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Neuroimaging
Original research
CT perfusion to measure venous outflow in acute ischemic stroke in patients with a large vessel occlusion
  1. Gautam Adusumilli1,
  2. Soren Christensen2,
  3. Nicole Yuen3,
  4. Michael Mlynash3,
  5. Tobias D Faizy4,
  6. Gregory W Albers3,
  7. Maarten G Lansberg3,
  8. Jens Fiehler4,
  9. Jeremy J Heit5
  1. 1 Department of Radiology, Massachusetts General Hospital, Boston, Massachusetts, USA
  2. 2 StrokeImaging Solutions, Billund, Denmark
  3. 3 Stanford Stroke Center, Stanford University, Stanford, California, USA
  4. 4 Department of Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
  5. 5 Radiology, Neuroadiology and Neurointervention Division, Stanford University, Stanford, California, USA
  1. Correspondence to Dr Jeremy J Heit; jheit{at}stanford.edu

Abstract

Background Robust venous outflow (VO) profiles, measured by degree of venous opacification on pre-thrombectomy CT angiography (CTA) studies, are strongly correlated with favorable outcomes in patients with large vessel occlusion acute ischemic stroke treated by thrombectomy. However, VO measurements are laborious and require neuroimaging expertise.

Objective To develop a semi-automated method to measure VO using CTA and CT perfusion imaging studies.

Methods We developed a graphical interface using The Visualization Toolkit, allowing for voxel selection at the confluence and bilateral internal cerebral veins on CTA along with arterial input functions (AIFs) from both internal carotid arteries. We extracted concentration–time curves from the CT perfusion study at the corresponding locations associated with AIF and venous output function (VOF). Outcome analyses were primarily conducted by the Mann-Whitney U and Jonckheere-Terpstra tests.

Results Segmentation at the pre-selected AIF and VOF locations was performed on a sample of 97 patients. 65 patients had favorable VO (VO+) and 32 patients had unfavorable VO (VO−). VO+ patients were found to have a significantly shorter VOF time to peak (8.26; 95% CI 7.07 to 10.34) than VO− patients (9.44; 95% CI 8.61 to 10.91), P=0.007. No significant difference was found in VOF curve width and the difference in time between AIF and VOF peaks.

Conclusions Time to peak of VOF at the confluence of sinuses was significantly associated with manually scored venous outflow. Further studies should aim to understand better the association between arterial inflow and venous outflow, and capture quantitative metrics of venous outflow at other locations.

  • Stroke
  • Vein
  • Thrombectomy
  • CT perfusion
  • Blood Flow

Data availability statement

Data are available upon reasonable request. Data generated or analyzed during the study are available from the corresponding author by request.

https://doi.org/10.1136/jnis-2023-020727

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    Data availability statement

    Data are available upon reasonable request. Data generated or analyzed during the study are available from the corresponding author by request.

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    Footnotes

    • X @MDDarkKnight, @Fie0815, @JeremyHeitMDPHD

    • Contributors GA made substantial contributions to the conception and design of the work, the acquisition, analysis, and interpretation of data for the work, drafted the work, and gave final approval of the version to the published. SC, NY, TDF made substantial contributions to the acquisition and interpretation of data for the work, revised it critically for important intellectual content, and gave final approval of the version to the published. MM made substantial contributions to the analysis and interpretation of data for the work, revised it critically for important intellectual content, and gave final approval of the version to the published. GWA made substantial contributions to the acquisition of data for the work, revised it critically for important intellectual content, and gave final approval of the version to the published. MGL, JF made substantial contributions to the conception and design of the work, revised it critically for important intellectual content the work, and gave final approval of the version to the published. JJH made substantial contributions to the conception and design of the work, the interpretation of data for the work, drafted the work, revised it critically for important intellectual content, and gave final approval of the version to the published. JJH is the guarantor of the study and accepts full responsibility for the work and/or the conduct of the study, had access to the data, and controlled the decision to publish.

    • Funding Kent and Polli Smith Family Fund by Hawaii: contributed a significant amount of funding used partly towards the conception and execution of this project

    • Competing interests GA, NY, MM, TDF, MGL have no relevant relationships to disclose. SC discloses equity and consulting for iSchemaView. GWA discloses equity and consulting for iSchemaView and consulting for Genentech. JF discloses grants and personal fees from Acandis, Cerenovus, MicroVention,Medtronic, and Stryker; grants from Route 92; and personal fees from Phenox and Penumbra outside of the submitted work. JJH discloses consulting for Medtronic and MicroVention and membership of the medical and scientific advisory board for iSchemaView.

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