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Review
Utility of perfusion imaging in acute stroke treatment: a systematic review and meta-analysis
  1. Won Hyung A Ryu1,
  2. Michael B Avery1,
  3. Navjit Dharampal2,
  4. Isabel E Allen3,
  5. Steven W Hetts4
  1. 1Department of Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada
  2. 2Department of Surgery, University of Calgary, Calgary, Alberta, Canada
  3. 3Department of Epidemiology and Biostatistics, University of California San Francisco (UCSF), San Francisco, California, USA
  4. 4Department of Radiology and Biomedical Imaging, UCSF, San Francisco, California, USA
  1. Correspondence to Dr Steven W Hetts, Department of Radiology and Biomedical Imaging, UCSF School of Medicine, 505 Parnassus Avenue, L-351, San Francisco, CA 94143-0628, USA; Steven.Hetts{at}ucsf.edu

Abstract

Background Variability in imaging protocols and techniques has resulted in a lack of consensus regarding the incorporation of perfusion imaging into stroke triage and treatment. The objective of our study was to evaluate the available scientific evidence regarding the utility of perfusion imaging in determining treatment eligibility in patients with acute stroke and in predicting their clinical outcome.

Methods We performed a systematic review of the literature using PubMed, Web of Science, and Cochrane Library focusing on themes of medical imaging, stroke, treatment, and outcome (CRD42016037817). We included randomized controlled trials, cohort studies, and case-controlled studies published from 2011 to 2016. Two independent reviewers conducted the study appraisal, data abstraction, and quality assessments of the studies.

Results Our literature search yielded 13 studies that met our inclusion criteria. In total, 994 patients were treated with the aid of perfusion imaging compared with 1819 patients treated with standard care. In the intervention group 51.1% of patients had a favorable outcome at 3 months compared with 45.6% of patients in the control group (p=0.06). Subgroup analysis of studies that used multimodal therapy (IV tissue plasminogen activator, endovascular thrombectomy) showed a significant benefit of perfusion imaging (OR 1.89, 95% CI 1.43 to 2.51, p<0.01).

Conclusions Perfusion imaging may represent a complementary tool to standard radiographic assessment in enhancing patient selection for reperfusion therapy, with a subset of patients having up to 1.9 times the odds of achieving independent functional status at 3 months. This is particularly important as patients selected based on perfusion status often included individuals who did not meet the current treatment eligibility criteria.

  • Stroke
  • CT perfusion
  • MR perfusion

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Footnotes

  • Contributors WHAR: Conception, design of the work; acquisition, analysis, interpretation of data; drafting the work and revising it critically for important intellectual content; final approval of the version to be published; and agreement to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. MBA: acquisition and interpretation of data; revising it critically for important intellectual content; final approval of the version to be published; and agreement to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. ND: Conception, design of the work; interpretation of data; revising it critically for important intellectual content; final approval of the version to be published; and agreement to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. IEA: Analysis and interpretation of data; revising it critically for important intellectual content; final approval of the version to be published; and agreement to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. SWH: Conception, design of the work; analysis, interpretation of data; revising it critically for important intellectual content; final approval of the version to be published; and agreement to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

  • Funding This work was supported by National Institutes of Health grant numbers 5R01EB012031 and 5R01CA194533, Alberta Innovates Health Solution Clinician Fellowship (no grant number), University of Calgary Surgeon Scientist Program Scholarship (no grant number), and University of Calgary Clinician Investigator Program (no grant number).

  • Competing interests SWH: co-investigator in DAWN-NCT02142283; DEFUSE 3-NCT02586415.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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