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Original research
Core overestimation of CT perfusion in patients with cardiac insufficiency who had a stroke is mediated by impaired collaterals
  1. Guangchen He1,
  2. Liming Wei1,
  3. Haitao Lu1,
  4. Jiangshan Deng2,
  5. Feng Wang2,
  6. Yueqi Zhu1
  1. 1 Department of Radiology, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
  2. 2 Department of Neurology, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
  1. Correspondence to Dr Yueqi Zhu, Radiology, Shanghai 6th Peoples Hospital Affiliated to Shanghai Jiao Tong University, Shanghai, China; zhuyueqi{at}


Background We hypothesized that left ventricular systolic dysfunction (LVSD) would lead to an ischemic core overestimation in patients with acute ischemic stroke (AIS), and impaired collateral status might partly mediate this effect.

Objective A pixel-based analysis of CT perfusion (CTP) and follow-up CT was undertaken to investigate the optimum CTP thresholds for the ischemic core if overestimation was found.

Methods A total of 208 consecutive patients with AIS with large vessel occlusion in the anterior circulation, who received initial CTP evaluation and successful reperfusion, were retrospectively analyzed and divided into an LVSD (left ventricular ejection fraction (LVEF) ratio <50%; n=40) and a normal cardiac function (LVEF≥50%; n=168) group. Ischemic core overestimation was considered when the CTP-derived core was larger than the final infarct volume. We investigated the relationship between cardiac function, probability for core overestimation, and collateral scores using mediation analysis. A pixel-based analysis was undertaken to define the optimum CTP thresholds for ischemic core.

Results LVSD was independently associated with impaired collaterals (aOR=4.28, 95% CI 2.01 to 9.80, P<0.001) and core overestimation (aOR=2.52, 95% CI 1.07 to 5.72, P=0.030). In mediation analysis, the total effect on core overestimation is composed of the direct effect of LVSD (+17%, P=0.034) and the mediated indirect effect of collateral status (+6%, P=0.020). Collaterals explained 26% of the effect of LVSD on core overestimation. Compared with relative cerebral blood flow (rCBF) thresholds of <35%, <30%, and <20%, a rCBF <25% cut-off point had the highest correlation (r=0.91) and best agreement (mean difference 3.2±7.3 mL) with the final infarct volume to determine the CTP-derived ischemic core in patients with LVSD.

Conclusions LVSD increased the possibility of ischemic core overestimation on baseline CTP, partly due to impaired collateral status, and a stricter rCBF threshold should be considered.

  • Stroke
  • Thrombectomy
  • CT perfusion

Data availability statement

Data are available upon reasonable request. NA.

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Data availability statement

Data are available upon reasonable request. NA.

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  • Contributors GH: acquisition of data, analysis and interpretation of data, and drafting of the manuscript. YZ: study concept and design, critical revision of the manuscript for important intellectual content, study supervision and responsible for the overall content as guarantor. JD, HL, L-MW, FW: acquisition of data, revision of the manuscript. GH: statistical analysis.

  • Funding 1.Shanghai Municipal Health Commission Emerging Interdisciplinary Field Research Project (No.2022JC022). 2. Shanghai Jiao Tong University “Medical and Research” Program (ZH2018ZDA19). 3. Foundation of National Facility for Translational Medicine (Shanghai, TMSK-2020-108).

  • Competing interests None declared.

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

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