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Case series
Admission CT perfusion may overestimate initial infarct core: the ghost infarct core concept
  1. Sandra Boned1,2,
  2. Marina Padroni3,
  3. Marta Rubiera1,2,
  4. Alejandro Tomasello4,
  5. Pilar Coscojuela4,
  6. Nicolás Romero4,
  7. Marián Muchada1,2,
  8. David Rodríguez-Luna1,2,
  9. Alan Flores1,2,
  10. Noelia Rodríguez1,2,
  11. Jesús Juega1,2,
  12. Jorge Pagola1,2,
  13. José Alvarez-Sabin1,2,
  14. Carlos A Molina1,2,
  15. Marc Ribó1,2
  1. 1Stroke Unit, Department of Neurology, Vall d'Hebron University Hospital, Vall d'Hebron Research Institute, Barcelona, Spain
  2. 2Departament de Medicina, Universitat Autónoma de Barcelona, Barcelona, Spain
  3. 3Università di Ferrara, Sezione di Clinica Neurologica, Ferrara, Italia
  4. 4Department of Neuroradiology, Vall d'Hebron University Hospital, Barcelona, Spain
  1. Correspondence to Dr Marc Ribo, Unitat d'Ictus, Servei de Neurologia, Hospital Vall d'Hebron, Passeig de la Vall d'Hebron, Barcelona 119-129, Spain; marcriboj{at}


Background Identifying infarct core on admission is essential to establish the amount of salvageable tissue and indicate reperfusion therapies. Infarct core is established on CT perfusion (CTP) as the severely hypoperfused area, however the correlation between hypoperfusion and infarct core may be time-dependent as it is not a direct indicator of tissue damage. This study aims to characterize those cases in which the admission core lesion on CTP does not reflect an infarct on follow-up imaging.

Methods We studied patients with cerebral large vessel occlusion who underwent CTP on admission but received endovascular thrombectomy based on a non-contrast CT Alberta Stroke Program Early CT Score (ASPECTS) >6. Admission infarct core was measured on initial cerebral blood volume (CBV) CTP and final infarct on follow-up CT. We defined ghost infarct core (GIC) as initial core minus final infarct >10 mL.

Results 79 patients were studied. Median National Institutes of Health Stroke Scale (NIHSS) score was 17 (11–20), median time from symptoms to CTP was 215 (87–327) min, and recanalization rate (TICI 2b–3) was 77%. Thirty patients (38%) presented with a GIC >10 mL. GIC >10 mL was associated with recanalization (TICI 2b–3: 90% vs 68%; p=0.026), admission glycemia (<185 mg/dL: 42% vs 0%; p=0.028), and time to CTP (<185 min: 51% vs >185 min: 26%; p=0.033). An adjusted logistic regression model identified time from symptom to CTP imaging <185 min as the only predictor of GIC >10 mL (OR 2.89, 95% CI 1.04 to 8.09). At 24 hours, clinical improvement was more frequent in patients with GIC >10 mL (66.6% vs 39%; p=0.017).

Conclusions CT perfusion may overestimate final infarct core, especially in the early time window. Selecting patients for reperfusion therapies based on the CTP mismatch concept may deny treatment to patients who might still benefit from reperfusion.

  • CT perfusion
  • Stroke
  • Thrombectomy

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  • Contributors MRi and SB participated in the conception and design of the study. MRi, MP and SB analyzed and interpreted the data. MRi, MRu, MM, DR-L, AF, NR, JJ and JP treated and included the patients in the study. MRi and SB performed the statistical analysis and wrote the article. All the authors reviewed and approved the manuscript.

  • Competing interests None declared.

  • Patient consent Obtained.

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