Noncontrast CT vs CT Perfusion or MRI Selection in Late Presentation of Large-Vessel–Occlusion Stroke | Cerebrovascular Disease | JN Learning | AMA Ed Hub [Skip to Content]
[Skip to Content Landing]

Noncontrast Computed Tomography vs Computed Tomography Perfusion or Magnetic Resonance Imaging Selection in Late Presentation of Stroke With Large-Vessel Occlusion

Educational Objective
To compare the clinical outcomes of patients selected for mechanical thrombectomy by noncontrast computed tomography (CT) vs those selected by CT perfusion (CTP) or magnetic resonance imaging (MRI) in the extended time window.
1 Credit CME
Key Points

Question  In patients with proximal anterior circulation occlusion stroke presenting in the extended window, are rates of favorable outcomes at 90 days comparable in the patients selected for thrombectomy with noncontrast computed tomography vs patients selected with computed tomography perfusion or magnetic resonance imaging?

Findings  In a multicenter cohort of 1604 patients in the extended window with large-vessel occlusion, patients selected by noncontrast computed tomography had comparable clinical and safety outcomes with patients selected by computed tomography perfusion or magnetic resonance imaging.

Meaning  These findings suggest noncontrast computed tomography alone may be used as an alternative to advanced imaging in selecting patients with late-presenting large-vessel occlusion for mechanical thrombectomy.

Abstract

Importance  Advanced imaging for patient selection in mechanical thrombectomy is not widely available.

Objective  To compare the clinical outcomes of patients selected for mechanical thrombectomy by noncontrast computed tomography (CT) vs those selected by computed tomography perfusion (CTP) or magnetic resonance imaging (MRI) in the extended time window.

Design, Setting, and Participants  This multinational cohort study included consecutive patients with proximal anterior circulation occlusion stroke presenting within 6 to 24 hours of time last seen well from January 2014 to December 2020. This study was conducted at 15 sites across 5 countries in Europe and North America. The duration of follow-up was 90 days from stroke onset.

Exposures  Computed tomography with Alberta Stroke Program Early CT Score, CTP, or MRI.

Main Outcomes and Measures  The primary end point was the distribution of modified Rankin Scale (mRS) scores at 90 days (ordinal shift). Secondary outcomes included the rates of 90-day functional independence (mRS scores of 0-2), symptomatic intracranial hemorrhage, and 90-day mortality.

Results  Of 2304 patients screened for eligibility, 1604 patients were included, with a median (IQR) age of 70 (59-80) years; 848 (52.9%) were women. A total of 534 patients were selected to undergo mechanical thrombectomy by CT, 752 by CTP, and 318 by MRI. After adjustment of confounders, there was no difference in 90-day ordinal mRS shift between patients selected by CT vs CTP (adjusted odds ratio [aOR], 0.95 [95% CI, 0.77-1.17]; P = .64) or CT vs MRI (aOR, 0.95 [95% CI, 0.8-1.13]; P = .55). The rates of 90-day functional independence (mRS scores 0-2 vs 3-6) were similar between patients selected by CT vs CTP (aOR, 0.90 [95% CI, 0.7-1.16]; P = .42) but lower in patients selected by MRI than CT (aOR, 0.79 [95% CI, 0.64-0.98]; P = .03). Successful reperfusion was more common in the CT and CTP groups compared with the MRI group (474 [88.9%] and 670 [89.5%] vs 250 [78.9%]; P < .001). No significant differences in symptomatic intracranial hemorrhage (CT, 42 [8.1%]; CTP, 43 [5.8%]; MRI, 15 [4.7%]; P = .11) or 90-day mortality (CT, 125 [23.4%]; CTP, 159 [21.1%]; MRI, 62 [19.5%]; P = .38) were observed.

Conclusions and Relevance  In patients undergoing proximal anterior circulation mechanical thrombectomy in the extended time window, there were no significant differences in the clinical outcomes of patients selected with noncontrast CT compared with those selected with CTP or MRI. These findings have the potential to widen the indication for treating patients in the extended window using a simpler and more widespread noncontrast CT–only paradigm.

Sign in to take quiz and track your certificates

Buy This Activity

JN Learning™ is the home for CME and MOC from the JAMA Network. Search by specialty or US state and earn AMA PRA Category 1 CME Credit™ from articles, audio, Clinical Challenges and more. Learn more about CME/MOC

CME Disclosure Statement: Unless noted, all individuals in control of content reported no relevant financial relationships. If applicable, all relevant financial relationships have been mitigated.

