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Systematic CT perfusion acquisition in acute stroke increases vascular occlusion detection and thrombectomy rates
  1. Marta Olive-Gadea1,2,
  2. Manuel Requena1,3,
  3. Facundo Diaz4,
  4. Sandra Boned1,
  5. Alvaro Garcia-Tornel1,
  6. Marian Muchada1,
  7. Matias Deck1,
  8. Prudencio Lozano1,
  9. Noelia Rodriguez-Villatoro1,
  10. Jesus Juega1,
  11. Jorge Pagola1,
  12. David Rodriguez-Luna1,
  13. Marta Rubiera1,
  14. Cristian Marti4,
  15. Carlos A Molina1,
  16. Carlos Piñana3,
  17. David Hernandez3,
  18. Alejandro Tomasello3,
  19. Marc Ribo1,2
  1. 1 Stroke Unit, Neurology, Hospital Vall d'Hebron, Barcelona, Barcelona, Spain
  2. 2 Departament de Medicina, Universitat Autonoma de Barcelona, Barcelona, Spain
  3. 3 Interventional Neuroradiology, Vall d'Hebron Hospital Universitari, Barcelona, Spain
  4. 4 Methinks, Barcelona, Spain
  1. Correspondence to Dr Marc Ribo, Stroke Unit, Neurology, Vall d'Hebron Hospital Universitari, Barcelona 08035, Spain; marcriboj{at}


Background In patients with stroke, current guidelines recommend non-invasive vascular imaging to identify intracranial vessel occlusions (VO) that may benefit from endovascular treatment (EVT). However, VO can be missed in CT angiography (CTA) readings. We aim to evaluate the impact of consistently including CT perfusion (CTP) in admission stroke imaging protocols.

Methods From April to October 2020 all patients admitted with a suspected acute ischemic stroke underwent urgent non-contrast CT, CTA and CTP and were treated accordingly. Hypoperfusion areas defined by time-to-maximum of the tissue residue function (Tmax) >6 s, congruent with the clinical symptoms and a vascular territory, were considered VO (CTP-VO). In addition, two experienced neuroradiologists blinded to CTP but not to clinical symptoms retrospectively evaluated non-contrast CT and CTA to identify intracranial VO (CTA-VO).

Results Of the 338 patients included in the analysis, 157 (46.5%) presented with CTP-VO (median Tmax >6s: 73 (29–127) mL). CTA-VO was identified in 83 (24.5%) of the cases. Overall CTA-VO sensitivity for the detection of CTP-VO was 50.3% and specificity was 97.8%. Higher hypoperfusion volume was associated with increased CTA-VO detection (OR 1.03; 95% CI 1.02 to 1.04). EVT was performed in 103 patients (30.5%; Tmax >6s: 102 (63–160) mL), representing 65.6% of all CTP-VO. Overall CTA-VO sensitivity for the detection of EVT-VO was 69.9% and specificity was 95.3%. Among patients who received EVT, the rate of false negative CTA-VO was 30.1% (Tmax >6s: 69 (46–99.5) mL).

Conclusion Systematically including CTP in acute stroke admission imaging protocols may increase the diagnosis of VO and rate of EVT.

  • stroke
  • CT perfusion
  • CT angiography

Data availability statement

Data are available upon reasonable request. Not applicable.

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Data availability statement

Data are available upon reasonable request. Not applicable.

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  • Twitter @marcriboj

  • Contributors MOG and MRi conceived and designed the study, MRi is the guarantor of this work. MOG, MRi, SB, MM, MRe, MRu, AG-T, MD, PL, JJ, NR-V, DR-L, JP, CAM, CP, DH and AT contributed to the acquisition and analysis of data. FD and CAM contributed to the analysis of data. MOG drafted the manuscript. All authors reviewed and provided critical feedback of the manuscript.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests CM is the founder of Methinks Software and declares significant ownership. FD is employed by Methinks Software. MRi has modest ownership and serves on the advisory board of Methinks Software; he has a consulting agreement with Medtronic, Stryker, Johnson and Johnson, Perflow Medical, Anaconda Biomed and Apta Targets. The other authors have no disclosures directly related to whole or part of the research described in the present manuscript.

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

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.