Value of Computed Tomographic Perfusion–Based Patient Selection for Intra-Arterial Acute Ischemic Stroke Treatment
Authors: Borst Jordi , Berkhemer Olvert A. , Roos Yvo B.W.E.M. , van Bavel Ed , van Zwam Wim H. , van Oostenbrugge Robert J. , van Walderveen Marianne A.A. , Lingsma Hester F. , van der Lugt Aad , Dippel Diederik W.J. , Yoo Albert J. , Marquering Henk A. , Majoie Charles B.L.M. ,   MR CLEAN Investigators and Affiliations, Fransen Puck S.S. , Beumer Debbie , van den Berg Lucie A. , Schonewille Wouter J. , Vos Jan Albert , Nederkoorn Paul J. , Wermer Marieke J.H. , Staals Julie , Hofmeijer Jeannette , van Oostayen Jacques A. , Lycklama à Nijeholt Geert J. , Boiten Jelis , Brouwer Patrick A. , Emmer Bart J. , de Bruijn Sebastiaan F. , van Dijk Lukas C. , Kappelle L. Jaap , Lo Rob H. , van Dijk Ewoud J. , de Vries Joost , de Kort Paul L.M. , van den Berg Jan S.P. , van Hasselt Boudewijn A.A.M. , Aerden Leo A.M. , Dallinga René J. , Visser Marieke C. , Bot Joseph C.J. , Vroomen Patrick C. , Eshghi Omid , Schreuder Tobien H.C.M.L. , Heijboer Roel J.J. , Keizer Koos , Tielbeek Alexander V. , den Hertog Heleen M. , Gerrits Dick G. , van den Berg-Vos Renske M. , Karas Giorgos B. , Steyerberg Ewout W. , Flach H. Zwenneke , Sprengers Marieke E.S. , Jenniskens Sjoerd F.M. , Beenen Ludo F.M. , van den Berg René , Koudstaal Peter J. , Brown Martin M. , Liebig Thomas , Stijnen Theo , Andersson Tommy , Mattle Heinrich , Wahlgren Nils , van der Heijden Esther , Ghannouti Naziha , Fleitour Nadine , Hooijenga Imke , Puppels Corina , Pellikaan Wilma , Geerling Annet , Lindl-Velema Annemieke , van Vemde Gina , de Ridder Ans , Greebe Paut , de Bont-Stikkelbroeck José , de Meris Joke , Janssen Kirsten , Struijk Willy , Simons Tiny , Messchendorp Gert , van der Minne Friedus , Bongenaar Hester , Licher Silvan , Boodt Nikki , Ros Adriaan , Venema Esmee , Slokkers Ilse , Ganpat Raymie-Jayce , Mulder Maxim , Saiedie Nawid , Heshmatollah Alis , Schipperen Stefanie , Vinken Stefan , van Boxtel Tiemen , Koets Jeroen , Boers Merel , Santos Emilie , Jansen Ivo , Kappelhof Manon , Lucas Marit , Geuskens Ralph , Barros Renan Sales , Dobbe Roeland , Csizmadia Marloes 
Published: November 2015

Background and Purpose—
The utility of computed tomographic perfusion (CTP)–based patient selection for intra-arterial treatment of acute ischemic stroke has not been proven in randomized trials and requires further study in a cohort that was not selected based on CTP. Our objective was to study the relationship between CTP-derived parameters and outcome and treatment effect in patients with acute ischemic stroke because of a proximal intracranial arterial occlusion.

Methods—
We included 175 patients who underwent CTP in the Multicenter Randomized Clinical Trial of Endovascular Treatment for Acute Ischemic Stroke in The Netherlands (MR CLEAN). Association of CTP-derived parameters (ischemic-core volume, penumbra volume, and percentage ischemic core) with outcome was estimated with multivariable ordinal logistic regression as an adjusted odds ratio for a shift in the direction of a better outcome on the modified Rankin Scale. Interaction between CTP-derived parameters and treatment effect was determined using multivariable ordinal logistic regression. Interaction with treatment effect was also tested for mismatch (core <70 mL; penumbra core >1.2; penumbra core >10 mL).

Results—

The adjusted odds ratio for improved functional outcome for ischemic core, percentage ischemic core, and penumbra were 0.79 per 10 mL (95% confidence interval: 0.71–0.89;
P
<0.001), 0.82 per 10% (95% confidence interval: 0.66–0.90;
P
=0.002), and 0.97 per 10 mL (96% confidence interval: 0.92–1.01;
P
=0.15), respectively. No significant interaction between any of the CTP-derived parameters and treatment effect was observed. We observed no significant interaction between mismatch and treatment effect.

Conclusions—
CTP seems useful for predicting functional outcome, but cannot reliably identify patients who will not benefit from intra-arterial therapy.