Article Information

Accepted for Publication: September 17, 2021.

Published Online: November 8, 2021. doi:10.1001/jamaneurol.2021.4082

Corresponding Authors: Thanh N. Nguyen, MD, Department of Neurology and Radiology, Boston Medical Center, 725 Albany St, Neurology 7th Floor, Boston, MA 02118 (thanh.nguyen@bmc.org); Raul G. Nogueira, MD, Department of Neurology, Grady Memorial Hospital, Emory University School of Medicine, 80 Jesse Hill Jr Drive SE, Atlanta, GA 30303 (raul.g.nogueira@emory.edu).

Correction: This article was corrected on January 10, 2022, to fix an error in the byline.

Open Access: This is an open access article distributed under the terms of the CC-BY-NC-ND License. © 2021 Nguyen TN et al. JAMA Neurology.

Author Contributions: Drs Nguyen and Qureshi had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Nguyen, Abdalkader, Qureshi, Sheth, Siegler, Castonguay, Jovin, Zaidat, Nogueira.

Acquisition, analysis, or interpretation of data: Nguyen, Nagel, Qureshi, Ribo, Caparros, Haussen, Mohammaden, Sheth, Ortega-Gutierrez, Siegler, Zaidi, Olivé-Gadea, Henon, Möhlenbruch, Castonguay, Nannoni, Kaesmacher, Puri, Seker, Farooqui, Salazar-Marioni, Kuhn, Kaliaev, Farzin, Boisseau, Masoud, Lopez, Rana, Kareem, Sathya, Klein, Kassem, Ringleb, Cordonnier, Gralla, Fischer, Michel, Raymond, Zaidat, Nogueira.

Drafting of the manuscript: Nguyen, Qureshi, Sheth, Castonguay, Farooqui, Salazar-Marioni, Kaliaev, Farzin, Kareem, Klein.

Critical revision of the manuscript for important intellectual content: Abdalkader, Nagel, Ribo, Caparros, Haussen, Mohammaden, Sheth, Ortega-Gutierrez, Siegler, Zaidi, Olivé-Gadea, Henon, Möhlenbruch, Castonguay, Nannoni, Kaesmacher, Puri, Seker, Kuhn, Boisseau, Masoud, Lopez, Rana, Sathya, Kassem, Ringleb, Cordonnier, Gralla, Fischer, Michel, Jovin, Raymond, Zaidat, Nogueira.

Statistical analysis: Qureshi, Sheth, Castonguay, Kaesmacher, Farooqui, Farzin, Nogueira.

Obtained funding: Nguyen, Castonguay, Michel, Zaidat.

Administrative, technical, or material support: Nguyen, Abdalkader, Mohammaden, Ortega-Gutierrez, Siegler, Zaidi, Castonguay, Kaliaev, Lopez, Kareem, Cordonnier, Gralla, Michel.

Supervision: Nguyen, Sheth, Ortega-Gutierrez, Puri, Kuhn, Ringleb, Jovin, Raymond, Zaidat, Nogueira.

Other—data collection: Kareem.

Other–contribution of data: Nagel.

