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. 2022 Aug 2;17(8):e0272276.
doi: 10.1371/journal.pone.0272276. eCollection 2022.

Accuracy of CT perfusion ischemic core volume and location estimation: A comparison between four ischemic core estimation approaches using syngo.via

Jan W Hoving  1 , Miou S Koopman  1 , Manon L Tolhuisen  1   2 , Henk van Voorst  1   2 , Marcus Brehm  3 , Olvert A Berkhemer  1 , Jonathan M Coutinho  4 , Ludo F M Beenen  1 , Henk A Marquering  1   2 , Bart J Emmer  1 , Charles B L M Majoie  1
Affiliations

Accuracy of CT perfusion ischemic core volume and location estimation: A comparison between four ischemic core estimation approaches using syngo.via

Jan W Hoving et al. PLoS One. .

Abstract

Background and objective: Computed tomography perfusion (CTP) is widely used in the evaluation of acute ischemic stroke patients for endovascular thrombectomy (EVT). The stability of CTP core estimation is suboptimal and varies between software packages. We aimed to quantify the volumetric and spatial agreement between the CTP ischemic core and follow-up infarct for four ischemic core estimation approaches using syngo.via.

Methods: We included successfully reperfused, EVT-treated patients with baseline CTP and 24h follow-up diffusion weighted magnetic resonance imaging (DWI) (November 2017-September 2020). Data were processed with syngo.via VB40 using four core estimation approaches based on: cerebral blood volume (CBV)<1.2mL/100mL with and without smoothing filter, relative cerebral blood flow (rCBF)<30%, and rCBF<20%. The follow-up infarct was segmented on DWI.

Results: In 59 patients, median estimated CTP core volumes for four core estimation approaches ranged from 12-39 mL. Median 24h follow-up DWI infarct volume was 11 mL. The intraclass correlation coefficient (ICC) showed moderate-good volumetric agreement for all approaches (range 0.61-0.76). Median Dice was low for all approaches (range 0.16-0.21). CTP core overestimation >10mL occurred least frequent (14/59 [24%] patients) using the CBV-based core estimation approach with smoothing filter.

Conclusions: In successfully reperfused patients who underwent EVT, syngo.via CTP ischemic core estimation showed moderate volumetric and spatial agreement with the follow-up infarct on DWI. In patients with complete reperfusion after EVT, the volumetric agreement was excellent. A CTP core estimation approach based on CBV<1.2 mL/100mL with smoothing filter least often overestimated the follow-up infarct volume and is therefore preferred for clinical decision making using syngo.via.

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Conflict of interest statement

We have read the journal’s policy and the authors of this manuscript have the following competing interests: HAM is co-founder and shareholder of Nicolab. BJE reports grants from Stryker Neurovascular and personal fees from Dekra and Novartis outside the submitted work. CBLMM is shareholder of Nicolab and reports grants from TWIN, CVON/Dutch Heart Foundation, and Stryker outside the submitted work. This does not alter our adherence to PLOS ONE policies on sharing data and materials. All other authors declare no support from any organization or financial relationships with any organizations that might have an interest in the submitted work. All authors declare no other relationships or activities that could appear to have influenced the submitted work.

Figures

Fig 1
Fig 1. Flowchart of patient selection.
Fig 2
Fig 2
Bland-Altman plots comparing the estimated CTP ischemic core volume and DWI follow-up infarct volume for (a) approach 1, (b) approach 2, (c) approach 3, and (d) approach 4. The mean bias (blue), lower (red) and upper (green) Limits of Agreement are shown with 95% confidence intervals. The bias with 95% confidence intervals is shown in blue. Negative values indicate overestimation by CTP. CTP = CT perfusion; DWI = diffusion weighted imaging.
Fig 3
Fig 3. Baseline CTP of a patient with a right-sided M1 occlusion with successful reperfusion (eTICI 3).
The ischemic core (red) and penumbra (green) for (a) approach 1, (b) approach 2, (c) approach 3, and (d) approach 4. (e) Follow-up DWI acquired at 17 hours after baseline imaging and (f) follow-up DWI image with follow-up infarct segmentation (red). A = anterior; CTP = CT perfusion; DWI = diffusion weighted imaging; MRI = magnetic resonance imaging; R = right.
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