Abstract
Background And PurposeWhile penumbra assessment has become an important part of the clinical decision making for acute stroke patients, there is a lack of studies measuring the reliability and reproducibility of defined assessment techniques in the clinical setting. Our aim was to determine reliability and reproducibility of different types of three-dimensional penumbra assessment methods in stroke patients who underwent whole brain CT perfusion imaging (WB-CTP).Materials And MethodsWe included 29 patients with a confirmed MCA infarction who underwent initial WB-CTP with a scan coverage of 100 mm in the z-axis. Two blinded and experienced readers assessed the flow-volume-mismatch twice and in two quantitative ways: Performing a volumetric mismatch analysis using OsiriX imaging software (MMVOL) and visual estimation of mismatch (MMEST). Complementarily, the semiquantitative Alberta Stroke Programme Early CT Score for CT perfusion was used to define mismatch (MMASPECTS). A favorable penumbral pattern was defined by a mismatch of ≥30% in combination with a cerebral blood flow deficit of ≤90 ml and an MMASPECTS score of ≥1, respectively. Inter- and intrareader agreement was determined by Kappa-values and ICCs.ResultsOverall, MMVOL showed considerably higher inter-/intrareader agreement (ICCs: 0.751/0.843) compared to MMEST (0.292/0.749). In the subgroup of large (≥50 mL) perfusion deficits, inter- and intrareader agreement of MMVOL was excellent (ICCs: 0.961/0.942), while MMEST interreader agreement was poor (0.415) and intrareader agreement was good (0.919). With respect to penumbra classification, MMVOL showed the highest agreement (interreader agreement: 25 agreements/4 non-agreements/κ: 0.595; intrareader agreement 27/2/0.833), followed by MMEST (22/7/0.471; 23/6/0.577), and MMASPECTS (18/11/0.133; 21/8/0.340).ConclusionThe evaluated approach of volumetric mismatch assessment is superior to pure visual and ASPECTS penumbra pattern assessment in WB-CTP and helps to precisely judge the extent of 3-dimensional mismatch in acute stroke patients.
Highlights
The selection of patients who may benefit from reperfusion therapy is a major issue in acute stroke imaging [1]
Recent studies have used the extent of blood flow-blood volume mismatch in CT perfusion (CTP) or perfusion-diffusion mismatch in magnetic resonance imaging (MRI) as their inclusion criterion for reperfusion therapy [1,4]
There is no consensus on the exact definition of a ‘‘substantial’’ or ‘‘meaningful’’ mismatch suggesting that there is a considerable volume of savable tissue, supporting the decision for reperfusion therapy [5,6]
Summary
The selection of patients who may benefit from reperfusion therapy is a major issue in acute stroke imaging [1]. Recent studies have used the extent of blood flow-blood volume mismatch in CTP or perfusion-diffusion mismatch in MRI as their inclusion criterion for reperfusion therapy [1,4]. While penumbra assessment has become an important part of the clinical decision making for acute stroke patients, there is a lack of studies measuring the reliability and reproducibility of defined assessment techniques in the clinical setting. Our aim was to determine reliability and reproducibility of different types of threedimensional penumbra assessment methods in stroke patients who underwent whole brain CT perfusion imaging (WB-CTP)
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