Conflict of Interest Disclosures: Dr Nguyen reported research support from Medtronic and the Society of Vascular and Interventional Neurology with data safety monitoring board involvement for Thrombectomy for Emergent Salvage of Large Anterior Circulation Ischemic Stroke (TESLA), Endovascular Therapy for Low NIHSS Ischemic Strokes (ENDOLOW), a Randomized Controlled Trial to Optimize Patient’s Selection for Endovascular Treatment in Acute Ischemic Stroke (SELECT 2), pRESET for Occlusive Stroke Treatment (PROST), Carotid Revascularization and Medical Management for Asymptomatic Carotid Stenosis Trial (CREST-2), and Workflow Optimization to Reduce Time to Endovascular Reperfusion in Stroke Treatment (WE-TRUST) trials. Dr Nagel reported personal fees for consultancy for Brainomix and payment for lectures including speaker bureaus with Boehringer Ingelheim and Pfizer outside the submitted work. Dr Ribo reported being a cofounder of Anaconda Biomed; a consultant with Methinks, Medtronic, Cerenovus, Apta Targets, Anaconda Biomed, and Philips; and grants from CVAid, outside the submitted work. Dr Haussen reported being a consultant for Stryker, Vesalio, Cerenovus, and Jacobs Institute and holding stock options with VizAi during the conduct of the study. Dr Siegler reported consulting fees from Ceribell and speakers’ bureau involvement with AstraZeneca outside the submitted work. Dr Ortega-Gutierrez reports being a consultant for Medtronic and Stryker Neurovascular and receiving grants from Stryker, IschemiaView, Viz.ai, and Siemens. Dr Möhlenbruch reports consultancy at Medtronic, MicroVention, and Stryker; grants or grants pending from Medtronic, Stryker, Balt, and MicroVention (money paid to his institution); and payment for lectures including service on speakers’ bureaus from Medtronic, MicroVention, and Stryker, outside the submitted work. Dr Zaidat reported consulting fees for Stryker, Medtronic, Cerenovus, and Penumbra; research grants from Stryker, Medtronic, Cerenovus, Penumbra, and Genentech; in addition, Dr Zaidat had a patent for Ischemic Stroke issued. Dr Sheth reported research grants from the National Institutes of Health (grants U18EB029353 and R01NS121154) and American Academy of Neurology/the Society of Vascular and Interventional Neurology and consultancy fees from Penumbra and Cerenovus. Dr Fischer reported research grants from Medtronic (BEYOND SWIFT and SWIFT DIRECT); serving as consultant for Medtronic, Stryker, CSL Behring; and participating in an advisory board for Alexion/Portola outside the submitted work. Dr Jovin reported being an investigator with Stryker (DAWN and AURORA trials); an advisor or investor for Anaconda, Route92, VizAi, FreeOx, Methinks, and Blockade Medical; a recipient of personal fees, data safety monitoring board, and steering committee fees from Cerenovus and grants from Medtronic; an advisor and stockholder for Corindus; and a member of a medical committee for Contego outside the submitted work. Dr Nogueira reported involvement with Stryker as part of the DAWN trial; the Trevo-2 trial and Trevo registry steering committee; Medtronic as part of the SWIFT/SWIFT-PRIME steering committee and STAR trial core laboratory; Penumbra as part of the 3D Trial executive committee; Cerenovus/Neuravi as part of the ENDOLOW Trial, EXCELLENT Registry, and ARISE-2 trial steering committee; Phenox as part of the PROST Trial; Imperative Care as part of the Imperative Trial; and Philips as part of the WE-TRUST trial. Dr Nogueira also reported consulting fees for advisory roles with Anaconda, Biogen, Cerenovus, Genentech, Hybernia, Imperative Care, Medtronic, Phenox, Philips, Prolong Pharmaceuticals, Stryker Neurovascular, Shanghai Wallaby, and Synchron and stock options for advisory roles with Astrocyte, Brainomix, Cerebrotech, Ceretrieve, Corindus Vascular Robotics, Vesalio, Viz-AI, RapidPulse, and Perfuze; and investments in Viz-AI, Perfuze, Cerebrotech, Reist/Q'Apel Medical, Truvic, and Viseon. Dr Kaesmacher reported grants from SAMW/Bangerter Foundation, Swiss Stroke Society, and CTU Bern outside the submitted work. Dr Puri reported personal fees from Stryker Neurovascular, Cerenovus, Medtronic, Merit, CereVasc, Microvention, and Arsenal Medical; stocks with InNeuroCo, Galaxy, NTI, Agile, and Perfuze; and grants from the National Institutes of Health outside the submitted work. Dr Kaliaev reported grants from Medtronic and SVIN during the conduct of the study. Dr Ringleb reported personal fees from Boehringer Ingelheim, Bayer, Bristol Myers Squibb, and Pfizer outside the submitted work. Dr Cordonnier reported personal fees from Boehringer Ingelheim and advisory board participation from Bristol Myers Squibb, AstraZeneca, and Biogen outside the submitted work. Dr Gralla reported grants from Medtronic (SWIFT DIRECT trial) and SNF outside the submitted work. Dr Michel reported grants from Swiss National Science Foundation and Swiss Heart Foundation outside the submitted work. No other disclosures were reported.

Additional Contributions: We would like to acknowledge the following persons who contributed to this work: Oscar Bolanos, Medtronic; Margaret Lavoye, RN, Boston Medical Center; Kristine Below, BS, Umera Paracha, MD, Sakshi Kaul, DO, MS, Mercy Health St. Vincent Medical Center; Viraj M. Moholkar, BS. These individuals were not compensated for their contributions. We express gratitude to all CLEAR study investigators.

