Hyperglycemia Is Associated With Computed Tomography Perfusion Core Volume Underestimation in Patients With Acute Ischemic Stroke With Large‐Vessel Occlusion
Authors: Niktabe Arash , Martinez‐Gutierrez Juan Carlos , Salazar‐Marioni Sergio , Abdelkhaleq Rania , Quintero Juan Carlos Rodriguez , Jeevarajan Jerome A. , Tariq Muhammad Bilal , Iyyangar Ananya S. , Azeem Hussain M. , Ballekere Anjan Nagesh , Le Ngoc Mai , McCullough Louise D. , Sheth Sunil A. , Kim Youngran 
Published: April 2024

Background
Computed tomography perfusion (CTP) predictions of infarct core play an important role in the determination of treatment eligibility in large‐vessel occlusion acute ischemic stroke. Prior studies have demonstrated that blood glucose can affect cerebral blood flow. Here, we examine the influence of acute and chronic hyperglycemia on CTP estimations of infarct core.

Methods
From our prospectively collected multicenter observational cohort, we identified patients with large‐vessel occlusion acute ischemic stroke who underwent CTP with RAPID (IschemaView, Stanford, CA) postprocessing, followed by endovascular therapy with substantial reperfusion (Thrombolysis in Cerebral Infarction 2b–3) within 90 minutes, and final infarct volume determination by magnetic resonance imaging 48 to 72 hours posttreatment. Core volume overestimations and underestimations were defined as a difference of at least 20 mL between CTP‐RAPID predicted infarct core and Diffusion Weighted Imaging (DWI) final infarct volume. Primary outcome was the association of presentation glucose and hemoglobin A1c (HgbA1c) with underestimation of core volume and was measured using multivariable logistic regression adjusted for comorbidities and presentation characteristics. Secondary outcomes included frequency of overestimation of infarct core.

Results

Among 256 patients meeting inclusion criteria, median age was 67 (interquartile range [IQR], 57–77) years, 51.6% were women, and 132 (51.6%) and 93 (36.3%) had elevated presentation glucose and elevated HgbA1c, respectively. Median CTP‐predicted core was 6 mL (IQR, 0–30 mL), median DWI final infarct volume was 14 mL (IQR, 6‐43 mL), and median difference was 12 mL (IQR, 5–35 mL). Twenty‐eight (10.9%) patients had infarct core overestimation and 68 (26.6%) had underestimation. Compared with those with no underestimation, patients with underestimation had elevated blood glucose (median, 119 [IQR, 103–155] versus 138 [IQR, 117–195] mg/dL;
P
= 0.002) and HgbA1c (median, 5.80% [IQR, 5.40–6.40] versus 6.40% [IQR, 5.50–7.90];
P
= 0.009). In multivariable analysis, underestimation was independently associated with elevated glucose (adjusted odds ratio [OR], 2.10;
P
= 0.038) and HgbA1c (adjusted OR, 2.37;
P
= 0.012). Overestimation was associated with lower presentation blood glucose (median, 109 [IQR, 99–132] in overestimation versus 127 [IQR, 107–172] mg/dL in no overestimation;
P
= 0.003) and HgbA1c (5.6%[IQR 5.1–6.2] in overestimation versus 5.90%[IQR, 5.50–6.70] in no overestimation;
P
= 0.012).

Conclusions
Acute and chronic hyperglycemia were strongly associated with CTP underestimation in patients with large‐vessel occlusion acute ischemic stroke undergoing endovascular therapy. Glycemic state should be considered when interpreting CTP findings in patients with large‐vessel occlusion acute ischemic stroke.