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  • DOT sign indicates persistent hypoperfusion and poor outcome in patients with incomplete reperfusion following thrombectomy

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Neuroimaging
Original research
DOT sign indicates persistent hypoperfusion and poor outcome in patients with incomplete reperfusion following thrombectomy
  1. Adnan Mujanovic1,2,
  2. Daniel Windecker1,
  3. Bettina Serrallach1,
  4. Christoph C Kurmann1,2,3,
  5. Roman Rohner1,2,
  6. Elias Auer4,
  7. Petra Cimflova1,5,6,
  8. Thomas R Meinel4,
  9. Franziska Dorn7,
  10. René Chapot8,
  11. David Seiffge4,
  12. Eike Immo I Piechowiak1,
  13. Tomas Dobrocky1,
  14. Jan Gralla1,
  15. Urs Fischer4,
  16. Sara Pilgram-Pastor1,
  17. Johannes Kaesmacher1,9,10
    1. 1Department of Diagnostic and Interventional Neuroradiology, University Hospital Bern Inselspital, Bern, Switzerland
    2. 2Graduate School for Health Sciences, University of Bern, Bern, Switzerland
    3. 3Department of Diagnostic, Interventional and Pediatric Radiology, University Hospital Bern Inselspital, Bern, Switzerland
    4. 4Department of Neurology, Inselspital University Hospital Bern, Bern, Switzerland
    5. 5Department of Neuroradiology, University Hospital Freiburg, Freiburg, Germany
    6. 6Department of Medical Imaging, St. Anne’s University Hospital Brno, Brno, Czech Republic
    7. 7Department of Neuroradiology, University Hospital Bonn, Bonn, Germany
    8. 8Department of Neuroradiology and Endovascular Therapy, Alfried Krupp Krankenhaus Ruttenscheid, Essen, Germany
    9. 9Diagnostic and Interventional Neuroradiology, CIC-IT 1415, CHRU de Tours, Tours, France
    10. 10Le Studium Loire Valley Institute for Advanced Studies, Orléans, France
    1. Correspondence to Johannes Kaesmacher; johannes.kaesmacher{at}insel.ch

    Abstract

    Background Distal occlusions associated with incomplete reperfusion (expanded Thrombolysis in Cerebral Infarction, <eTICI 3) may not reperfuse spontaneously and thus prompt ischemia (ie, persistent hypoperfusion). We aimed to assess whether the recently reported Distal Occlusion Tracker (DOT) sign on immediate non-contrast post-interventional flat-panel detector computed tomography (FPDCT) is associated with persistent hypoperfusion.

    Methods Retrospective registry analysis of patients undergoing endovascular therapy between July 2020 and December 2022, with available immediate post-interventional FPDCT and 24 hours follow-up perfusion imaging. Persistent hypoperfusion was defined as a perfusion deficit at 24 hours directly corresponding to the area of incomplete reperfusion on final angiography run. The DOT sign was defined as a punctiform or tubular hyperdense signal increase on FPDCT indicative of a residual occlusion. Association between the DOT sign (present/absent) with the occurrence of persistent hypoperfusion and poor outcome (modified Rankin scale (mRS) score 3–6) was evaluated using logistic regression analysis.

    Results Of 292 patients included (median age 73 years; 47% female), 209 had incomplete reperfusion. Among patients with incomplete reperfusion, 61% had a present DOT sign and 46% had persistent hypoperfusion. In the overall cohort, but also within each eTICI stratum, a present DOT sign was associated with persistent hypoperfusion on 24±12 hours follow-up perfusion imaging (adjusted odds ratio (aOR) 4.8, 95% confidence interval (CI) 2.0 to 12.3 for patients with eTICI 2 a-2c). A present DOT sign was also associated with poor outcome (aOR 2.6, 95% CI 1.1 to 6.2).

    Conclusion Patients with <eTICI 3 and a present DOT sign have a higher likelihood of persistent hypoperfusion and might constitute a subgroup that could particularly benefit from additional reperfusion attempts.