References
1.
Nogueira  RG , Jadhav  AP , Haussen  DC ,  et al; DAWN Trial Investigators.  Thrombectomy 6 to 24 hours after stroke with a mismatch between deficit and infarct.   N Engl J Med. 2018;378(1):11-21. doi:10.1056/NEJMoa1706442 PubMedGoogle ScholarCrossref
2.
Albers  GW , Marks  MP , Kemp  S ,  et al; DEFUSE 3 Investigators.  Thrombectomy for stroke at 6 to 16 hours with selection by perfusion imaging.   N Engl J Med. 2018;378(8):708-718. doi:10.1056/NEJMoa1713973 PubMedGoogle ScholarCrossref
3.
Powers  WJ , Rabinstein  AA , Ackerson  T ,  et al; American Heart Association Stroke Council.  2018 guidelines for the early management of patients with acute ischemic stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association.   Stroke. 2018;49(3):e46-e110. doi:10.1161/STR.0000000000000158 PubMedGoogle ScholarCrossref
4.
Turc  G , Bhogal  P , Fischer  U ,  et al.  European Stroke Organisation (ESO)—European Society for Minimally Invasive Neurological Therapy (ESMINT) guidelines on mechanical thrombectomy in acute ischaemic stroke endorsed by Stroke Alliance for Europe (SAFE).   Eur Stroke J. 2019;4(1):6-12. doi:10.1177/2396987319832140 PubMedGoogle ScholarCrossref
5.
Kim  Y , Lee  S , Abdelkhaleq  R ,  et al.  Utilization and availability of advanced imaging in patients with acute ischemic stroke.   Circ Cardiovasc Qual Outcomes. 2021;14(4):e006989. doi:10.1161/CIRCOUTCOMES.120.006989 PubMedGoogle Scholar
6.
Kane  I , Whiteley  WN , Sandercock  PAG , Wardlaw  JM .  Availability of CT and MR for assessing patients with acute stroke.   Cerebrovasc Dis. 2008;25(4):375-377. doi:10.1159/000120688 PubMedGoogle ScholarCrossref
7.
Nogueira  RG , Haussen  DC , Liebeskind  D ,  et al; Trevo Registry and DAWN Trial Investigators.  Stroke imaging selection modality and endovascular therapy outcomes in the early and extended time windows.   Stroke. 2021;52(2):491-497. doi:10.1161/STROKEAHA.120.031685 PubMedGoogle ScholarCrossref
8.
Demeestere  J , Garcia-Esperon  C , Garcia-Bermejo  P ,  et al.  Evaluation of hyperacute infarct volume using ASPECTS and brain CT perfusion core volume.   Neurology. 2017;88(24):2248-2253. doi:10.1212/WNL.0000000000004028 PubMedGoogle ScholarCrossref
9.
Siegler  JE , Messé  SR , Sucharew  H ,  et al.  Noncontrast CT versus perfusion-based core estimation in large vessel occlusion: the Blood Pressure after Endovascular Stroke Therapy Study.   J Neuroimaging. 2020;30(2):219-226. doi:10.1111/jon.12682 PubMedGoogle ScholarCrossref
10.
Farzin  B , Fahed  R , Guilbert  F ,  et al.  Early CT changes in patients admitted for thrombectomy: intrarater and interrater agreement.   Neurology. 2016;87(3):249-256. doi:10.1212/WNL.0000000000002860 PubMedGoogle ScholarCrossref
11.
Nogueira  RG , Ribó  M .  Endovascular treatment of acute stroke.   Stroke. 2019;50(9):2612-2618. doi:10.1161/STROKEAHA.119.023811 PubMedGoogle ScholarCrossref
12.
García-Tornel  Á , Campos  D , Rubiera  M ,  et al.  Ischemic core overestimation on computed tomography perfusion.   Stroke. 2021;52(5):1751-1760. doi:10.1161/STROKEAHA.120.031800 PubMedGoogle ScholarCrossref
13.
Hacke  W , Kaste  M , Bluhmki  E ,  et al; ECASS Investigators.  Thrombolysis with alteplase 3 to 4.5 hours after acute ischemic stroke.   N Engl J Med. 2008;359(13):1317-1329. doi:10.1056/NEJMoa0804656 PubMedGoogle ScholarCrossref
14.
Sun  CHJ , Ribo  M , Goyal  M ,  et al.  Door-to-puncture: a practical metric for capturing and enhancing system processes associated with endovascular stroke care, preliminary results from the rapid reperfusion registry.   J Am Heart Assoc. 2014;3(2):e000859. doi:10.1161/JAHA.114.000859 PubMedGoogle Scholar
15.
