology, Hospital Clinic of Barcelona, Barcelona, Spain

    Antonio López-Rueda & Napoleón G. Macías

Authors
  1. Carlos Laredo
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  2. Aleix Solanes
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  13. Joaquim Radua
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  14. Sergio Amaro
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Corresponding authors

Correspondence to Joaquim Radua or Sergio Amaro.

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Guarantor

The scientific guarantor of this publication is Sergio Amaro, MD, PhD.

Conflict of Interest

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.

Statistics and Biometry

Two of the authors have significant statistical expertise.

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Written informed consent was waived by the Institutional Review Board.

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Methodology

  • Retrospective

  • Cross-sectional study

  • Performed at one institution

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Laredo, C., Solanes, A., Renú, A. et al. Clinical and therapeutic variables may influence the association between infarct core predicted by CT perfusion and clinical outcome in acute stroke. Eur Radiol 32, 4510–4520 (2022). https://doi.org/10.1007/s00330-022-08590-0

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  • DOI: https://doi.org/10.1007/s00330-022-08590-0

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