Published online before print March 2, 2006, doi: 10.1161/01.STR.0000209238.61459.39
(Stroke. 2006;37:979.)
© 2006 American Heart Association, Inc.
Original Contributions |
Perfusion-CT Assessment of Infarct Core and Penumbra
Receiver Operating Characteristic Curve Analysis in 130 Patients Suspected of Acute Hemispheric Stroke
From the Department of Radiology, Neuroradiology Section (M.W., W.P.D.), University of California, San Francisco; the Departments of Radiology (V.M., A.Q., S.P.) and Neurology (J.S.), Hospital Doctor Josep Trueta, Girona, Spain; the Departments of Radiology (A.E.F.) and Neurology (C.P.), Thomas Jefferson University Hospital, Philadelphia, Pa; the Department of Radiology (B.V., M.v.L., I.v.d.S., A.W.), University Medical Center Utrecht, The Netherlands; the Departments of Radiology (R.M., P.S.) and Neurology (J.B.), University Hospital (CHUV), Lausanne, Switzerland; the Departments of Radiology (D.G.) and Neurology (I.G.), Rambam Medical Center, Haifa, Israel; the Department of Radiology (J.A., G.N.), Oregon Health and Science University, Portland, Ore; CT Clinical Science (S.P.), Philips Medical Systems, Cleveland, OH; and Medical IT - Advanced Development (M.Q.), Philips Medical Systems, Best, The Netherlands.
Correspondence and reprint requests to Max Wintermark, MD, University of California, San Francisco, Department of Radiology, Neuroradiology Section, 505 Parnassus Avenue, Box 0628, San Francisco, CA 94143-0628. E-mail Max.Wintermark{at}radiology.ucsf.edu
Background and Purpose— Different definitions have been proposed to define the ischemic penumbra from perfusion-CT (PCT) data, based on parameters and thresholds tested only in small pilot studies. The purpose of this study was to perform a systematic evaluation of all PCT parameters (cerebral blood flow, volume [CBV], mean transit time [MTT], time-to-peak) in a large series of acute stroke patients, to determine which (combination of) parameters most accurately predicts infarct and penumbra.
Methods— One hundred and thirty patients with symptoms suggesting hemispheric stroke 
12 hours from onset were enrolled in a prospective multicenter trial. They all underwent admission PCT and follow-up diffusion-weighted imaging/fluid-attenuated inversion recovery (DWI/FLAIR); 25 patients also underwent admission DWI/FLAIR. PCT maps were assessed for absolute and relative reduced CBV, reduced cerebral blood flow, increased MTT, and increased time-to-peak. Receiver-operating characteristic curve analysis was performed to determine the most accurate PCT parameter, and the optimal threshold for each parameter, using DWI/FLAIR as the gold standard.
Results— The PCT parameter that most accurately describes the tissue at risk of infarction in case of persistent arterial occlusion is the relative MTT (area under the curve=0.962), with an optimal threshold of 145%. The PCT parameter that most accurately describes the infarct core on admission is the absolute CBV (area under the curve=0.927), with an optimal threshold at 2.0 mlx100 g–1.
Conclusion— In a large series of 130 patients, the optimal approach to define the infarct and the penumbra is a combined approach using 2 PCT parameters: relative MTT and absolute CBV, with dedicated thresholds.
Key Words: computed tomography • perfusion • ROC analysis • stroke
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