Sheth  KN , Terry  JB , Nogueira  RG ,  et al.  Advanced modality imaging evaluation in acute ischemic stroke may lead to delayed endovascular reperfusion therapy without improvement in clinical outcomes.   J Neurointerv Surg. 2013;5(suppl 1):i62-i65. doi:10.1136/neurintsurg-2012-010512PubMedGoogle ScholarCrossref
16.
Meinel  TR , Kaesmacher  J , Mosimann  PJ ,  et al.  Association of initial imaging modality and futile recanalization after thrombectomy.   Neurology. 2020;95(17):e2331-e2342. doi:10.1212/WNL.0000000000010614 PubMedGoogle ScholarCrossref
17.
Raymond  J , Fahed  R , Roy  D , Darsaut  TE .  The 2018 ter Brugge lecture: problems with the introduction of innovations in neurovascular care.   Can J Neurol Sci. 2019;46(2):151-158. doi:10.1017/cjn.2018.391 PubMedGoogle ScholarCrossref
18.
Haussen  DC , Dehkharghani  S , Rangaraju  S ,  et al.  Automated CT perfusion ischemic core volume and noncontrast CT ASPECTS (Alberta Stroke Program Early CT Score): correlation and clinical outcome prediction in large vessel stroke.   Stroke. 2016;47(9):2318-2322. doi:10.1161/STROKEAHA.116.014117 PubMedGoogle ScholarCrossref
19.
Nannoni  S , Ricciardi  F , Strambo  D ,  et al.  Correlation between ASPECTS and core volume on CT perfusion: impact of time since stroke onset and presence of large-vessel occlusion.   AJNR Am J Neuroradiol. 2021;42(3):422-428. doi:10.3174/ajnr.A6959 PubMedGoogle ScholarCrossref
20.
Desai  SM , Tonetti  DA , Molyneaux  BJ ,  et al.  Interaction between time, ASPECTS, and clinical mismatch.   J Neurointerv Surg. 2020;12(9):911-914. doi:10.1136/neurintsurg-2020-015921 PubMedGoogle ScholarCrossref
21.
Nagel  S , Herweh  C , Pfaff  JAR ,  et al.  Simplified selection criteria for patients with longer or unknown time to treatment predict good outcome after mechanical thrombectomy.   J Neurointerv Surg. 2019;11(6):559-562. doi:10.1136/neurintsurg-2018-014347 PubMedGoogle ScholarCrossref
22.
Nannoni  S , Kaesmacher  J , Ricciardi  F ,  et al.  ASPECTS-based selection for late endovascular treatment: a retrospective two-site cohort study.   Int J Stroke. 2021;17474930211009806. doi:10.1177/17474930211009806:17474930211009806PubMedGoogle Scholar
23.
Bouslama  M , Haussen  DC , Rodrigues  G , Barreira  C , Frankel  M , Nogueira  RG .  Novel selection paradigms for endovascular stroke treatment in the extended time window.   J Neurol Neurosurg Psychiatry. 2021;jnnp-2020-325284. doi:10.1136/jnnp-2020-325284PubMedGoogle Scholar
24.
Lopez-Rivera  V , Abdelkhaleq  R , Yamal  J-M ,  et al.  Impact of initial imaging protocol on likelihood of endovascular stroke therapy.   Stroke. 2020;51(10):3055-3063. doi:10.1161/STROKEAHA.120.030122 PubMedGoogle ScholarCrossref
If you are not a JN Learning subscriber, you can either:
Subscribe to JN Learning for one year
Buy this activity
jn-learning_Modal_Multimedia_LoginSubscribe_Purchase
Close
If you are not a JN Learning subscriber, you can either:
Subscribe to JN Learning for one year
Buy this activity
jn-learning_Modal_Multimedia_LoginSubscribe_Purchase
Close
With a personal account, you can:
  • Access free activities and track your credits
  • Personalize content alerts
  • Customize your interests
  • Fully personalize your learning experience
Education Center Collection Sign In Modal Right
Close

Name Your Search

Save Search
Close
With a personal account, you can:
  • Track your credits
  • Personalize content alerts
  • Customize your interests
  • Fully personalize your learning experience
jn-learning_Modal_SaveSearch_NoAccess_Purchase
Close

Lookup An Activity

or

Close

My Saved Searches

You currently have no searches saved.

Close

My Saved Courses

You currently have no courses saved.

Close
With a personal account, you can:
  • Access free activities and track your credits
  • Personalize content alerts
  • Customize your interests
  • Fully personalize your learning experience
Education Center Collection Sign In Modal Right
Close