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Comparison of multimodal CT scan protocols used for decision-making on mechanical thrombectomy in acute ischemic stroke

  • Interventional Neuroradiology
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Abstract

Purpose

Different CT-based protocols are being used in acute ischemic stroke. We aimed to assess the added value of delayed-phase CT angiography (CTA) and CT perfusion (CTP) to a basic protocol using non-contrast computerized tomography (NCCT) with arterial-phase CTA in patient selection for mechanical thrombectomy.

Methods

We retrospectively included consecutive acute ischemic stroke patients with a symptomatic intracranial arterial occlusion between January 2015 and November 2016 who underwent NCCT, arterial and delayed-phase CTA, and CTP. These imaging studies were grouped into five protocols: (1) NCCT and arterial-phase CTA; (2) NCCT, arterial-phase CTA, and CTP; (3) NCCT, arterial- and delayed-phase CTA; (4) NCCT, arterial- and delayed-phase CTA, and CTP; and (5) NCCT and delayed-phase CTA. Two interventional neuro-radiologists independently decided on mechanical thrombectomy for each patient based on the protocols. They reached consensus for discrepant decisions. We assessed the raters’ confidence level, inter-rater agreement, and compared treatment decisions for the different protocols.

Results

We included 73 patients (44% male, mean age 74). The inter-rater agreement was substantial for protocols with three or more modalities (ҡ = 0.613–0.704) and moderate for two-modality protocols (ҡ = 0.506–0.529). The highest agreement and confidence level was achieved for the combination of NCCT, arterial-phase CTA, and CTP. Adding CTP to NCCT and arterial-phase CTA resulted in a 10% increase of recommendations for mechanical thrombectomy and adding delayed-phase CTA resulted in a 4% increase. These management changes did not reach statistical significance (p = 0.07; p = 0.25, respectively).

Conclusion

Adding CTP and/or a delayed-phase CTA to NCCT with arterial-phase CTA improves the decision-maker’s confidence level and creates a trend towards a lower threshold for mechanical thrombectomy.

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Funding

No funding was received for this study.

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Authors and Affiliations

  1. Division of Neuroradiology, Department of Medical Imaging, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, Canada

    Rujimas Khumtong, Timo Krings & Vitor M. Pereira

  2. Division of Diagnostic Radiology, Department of Radiology, Songklanagarind Hospital, Prince of Songkhla University, Songkhla, Thailand

    Rujimas Khumtong

  3. Division of Neurology, Department of Medicine, Toronto Western Hospital, University Health Network, University of Toronto, 5WW-425, Toronto Western Hospital, 399 Bathurst Street, Toronto, ON, M5T 2S8, Canada

    Aleksandra Pikula & Joanna D. Schaafsma

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  1. Rujimas Khumtong
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  2. Timo Krings
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  5. Joanna D. Schaafsma
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Correspondence to Joanna D. Schaafsma.

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All procedures performed in this study were in accordance with the ethical standards of the institutional and national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards.

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We obtained approval from the Research Ethics Board of our institution. The board waived the need for patient consent because of the retrospective nature of the study.

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Khumtong, R., Krings, T., Pereira, V.M. et al. Comparison of multimodal CT scan protocols used for decision-making on mechanical thrombectomy in acute ischemic stroke. Neuroradiology 62, 399–406 (2020). https://doi.org/10.1007/s00234-019-02351-5

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