    • Stroke
    • CT Angiography
    • Intervention
    • MR perfusion
    • Thrombectomy

    Data availability statement

    Data are available upon reasonable request. All study data are available from the corresponding author upon received research plan and clearance by the ethics committee.

    https://doi.org/10.1136/jnis-2024-022253

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      Data availability statement

      Data are available upon reasonable request. All study data are available from the corresponding author upon received research plan and clearance by the ethics committee.

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      Footnotes

      • X @adnan_mujanovic, @DOWindecker, @chris_kurmann, @rorohner

      • AM and DW contributed equally.

      • Contributors AM and DW contributed to conception and design, analysis and interpretation of data, and writing of the original draft. BS contributed to data acquisition and critical revision of the manuscript for important intellectual content. CCK contributed to the design and critical revision of the manuscript for important intellectual content. RR contributed to the design and critical revision of the manuscript for important intellectual content. EA contributed to data acquisition, interpretation, and critical revision of the manuscript for important intellectual content. PC contributed to data acquisition, interpretation, and critical revision of the manuscript for important intellectual content. TRM contributed to data acquisition, interpretation, and critical revision of the manuscript for important intellectual content. FD contributed to data acquisition, interpretation, and critical revision of the manuscript for important intellectual content. RC contributed to data acquisition, interpretation, and critical revision of the manuscript for important intellectual content. DS contributed to data acquisition, interpretation, and critical revision of the manuscript for important intellectual content. EIIP contributed to data acquisition, interpretation, and critical revision of the manuscript for important intellectual content. TD contributed to data acquisition, interpretation, and critical revision of the manuscript for important intellectual content. JG and UF contributed to conception and design, critical revision of the publication for important intellectual content, and supervision. SP-P contributed to the design and critical revision of the manuscript for important intellectual content. JK contributed to conception and design, critical revision of the publication for important intellectual content, and supervision. JK serves as the guarantor of the study.

      • Funding This study has been funded by the Swiss National Science Foundation (ID 32003B_204977/1).

      • Competing interests AM reports financial support from the Swiss National Science Foundation (fees paid to institution). BLS reports financial support from the Department of Teaching and Research of the Insel Gruppe AG (fees paid to institution). CK reports financial support from Clinical Trials Unit Bern/Inselspital Bern (fees paid to institution). FD reports consultancy for Microvention, Balt and Cerenovus; research grants from Johnson & Johnson and honoraria for speeches and lectures from Asahi, Acandis, Penumbra, Stryker, Cerenovus, Tonbridge, Medtronic, Q'Apel, Inspire. TD reports consultancy for Microvention and OM Pharma. UF reports research support of the Swiss National Science Foundation and the Swiss Heart Foundation; PI of the ELAN trial, Co-PI of the DISTAL, TECNO, SWIFT DIRECT, SWITCH, ELAPSE and ICARUS trial; Steering committee member of the DO_IT trial; research grants from Medtronic (BEYOND SWIFT, SWIFT DIRECT), from Stryker, Rapid medical, Penumbra, Medtronic and Phenox (DISTAL), and from Boehringer Ingelheim (TECNO), whereas all fees were paid to the institution; consultancies for Medtronic, Stryker, and CSL Behring (fees paid to institution); participation in an advisory board for AstraZeneca (former Alexion/Portola), Boehringer Ingelheim, Biogen, AbbVie and Acthera (fees paid to institution); member of a clinical event committee (CEC) of the COATING study (Phenox) and member of the data and safety monitoring committee (DSMB) of the TITAN, LATE_MT and IN EXTREMIS trials; president of the Swiss Neurological Society, president-elect of the European Stroke Organization. JK reports Microvention consultancy within the framework of a corelab, financial support from Medtronic for the BEYOND SWIFT registry and SWIFT DIRECT trial; medication supply support from Boheringer-Ingelheim for the TECNO trial, a research agreement with Siemens Healthineers regarding flat panel perfusion imaging and research grants from the Swiss National Science Foundation supporting the TECNO trial, Swiss Academy of Medical Sciences supporting MRI research and Swiss Heart Foundation supporting cardiac MRI in the aetiological work-up of stroke patients. All fees are paid to the institutions.

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

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